Always Read the Label
There is an advertisement in the UK which extols the virtues of a certain type of varnish. The line is, It does exactly what it says on the tin. And so, we read the label and know what to expect when we open the tin and use the product. This is repeated in many aspects of life and can be very useful so that we don't try to paint with milk or drink varnish. It can also be very unhelpful if the label is less than economical with the truth. Advertising is full of such examples where, on reflection, we may doubt whether a particular lager is probably the best in the world or that a skin cream will get rid of our wrinkles. Often times, the presence of a label is almost ridiculous. There are small packets of dried granules contained in boxes of electrical equipment do we really need to be told, Not to be eaten?
Conventional medicine is no stranger to labels either. For anyone studying the subject, it can seem to be only labels. There is even a label for the labels nosology (not the study of noses) - the naming of diseases. So, we see names which are merely descriptions of the symptoms. Tonsillitis, for example, is merely a term describing hot, red, swollen and painful tonsils. Not very enlightening in terms of diagnosis or treatment but strangely reassuring in many cases. There is something calming about the fact of having a label attached as if its mere presence reassures us. This may be the reason why patients seek to have a conventional diagnosis whatever other treatment they explore later.
As Chinese medicine practitioners we can have a superior attitude that we individualise the person and treat their innermost being. Whilst we may aspire to this, we have our own system of labelling Spleen Qi Deficiency, Liver Qi Stagnation and so forth. There are risks with this in that we can mistake this shorthand method of describing symptoms and patterns as being the same as the person themselves. We should only see them as a guide not as an end in themselves otherwise we can retreat into formulaic prescriptions and treatments which treat the label not the person.
Conventional medicine, of course, is a prime example of how to treat labels. Of all the people diagnosed with asthma (14 15 million people in the US), they will all be given the same treatment bronchodilators and corticosteroids. There is no individualisation either in the diagnosis or the treatment. Such an approach can be helpful, in the short term, for strong acute patterns. In the case of meningitis, for example, intravenous antibiotics will be given to all with effects of clearing the Heat and calming the Wind. A beneficial approach I would have thought but not one which would be appropriate in all cases of infection.
When Mary came to see me after a diagnosis of Addison's disease under activity of the adrenal cortex - I found myself being drawn into the label itself with all its supposed meanings and outcomes. We are told that Addison's disease is one of those conditions, together with its treatment by corticosteroids, which needs conventional treatment. Patients are given dire warnings of what will happen if they stop their medication. They are told that they will need this medication for the rest of their lives and to carry a warning card in case they ever need to consult a doctor or attend a hospital. So, it was in this atmosphere of fear and anxiety that Mary sought out my help. She wanted help with her health certainly but also wanted to know if it was possible to reduce or even stop her medication.
Mary is 47 years old and first came for treatment in February of this year. A routine blood test the previous year had revealed a low iron count and she was put on iron supplementation. Then after feeling tired around Christmas, a blood sugar test showed a slightly raised level of 6.5 mmol/L-1 (normal 4.5 5.6 mmol/L-1). Her GP, conscientiously, performed a glucose tolerance test a blood sugar estimation after a sugary drink which tests response to a sugar load. This revealed an abnormally low level of sugar after 2 hours - .1.4 mmol/L-1. There are several, usually endocrinological, reasons for such readings including Addison's disease. A consultation with an endrinocologist led to an ACTH stimulation test (ACTH is the pituitary hormone which stimulates adrenal function). This showed a low response with reduced levels of cortisone produced by the adrenal gland in response to this stimulation (basal cortisol level of 343 nmol/L rising to 434 nmol/L). A diagnosis of Addison's disease was made and she was put on fludrocortisone 0.1 mg daily and hydrocortisone 20 mg morning and 10 mg evening.
An important point here is that corticosteroids can be given for reasons varying from Addison's disease to asthma, from ulcerative colitis to eczema. Clearly, in Addison's disease, these hormones are given as a replacement for that which should normally be produced similar to thyroxine given for hypothyroidism. If you ever see someone taking fludrocortisone, this points to adrenal under activity as the conventional diagnosis.
The key is always to take the case and determine a diagnosis and treatment principles. This is the basis whatever the conventional diagnosis or treatment.
Mary told me that she had always had a low blood pressure and slow heart rate. She would get slightly dizzy and light-headed on standing particular after exercise. She did not feel particularly tired. Her blood pressure when I saw her was 118/75 although this was a reflection of her medication as the endocrinologist had found it was 80/40. Her low back had been troublesome in recent years particularly when stressed. She felt generally chilly. Urination was often frequent with nocturia. She had just completed a degree in counselling and psychotherapy which, whilst rewarding, was stressful and hard work.
