The object was removed from the chamber pot with fire tongs, washed off with water, and then carefully examined. It was a “duck butt.” The patient had attended a banquet about 10 days previously where he ate a piece of under cooked duck meat. Because of the circumstances he was too embarrassed to spit it out and reluctantly swallowed it resulting in the illness described above.

又如一76歲老人陳某，15年前患結腸癌，曾手術切除，自後身體一直健康。近1周來，大便不通，少腹手術一側又捫及一塊狀物，幾個醫院均要患者入院作進一步檢查，并認為手術也無希望。要求中醫服些中藥，也覺無能為力而未給處方。後病人竟排出一粒硬屎，頓覺少腹輕鬆。用火鉗從便桶中鉗出硬物，用水沖洗之後仔細辨認，原來是一個“”，是十幾天前赴宴，揀得一塊鴨肉，覺得未燒酥，礙於親朋面前不便吐掉而囫圇吞下，於是發生前述的病證。

Qì and Blood Depletion – Liver and Kidney insufficiency mistaken for wind-cold-damp painful obstruction.

Misuse of the Fire Spirit Current.

[Patient] Xu was a 59 year old woman who is chronically exposed to water- damp while working. After many years she developed joint-bone limp aching pain that sometimes was mild and sometimes was serious. After retirement it progressively worsened year after year. She sought out many treatments from the hospital, but with no results. Someone recommended her an empirical formula of chuan cao wu (Aconiti et Aconiti Kusnezoffii Radix Lateralis) 50g, zhi fu zi (Aconiti Radix Lateralis Praeparata) 50g, gui zhi (Cinnamomi Ramulus 30g, qiang huo Notopterygii Rhizoma seu Radix) 30g, chuan xiong (Chuanxiong Rhizoma) 30g, ma huang (Ephedrae Herba) 15g, xi xin  (Asari Herba) 15g, gan song (Nardostachydis Radix seu Rhizoma) 30g, tao ren (Persicae Semen) 15g, hong hua (Carthami Flos) 15g, chi shao (Paeoniae Radix rubra) 15g, ru xiang (Olibanum) 15g, mo yao (Myrrha) 15g, and qian nian jian (Homalomenae Rhizoma) 30g.

One packet of this formula was taken and the pain did not decrease but instead there was incessant great sweating, flusterdness, and palpitations. At nightfall her extremities would alternately stretch out and contract, quiver, shake, tremor, and when serious they would jerk, cramp and produce pain that was difficult to endure. Although she went through emergency western medicine treatment to resolve the spasms and stop the pain, there still was no long-term relief. She therefore sought out Chinese medicine.

Upon examination, she had a bright white facial complexion and the tip of her nose, lips, mouth, and yin tang [area] all were green-blue purplish. [In general] her extremities would spasm and at times her muscles were stiff and rigid.  Massage felt good, although she incessantly moaned. In her retelling of the past, she reported that after taking the medicine, mentioned above, she had shortness of breath, lack of strength, incessant sweating, aversion to wind, fear of cold, whole body stiffness, and increasing pain. Her tongue body was dark and crimson, the fur was thin with little fluid, and the centre of the tongue had fissures. Her pulse was thin, weak, and slightly rapid.

Differential Diagnosis: This was a deficiency painful obstruction with a misuse of a big formula that effused, dissipated, and attacked the painful obstruction [disease] which further damaged the qi, blood, and fluids,  loss of nourishment of her sinews (and vessels), which lead to convulsions.

 The treatment method was to augment qi and nourish blood, tonify and augment the Liver and Kidneys in order to treat the root, as well as to dispel wind, eliminate dampness, and stop painful obstruction pain, simultaneously treating the tip. The formula given was a modified ba zhen juan bi tang jia jian (Eight Treasure Remove Painful Obstruction Decoction). After 2 packets the convulsions were reduced, pain was clearly relieved, and afterwards the method of supporting the right and dispelling pathogen was applied to bring about recuperative care and healing.

