Case Histories - Diagnosis of Contradictory And Complicated Cases
"In confusing and complicated conditions,
treat Phlegm"
Case history
A 35-year-old man had been suffering from a hot sensation of the
palms and soles and ache of fingers and toes for about 6 months:
the fingers and toes were not swollen nor hot to the touch. He had
no other symptom apart from an annoying phlegm in the throat which
he had to clear a few times a day. The tongue was quite normal and
the pulse was very slightly Slippery. The hot sensation of palms
and soles strongly suggests Yin deficiency, possibly of the Heart
and Kidneys or Lung and Kidneys. However, there was no other symptom
or sign of Yin deficiency at all and neither the pulse nor tongue
indicates Yin deficiency at all. The ache of the hands and feet
could be a form of Painful Obstruction Syndrome (Bi
syndrome) due to Wind, Cold or Dampness in the joints but the ache
did not react to changes in weather, a symptom that is normally
present in Painful Obstruction Syndrome: furthermore, the hot sensation
of palms and soles could be due to Heat Painful Obstruction Syndrome
but this was clearly not the case as the joints were not swollen
or hot.
Considering that it was difficult to find a proper explanation for
this patient's symptoms, I concluded that, according to the principle
"in complicated and difficult-to-explain
conditions, treat Phlegm", they were due to Phlegm and
the need to clear his throat frequently would support this conclusion.
I therefore set out to resolve Phlegm by using the following points:
-LU-9 Taiyuan to resolve Phlegm from the Lung channel and thus affects
his fingers and palms.
-Ren-12 Zhongwan, ST-36 Zusanli, ST-40 Fenglong and SP-9 Yinlingquan
to resolve Phlegm.
-KI-3 Taixi to affect soles and toes.
Using these combination of points four times at weekly interval
cleared the problem completely.
"Pulse determinant in diagnosis"
Case history
A 53-year-old woman had been suffering from hair loss for 6 years
after a period of intense stress. At that time, her periods also
stopped abruptly. She had no other symptoms apart from tiredness.
Her tongue was Pale, slightly Purple on the right side in the breast
area, and Swollen. The pulse was clearly Wiry all over.
This is a good example of the determinant importance of pulse diagnosis
when there are few symptoms and signs to go by. The pulse should
never be dismissed as a factor in diagnosis but even less so when
there are few symptoms and signs. Falling hair may be due either
to a Deficiency (usually of Liver-Blood or Kidney-Essence) or to
an Excess, usually Liver-Wind. When falling hair is due to internal
Wind, the hair loss occurs suddenly: the Wiry pulse definitely indicated
that the hair loss was not due to a Deficiency but to Liver-Wind:
this is also confirmed by the abrupt onset after a period of stress.
"Never ignore the tongue"
Case history
A 33-year-old woman had been suffering from otitis media for 18
months: she had a thick, yellow discharge from the ear. She had
resorted to antibiotics five times but the middle-ear infection
always returned. She also suffered from asthma since two years and
allergic rhinitis since she was 21. Her tongue was Red, Peeled in
the centre and front, and had a bilateral thin-white coating. Her
pulse was Weak on the right and slightly Wiry on the left.
The middle-ear infection is clearly due to Damp-Heat in the Gall-Bladder
channel: that it is Damp-Heat is clear from the thick, yellow discharge;
that it is in the Gall-Bladder channel is clear from the bilateral
coating (a sign of Gall-Bladder problems) and the Wiry pulse. However,
treating her only for Damp-Heat in the Gall-Bladder channel would
be a mistake and would be not much better than using antibiotics.
In fact, the tongue shows other important patterns that cannot be
ignored. The lack of coating in the centre and front indicates Stomach-
and Lung-Yin deficiency while the redness of the tongue body (combined
with the absence of coating) indicates Empty Heat in these organs.
Although there are no symptoms and signs of Yin deficiency with
Empty Heat of Stomach and Lungs, the tongue appearance is enough
to diagnose this condition. Thus, treatment should be aimed not
only at resolving Damp-Heat from the Gall-Bladder channel, but also
at nourishing Stomach- and Lung-Yin: nourishing these two organs
will tonify the Upright Qi and strengthen the immune system which
should help her to fight off the ear infections. Indeed, it could
be said that the deficiency of the Stomach and Lungs is the reason
that the antibiotics did not clear her condition and that it returned
each time. Had the tongue shown only the retention of Damp-Heat
in the Gall-Bladder with a sticky coating, it could be argued that
the ear infection would not have recurred after the course of antibiotics.
Thus, this case history is a good example of two principles, i.e.
that the tongue should never be ignored, and that the tongue may
also assist in predicting the possible effect of Western medication.
In this case, the deficiency of Stomach- and Lung-Yin indicated
by the absence of coating clearly alerts us to a deficiency of the
Upright Qi (and the immune system from a Western perspective) and
therefore the possibility that the antibiotic treatment might not
work.