Her tongue was pale and swollen, pulse thready on the right side.
I made a diagnosis of Spleen Qi and Kidney Yang Deficiency. The aim here is to tonify Spleen Qi and warm Kidney Yang.
Acupuncture points Ren 4 and Kidney 3 with moxa.
Shu Di Huang Radix Rehmanniae Glutinosae Conquitae 24 g
Shan Yao Radix Dioscoreae Oppositae 12 g
Shan Zhu Yu Fructus Corni Officinalis 12 g
Mu Dan Pi Cortex Moutan Radicis 9 g
Fu Ling Sclerotium Poriae Cocos 9 g
Ze Xie Rhizoma Alismatis Plantago-aquaticae 6 g
Rou Gui Cortex Cinnamomi Cassiae 3 g
Fu Zi Radix Lateralis Aconiti Carmichaeli Praeparata 3 g
Du Zhong Cortex Eucommiae Ulmoidis 6 g
Niu Xi Radix Achyranthis Bidentatae 5 g
I use herbal powders and she took 1 teaspoon daily.
We discussed the question of the medication and decided to reduce it by 50%. This was made on the basis of an absence of marked symptoms of adrenal insufficiency and her blood results. A normal cortisol level should exceed 170 nmol/L (which hers did) and rise after ACTH stimulation to over 500 nmol/L (usually between 500 and 1250 nmol/L). Mary's did not respond in quite this way but there was a rise and her final level of 434 was only slightly lower than expected. Clearly, you would not want to reduce the medication too suddenly or completely.
In addition to herbs and acupuncture, I discussed diet with her and especially the importance of warm food, eaten regularly. I talked about the benefits of meditation practice as this has great benefits in strengthening Kidney energy, as does tai chi and qi gong. She attended a vipassana (insight) meditation course and developed a regular meditation practice.
On her second visit some 2 weeks later, her blood pressure had fallen slightly to 95/55 as would be expected with the medication reduction but not as low as initially. She felt well, her energy was good. Her pulse was stronger on the right side although her Kidneys pulse were deep and weak. Her tongue was pale and wet with occasional teeth marks. I repeated the acupuncture treatment with the addition of Stomach 36, Ren 12 and Du 20. I told her to take the herbs twice daily. She reduced the medication to every second day.
At the third visit 3 days later, she felt well, blood pressure at 105/80. She reported occasional loose bowels after salad. She also told me that in the previous several months, she had noticed sweating in cold weather. This had now stopped since commencing treatment. The Kidney pulses had improved and tongue was a much better colour, not wet and less swollen. I repeated the previous acupuncture treatment.
At visit 4 some 8 days later, her blood pressure was 95/70. This is still low but adequate considering that she was now only taking her medication every 3rd day. She had had some increased tiredness. Treatment was repeated.
She attended for treatment every 2 3 weeks and continued to improve. She was able to stop her medication in late March. I essentially used the same herbal formula or slight variations of it. At one point, when she had more trouble with loose stools, I also gave her Bu Zhong Yi Qi Wan to support her Spleen Qi.
In July, she had been off her medication for 3 or 4 months. She had a good trip to the US although was somewhat tired on her return. Her blood pressure was now regularly 115/75. She had a repeat glucose tolerance test and these results were now normal (4.8 mmol/L-1 fasting and 4.9 mmol/L-1 two hours after a sugar load). She is going to have a repeat of her ACTH stimulation test in September and I am expecting that to be significantly improved if not normal. Watch this space!
So, what does this mean in terms of labels? We must always look at people from the perspective of Chinese medicine which gives great insight into both how we develop imbalances and also how to ameliorate them. The more commitment that the patient makes leads to increased benefits. In this case, Mary was keen to take responsibility for her own health and to make positive changes. These enabled her to take charge of her condition and her medication. So often in life we don't look behind the superficial and limit our hopes, aspirations and dreams. However, if we choose to look deeper there is so much potential.
Stephen Gascoigne qualified in medicine in 1976 in Liverpool, UK and worked for 6 years in hospital and general practice. Stephen trained in acupuncture in China and subsequently in Chinese herbal medicine in London with the esteemed Vietnamese practitioner, Tinh Thong Nguyen. Stephen is the author of The Chinese Way to Health (Connections, 2000), an introduction to Chinese medicine and its methods for the general public and two textbooks for students and practitioners of holistic medicine - The Clinical Medicine Guide (Jigme Press, 2001) and The Prescribed Drug Guide (Jigme Press, 2003).