Commentary: This is a pattern of deficiency painful obstruction. The patient was close to 60 years old, and had chronic painful obstruction disease. Qì, blood, yīn and yàng all were deficient and  normal [qì] deficiency was at the root. A lodged pathogen was the tip. The treatment method should support the normal as well as eliminate the pathogen. However, the first doctor thought the disease was an excess painful obstruction [disease], and stubbornly dispelled wind and eliminated dampness. Furthermore he used a large formula with chuan cao wu (Aconiti et Aconiti Kusnezoffii Radix Lateralis), zhi fu zi (Aconiti Radix Lateralis Praeparata), ma huang (Ephedrae Herba), xì xīn (Asari Herba), gui zhi (Cinnamomi Ramulus, and qiang huo (Notopterygii Rhizoma seu Radix) to effuse, dissipate, and attack the painful obstruction which consumed and damaged the qi, blood and fluids. This resulted in the channels [and vessels] losing nourishment and leading to convulsion. From the second examination the patient was seen to have flusteredness and palpations at night fall, her extremities alternately expanded and contracted, quivered and had tremors, bright white facial complexion, shortness of breath, lack of strength, dark crimson and red tongue with fissures and fur that was shiny with little fluids, and a weak slightly rapid pulse. This was a pattern of qi and blood deficiency and Liver and Kidney insufficiency.

Source:  [缪以星•临证随笔2 则•湖南中医学院学报，1986,(1):33]

Translated by: Jason Blalack

Commentary: I found this case interesting because it demonstrated how quickly and severely an incorrect formula can cause problems. The original formula was a fire spirit current approach. At first sight, it looks incredibly odd and somewhat incomprehensible as to why one would would give such high dosages of such medicinals. However, this type of formula (and dosages) is not uncommon in the fire spirit current. Such dramatic formulas, can have incredibly fast results, however they can also be extremely damaging. Obviously, correct diagnosis is important.

Intro: This is a somewhat informal presentation of a recent case that I found quite educational for myself. It is definitely not the cleanest case (easy success) but that is why I like it. I am still working out the best way to present these cases and if anyone has any suggestions please let me know. I also welcome others to submit their cases for us to learn from. I hope you enjoy it and welcome any feedback or criticisms.

Case: 55 year old male presented with testicular and perineal pain, sensation of “peeing glass”, strong sensation heat in the lower burner, unable to sit due to the pain, and frequent urination in both night and day. This had persisted for many months and had been labeled “chronic prostatitis.” He also presented with a painful left big toe, dry mouth, and very strong emotions (anger, anxiety, fear etc.). The pulse was cloudy (模糊,mó hú mài) and wiry, and his tongue was dark red/purple with a thick coat. The diagnosis was damp-heat stasis in the lower with the treatment principle of transform damp, clear heat, promote urination, and promote the movement of blood.

Long dan cao     6
Che qian zi           9
Huang qin            9        
Zhi zi                      9
Sheng di                9         
Ze xie                     9
Dang gui               6        
Mu tong                6
Chai hu                 6         
Gan cao                6
Huang bai            6
Ku ding cha         2

Instructions: 1 bag=2 days. Cook time =45 minutes. Take 2-3 times a day.

Visit #2: Heat was 40-50% better. Pain had improved. Started a course of Cipro for 1 month. Tongue was red.

Visit #3: In the previous three days the pain was severe. Dx: damp heat + toxin pouring into the lower burner.

Visit #4: Feels very hot, insomnia, urine is yellow, very angry, dry mouth, thirst, and feels energy shooting up. Uncomfortable sensation over his liver. Red tongue, wiry pulse. Diagnosis: Liver Fire.

Visit 5-6: more of the same.

Commentary: Throughout all of these visits a modified Gentian Decoction to Drain the Liver (lóng dân xiè gän täng) was used with various additions to emphasize more blood invigorating (e.g. Vaccariae Semen (wáng bù liú xíng), Manitis Squama (chuän shän jiâ)), pain relieving (e.g. Corydalis Rhizoma (yán hú suô)), toxin clearing (e.g. Patriniae Herba (bài jiàng câo),Taraxaci Herba (pú göng yïng)) , cooling the blood (e.g. Paeoniae Radix rubra (chì sháo)), protecting the yin (e.g. Dendrobii Herba (shí hú)), and descending the yang and calming the spirit (e.g. Fossilia Ossis Mastodi (lóng gû), Poriae Sclerotium pararadicis (fú shén)). But the overall presentation had hardly budged. Pain and heat was certainly still an issue as well as the severe emotions (anger, fear, sadness etc.). Other modalities were also used at this time by other practitioners.

