Chapter III/2:
Written by Dr Szilard Hamvas (chapters are translated from my book published in Hungarian)
Hypertonia, Obesity – Case Study
Tamás J., 18 years
1.) Anamnesis, main complaints:
The subject is 180 cm tall; his body weight is 116 kg. BMI: 35,8kg/m2. (BMI: Weight in kilograms divided by height in meters squared). He would like to lose weight. He has stretch marks on his abdomen. His abdominal circumference is 128cm. Another of his complaints is palpitations in the back of his neck in the evening. He has high blood pressure: 180/90Hgmm.
He lives with his parents. His older brother married and moved out years ago. He initially denies having any psychological problems.
He does not take any medicines. Despite his young age he smokes regularly.
2.) Symptoms and complaints:
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Obesity |
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Palpitations in the back of the neck, generally in the evening |
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BP:180/90 Hgmm |
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Nose bleeds in the summer |
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Heartburn, large appetite |
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Bowel movement on every second day only, consistency normal |
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Sensory organs: colour blindness |
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Tongue: spots |
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Tongue coating: greasy yellow |
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Pulse: left: xi, duan (Yin Kidney, Heart empty) Pulse: right: xi, hua |
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Table 2/1
3.) Symptoms and complaints:
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Obesity |
Damp-Phlegm stagnation and Spleen deficiency |
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Palpitation in the back of the neck, generally in the evening |
Liver Yang Rising in the Gall Bladder Channel, Yin deficiency |
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BP:180/90 Hgmm |
Phlegm and /or Liver Yang Rising |
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Nose bleeds in the summer |
Stomach Heat |
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Heartburn, large appetite |
Stomach Heat |
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Bowel movement on every second day only, consistency normal |
Yang Ming Heat / Liver Qi Stagnation |
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Sensory organs: colour blindness |
? |
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Tongue: spots |
Qi stagnation |
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Tongue coating: greasy yellow |
Phlegm Heat |
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Pulse: left: xi, duan (Yin Kidney, Heart empty) Pulse: right: xi, hua |
Heart – Kidney Yin deficiency, Liver Blood deficiency. Weak Spleen Qi, Phlegm stagnation. |
Table 2/2
4.) Differential diagnostic interpretation and possible pathomechanism:
I infer that the root of the problem is Liver Qi Stagnation. The stagnant Liver Qi has disturbed the harmony of the Stomach and the Spleen, resulting in Spleen deficiency and Stomach Heat. It is highly likely that these two factors together will lead to obesity. This is because the Stomach Heat causes constant feelings of hunger, but the body is unable to process the nutrients due to the deficient Spleen. Rather, it will produce Phlegm instead of Food Essence (Gu qi). (Perhaps we could translate this phenomenon into the language of academic medicine in the following way: because of insulin resistance his muscles are not able to absorb sugar at an appropriate rate, so the body is starving and he consumes a lot more food, than necessary. The body stores the excess calories in fat.)
Furthermore Liver Qi Stagnation in Yin deficient surroundings leads to Liver Yang Rising. This will manifest in the form of headaches and high blood pressure. So we need to find out what is causing his Liver Qi Stagnation. Initially the patient denies any sort of psychological problem. However, based on the collateral information gathered from his mother, I began to suspect that the patient often swallows the anger provoked by his mother’s over-protective and over-controlling behaviour. In my opinion this is what is causing his Liver Qi Stagnation.
In the language of psychology, the patient’s obesity is a defence mechanism against his mother’s over-controlling behaviour, ensuring his status in a family where even though he feels grown-up, he is still regarded as a child.
Finally, let us not forget that the patient smokes. Smoking causes Phlegm Heat, so in this case it further exacerbates the existing Heat and Damp Phlegm Stagnation.
5.) Therapeutic aims:
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Treatment of the Root |
Harmonise the Liver Qi, pacify the Liver Yang |
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Dispel Yang Ming Heat |
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Strengthen Spleen, to dissipate Phlegm |
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Treatment of the Manifestation |
Promote weight loss |
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Correct blood pressure |
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Stop headaches |
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Table 2/3.
