[The patient] had blood loss for many years with chronic damage to the yin qi. There was a relapse due to worry, sadness, and melancholy, where yang linked with internal wind which led to a great uprushing to the head (da mao 大冒). The blood residence became empty and qi overwhelmed the left side of the body, producing a deviated mouth, numbness and tingling in the limbs, dark tongue, inability to speak, and foot atrophy with an inability to walk. Obviously the Liver and Kidneys were deficient and famished, the yin qi was unable to govern the bearing upwards. It was important to nurture the lower to extinguish wind. A method [designed by] Liu He-Jian was used.

Make into honey pills and take four qian a day.

Qin Bo-Wei’s Commentary: This is also a wind-stroke pattern from a blood deficiency not nourishing the sinews and bones, with internal wind assaulting the collaterals. However, there was left-sided numbness and tingling in the limbs that had not yet reached the degree of hemilateral withering.

The chief manifestation was wind harassing the upper burner leading to a deviated mouth and dark tongue. There was also lower burner yin exhaustion which resulted in foot atrophy and lack of strength. The origin of the onset of disease was a loss of blood and melancholy. The diagnosis is Liver and Kidney yin deficiency unable to govern the bearing upwards, which warranted an emphasis on nurturing the lower burner in order to extinguish wind.

The pattern belonged to silent collapse^（1） wind-stroke disability⁽²⁾. He adapted Liu He-Jian’s Di Huang Yin Zi (Rehmannia Drink). Since there were no yang deficiency signs he did not use Zhi Fu Zi (Aconiti Radix Lateralis Preparata), Rou Gui (Cinnamomi Cortex) or Ba Ji Tian (Morindae Officinalis Radix). In addition because there was yin deficiency stirring wind heat, he removed the fragrant penetrating Shi Chang Pu (Acori Tatarinowii Rhizoma) and added Gou Qi Zi (Lycii Fructus) and Ju Hua (Chrysanthemi Flos) in order to nourish the blood and extinguish wind. He used Niu Xi (Achyranthis Bidentatae Radix) in order to descend, treating the foot atrophy.

Notes:

(1) Yin jue (喑厥) . This is an inability to talk due to a stiff tongue with reversal cold in the limbs.
(2) Feng fei (风痱) . This refers to atrophy of the limbs with an inability to move, or a paralysis after wind-stroke.

Translated by: Jason Blalack

Original Chinese:

案二:失血有年，阴 气久伤。复遭忧悲悒郁。阳挟内风大冒。血舍自空。气乘于左。口肢麻。舌喑 无声。足痿不耐行走。明明肝肾虚馁。阴气不主上承。重培其下。冀得风熄。议以河间法。熟地四两，牛膝-两半，莫肉二两，炒黑远志一两半，柜子二两，炒菊花二两，五味子-两半，川斜二两四钱，获神二两，淡灰蓉-两二钱，加蜜丸，服四钱。(中风门)

按:此亦血虚不荣筋骨，内风袭络的中风证，但偏左肢麻，末至偏枯程度。其主证为风扰于上而口喝舌暗，阴亏于下而足痞无力。故从发病的根源失血和僵郁等，诊断为 肝肾阴虚不主上承，主张重培其下以冀风熄。证属啃撅风痒，采取了刘河间的地黄饮子，因没有阳虚现象，除附子、肉桂、巴哉，并因阴虚风动，去莒蒲的香窜，加柏菊以养血熄风，牛膝下行以治足屡。

Source: Case from the Wind Stroke chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》. Commentary from Complete Famous Medical Works of Qin Bo-Wei.

At the onset of the illness there was numbness and tingling, the tongue was stiff, the sinews were hoisted (tight?) and back of the head was painful. There was also phlegm obstruction in the throat. This is Liver wind ascending and guiding. This certainly is caused from constraint and clumping of the  emotions.

Saigae tataricae Cornu (líng yáng jiâo)
Forsythiae Semen (lián qiáo xïn)
Fresh Rehmanniae Radix (xiān shëng dì huáng)
Scrophulariae Radix (xuán shën)
Acori tatarinowii Rhizoma (shí chäng pû)
Curcumae Radix juice (yù jïn zhī)

Original Chinese: 某 初起左边麻木。舌强。筋吊脑后痛。痰阻咽喉。此系肝风上引。必由情怀郁勃所致。羚羊角 连翘心 鲜生地 元参 石菖蒲 郁金汁

Source: From the Constraint Chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》.

Translated by:Jason Blalack

Translation Discussion:

1) 郁勃 (yu bo) – 勃 (bo) - by itself  means vigorous, flourishing, thriving, or abrupt or sudden. I originally thought this sudden/abrupt meaning was important due to the nature of the case. However, I am not sure it is likely that there was a sudden constraint of emotions that caused this problem. It should be noted that historically (non-medical) it (勃) has been used as a compound (郁勃) with various meanings, one of them being, “constraint, clumping, and congestion (郁结壅塞).” Interestingly,  in this usage (this constraint and clumping of the emotions) is compared to a wild animal trapped in a house grabbing, scratching, colliding into the walls, unable to find its way out. Other thoughts?

2) I think that this “guiding (引)”, has the meaning of taking phlegm, fire etc. upward with the ascending Liver wind. Do others have a different opinion?

3) 筋吊 – This 吊 (diao) means to hang, hoisten, lift up, or even to drop, fall, fall down or descend. Therefore here, the sinews may be considered slackened, however due to the pain, the stiff tongue, and nature of many strokes I went with a idea of tenseness. What do others think?

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.