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.

Spleen and Stomach Yang Deficiency
(Chronic Hepatitis)

(Thanks Greg for this instructive case!)

Bai, male, 39. January 24, 1964, initial consultation, in-patient department. Patient had suffered from chronic hepatitis for six years with intermittent bilateral flank pain, abdominal distention and bloating, anorexia, frequent belching, borborygmus, flatulence, and loose stools one to two times per day or once every-other day. Previously, he had been admitted to the hospital five successive times and undergone hepato-protective therapies, testosterone propionate therapy, etc., all with only temporary effects. When his job was stressful the condition would flare. Formulas such as Chai Hu Shu Gan San (Bupleurum Liver-Coursing Powder) had been applied in the past without obvious benefit. Upon examination, all six pulses were deficient, slow, and weak, and the tongue was swollen and large with a greasy, floating coat. Origin of the disease occurred in his early years when famine and forced labor led to dysfunction of Spleen and Stomach ascension, descension, and transportation. His presentation closely resembled a syndrome from Essential Prescriptions of the Golden Coffer (Jin Gui Yao Lue) “nausea and borborygmus, epigastric distention, Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction) commands.” The prescription followed:

法半夏 fa ban xia (Pinelliae Ternatae, Rhizoma Praeparata) 9g
萸炒连 huang lian fried with wu zhu yu (Coptidis Chinensis, Rhizoma fried with Evodiae Rutecarpae, Fructus) 3g
黄芩 huang qin (Scutellariae Baicalensis, Radix) 9g
干姜片 gan jiang (Zingiberis, Rhizoma) 6g
炙甘草 zhi gan cao (Glycyrrhizae Melle Tosta, Radix) 6g
潞党参 dang shen (Codonopsitis Pilosulae, Radix) 9g
大枣 da zao (Zizyphi Jujubae, Fructus ) 4 pieces

2^nd consultation: February 29, 1964. One package of the previous prescription was taken each day, and one month later the poor appetite, borborygmus, flatulence, and other symptoms had decreased significantly. However, there was still abdominal distention and flank pain, and the tongue and pulse were same as before. It was suitable to use Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) from On Cold Damage (Shang Han Lun):

厚朴 hou po (Magnoliae Officinalis, Cortex) 9g
生姜 sheng jiang (Zingiberis Rhizoma Recens) 6g
半夏 ban xia (Pinelliae Ternatae, Rhizoma Praeparata) 6g
党参 dang shen (Codonopsitis Pilosulae, Radix) 9g
炙甘草 zhi gan cao (Glycyrrhizae Melle Tosta, Radix) 6g

3^rd consultation: 20 bags of the above prescription were taken, the abdominal distention was essentially resolved, and aside from some lurking flank pain, all other symptoms were gone. The pulse had more strength than before, energy was abundant, and the patient was discharged from the hospital and returned to his job in Sichuan province. He was advised to continue taking Ban Xia Xie Xin Tang and Bu Zhong Yi Qi Wan for a short period of time to assist with his recuperation.

Commentary: The treatment in this case of chronic hepatitis differed from most common methods. The patient had been ill for six years, with symptoms of abdominal distention, anorexia, borborygmus, diarrhea, deficient, slow, and weak pulses, enlarged tongue, etc. Even though flank pain was present, use of  “soothing the Liver and rectifying the qi” method, as in Chai Hu Shu Gan San (Bupleurum Liver-Coursing Powder), was ineffective. This shows that it was not a case of Liver and Stomach disharmony, but rather of Spleen and Stomach Yang Deficiency. Initially, Ban Xia Xie Xin Tang, “pungent opening, bitter downbearing”, was used, and after one month the anorexia, belching, borborygmus, and other symptoms were greatly reduced. However, the abdominal distention remained, and the six pulses were as before, showing that the Spleen yang was severely debilitated. Shang Han Lun states, “After sweating, abdominal distention and bloating, Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang commands.” “After sweating” refers to an etiology whereby sweating results in damage to the Spleen yang. Even though this case was not the result of [improper] sweating, because the condition had existed for six years there was significant debilitation of Spleen yang, with stubborn abdominal distention, and deficient, slow, and weak pulses. Although the etiology is different, the syndrome is similar. Therefore, after switching to Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) for 20-plus bags, significant results were obtained.

Source: From Yue Mei-Zhong’s Case Record Collection (Yue Mei Zhong Yi An Ji) 《岳美中医案集》, People’s Medical Publishing House, 1978.

Commentary by Dr. Huang Huang:

This case began with the use of Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction), bitter and pungent to free and descend and eliminate glomus, followed by Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) to warm the Stomach yang and eliminate fullness. The treatment followed an orderly progression, and its effectiveness is quite believable. Ban Xia Xie Xin Tang traditionally treats nausea, diarrhea, and glomus, with most patients presenting with epigastric glomus oppression and distending pain that feels worse with palpation, as well as nausea and vomiting, borborygmus and diarrhea, anorexia, vexation heat, insomnia, and often a yellow and greasy tongue coating. Hou po traditionally eliminates distention and fullness, and Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang is composed of Ban Xia Xie Xin Tang with the omission of huang lian, huang qin, and da zao, and the addition of hou po. Both formulas contain ginseng, pinellia, ginger, and licorice, and in this case while dispersion of glomus and elimination of fullness followed a specific order, warming the middle and harmonizing the stomach was present from beginning to end. (From Yi An Zhu Du 《医案助读》 2001: 314)

Translated by: Greg Livingston

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.

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]