6.) Thearpeutic aims and possible acupuncture points:
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Treatment of the Root |
Harmonise the Liver Qi, pacify the Liver Yang |
Liv3-LI4, Liv3-G34, Liv3-Liv14, G20 (-) Sp6, K3 (+) |
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Dispel Yang Ming Heat |
St44 (-) |
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Strengthen Spleen, to dissipate Phlegm |
St36, Cv12 (+), St40 (-) |
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Treatment of the Manifestation |
Promote weight loss |
St21, St25, St36, St40, St44, Cv9, Cv11, Cv12, Sp9 |
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Ears: Shen Men, Nei Fen Mi, Kidney, Stomach, Spleen, Colon |
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Correct blood pressure |
LI11, St36, G20, Liv3 |
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Stop headaches |
G20, G34, Liv3 (-) |
Table 2/4
The patient’s main aim was to lose weight, so when I created the prescription for the first phase of the treatment I placed the greatest emphasis on this symptom as the manifestation, and most points served this aim. We monitored his weight loss by measuring his abdominal circumference.
As shown in table 2/4 in the above case I chose points that treated the manifestation as well as the root, except for points K3 and Sp6.
The Nei Fen Mi is the collection point of the endocrine glands in the ear. The Shen Men (Gate of Spirit) point has a relaxing effect.
Losing weight with acupuncture cannot be effective without the co-operation of the patient. Acupuncture is able to speed up metabolism, improve digestion and decrease the tension caused by hunger, but it does not replace diet and exercise.
In the above case we only agreed to the following dietary restrictions: Snacking is prohibited! Eating after seven pm is prohibited!
Apart from that he could eat three times a day without further restrictions. Furthermore, the patient undertook to go to the gym three times a week.
7/a) Detailed steps of the completed treatment:
First treatment: L11, St36, G20, K3 (+), St25, St40 (-).
Ears: Shen Men, Nei Fen Mi, Kidney, Stomach, Spleen, Large Intestine.
I placed needles into one of his ears each treatment. I kept them in for thirty minutes. In his other ear I placed vaccaria seeds instead of needles and suggested that he should press on the seeds at least three times a day. It is best to stop all activities while pressing the seeds and breathe deeply. Deep breathing stimulates the circulation of the Qi, so the information coming from the ear has a better chance of being effective.
Result after the first treatment: There was no heartburn; BP: 140/70Hgmm.
Tongue: uncoated patches. (Phlegm decreased, Yin deficiency stayed.)
Second treatment: LI11, St36, G20 (harmonised). St25, Cv12 (+), St40, St44, Liv3-LI4, Cv9 (-). (Left out: K3).
Result after the second treatment: the palpitation in the back of the neck
almost entirely ceased. BP130/70Hgmm.
Third treatment: same as before.
Result after the third treatment: No palpitation in the back of the neck.
Acid belching occurred at the same time! (?)
Fourth treatment: Cv12, St25, instead of Cv9, St21, Cv11, Sp9 (-).
Liv3-G34 instead of Liv3-LI4.
Choosing St21 and Cv11 focuses on restoring the energy state of the Stomach
(The vertex of the triangle formed by points St21 and Cv11 points downwards. Many experts believe that the direction of the vertex determines the direction of the flow of Qi.) The Qi moving effect of Liv3-G34 is less general than the Qi moving effect of Liv3-LI4; however it regulates the Qi circulation of the gastrointestinal system more effectively.
Result after the fourth treatment: Physical symptoms have improved. At the same time he reports increased irritability. In my opinion this is because he is no longer repressing the psychological factors that are triggering his condition (thus forcing the problem on a physical level), but instead is dealing with them at the appropriate level (that of the psyche).
Fifth treatment: Adding Cv15-ExHN3 to calm the psyche.
Result after the fifth treatment: Abdominal circumference 121cm (Weight loss of 7cm).
BP: 120/80Hgmm. No complaints.
Tongue: pale. There is a yellowish and greasy coating at the root.
Pulse: does not show any significant improvement. (?)
Sixth treatment: same as before.
Change in his state after the sixth treatment: The patient has developed a cold. His illness started with a blocked nose, followed by nausea, headache and general malaise. He is coughing and his sputum is greenish. Because of his blocked nose he could not get to sleep.
Tongue: red tip. Spots. Tongue coating: thick and greasy.
Pulse: right: ruo. Left: xi, hua. (My assumption and explanation is: the strong presence of Dampness modifies the pulse hence the External Pathogenic Cause does not manifest itself in the pulse. The weakness of the right pulse (that is “ruo”) points to the strong presence of Dampness, and to its suppressive effect on Spleen Yang.
