Phlegm Misting Mind
Signalment: 6 ½ year old, male neutered Border Collie
Guardian’s Complaint: Seizuring frequently despite conventional therapy
History: The patient was walking, lost balance, seizured and has been having two to three convulsive episodes per month for the past 1 ½ years. Potassium bromide 700 mg SID was prescribed August 2007. A bromide level of 0.6 mg/ml was reported 09/24/07. Therapeutic reference range was 1-3 mg/ml. The dosage of KBr was increased to 875 mg SID. A bromide level of 0.7 mg/ml was reported 11/14/07. The dosage of KBr was increased to 1100 mg SID. A bromide level of 0.9 mg/ml was reported 12/23/07. A fT4 by Ed and TT4 were within range on 2/08/08. A CBC/Chem revealed mildly decreased absolute lymphs and an elevation of SGPT/ALT 198 (5-107) on 02/08/08 and a chloride of 130 (105-115) due to bromide therapy. The bromide level was still 0.9 mg/ml. Diet has been Iams dry kibble. The dog has a normal appetite, no vomiting. Stool, thirst, and urination normal per guardian. Vaccinations current guardian reports. Dog has been very healthy.
Physical Examination: The dog was presented BAR with good hydration status. The oral mucous membranes were moist and pink with a capillary refill 2 seconds. The overall conformation was good with a healthy coat, but approximately 10% overweight. Eyes were clear and briht, teeth good, minimal tartar, chipped lower left canine, no gingivitis. Heart and lungs ausculted normal. Ears clean and abdomen palpated normal. No enlarged lymph nodes. No masses noted. Gait normal, no neurologic signs at this time.
Client Consultation: Based upon history and previous blood work, a diagnosis of idiopathic epilepsy was made. A referral to a neurologist for examination and possible MRI was offered but declined. The client was interested in alternative and natural care options. The pet guardian’s goal was to decrease or eliminate conventional drug therapy. The client wanted to try acupuncture treatment.
Traditional Chinese Medicine (TCM) Examination: The patient has an outward appearance as previously described. In addition, he was quite calm for his breed-type, but very friendly. He was a little obsessive with face licking. (He was on KBr at the time). This can cause some mild sedation. The guardian expressed no knowledge of any consistent seizure pattern. The pet was still described as high energy and a “cool-seeker”. The dog does not exhibit signs of dreaming. The patient is disoriented after a seizure. The tongue was pale, slight lavender, moist, with a white coat and a few cracks. Average thickness. The pulse was thin, not rapid, similar on both sides, strongest at the LIV/GB and SP/ST positions.
TCM Diagnosis: Typically Border Collies are a “Fire” constitution. This patient is mid-life and perhaps subdued mentally due to the sedative effects of the drug therapy. This
treatment may have caused mixed signals in TCM diagnostic parameters. The dog’s constitution would make heart element problems more likely. The first convulsion was acute and unexpected. Initially this was an excess. A current heat sign was the guardian statement that the patient is a “cool-seeker”. In the exam room he was comfortable on the rug or a blanket. He did not gravitate to the cold floor. He did not pant, his tongue was not red. His pulse was not rapid. The moistness, white coat on the tongue and post-ictal disorientation are consistent with non-substantial phlegm. The heart houses the mind (shen). The TCM diagnosis could be a severe shen disturbance: Phlegm Misting Mind generating an internal wind. Illness of the child (Fire) can be transferred to the mother (Liver). Heat generates Liver-Wind. Convulsions are a sign of internal wind. Wind Phlegm is a TCM liver element diagnosis.
Current tongue (pale) and pulse (thin) were beginning to show signs of deficiency, and tongue (lavender) some developing stagnation. However, the primary diagnosis which addresses the client complaint of intermittent seizures, in an otherwise healthy mid-life dog, seems to be one of excess due to Wind Phlegm.
TCM Treatment: The commercial kibble diet being fed consists primarily of “hot” foods: corn and chicken. A commercial raw diet of beef was recommended as a more intermediate not “hot” food, but also not as cooling as fish or duck since the current tongue and pulse signs did not indicate heat. (Except for the cracks). The hot foods were not appropriate for the underlying “Fire” constitution.
The Chinese herbal formula Ding Xin Wan was chosen and prescribed in the amount of one teaspoon twice daily. Indications for this formula which are consistent with this patient are temporary disorientation, sudden seizure, internal wind due to wind-phlegm, tongue purple with white, greasy coating. Treatment principles include expel phlegm, extinguish wind, open orifices, stabilize seizures. Individual herbs in the formula can transform phlegm, clear heat, extinguish wind, nourish yin (cooling effect), calm shen, tranquilize liver, move Qi, stop seizure and harmonize.
Since electroacupuncture is contraindicated for epileptic patients, a combination of only dry needles (DA) and aquapuncture (AqP) were used. A minimum of four initial weekly treatments were recommended. The duration of the treatment was ten to twenty minutes. Approximately 0.5 cc B12 (1000ug/mL) solution was used at each aquapuncture point.
