Modern case studies 150 Summary 166
Qin Bo-Wei, the great TCM doctor of the twenti-eth century, stresses the importance of analysing cases studies, which is the last step of studying TCM. It should become the life-long habit of every TCM doctor. By doing so, every newcomer can retrace the thoughts of ‘master doctors’, everyone at an advanced stage can learn from his col-leagues and every ‘master doctor’ can see that there is more than one way of treating patients successfully.
The examples contained herein – like those cases presented in the first section of this book – come from classical and modern works, so a wide variety of case histories is ensured.
CLASSICAL CASE STUDIES
These stem predominantly from the Ming and Qing dynasties, where it first became the custom to draw up case records and to pass them on to other people for study. I have attached a short analysis to every case.
The first three cases were handed down by Ye Tian-Shi (1667–1746), one of the fathers of the febrile disease theory (Wen Bing). The work ‘Ling Zheng Zhi Nan Yi An’ is not from him, but from the records of his students.
Ye was convinced that in long-term disease or enduring pain conditions the Luo vessels had to be treated as well, as it is stated in the ‘Nei Jing’: ‘Long-term disease enters the Luo vessels.’ His conclusion was that repeated damage to the Luo vessels leads
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to Qi stagnation and Blood stasis, so he developed a ‘Luo freeing method’ (Tong Luo Fa).
For mild cases, this method employs laxatives with a pungent flavour, like Zhang Zhong-Jing’s Xuan Fu Hua Tang (Inula Decoction), combined with Blood invigorating medicinals. For severe cases insects (Chong) are used as medicinals to break Blood stasis, as in Zhang’s Da Huang Zhe Chong Wan (Rheum Eupolyphaga Pill), along with Lumbricus, Buthus and so on.
Ye coined this phrase: ‘Blood stasis disorders also affect the Qi and in Qi disorders Phlegm is certain to accumulate.’ This is clearly reflected in his treatment style.
Case 4 stems from Xu Da-Chun (1693–1772), the
‘Leonardo’ of Qing dynasty China, who was a bril-liant physician, scientist and artist. Many case studies are to be found in the extensive works he left behind.
Case 5 was written by the famous physician Wu Ju-Tong (1758–1836), alongside Ye Tian-Shi another protagonist of the febrile disease theory (Wen Bing), who elegantly brought together the works of his predecessors and combined them with his own experiences.
Case 6 stems from Ding Gan-Ren (1866–1926), who assisted in creating modern TCM with his research and teaching in Shanghai. Here, he dis-cusses the same syndrome as Ye Tian-Shi. While Ye describes the syndrome in the first case from the point of view of the febrile disease school (Wen Bing) and uses the so-called Shi-Fang (modern prescrip-tions), Ding presents the point of view of the Jing-Fang school (Shang Han/Jing Kui prescriptions).
Case 7 stems from Zhang Zhong-Hua from the middle of the Qing dynasty (approximately 1790).
He devised plain and logical treatment principles but was also willing to strike new paths. He was
also very concerned with gynaecology, as seen in this case of infertility.
Case 8 stems from the records of Zhang Xi-Chun (1860–1933), who stood at the borderline of classic (imperial) and modern TCM. He tried to integrate Western medical knowledge with TCM.
Case 9 stems from Zhao Wen-Kui (1870–1933), who still treated the imperial family at their court at the end of the Qing dynasty, and remained active as a doctor in the first days of the Republic.
He was a specialist in pulse diagnosis, about which he published a book called the ‘Wen Kui Mai Xue’ (Wen-Kui’s Pulse Diagnosis). Unfortunately, nothing is mentioned about the pulse in this case study. It is interesting to compare this case to case 5, as Zhao also supported the Wen Bing school, and represents here the opinion of his time faced with the same syndrome.
Case 10 was penned by Cao Ren-Bai (1767–1834) of the Qing dynasty, whose case records – like those of Zhang Zhong-Hua – were collected by Qin Bo-Wei (1901–1970), the ‘great TCM doctor of modern times’, and thus remained preserved for our time. He set high standards for himself and others, as shown by his remark:
‘When a physician devotes all his abilities to treat-ment, there is no disease under the sun he could not cure. If a disease is not cured, in my opinion this is due to the physician not having devoted all his abilities to the treatment.’
Compared with modern case studies, the ancient case records may often appear very short, reduced to the essentials; it was assumed that the reader already had good medical knowledge. For example, indications of the dosage or the pulse rate were often left out. Nevertheless, these cases still provide a fund of information with regard to the genuine, classic thinking of the ancients.
