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Case Histories - Diagnosis of Contradictory And Complicated Cases
"In confusing and complicated conditions, treat Phlegm"
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"
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"
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"
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"
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"
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.