Misdiagnosed – Painful obstruction #3November 5th, 2009
Phlegm obstructing the channels and collaterals mistaken for wind-cold-damp painful obstruction.
Wang, a 30 year old woman peasant, on Oct. 2, 1976 came into a hospital in Zhu Ma Dian for treatment. She presented with fatigue, achiness, and numbness / tingling in both her lower limbs. She was diagnosed with “rheumatism”. As a result she was given Phenyl Butazone and antibiotics, which had no effect. Afterwards she received treatment in a TCM hospital in Wu Han for more than a month, but whenever she would sweat and was exposed to wind, her pain would increase.
For the next six months there was pain that sometimes mild and sometimes serious. She walked with a limp requiring her to lean on a staff with the need for people to support her with movement, numbness and tingling in the lower limbs, as well as severe pain in her knee joint. Her knee was cold with palpation and cold aggravated the pain while heat soothed it. This was accompanied with chest oppression, torpid intake, occasional nausea, menstrual flow that was like yellow water, a large amount of white sticky slimy vaginal discharge with a fishy smell, lusterless facial color, disquieted sleep, essences-spirit melancholic, and diffuse swelling in the knee joints that were not red.
Her pulse was wiry, thin, and slippery and she had a pale tongue with a white and slimy coat. She was diagnosed with cold-damp type painful obstruction pattern and the treatment was to warm the channels, scatter cold, and resolve dampness.
Next visit on Oct.6: After taking the medicinals the previous symptoms did not decrease. On the contrary she became agitated and irritable, but her tongue and pulse were the same as before. The patient’s condition was still considered to be caused by cold-damp and was just entrenched and difficult to heal. Therefore the formula was unchanged and three additional packets were given. After finishing the herbs, the cold in her legs became more severe. At night there was severe pain and she would incessantly cry out in distress. It was considered that the amount of scattering cold medicinals was too small and the warming medicinals were not doing their job of moving. Consequently zhi chuan wu 10g and fu zi 15g were added to the original formula and three more packets were given. After taking the medicinals her symptoms still did not lessen, and on the contrary a cough with profuse phlegm emerged. Furthermore, the previous symptoms of chest oppression, poor food intake, nausea and vomiting, and the tongue and pulse still not change.
There was a careful review of the symptoms. Although her lower limbs were painful, and there was numbness and tingling, taking medicals that warm the channels, scatter cold, and resolve dampness were ineffective. Her accompanying symptoms of chest oppression, poor food intake, nausea and vomiting, profuse amount of white vaginal discharge, menstrual color like yellow water, and the new emergence of cough with profuse phlegm, made one think, is there a relationship with these symptoms and the leg pain?
I (the physician) remembered that previous experts had used phlegm in such painful distraction cases, therefore I gave a dispel phlegm formula, jia wei er chen tang.
After 10 days there was another exam: She had taken the medicine and her condition had improved. Her pain was greatly reduced, although she still had short periods of numbness and tingling from time to time, the cough’s phlegm was reduced. The formula was not changed due to the success and five more packets were given. After taking the herbs, her legs began to warm, knee swelling disappeared, there was no pain or numbness and tingling, the oppression in the chest disappeared, and the appetite increased. To the previous formulas, 15 grams of di long was added, bai jie zi was increased to 20, and fang ji to 10. Ten more bags were given in succession. All symptoms disappeared, and a follow-up with a patient 2 years later revealed that there had been no flare-ups.
Commentary: This is a case of severe pain that is worse with cold and improves with heat. A diagnosis of cold-damp was certainly reasonable with the clinical manifestations. However, the treatment was ineffective and the patient’s condition gradually worsened. Consequently, there was a prompt decision for a fresh evaluation, which resulted in considering the diagnosis of phlegm, although there was not the typical signs and symptoms of phlegm. There was though vaginal discharge, poor food intake, chest oppression, cough with much phlegm, which ended up pointing to the road of treatment.
Jason’s commentary: I personally like this case because the initial treatment makes sense and just did not work. This is not uncommon, at least in my practice. However, when something doesn’t work the side effects are the gift. These “unpleasantries” can be used to decipher the underlying cause. In difficult cases, I sometimes even go out of my way to push the body in one direction to try to elicit some side effects. I will of course explain the process to the patient, and often jokingly say “have you seen the show House…” they get the idea and are usually happy that someone is willing to try to figure out what is actually happening to them.