Visit 7: Due to unclear results, I decided to switch to a more modern prostatitis formula:

Huang qi                     10
Yan hu suo                  6
Di long                        4.5      
Zhi gan cao                 6
Hu zhang                     9         
Bai hua she she cao     9
Huang bai                    9         
Sheng di huang           12
He huan pi                   9         
Wang bu liu xing         9
Nu zhen zi                   12       
Ze xie                          6

Visit 8-9: “prostate” seems better. He has noticed that stress makes it worse. Anxiety is less. Pain is 5/10 (was 8/10). Feels like the muscles are very tight/pulled muscle around the perineum. Added 20 grams of Paeoniae Radix alba (bái sháo).

Visit 10: Urethral pain is still severe, pelvic pain is getting better. Lots of emotion. Pulse is very tight and wiry. Fatigue (mentioned that had been going on for awhile).

Chao Chuan lian zi      6
Mai dong                     9
Bai zi ren                     9         
Tao ren                        9
Dang gui                     6         
Huang bai                    9
Yan hu suo                  9         
He huan pi                   9

Commentary: Over the last 10 visits the pain had gone up and down many times. However even though the pain had decreased it was still significantly present. The heat was also very obvious. Due to the unclear results from the above more straightforward approaches. I decided to consider the underlying mechanism for the fire/heat. Taking inspiration from Ye Tian-Shi, I prescribed the above formula (see his constraint case). Notice the more softening approach.

Visit 11: significant improvement, pain and pelvic floor tension was much less. 3 bags of previous. Of Note: Almost all of the previous formulas contained Corydalis Rhizoma (yán hú suô).

Visit 12: + Paeoniae Radix alba (bái sháo) 25.

Visit 13: It was unclear if Paeoniae Radix alba (bái sháo) made any difference) – feeling much better.

Visit 14: Common cold / flu (gan mao), stopped herbs, pain became worse. Thought there might be a lurking pathogen and switch strategies to a yin deficient venting idea. (I was wrong)

Visit 15: Pain became much worse, went back to previous formula (visit 12-13) and pain continued to decrease once again. This confirmed that addressing the underlying mechanism, causing the fire was actually effective. Over the next few weeks the pain completely resolved.

Visit 16: Although no pain remained, there was anxiety, fear, pressure in the chest, and palpitations. This had been going on for many years since the death of his wife. He (and I) thought that this was the underlying cause of all his problems including the fire/prostatitis. This was qi and blood stagnation in the collaterals. The treatment principle was to dredge the liver and open the collaterals. I decided to use a modified Inula Decoction (xuán fù huä tang) from the Essentials from the Golden Cabinet.

Xuan fu hua                9
Hong hua                    6
Tao ren                        9         
Dang gui wei               6
Ze lan                          3         
Lu lu tong                   3
Wang bu liu xing         6         
Mei gui hua                 3

Note: Carthami Flos (hóng huä) sub for New crimson (xïn jiàng).

Emotional symptoms, energy, sensation in the chest all dramatically improved over the next couple weeks.

Location: Boulder, Colorado

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.

[朱光宗竿•临症失误救治2则•中医研究，1991,4(1):34]

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.

Liao was a 62 year old man who was hospitalized because of left buttock and left lower limb pain that had been going on for 3 months. He presented with left buttock and left posterior thigh muscular pain, fatigued spirit and lack of strength, poor food intake, bland / lack of taste in the mouth that was slightly dry, dry stools, facial color was dark and stagnant.

Tongue: pale purple body and a thin yellow coat
Pulse: wiry

He was given a formula to scatter cold, dry damp, boost qi and quicken the blood. After taking 30 bags of herbs, the pain did not decrease. On the contrary there was an increase in distending pain as well as numbness and tingling in both lower legs, occasional hypertonicity of the foot, dry mouth, yellow urine, dry bowel movements. His tongue became pale purple, and he had a thin yellow coat and wiry pulse.

The formula was changed to enriching yīn, nourishing blood, and quickening the blood. After 15 packets both lower leg muscle symptoms of distending pain, numbness and tingling etc. were  gone.