I therefore treated this patient by simultaneously resolving Damp-Heat
from the Gall-Bladder channel and nourishing Stomach- and Lung-Yin
with a variation of the formula Xiao Chai Hu
Tang Small Bupleurum Decoction:
Chai Hu Radix
Bupleuri 6g
Huang Qin Radix
Scutellariae baicalensis 6g
Ban Xia Rhizoma
Pinelliae ternatae 6g
Dang Shen Radix
Codonopsis pilosulae 6g
Yin Chen Hao Herba
Artemisiae capillaris 6g
Shan Zhi Zi Fructus
Gardeniae jasminoidis 4g
Mai Men Dong Tuber
Ophiopogonis japonici 6g
Tai Zi Shen Radix
Pseudostellariae 6g
Shan Yao Radix
Dioscoreae oppositae 6g
With acupuncture, I treated the following points:
-Ren-12 Zhongwan and SP-9 Yinlingquan to resolve Dampness in general.
-ST-36 Zusanli and SP-6 Sanyinjiao to nourish Stomach- and Lung-Yin.
-T.B.-5 Waiguan and G.B.-41 Zulinqi to resolve Damp-Heat from the
Gall-Bladder channel.
"In men, the clinical manifestations sometimes
mimic Yin deficiency but are not due to Yin deficiency"
Case history
A 31-year-old man had been suffering from tiredness, insomnia, expectoration
of phlegm, nausea, backache, tinnitus and night-sweating. His tongue
was slightly Red and Swollen and had teethmarks and his pulse was
Weak especially on the left-front position.
The tiredness, backache, tinnitus and night-sweating could be easily
interpreted as being due to Kidney-Yin deficiency. However, closer
examination and questioning revealed that each symptom could be
explained differently. The backache was due to excessive lifting,
the tinnitus was due to working in a band and listening to very
loud music, and the night-sweating was due to Phlegm-Heat. The symptoms
of Phlegm-Heat are the expectoration of phlegm, the nausea, the
insomnia, the night-sweating and the Red-Swollen tongue. Thus, although
the manifestations could have easily led us to diagnose Kidney-Yin
deficiency, the real problem is Phlegm-Heat. The tongue was important
to confirm this diagnosis.
Sometimes men display manifestations that resemble Kidney-Yin deficiency
but are due to Heart patterns (see article on Heart in this website).
"When the pulse contradicts the clinical
manifestations"
Case history
A 41-year-old man complained of tiredness, sleepiness and lack of
motivation. He had been feeling like that for about 1 year. He also
complained of a feeling of cold "of the skin" for about
2 years. His tongue was Red, completely Peeled, with a very deep
Heart crack and Spleen cracks (transversal cracks on the sides in
the middle section); his pulse was Slow (60), Empty at the deep
level on the left side, especially so in the Heart position. His
eyes were rather dull and lacking in shen.
These were the presenting symptoms. On the face of it, there is
a striking contradiction between the tongue that indicates Empty
Heat from Yin deficiency and the pulse that indicates Cold (being
Slow). The cold feeling of the skin also indicates Cold and possibly
Yang deficiency. When a slow pulse contradicts the other manifestations
and especially the tongue, the first thing to check is whether it
is due to exercise. In this case it was, as this patient had been
doing a lot of vigorous exercise and many sports over many years
when he was younger: thus, this could account for the slow pulse.
On enquiring about other manifestations, it turned out that he felt
often thirsty and drank a lot of water, his mouth was often dry,
his sleep was very restless and he had a burning sensation of his
feet occasionally, all symptoms which confirm the Empty Heat. The
dull shen of his eyes, together with the very deep Heart crack on
the tongue indicates deep emotional problems and stress which he
admitted to when asked. What to make of the cold sensation "of
the skin"? I interpreted this as being due to his mental depression
and emotional stress: it is therefore neither Full nor Empty Cold
but False Cold.
Thus, the appearance of the tongue and the symptoms of Empty Heat
(restless sleep, dry mouth and burning sensation of feet) definitely
warrant a diagnosis of Empty Heat from Yin deficiency in spite of
the cold feeling of the skin and Slow pulse; furthermore, the emptiness
of the pulse at deep level confirms Yin deficiency.
"When the pulse contradicts the other clinical
manifestations"
Case history
A 37-year-old woman had been suffering from a shortening of her
menstrual cycle for the previous 2 years; the period was also becoming
scantier in amount. Other symptoms included a gradual loss of hair,
the occasional expectoration of phlegm, poor memory, poor concentration,
floaters, palpitations, feeling cold, backache, tinnitus and night-sweating.
She had also been diagnosed as having the beginning of osteoporosis
and a gynaecological examination revealed that she suffered from
the early stages of poli-cystic ovary syndrome. Her tongue was Pale
with a white-sticky coating and her pulse was Slippery and Rapid
(88).
Most of her symptoms clearly show a deficiency of Blood (loss of
hair, poor memory and concentration, floaters and palpitations)
and of Kidney-Yang (feeling cold, backache, tinnitus, night-sweating
and osteoporosis). Although night-sweating is a symptom of Yin deficiency,
in women it often accompanies also Kidney-Yang deficiency. There
are also a few manifestations of Phlegm, these being the expectoration
of phlegm, the Slippery pulse, the sticky tongue coating and the
poli-cystic ovary syndrome (usually due to Dampness and Phlegm against
a background of Kidney deficiency). However, there is one symptom
that does not fit all the manifestations and that is the Rapid pulse:
this could conceivably be due to Phlegm-Heat but there are no signs
of Heat.
A Rapid pulse in the absence of Heat symptoms is often due to shock
and emotional upset. Asking the patient about this, she confirmed
that this was the case. |
|