Diagnosing Pain Beyond Qi and Blood Stagnation. A Look at Painful Obstruction - Part Two
Mistaken differentiation between hot and cold painful obstruction.
Case 1: Cold damp painful obstruction mistakenly diagnosed as damp-heat painful obstruction.
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 (see note 7).
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 Huantiao (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 Ru Xiang (Olibani, Resina)and Mo Yao (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 (see note 8).
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.
Case 2 : Yin and blood insufficiency mistakenly diagnosed as cold-damp painful obstruction pattern.
Liao was a 62 year old man who was hospitalised because of left buttock and left lower limb pain that had been going on for 3 months. In the hospital his condition was: left buttock and posterior left thigh muscular pain, fatigued spirit and lack of strength, poor food intake, bland and dull lack of taste in the mouth, mouth was slightly dry, dry stools, facial colour being dark and stagnant, with a pale purple tongue body and a thin yellow coating and a wiry pulse. 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, mouth slightly dry, yellow urine, dry bowel movements. His tongue was pale purple, and he had a thin yellow coat and wiry pulse. The formula was changed to enriching yin, nourishing blood, and quickening the blood... after 15 packets both lower leg muscle symptoms of distending pain, numbness and tingling etc. were gone (see note 9).
This case does not have clear cold signs. The doctor stubbornly latched on the words of su wen (painful obstruction chapter), that says "when the three qì of wind, cold, and damp combine (attacking at the same time), this becomes painful obstruction disease". Therefore his mistaken differentiation was a cold-damp painful obstruction pattern, and the formula given scattered cold and dried damp. Although the patient was venerable, his body was blood deficient and fluids were depleted, which prevented him from lubricating his intestines below, and enrich his mouth. Therefore his stools were dry and his mouth was slightly dry. His limb's sinews (and vessels) lost moisture; therefore there was 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.
Case 3: Qì and Blood Depletion – Liver and Kidney insufficiency mistaken for wind-cold-damp painful obstruction.
Xu was a 59 year old woman that came into contact with water-damp for a long time 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 chuann cao wu; (Aconiti et Aconiti Kusnezoffii Radix Lateralis) 50g, fu pian (Aconiti Radix Lateralis Praeparata) 50g, guì zhi; (Cinnamomi Ramulus 30g, qiang huo Notopterygii Rhizoma seu Radix) 30, 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) 15, hong hua (Carthami Flos) 15, chi shao (Paeoniae Radix rubra) 15, 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 great sweating, incessant flusterdness, and palpitations. At nightfall her extremities would alternately expand 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.
When she came in she was observed to have a bright white facial complexion. The tip of her nose, lips, mouth, and yin tang all were green-blue purplish. Her extremities were jerking and occasionally her muscles were stiff. They felt good with rubbing, 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, fur was thin with little fluid, the centre of the tongue had fissures and the pulse was thin, weak and slightly rapid.
Differential Diagnosis: This was a vacuity painful obstruction with a misuse of a big formula that effuses, dissipates, and attacks painful obstruction [disease] further damaging the qi, blood, and fluids, loss of nourishment of her sinews (and vessels), which lead to convulsions. The treatment method was to boost qi and nourish blood, supplement and boost 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 Ba Zhen Juan Bi Tang Jia Jian (Eight Treasure Remove Painful Obstruction Decoction) (modified). After 2 packets the convulsions were reduced, pain was clearly relieved, and afterwards the method of supporting the right and dispelling evil 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 painful obstruction disease for a long time. Qì, blood, yin and yang all were deficient, right [qi] deficiency was the root, lodged evil was the tip, and the treatment method should support the right as well as eliminate the evil.
However, the first doctor thought the disease was a excess painful obstruction (disease), and stubbornly dispelled wind and eliminated dampness. Furthermore he used a large formula w/ Chuan Cao Wu (Aconiti et Aconiti Kusnezoffii Radix Lateralis), Fu Pian (Aconiti Radix Lateralis Praeparata), Ma Huang (Ephedrae Herba), Xi Xin (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, quivering and 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. This is a fine example.
Clinging stubbornly to convention, differential diagnosis not precise
Case 4: Phlegm obstructing the channels and network vessels mistaken for wind-damp painful obstruction.
Wang was a 30 year old woman peasant. She complained of fatigue, aching, numbness, and tingling in both her lower limbs. She had a diagnosis of "rheumatism" which resulted in her being 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. Consequently though, when exposed to wind she would sweat and her pain would increase.
For half a year there was pain that was sometimes mild and sometimes serious. She walked with a limp which required her to lean on a staff and needed people to support her. Both lower limbs had numbness and tingling, as well as severe pain in her knee joint, her knee was cold with palpation, cold aggravated the pain and heat soothed it. These were 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, facial colour lacked lustre, disquieted sleep at night, essences-spirit melancholic, both knee joints had diffuse swelling but were not red. The pulse was wiry, thin, and slippery, whilst the tongue was pale with a white and slimy coat. She was diagnosed with painful obstruction pattern (cold-damp type) and the treatment was to warm the channels, scatter the cold and disinhibit dampness.
After taking the medicinals her symptoms did not decrease. On the contrary she became agitated and vexed, but her tongue and pulse were the same as before. The patient's condition was considered cold-damp which was intermingled and difficult to heal, therefore the formula was not changed and three additional bags were given. After taking these she reported that the cold in her legs was more severe, and at night there was very severe pain which resulted in an incessant crying 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 Zhì Chuan Wu (Aconiti Radix Praeperata) 10 g and Fu Zi (Aconiti Radix lateralis preparata) 15g were added to the original formula and three more packets were given. After taking the medicinals her symptoms still did not lessen. On the contrary, a cough with copious phlegm emerged. Furthermore, the previous symptoms of chest oppression, poor food intake, nausea and vomiting, and the tongue and pulse still did not change.
There was a careful review of her symptoms. Although both her lower limbs were painful, and had numbness and tingling, taking medicals that warm the channels, scatter the cold, and disinhibit dampness were ineffective. Her accompanying symptoms of chest oppression, poor food intake, nausea and vomiting, large amount of white vaginal discharge, and menstrual colour like yellow water, as well as the new emergence of cough with copious phlegm, made one think, is there a relationship here (with these symptoms) with the leg pain? Furthermore, previous experts have used phlegm in such cases of painful obstruction, therefore a dispel phlegm formula was used. Jia Wei Er Chen Tang (Augmented Two-Cured Decoction) was given. After 10 days there was another examination. The 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, 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 (Pheretima) was added, Bai Jie Zi (Sinapis Semen) increased to 20, and Fang Ji (Stephaniae tetrandrae Radix) to 10. Ten more bags were given in succession. All symptoms disappeared, and a follow-up with the patient two years later revealed there had been no flare-ups (see note 11).
This case is one of severe pain with a like and dislike of cold and heat. A diagnosis of cold-damp was reasonable with the clinical manifestations. But 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 patient as having phlegm, although there were no typical phlegm signs and symptoms. There was though vaginal discharge, poor food intake, chest oppression, cough with copious phlegm, which ended up pointing to the road of treatment.
The above case studies help demonstrate the importance of proper diagnosis as well as being flexible in one's thinking. Furthermore, even though all of the above cases utilize herbal treatment strategies, many of the basic concepts can be successfully applied to acupuncture. For example, merely grasping the proper diagnosis in regard to excess and deficiency can lead to more refined needling techniques. In the end though, one should do a complete differential diagnosis to give the best care possible to the patients. Just diagnosing qi and blood stagnation and then sticking needles in where there is pain misses the essence of Chinese medicine. Finally, the above mentioned approaches to diagnosis are by no means exhaustive. There are many other ways to diagnose and treat painful obstruction. For that matter, there are many other ways to diagnose and treat pain. Nonetheless, consulting the books & articles contained in the reference section below will help broaden one's perspective on the subject.
Jason Blalack, foremost a clinician, has written and published many articles that integrate material he has translated with his own clinical and theoretical understanding. He graduated from PCOM in San Diego, and since has pursued advanced training in Asia. He has held teaching and clinical supervisor positions at SWAC (Boulder Campus) and CSTCM (Denver) and currently maintains a private practice in Boulder, Colorado. Questions or comments can be sent to: firstname.lastname@example.org
Note 7: This most likely is interpreted to mean that the whole hospital stay lasted about two hours.
Note 8: [侯恒太•临证求真琐谈•江西中医药，1988,(2):54].
Note 9: [缪以星•临证随笔2则•湖南中医学院学报，1986,(1):33].
Note 10: Rhizoma Pinelliae Ternatae (ban xia) Pericarpium Citri Reticulatae (chen pi) Sclerotium Poriae Cocos (fu ling) Radix Glycyrrhizae Uralensis (gan cao) Radix Scutellariae (huang qin) Rhizoma Coptidis (huang lian) Herba Menthae Haplocalycis (Bo He).
Note 11: [朱光宗竿•临症失误救治2则•中医研究，1991,4(1):34].
Note 12: One should consult Guillaume's Rheumatology in Chinese Medicine for more details on the following patterns.