Source: [缪以星•临证随笔2 则•湖南中医学院学报，1986,(1):33]

Translated by: Jason Blalack

Commentary:

Although this case seems a bit obvious in retrospect, it is far from an uncommon occurrence among inexperienced herbalists. This case does not have clear cold signs, yet the doctor stubbornly latched on the words of Elementary Questions (sù wèn, painful obstruction chapter), which says,

when the three qi of wind, cold, and damp combine (attacking at the same time), this becomes painful obstruction disease”

Consequently there was an incorrect diagnosis of cold-damp painful obstruction pattern, and scatter cold and dry damp formula was given . Although the patient was venerable, his  was blood deficient and his fluids were depleted, which prevented him from lubricating his intestines below, and enriching his mouth above. Therefore his stools were dry and his mouth was slightly dry. His limb’s sinews (and vessels) lost moisture, resulting in pain, numbness, and tingling. Because of the fluid and blood body depletion and the ongoing use of spicy, warm, fragrant, and dry medicinals, which further damaged the fluid and consumed the blood, the disease was aggravated. It was like adding fuel to the fire.

By: Steven Clavey

(Thanks Steve for this case and the one’s that follow. Please check out his journal, The Lantern)

Insomnia: Case number 12, by Xu Shu-Wei

A local notable named Chen, when he first became sick, had fever, floating pulse and spontaneous perspiration. The doctor used Ma Huang Tang to cause sweating, but the fever became severe, Chen could not get to sleep, his head was heavy, there were palpitations and he complained of a restless cooped-up feeling. The mistake was insisting on a strong diaphoretic formula when the condition was [not cold invasion but rather] a wind invasion — zhong feng. Zhong-Jing says:

Tai Yang illness: after using diaphoresis the sweat is heavy, there is parched dryness in the Stomach and insomnia. The patient desires to drink water — give him a little at a time: this will cause the Stomach qi to harmonise and he will be cured. [Clause 71]“

I first used Zhu Ling Tang (Polyporus Decoction) followed by herbs like Dang Gui (Angelica Polymorpha, Radix), Shou Di (Rehmanniae Glutinosae Conquitae, Radix), Mai Men Dong (Ophiopogonis Japonici, Tuber), Bai Shao (Paeoniae Lactiflora, Radix) and Wu Mei (Pruni Mume, Fructus) as a soup to sip.

The sweat stopped and he recovered.

Xu’s Discussion:
The Huang Di Zhen Jing (The Yellow Emperor’s Classic of Needling — ie the Ling Shu) says:

Protective wei qi travels the surface yang during the day, but at night it moves to the internal yin. If it cannot move into the yin internally it will wander ceaselessly outside. This external movement makes the yang full, and this fullness makes the Yang Qiao channel surfeited and unable to transfer into yin. Weakened yin means inability to get to sleep [because the quiet settling of yin is reduced] (Ling Shu Chapter 80).”

In this case the jin and ye fluids are exhausted internally [because of the over-sweating of the treatment], the fluids of the Stomach are parched dry [because the sweating drained the Earth flesh]; the malady concentrated in yang, with no refuge for yin — the symptoms are as we have seen.
Thus Dang Gui and Shou Di are used to tonify blood, while [the sourness of Bai Shao and] Wu Mei are used to contract yin. This stopped the sweating and the patient naturally recovered.

Shi a 28 year old male motor vehicle driver was hospitalised on Sept 13. Two days
previous, the patient did some heavy moving from one house to the next in the rain. That
night he had very painful sciatica along his right leg. It gradually became worse and he
went to the local hospital where he received an injection of a heavy painkiller and
diazepam, which took about two hours.(1)

Presentation upon examination: cramping in the right lower leg, that was painful and
difficult to bear. There was numbness and tingling on the posterior lateral thigh that
occasionally felt like a fire burn, there was vexation and agitation, bitter taste in mouth,
constipation, red urination, difficultly sleeping, with tossing and turning in bed that lasted
the whole night. The tip of the tongue was red and the coating was thin yellow and
slightly slimy. The pulse was slippery, rapid, and had strength. There was a positive sign
for the straight leg raise, and huántiào (GB 30) and popliteal fossa were tender with
palpation.

An x-ray of the lumbar vertebrae revealed no unusual findings. Therefore, treatment was
given for sciatic damp-heat painful obstruction blocking the channels and network
vessels. After the patient took 2 bags of herbs, the pain was unchanged. Therefore rǔ
xiāng (Olibani, Resina) and mò yào (Myrrha, Resina) were added and again two bags
were given, but the pain still did not decrease.