Patient Wu, Heat disease for 70 days, right pulse long, left pulse deep, tongue appears shrunken.
Patient asks for cold drinks, there is restlessness and irritability. The Mind is sometimes clouded, sometimes clear.
The disease started on the third day of the menses. When the Heat-Qi sank downwards, Blood had just become deficient in the interior.
This should be dealt with as Blood stasis with internal Heat, but as the disease has already Case Study 9.1 Blood accumulation: Heat invading the room of Blood (Re Ru Xue Shi) (from Ye Tian-Zhi’s ‘Ling Zheng Zhi Nan Yi An’)
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progressed to a dangerous point, it must be treated (as described in the ‘Jin Kui ’) as a case of Blood accumulation, with mental symptoms (as if one had gone mad). Literally: ‘. . . the patient behaves as if mad, as the Heat has accumulated in the Lower Burner’ (i.e. there is no water
accumulation in the abdomen, but rather Blood stasis).
Prescription: Sheng Di (Rehmannia), Mu Dan Pi (Moutan), processed Da Huang (Rheum), Tao Ren (Persica), Ze Lan (Lycopus) and Ren Zhong Bai (Hominis Urinae Sedimentum).
Patient Qin has been suffering from stomach pain for a long time. The illness got worse due to heavy work and overexertion, and eventually led to Blood stasis in the collaterals. Furthermore, rebellious Qi and nausea suggest obstruction of the local vessels and collaterals. Exterior- and interior-attacking
medicinals were prescribed before, but this brought about no change for the patient. In this case, a quick-acting treatment is not suitable, because the patient is already emaciated and thin, therefore a gradual dispersal of Blood stasis should be employed.
Case Study 9.2 Stomach pain: long-term disease invades the Blood (Jiu Re Ru Xue) (from Ye Tian-Zhi’s ‘Ling Zheng Zhi Nan Yi An’)
Case Study continues Author’s commentary
As is the case in many classics, Ye Tian-Shi gives no dosages as this knowledge is assumed in the medically educated reader. His diagnosis is succinct:
with respect to the pathology he knows that during menstruation a febrile disease is more likely directly to attack the division of the Blood, which is empty due to the menses. The long pulse on the right confirms this: a long pulse indicates toxic Heat in the Blood or in the Yang Ming. A shrunken tongue suggests Yin deficiency, as the tongue obtains its full size from Body Fluids (Yin). A thirst for cold drinks and nervous irritability are also signs for Heat and deficiency of Body Fluids. Clouding of
consciousness suggests that the Pericardium is affected by Heat in the Blood.
Surprisingly, the formula contains only substances with Blood invigorating actions: Sheng Di Huang and Mu Dan Pi also cool the Blood, Ze Lan drains urine, Da Huang promotes stool (not added at the end here, therefore the effect is focused on moving Blood). Tao Ren also promotes stool, but moisturizes it as well. Finally, the formula contains Ren Zhong Bai, also known as Niao Bai Ning, urine sediment
(Hominis Urinae Sedimentum), which collects on the walls of latrines, and is then dried and heated. Li Shi-Zhen describes it in the ‘Ben Cao Gang Mu’: ‘. . . its effect is based on diuresis, it clears stasis in the Liver and Kidneys, Triple Burner, Lung, abdomen and lower abdomen. It is able to excrete pathogenic fluids and dispels Blood stasis.’
The reader may be surprised to hear that although today this ‘revolting excremental drug’ no longer belongs to the list of common medicinals, the urine of the working class masses is collected in each of the major cities of China in order to reclaim hormones which are excreted in trace amounts along with the urine. Hormones are active even in the smallest amounts; one should be careful not to deny this somewhat strange drug its effect. Today it is understood that the normally sterile urine contains urokinase and hormones such as 17-ketosteroids, oestrogen, 17-oxycorticosterone and gonadotrophins, as well as vitamins (B1, B2, B6and C) and essential minerals.
Case study 9.6 relates to the same syndrome, but is resolved in another way.
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Here the Yang-Qi is blocked by pathogens and cannot disperse in the orifices. In the classic text
‘Zhou Li’,2toxic3medicinals were used to cure
diseases. This text mentions that Chong-drugs are used for dispelling stasis in the Blood, attacking accumulated pathogens and for removing obstructions. This is a classical method that has been forgotten by physicians. As the pain floods the brain, nausea and a feeling of vomiting arise in the epigastrium; and so – if there is a concomitant Liver syndrome – a deficiency syndrome develops, Case Study 9.3 Headache: persistent Blood stasis in the Luo vessels (Jiu Re Ru Luo) (from Ye Tian-Zhi’s ‘Ling Zheng Zhi Nan Yi An’)
Dr1Ye writes in another paragraph concerning such diseases: ‘This treatment is suitable when the patient presents with a fixed pain in the stomach,
a purple and dark tongue, a choppy pulse and a dark and dull complexion.’