The following points were selected:
GV20: Calming point, shen disturbance, epilepsy (local point)
Da-feng-men (GV21): Classical point for internal wind, calming mind, seizures (local
GV14: Epilepsy, heat
Bai hui: Classical point, open the channel (distal point, balance)
BL18: Back-shu associate point for liver, epilepsy, Ah-shi
An-Shen: Classical point, pacify the Mind, Calm Internal Wind (local point)
Er-jian: Classical point, clear heat
ST-40: Influential point for Phlegm (distal point)
LIV-3: Yuan primary (source) point for liver (distal point)
Other points considered but not yet used. Difficult to needle legs, underside of chest, belly:
CV-17: Influential point for qi. Front alarm point for PC
GB-20: Wind, epilepsy
HT-7: Yuan (source) point for heart, son point for excess shen disturbance, epilepsy
PC-5: Epilepsy (distal point)
GV-26: Start heart, stop seizure
First treatment and response: DA was done at GV20/14, Bai hui, BL18 (bilat), LIV3
(bilat), Er-jian (bilat) with Korean hand needles. AqP was done at An-Shen (bilat) and in
Da-feng-men and after dry needle removal in GV20, Bai hui. Guardian was pleased that no seizures occurred between visits and that the patient seems to enjoy coming. (He licks my face after almost every needle placement).
Second treatment and response: Repeated above protocol. Add ST40 (bilat). Was only
able to do LIV3 on left. No seizures yet. Guardian ran out of KBr and elected not to refill
by his own decision. He is very pleased with diet and herbs. Patient likes the food!
Third treatment and response: Repeated same protocol since guardian pleased and no seizures yet. Only able to do ST40 on the left.
Fourth treatment and response: Repeated DA protocol. AqP only at An-shen. ST40 only on the left due to how patient chooses to lie down. No seizures. This was the patient’s longest seizure-free interval in a year.
The patient’s tongue appeared pale, pink, cracks, some moisture after four treatments. And his pulses were not rapid, deep, more firm, and strongest at middle positions on both sides. The dog’s ALT/SGPT had almost returned to normal 105 (10-100)U/L. His KBr level at the time was .59mg/mL.
In addition to acupuncture and Ding Xian Wan, two supplements were dispensed at the first visit. Standard Process Neuroplex (one tablet SID) is a glandular/protomorphogen/whole food vitamin intended to support nervous tissues. Cholodin (two tablets SID) is a commonly recommended B-vitamin, amino acid, choline supplement intended to enhance proper nerve conduction.
The client was very compliant with all recommendations.
Case Summary: This case represents a common epilepsy scenario in which the patient does not respond fully to conventional treatment and/or guardian becomes concerned with efficacy, toxicity, or sedative side effects of prescribed anticonvulsants.
This patient was a good candidate for TCVM because he had a compliant guardian and he had a personality amenable to acupuncture. There was also much room for improvement in his diet history. Changing from “hot” corn and chicken processed kibble to a fresh, cooler protein source surely has contributed to the positive outcome of this case.
This pet’s Fire constitution was not only cooled by food therapy but also the balanced combination of Chinese herbs in Ding Xian Wan. This formula has a reputation for preventing seizures in dogs by expelling wind, clearing heat, transforming phlegm and calming shen.
The rapidity of this patient’s response to TCVM treatment demonstrates how much more powerful and longer-lasting can be the effects of acupuncture when combined with the appropriate Chinese herbal formulation and food therapy.
There are many transpositional and classical points which are local or distant or special to the epileptic condition. This case demonstrates that choosing a comfortable, working group of points to which the pet is receptive and repeating the protocol can be very effective and pleasant to perform for the patient and the acupuncturist.
This case was also a good example of taking care to focus on TCM parameters which help the practitioner diagnose and treat the client (and patient’s) main concern, without being misled by perhaps, on the surface, conflicting diagnostic information. The drug use affecting demeanor and tongue and pulse could create some confusion.
The acute, intermittent seizures were diagnosed and treated as an excess condition, although the duration of the overall disorder and several tongue and pulse parameters may lead a practitioner to attempt to diagnose and treat a deficiency and even some stagnation. A future, maintenance plan can now address underlying deficiency which continues to be apparent at the tongue and pulse re-check after the 4th treatment.
Acupuncture point locations:
GV20: Midline center of ear canals
Da-feng-men (GV21): Midline cranial rim of ear bases
GV14: Midline between C7-T1
Bai hui: Midline L7-S1, big hole
BL18: 1.5 cun lateral to caudal border of the spinous process of the 10th thoracic vertebrae
An shen: Half-way between GB20 and TH17 (big holes back of head/neck), bilateral
Er-jian: Ear tip
ST40: One-half the distance between the lateral malleolus and the fibial plateau 2 cm lateral to the anterior tibial midline in the groove between the cranial tibial and long digital extensor muscles
LIV3: Between the 2nd and 3rd metatarsals, proximal to the metatarsophalangeal joint
GV1: Midline between anus and tail base
CV17: Ventral midline, 4th intercostal space
GB20: Rostral and medial to cranial edge of wings of atlas, below the occipital bones, medial to jugular process
HT7: Tranverse crease of carpal joint in large depression lateral to tendon of flexor carpi ulnaris muscle
PC5: Medial thoracic limb, 4 cun proximal to carpal crease between flexor carpi radials and superficial digital flexor muscles
GV26: In ventral limit of philtrum between nostrils