Diagnosis: As a result of External Pathogenic Cause Phlegm Heat was formed. The transmission from the Surface to the Interior had not been completed, since the symptoms characteristic of the Biao (exterior) state were present as well. The Weak Spleen as Mother must have contributed to the Lung as Child getting the disease.
Change of therapy: temporarily I concentrated on the actual manifestation, which was the patient’s cold.
Seventh treatment: Treatment of Biao, releasing Surface: LI20, L14 (-), Lu7. (Explanation: L14-Lu7 were used according to the Host-Guest rule. Host-Guest rule using Yuan (source) point and Luo (connecting) point together to enhance the effect of the source point. Host: the primarily effected meridian/organ. We select Yuan point on the Host meridian. If the Host meridian/organ is in Excess condition, we should use the Reducing method. The meridian/organ that belongs to the same Phase will be the Guest. We select the Luo point of the Guest meridian. To enhance the effect we use the opposite type of needle manipulation, hence we should tonify the Luo point.)
Eliminate Inner Phlegm Heat: Lu5 (-), St40 (-). (Explanation: Lu5 is the Water point of the Lung meridian, it is the He (Sea) Point and at the same time its Child point. (In a different point combination Lu5 as Water point can also be used to support Yin.) Lu 5 as Child point can be used to drain the Phlegm Surplus in the Lung.)
Further points:
Weight loss: St25.
Strengthen Spleen: St 36, Cv12. Dissolve Phlegm: St40 (-).
Harmonise Liver Yang: G20, Liv3-G34.
Result after the seventh treatment: Nose is still a little blocked, but the patient can now sleep. He still produces phlegm, but hardly ever coughs any more.
Tongue: pale. Spots disappeared. (These spots were probably not signs of Liver Qi Stagnation, but of Wei Qi Stagnation brought about by Wind External Pathogen penetration.) Tongue coating: only at the root, thin, greasy, but white.
Pulse: left: xi. Right: hua. Yin and Blood deficiency still persists. Spleen is stronger, but still struggling with Damp Phlegm.
Earlier complaints did not recur.
Eighth treatment: LI20, LI4, Lu7, St25, St36, Cv12, St40, G20, Liv3-G34, LI11. (The Lu5 is no longer needed. It is enough to treat the Mother (the Earth element) in order to treat the Child.)
Return LI11 to prescription. (LI11 is a blood pressure regulator and immune system regulator.)
7/b.) Summary of the second phase of the treatment
As a result of the weight loss program the patient lost 18 centimetres altogether.
His abdominal circumference reduced from 128 cm to 114cm.
His headache stopped. His blood-pressure stabilised at a normal rate.
Tongue: pale. Tongue coating: greasy white at the root.
Pulse: huan.
8.) Lessons learnt
1.) It is not possible to work with an unchanging prescription throughout.
The treatment has to flexibly reflect changes in the illness. Firstly: because if all goes well the patient’s state of health will change, and as the symptoms are alleviated we can turn from the treatment of the manifestation to the treatment of the root. Secondly: we are not infallible and the diagnosis may require revision. Thirdly: as this case showed, external harmful forces can also attack the patient, further exacerbating existing problems. (In this case the weakness of Spleen.)
2) Young patients always have a better chance of healing. It is not likely that high blood pressure treated medically for years would have gone back to normal in such a short time.
4.) The treatment dealt most effectively with acute symptoms respond. (See 7th treatment.)
5.) It is important that the patient contributes to the treatment. It is not enough for the patient just to bring along his body like a motor vehicle needing repair. The patient has to take an active part in his/her own healing. This demands different kinds of involvement on different occasions. There are cases when life style changes are needed, at other time changes in eating habits. It is sometimes necessary that the changes go deeper: the patient has to undertake psychotherapeutic work as well.
6.) The psychic symptoms stay hidden if not enough attention is paid to them. At best, as the treatment proceeds the symptoms return from the physical level to the level of the psyche. This must always be regarded as improvement, because through this the energy block caused by the psychic symptoms will dissolve.
7.) As I have mentioned in the introduction, I am aware that the point collection applied during the treatment is not the only possible point collection, and I would not make the claim that it is the best of all the possible point collections. The prescription given is the authentic description of the individual stages of a therapy given to a sick patient.
8.) In a book of case studies I think that every author will show the successful cases, as I have done. Of course not all patients heal so successfully. Let us not forget that the best way to learn is by recognising mistakes. The only practitioner who will recognise his/her mistakes is the one who records both the status of his patient and the points he/she applied at every turn.
