by Steven Clavey
Angela M., 41, three kids, about school years 4-8.
Significant history: She reported that glandular fever (mono) as child had affected her all her life, giving her chronic fatigue.
1) Lower back pain all through the month, worse prior to menstruation, muscles spasm when tired.
2) Heavy periods the first two days, then much less the next three.
3) Migraines prior to periods.
Observation: Red hair, dry lips, malar flush.
Energy: Lowest at ovulation, the chronic fatigue demanding that she pace herself or become completely exhausted.
Appetite: Poor, becomes full with carbohydrates, craves chocolate at ovulation.
Bowels: Spasm with stress causing hot flushes and explosive diarrhea.
Sleep: “Poor.” Why? She explains that she wakes unrefreshed, no matter how long she sleeps. (This actually shows two things: she is tired on waking, and not thinking clearly enough to differentiate between this and poor sleep. This unclear thinking is a very common indication of damp clouding the mind). If you take her words “poor sleep” at face value, and treat her for poor sleep by using spirit calming herbs, she will just become more and more tired, and you will not know why. It is best to ask about waking up first, then if they say they have poor sleep, ask them if they really mean that they wake up tired.
Heat/cold: Dislikes heat.
Phlegm: Yellow in throat and sinus leading to post-nasal drip.
Other: Poor concentration, thirst, dry skin, psoriasis on R thumb, always swollen glands.
Periods: 5/32, heavy first two days, some clotting, deep maroon, and black clots that hurt to pass.
PMT: “Migraines” behind eyes and at temples, no nausea. Previous few months has had tender breasts and abdominal bloating.
R: Pulse deep thready languid, R guan esp thready.
L: Pulse short at guan, where it is thready.
Tongue: Purplish, swollen with teeth marks, tongue coat thin.
Differentiation: Constitutional qi and yin deficiency (including Lungs, Spleen, Liver, and Kidneys). Weak Spleen transportation and transformation allowing damp and phlegm to accumulate. There is also Liver qi blockage resulting from two factors: weak qi flow further obstructed by damp and phlegm, and underlying Liver yin deficiency so that Liver is not “soft” and pliable. This has further led to blood stagnation, which has caused the heavy period initially.
The major presenting symptom, the lower backache, is not solely from Kidney yin deficiency, or even primarily, although this lack of Kidney strength to support the lower back is an important factor; part of the blame for this weakness is the failure of Spleen to provide ongoing support for this “trust fund” of energy (see “Yang Sheng – Nourishing Life“).
The main problem is Spleen damp, which pours downward and obstructs the lower back channels and collaterals, and this starvation of nourishment manifests most clearly in the spasms that occur when she is tired. Acupuncture here would work temporarily, but she would become frustrated when it kept recurring. Dampness would simply pour in again, unless she was warned that this would occur and the dampness was addressed through enhancing the Spleen transport.
Another factor in the lower back pain is the lower jiao blood stagnation. “Long term illness enters the collaterals”: this is a phrase to remember when you are sure that you are doing all the right things, but the illness recurs despite this: look to the collaterals, either with herbs or with acupuncture. If with herbs, think of using vines (eg. Ji Xue Teng) all of which tend to enter the collaterals.
All the other symptoms reflect dampness as well. Waking up tired is not a lack of energy, as she has just rested. It is an accumulation of the heavy yin-natured dampness. Even the “migraines” are mainly due to sinus, worsened before the periods due to Liver qi obstruction and its effect on the Lung qi flow. Migraines from Liver qi or yang rebelling upward would have nausea, or even vomiting of bile.
Where Liver qi stagnation does show clearly is the spasming of the bowels with explosive diarrhea. If this was a major symptom, Tong Xie Yao Fang (Important Formula for Diarrhea) would be the treatment. Note that the hot flushes accompanying this symptom are due to her reaction to the colicy pain, not from internal pathogenic heat.
Her tiredness at ovulation is another point where Liver is preoccupied with assisting ovulation and is less able to help Spleen transport. This allows dampness to accumulate, making tiredness worse at this time.
The pulse is also clear: languid (huan) pulse shows the Spleen damp affecting transformation and transport, the threadiness shows that blood and fluids are affected, the deepness shows Liver and Kidney involved and damp oppression. The left pulse shortness at the guan position shows that blood is not even sufficient to fill the whole position — and even there it is thready. The tongue shows the stagnation, and the damp retention in the teethmarks. The coat is unremarkable.
My treatment aimed first at awakening Spleen, clearing damp, moving qi and blood, and helping the lower back. Here are the herbs:
Dang Shen 12g
Gua Lou Pi 15g
Zhi Ke 15g
Lai Fu Zi 6g
Fu Ling 12g
Gu Mai Ya each 9g
Xiang Fu 12g
He Huan Pi 15g
Shan Zha 15g
Dang Gui Wei 12g
Hong Hua 9g
Ji Xue Teng 30g
Chuan Duan 15g
Gou Ji 15g
Gan Cao 3g