After meticulously sorting out the etiology and pathomechanism, it was realised that the
lower limb hypertonicity and pain were actually the disease’s root. This was related to the
fact that after the move there was fatigue, he sweated, became wet whilst working in the
rain, and then caught a cold. This caused cold-damp obstruction in the vessels and
networks. His bitter taste and dryness in the mouth, constipation, red urine, red tip of the
tongue with a yellow coat, slippery and fast pulse was because of the severe pain and
vexation. Because of the vexation there was insomnia and stirring heart fire, and
furthermore this led to a lack of food intake. All of this belonged to the branch, which
was pain.

The first diagnosis did not grasp the disease root’s essence and therefore gave a treatment
that was ineffective. On the surface it looked like it was correct but it was really a mistake. The correct treatment principle was to scatter the cold and free the network
vessels, which assists in order to clear heat. The patient took this type of [medicine] and
immediately his pain was greatly reduced. As the pain diminished, his bitter taste,
vexation, insomnia, constipation, reddish urine, was also gradually eliminated. With
some slight modifications, three more bags of herbs were given and the pain was
essentially eliminated. Afterwards a formula that boosts the kidney and opens the
network vessels was given to continue the healing.(2)

Commentary:

Various kinds of clinical manifestations of disease have differentiations of root and tip.
The root is the essence of the disease; the branch is dependent on the root. If the root is
not understood and one mistakes the incidental for the fundamental this will certainly
bring about misdiagnosis and mistreatment.

In this case the doctor grasped the patient’s main pathological condition of cold-damp
painful obstruction blocking the channels and network vessels leading to lower limb
hypertonicity pain, which was due to the patient catching a cold after being fatigued,
sweating, and being out in the rain. At the same time there were the secondary symptoms
of, bitter taste, vexation, constipation, reddish urine, red tip of tongue and yellow coating,
slippery and rapid pulse that were all caused from the severe pain and vexation. The
vexation caused insomnia and stirring of heart fire which further led to low food intake.
Scattering cold and open the network vessels was the first priority in order to secondarily
clear the heat. This is all that was needed to avoid clinical error. On the contrary, merely
basing treatment on clinical manifestations and not meticulously inquiring into the
pathomechanisms and cause of disease, and by treating the damp-heat painful obstruction,
there was of course, no resolution.

(1) This most likely is interpreted to mean that the whole hospital stay lasted about two
hours.

(2) [侯恒太•临证求真琐谈•江西中医药，1988,(2):54]

[Patient] Lǐ was a 53 year old female that suffered from paroxysmal heat effusion and sweating for over one year.  This would occur 2-3 times every day.  A previous doctor treated her for a yin deficiency fever, but after taking over 20 bags there was no result.  When questioned, her diet, urination and bowel movements were normal.  She had a pale tongue with a white coat, slack and soft pulse that lacked strength.

The differential diagnosis was a pattern of nutritive and defensive disharmony, where defensive is not safeguarding the nutritive.  The treatment method was to harmonize the nutritive and defensive, yin and yang, and use the method of promoting a sweat in order to stop a sweat. She was given two packets of gui zhi tang: gui zhi 9, bai shao 9, sheng jiang 9, zhi gan cao 6, da zao 12p.  The medicinals were sipped warm with water gruel, and then she covered up, obtaining a light sweat. After this the disease was gone.

Source: (《刘渡舟临证验案精选》1996:3)

Commentary: There was heat effusion, sweating with a tongue that was not red, but pale; the coating is not scant, but white, the pulse was not thin but moderate. This is not a pattern of yin deficiency with fever. It is a disharmony between the nutritive and protective.  Nutritive and protective is the body’s yin and yang, it is more suitable for them to work together then for them to work apart. If the nutritive and protective are harmonious then yin and yang are coordinated and protective qi secures and the nutritive qi guards.  If the nutritive and protective are not harmonious then yin and yang mutually will go against each other. Nutritive-yin fails the protective-yang resulting in fever, protective-yang does not secure the nutritive-yin and there is sweat.  Gui zhi tang is used to “first promote a sweat which will then bring about a cure”

(Translated by:  Jason Blalack)

Original Chinese: