TCM pathology and treatment formulation
3CTA 501
Lilja Katanka
W0407020
Assignment 2: Case Study
QUESTIONS:
1: Give a diagnosis of this woman’s condition listing the signs
and symptoms that have informed your answer.
(20 marks)
This woman’s condition is slightly complicated in that it shows signs
of being a combined excess and deficient pattern.
As part of her chronic condition, she shows signs of Spleen deficiency,
Yang deficiency and Dampness:
Tiredness, loose stools (particularly the feeling that the stools “just fall
out”, indicating Spleen not holding), poor appetite and lack of taste all
indicate Spleen Qi xu. Her forceless pulse also indicates deficiency, as
does her pale and toothmarked tongue.
The muzzy feeling in her head indicates Dampness, as does the sticky
nature of her stools and tongue coating, her slippery pulse and her
vaginal discharge, which has been ‘on and off’ for years. This is
typical of Dampness which is often very stubborn and hard to clear.
Her yellowish complexion could be associated with Dampness, but
could also just indicate pain (Deng, 1999:10) or Spleen xu (Maciocia,
1989:146).
The fact that she suspected sinusitis also indicates Dampness, as it is
a feeling of being ‘stuffed up’ (Kaptchuck, 2000:250). Chronic
diarrhoea is commonly associated with Dampness anyway, and
according to Maciocia (1989:158) chronic diarrhoea is commonly
caused by Spleen yang or Kidney yang xu. However, we have no signs
indicating a Kidney pattern, such as breathlessness, dislike to speak,
abundant clear scanty urine, oedema, or a feeling of cold in the back
(Maciocia, 1989:262).
There are cold signs, which along with the Qi xu signs, point towards
Yang xu: the patient generally feels the cold easily, (especially in her
limbs- pointing towards Spleen Yang xu). If the Yang xu were allowed
to progress and become more serious, she may also have signs of
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TCM pathology and treatment formulation
3CTA 501
Lilja Katanka
W0407020
Assignment 2: Case Study
oedema. Fatigue and lack of strength also indicate Yang vacuity
(Deng 1999:182)
Her acute condition is slightly more confusing. Pain around the
umbilicus points towards a Spleen pattern. The fact that it is a
colicky, cramping pain and that it responds to warmth indicates Cold
(Maciocia, 1989:160), and the fact that the pain is severe and sudden
indicates a full/ excess condition- but the pain also responds to
pressure, which points towards a deficiency rather than an excess.
There are Damp signs associated with the acute condition too, such
as the thicker and more copious vaginal discharge with a fishy smell,
indicating cold-Damp (Maciocia, 1989 :161), and the thick white
sticky coat on the tongue also indicates the presence of cold-Damp.
The patient shows signs of Cold-Damp invading the Spleen (no
appetite, better for warmth, absence of taste, loose-thin stools, white
vaginal discharge, lassitude) but we don’t know whether she has a
feeling of oppression in chest and epigastrium, or heaviness of head
(Maciocia, 1989:245), and most of these signs could just be associated
with the chronic condition.
According to Deng (1999:177) because of this reaction to pressure and
as the pain is not unceasing, and the pulse is forceless, the root of the
disease is vacuity- a condition he calls ‘true vacuity false repletion’.
Maciocia (1994:434) and McLean (1999:37) also talk of the importance
of reaction to pressure in distinguishing between full and excess
conditions.
However, trying to differentiate between ‘cold accumulation abdominal
pain’ and vacuity cold abdominal pain’ is difficult in terms of this
patient’s signs and symptoms. Deng goes on to say that both patterns
have episodic pain of or around the umbilicus, and cold limbs, but
reiterates that the excess condition would be severe and refuse
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Lilja Katanka
W0407020
TCM pathology and treatment formulation
3CTA 501
Assignment 2: Case Study
pressure, whereas the vacuity pain would like warmth and pressure,
and would usually be a mild or cold pain which was more severe with
hunger or fatigue. He also says that this pattern is commonly
associated with Yang xu signs and manifestations of an unsettled
Spleen, which this patient displays. (Deng, 1999:463,464)
She seems like a generally yin and deficient person.
Hence, overall, I would diagnose her with Cold-Damp invasion of the
Spleen, with underlying Spleen Yang Xu and Damp.
2: Suggest one further question you would like to ask to help
you confirm your diagnosis.
(10 marks)
I would like to ask several questions (e.g. about her diet, whether she
felt better or worse for bowel movements, whether the diarrhoea has
been affected by her acute condition…), but mainly I want to confirm
that this is overall a deficient condition rather than an excess one.
This is important because if I treat the patient for deficiency, tonifying
the spleen, when there is actually an excess pattern, the condition
may be aggravated.
McLean (1999) talks about how Cold Damp in the intestines can be
recurrent and chronic as a result of an acute episode that was never
cleared properly, or that is continually fed by a cold or Damp diet. He
states that latent cold Damp can sometimes persist in the intestines
for months or years and may closely resemble deficiency diarrhoea
patterns.
He actually suggests that the test to determine whether this is the
case is by treatment tonification of the Spleen, and seeing whether
this aggravates the condition or is ineffective.
So perhaps the best question to ask the patient at this stage would be
whether there was any acute condition which started her diarrhoea a
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Lilja Katanka
W0407020
TCM pathology and treatment formulation
3CTA 501
Assignment 2: Case Study
year ago, or previously, as this could indicate this latent cold damp
(excess) condition and avoid having to ‘test’ the theory by using the
wrong treatment.
3: Explain the aetiology and pathology showing how her acute
and chronic problems are linked.
(25 marks)
This woman probably has a constitutional tendency towards Spleen
and Stomach problems, as her body shape shows her to be an ‘earth
type’ (Maciocia, 1989:144). We do not know about any hereditary
tendencies, or her general dietary preferences, so we cannot comment
on whether these have contributed to the chronic Dampness and
Spleen xu. We also do not know how long she has had a tendency to
feel the cold and have cold limbs and tiredness.
However, we do know that the chronic diarrhoea has lasted around a
year, and that she has also been working at the nursing home for the
same time. We can assume that she is fairly overworked, being a
mother of two as well, and that she has had emotional upsets as her
husband left her and stopped paying maintenance, which would
cause a lot of worry and anxiety due to financial worries, let alone
emotional concerns over the relationship. Emotional stress is an
important cause of a variety of digestive complaints (McLean, 1999:
35) and the Spleen particularly is associated with worry, overwork and
‘overthinking’. It is possible too that her work hours are irregular or
contribute to an irregular or insufficient diet.
Cold Damp in the intestinal tract will eventually weaken Spleen yang,
so deficiency will eventually intervene. (McLean, 1999:37) The
chronic Spleen yang xu and Dampness allowed the Spleen and
stomach to be more susceptible to cold invasion and Damp.
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Lilja Katanka
W0407020
TCM pathology and treatment formulation
3CTA 501
Assignment 2: Case Study
Dampness invading the Spleen interferes with its functions of
transforming and transporting, exacerbating the Damp pattern.
Once a patient has degree of Spleen deficiency, they are more prone to
invasion by external pathogens and the potential complications of a
mixed xu/shi pattern. (McLean, 1999:33).
Her acute condition she herself recognises as starting from consuming
cold drinks, in the winter, and eating pastries with cream (Cold Damp
invading the Spleen).
4: Formulate a treatment principle showing your understanding
of the principles and priorities of treatment formulation.
(15 marks)
As this is a mixed vacuity and repletion pattern, I would want to use a
combined method when treating, to expel the pathogen and tonify
depletion (Deng, 1999:176). However, in this case, I think that it is
more important to treat the deficiency and to tonify the upright Qi, by
tonifying and warming the Spleen Yang and draining Dampness.
Though it is a mixed pattern, it is predominantly deficient as shown
by the pulse and reaction to pressure, and tonifying the yang would
be warming and so should help with eliminating the cold.
However, I would like to initially use some local points to treat the
abdominal pain which is so severe and debilitating, and try to stop the
diarrhoea. Supporting the Spleen should help with the tiredness
which is also interfering with her work.
5: Formulate two points prescriptions showing what needle
technique you will use for each point.
You do NOT need to give an explanation for your choice.
(20 marks)
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Lilja Katanka
W0407020
TCM pathology and treatment formulation
3CTA 501
Assignment 2: Case Study
a) for the acute condition
SanJiaoJiu (M-CA-23) with moxa on ginger
Tianshu Stomach-25 with moxa on ginger
Daju Stomach-27 with moxa
Xiajuxu Stomach-39
Qihai Ren-6 with moxa on ginger
Taibai Spleen-3 reinforcing method
b) for the chronic condition
For a front treatment (to be combined with treatment for acute
condition)
Zusanli Stomach-36 – reinforcing method (having expelled the
pathogen, otherwise even method)
Sanyinjiao Spleen-6- even method
Zhongwan Ren-12 – even method
Tianshu Stomach-25 with moxa on ginger
Qihai Ren-6 with moxa on ginger
Shangjuxu Stomach-37- reinforcing method
Baihui Du-20 – reinforcing method
For a back treatment:
Pishu Bladder-20 – reinforcing method
Weishu Bladder-21 – reinforcing method
6: Outline your treatment plan and indicate the probable
prognosis for this woman.
(10 marks)
The acute condition should be improved after one treatment, or
possibly two, as abdominal pain generally responds well to
acupuncture (Maciocia, 1994: 446). The diarrhoea should also begin
to improve in this time, but will probably take a while to resolve
completely as it has been going on for a year. Dampness can be very
‘sticky’ and stubborn, so to completely eliminate this I would like to
propose 10 treatments to help clear the Damp, support and tonify the
Yang, and help her regain more energy.
I would also give lifestyle advice and suggest regular warm meals,
avoiding excess Damp and cold foods or drinks, and keeping her
stomach warm and well covered. Moderate exercise would be helpful
too, particularly for resolving Damp.
Word count - 1520
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Lilja Katanka
W0407020
TCM pathology and treatment formulation
3CTA 501
Assignment 2: Case Study
References
Deadman P, Al-Khafaji M, Baker K, (1998) A Manual of Acupuncture.
East Sussex: Journal of Chinese Medicine
Deng, T. (1999) Practical Diagnosis in Traditional Chinese Medicine.
London: Churchill Livingstone
Kaptchuck, T., (2000). Chinese Medicine ; The Web that has no
Weaver. London: Rider
Maciocia G.(1989) The Foundations of Chinese Medicine; A
comprehensive text for acupuncturists and herbalists. London:
Churchill Livingstone
Maciocia G. (1994) The Practice of Chinese Medicine: the treatment of
diseases with acupuncture and Chinese herbs. Edinburgh; London :
Churchill Livingstone
McLean, W. (1999) Diarrhoea* xie xie. Clinical Acupuncture and
Oriental Medicine 1, 33-54
Ross, J. (1984) Zang fu: the organ systems of Traditional Chinese
Medicine. Second edition. London: Churchill Livingstone
Larre E., Rochat de la Vallée E., 1994. Chinese medicine from the
classics: The Stomach and Spleen. Cambridge: Monkey Press
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