Prescription: Qing Lang Chong (Catharsius Molossus), Tu Bie Chong (Eupolyphaga), Wu Ling Zhi (Trogopterus), Tao Ren (Persica), Gui Zhi (Ramulus Cinnamomi), Chuan Niu Xi (Cyathula), the juice of one stored Xie Bai (Allium root, called Bai Niu Zhi Fa Wan).
1 At the imperial court, there was an equivalent of a doctorate; however, Ye Tian-Shi and most other physicians at that time and today did and do not hold a doctorate.
However, I will keep to the tradition of using the title ‘Dr’
for every Chinese whose occupation is that of physician.
2 Also called ‘Li Jing’, Classic of the Rites from the Zhou dynasty.
3 Toxic in the sense of being derived from poisonous animals like wasps, scorpions, snakes etc.
Author’s commentary
It was Ye Tian-Shi who developed the theory that chronic diseases can disturb the Blood and that treatment should proceed slowly using non-drastic medicinals. In this case, there are two causes for the Blood stasis: long-term disease and exhaustion.
Probably at the same time the Qi of the Liver, which stores Blood, was stagnated, so it attacked the Spleen, which in turn failed to process food as usual: as a result, the patient is emaciated, and the weakened Qi of the Stomach attacks upwards.
Thus, Doctor Ye prescribed onion juice and cinnamon to warm the Yang of the Middle and to treat the pain. These two medicinals remove obstructions from the Luo vessels (collaterals) and expel Cold – one of the three causes of the pain – at the same time.
Qing Lang Chong is cold, salty and goes into the Liver. Its action is to break stasis, dissolve hardness, calm and purge. New reports suggest it has anticarcinogenic effects. Tu Bie Chong also belongs
to the medicinals that break up stasis and dissolve hardness. Wu Ling Zhi stops pain and works on the Liver, but also on the Spleen, like the two previous medicinals. It is also used for a sensation of distension and heaviness (Pi) in the stomach. Chuan Niu Xi invigorates the Blood, like Huai Niu Xi;
however, it does not guide the action of the formula downwards but rather concentrates on the middle area. Tao Ren breaks up stasis and also treats abdominal pain and promotes stool. The whole effect of the formula is directed towards breaking up Blood stasis, stopping pain and warming the Middle. From today’s point of view, the formula may appear a little unbalanced, thus for long-term prescription one would have to add harmonizing medicinals such as Da Zao, Fo Shou or – provided the patient has no high blood pressure – Gan Cao, as the Chong-medicinals are not always very well tolerated by the stomach.
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A patient called Xiu-Dong in the town of Wu had a strange disease: he suffered from pain that started in his back and then travelled to his chest and ribs. During the daytime, everything was normal, including his food and drink intake, but in the evening his pain would start and cause him to scream with pain all night long, which also disturbed the entire neighbourhood. After 5 years of ineffective treatments by physicians, the family’s money was all used up and Xiu-Dong was ready to put an end to it all. However, his mother told him: ‘You already have children, a daughter and a son for whom you must care. Instead, let me die, then I will not have to listen to all the mourning.’ Because he wanted to drown himself, the relatives took pity on him and got a doctor (i.e. Dr Xu).
I said: ‘This is a case of Blood stasis blocking the channels and Luo vessels.’ I said to my son Xi:
‘This is an unusual disease. A wide variety of therapies needs to be tried to help this patient. We can learn a lot here.’
As he was treated at home, and nothing was lading, I used acupuncture, moxibustion, applied heat and all sorts of medicinal preparations.
Gradually, the pain was alleviated and was lasting for shorter periods of time. Eventually, after a month, he recovered and couldn’t stop thanking me. But I replied: ‘It’s me who should thank you.
Usually when I’m treating seriously ill patients I have to use all my knowledge to achieve success.
These days, however, patients want to see immediate results after just one prescription. If they still haven’t recovered after three
prescriptions, they just go to another physician.
But you believed in me all the way through, and eventually I learnt to understand your disease.
How could I not be indebted to you?’
Case Study 9.4 Pain: generalized Blood stasis in the channels and Luo vessels (from Xu Da-Chun)
with a long-term disease present. While the pathogen is attacked (which depletes Qi and Blood), the healthy (Blood) needs to be nourished at the same time.
