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.

The case of Tang: Right, posterior rib pain radiating to the low back and hip producing aversion to cold and icy-cold extremities. [The patient was so cold that] it took a long time to get the patient warm. This was a lack of movement of qi and blood within the vessels and networks, culminating in congealed cold producing pain that was an obstruction pattern of the vessels and networks and is understood in the context of a yang wei and yin wei disease.

Cervi Cornu degelatinatum (lu jiao shuang)
Foeniculi Fructus (xiao hui xiang)
Angelica sinensis Radix (dang gui)
Sechuan Cinnamomi Ramulus (gui zhi)
Astragali complanati Semen (sha yuan zi)
Poria (fu ling).[i]

Translated by: Charles Chace

Original Chinese: 唐（嶇）右後脅痛連腰胯。 發必惡寒逆冷。 暖護良久乃溫。 此脈絡中氣血不行。 遂至凝塞為痛。 乃脈絡之痹症。 從陽維陰維論病鹿角霜， 小茵香， 當歸， 川桂枝， 沙苑， 茯苓

Commentary: This case involves a yang wei disorder presenting as rib side pain radiating to the low back and hip, the supple, warm, essence-nourishing Cervi Cornu degelatinatum (lu jiao shuang) is added to the primary treatment method of opening the yang to harmonize the networks. In general, the drugs in this prescription enter the liver and kidney channels while Cinnamomi Ramulus (gui zhi) opens the yang qi in the foot greater yang.

For further reading, please view the intro to this case, Herbs & the Eight Extraordinary Vessels and Ye Tian-Shi & the Eight Extraordinary Channels.

[i] This case record appears in another anthology containing case records attributed to Ye Tian-Shi (葉天士), 2004i, Combined Case Records of Three Physicians (San jia yi an’ he ke 三家醫案合刻), juan 1, Minor Construct the Middle Decoction (xiao jian zhong tang 小建中湯), juan 7, “Obstruction” (bi 痹).

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.

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]