Prescription: Chuan Xiong (Ligusticum), Dang Gui (Radix Angelicae), Ban Xia (Rhizoma Pinelliae), Zhi Quan Xie (Scorpio Praeparata), Jiang Zhi (Sap Zingiberis Recens), Feng Fang (wasp’s nest).
Author’s commentary
In this third case study, which is similar to the second, Dr Ye uses the classical method of removing obstructions from the Luo vessels with Chong-drugs (wasp’s nest and scorpion), which in this respect prove more efficient than herbal drugs. He also considered Qi stagnation, caused by Phlegm and Blood stasis, which develops during chronic disease, and this is treated by Pinellia and Chuanxiong.
Ginger juice prevents nausea and warms the Yang.
Angelica root invigorates and nourishes the Blood.
As we can see, Dr Ye frequently used insect drugs, which used to be common in ancient times but had nearly been forgotten in his time. Most of these medicinals that remove obstructions from the collaterals or extinguish Wind also have a Blood invigorating effect.
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Author’s commentary
Judging from the context, in spite of the fact that the patient’s family hardly had any money, the physician adopted all available means to increase his own therapeutic knowledge. Although this case
does not describe the treatments in detail, and Dr Xu merely explains that he employed all known methods, we can take a leaf out of his book as regards his ethics even today.
Liver depression presenting with painful areas in the hypochondrium, called Gan Zhuo (Liver-Blood Qi stagnation),4is often encountered in
gynaecology. Many physicians fail to notice the presence of Heat and the aversion to Cold. Thus they falsely put this down to Wind-Cold and prescribe medicinals to treat Wind.
The Liver belongs to Wind (according to the Five Phases), so the use of Wind expelling (and warm) medicinals will increase Wind.
The Liver controls the sinews and ligaments. The presence of Cold contracts the sinews and
ligaments in the entire body (Liver-Wind convulsions).
The Liver opens into the eyes (orifice). When Cold is present, the eyes cannot close during night or day, and there is insomnia lasting for over a week. Moreover, the Liver regulates the smooth flow of Qi. In the case of a Liver condition (and when exterior relieving medicinals have been wrongly prescribed) Qi flows upwards but fails to descend, stagnation is generated and this results in constipation. Urine can be passed but it has a (dark) reddish colour. If the physician treats this with the wrong method once again, assuming a gastrointestinal disease, and prescribes Da Huang (Rheum) for purgation, or Huo Ma Ren (Semen Cannabis) for promoting the stool, the following symptoms will result: ‘no food, no appetite, no stool, no sleep’.
The pulse is unmistakably big and arrives in waves (Hong, Da Mai), the body is hot and restless and the patient cannot lie down flat to sleep;
there are persistent urges to vomit, nervousness and irritability. The deterioration is doubled due to the two wrong treatments. As it is stated in the
‘Jin Kui Yao Lüe’: ‘One wrong treatment can just be tolerated; however, two of them may lead to a life-threatening situation.’ Even someone who is not a sage will realize that such a case cannot turn out all right. . . .
When the disease manifests initially with pain in the costal arch and an incorrect tonifying method is employed, Blood stasis will accumulate further, and exhaustion (Lao) develops due to long-standing cough. This weakens the bones to such a degree that the patient will no longer be able to get up from bed. This is a sign of Blood stasis and stagnation. If the sputum smells foul, then abscesses have already developed from the Gan Zhuo (Liver-Blood Qi stagnation). If the pulse was hollow, big and choppy (Kou, Da, Se Mai= Blood deficiency) the day before yesterday, then big and with clear signs of Blood stasis yesterday, and today the Blood is in overwhelming motion, what else could it be other than Blood stasis?
If tonifying medicinals are given, the disease will reoccur after a short interruption; however, if the obstructions are removed from the vessels at the same time, it will work every time. This is my humble opinion. . . .
Prescription: Jiang Zhen Xiang (Lignum Acronychiae), Su Zi (Perilla), Dang Gui (Angelica Sinensis), Tao Ren (Persica), Xuan Fu Hua (Inula), Chen Xiang (Aquilaria), Chuan Lian Pi (Rhizoma Melia Toosendan), Huang Lian (Rhizoma Coptidis), Yu Jin (Tuber Curcuma).
Case Study 9.5 Blood stasis due to Liver depression (Gan Zhuo; also known by wiseman
Case Study 9.5 Blood stasis due to Liver depression (Gan Zhuo; also known by wiseman