A Very Sad but Useful Case Study

I have been busy translating cases for the handouts for my upcoming course on understanding physiology through classic formulas.  One of the formulas I will be covering in detail is Da Qing Long Tang.  I found this ever-so-interesting case study that was written around 1929.  It can be seen that this doctor is a really good doctor and knew his stuff.  However, he learns a lesson the hard way.  We can also learn a lesson from his experience.  I am very touched by his relationship with his teachers and his integrity.

By Dr. Song Dao Yuan宋道援

In 1929 during the spring holidays I took a boat from Shang Hai to Ping Feng Shan with some family members.  I met a Mr. Lei who had a son, age 20.  The son was in crisis.  The parents spoke for him.  “In the beginning he was doing manual labor in the extreme heat.  Then he took a cold bath.  At daybreak he developed chills and fever.  Because he was young and robust, they did not take this seriously but after 3 days the fever had not retreated.  Although he was treated, the illness only became more extreme.”  His wife supported him to go out of the house for which she wanted to change his clothing.  However the patient felt extremely cold and refused to take of his blankets.  His speech was resounding and he liked to drink cold tea.  Although the patient was exhausted, his face was red and the spirit in his eyes was very bright.  Around his lips was dry and scorched and split open with bloodstains.  I asked, “have there been nose bleeds?”  His wife answered “There has been bleeding from both his teeth and his nose.  This began the previous day and the amount was profuse.”  I had him open his mouth and the air coming out was hot and it smelled bad.  His eyes were blood shot.  His tongue was red and the moss was scorched and dry.  His pulse was floating and rapid, more than 6 times for each breath.  I pressed his chest and abdomen and his skin was dry and roasting hot.  His abdomen was soft and there was no pain anywhere on it.  I could even touch his spleen.  His urination was red and hot and in 6 days he had moved his bowels only twice.  His face was yellow and not black.  When doing abdominal diagnosis I saw that he would curl up and contract.  His mouth was red as if sunburned.  I asked, “in the past did you sweat?”  They said, “up to today there has been no sweating and so he took antipyretic medicine hoping for a sweat that would bring down the fever but after taking the medicine, the fever just got worse.  There has not been the slightest bit of sweating.”  I began by considering this a Da Qing Long Tang pattern.  The patient had a nosebleed so could it be that this a blood heat pattern?  I continued to consider this.  His tongue body was not crimson and his mental faculties were not clouded. There were no red stripes on his body.  In addition he had thirst for cold beverages.  All of this told me that the heat was on the Qi level and not the blood level.  It had not entered the blood.  Blockage was the cause.  It is as the Shang Han Lun says “When severe, there is nose bleed.” And “Yang Qi is abundant.”

Heat is due to cold oppression.  It is caused because the heat wants to penetrate through but it is constrained.  Hence it blazes.  The Yang Qi becomes over-abundant when it is blocked.  When there is thirst with a desire for cold beverages, a clear spirit and the tongue is not crimson, this is not a blood or Ying level pattern.  It is still okay to use warm and pungent to induce a sweat.  Because the exterior is covered by extreme cold, the blazing heat in the interior cannot leave.  Since the heat had spread all over and he was really in terrible trouble, one had to slightly stress pungent and cold.  I gave Da Qing Long Tang with 6 qian Ma Huang, 2 qian Gui Zhi, 8 qian Sheng Shi Gao, 5 qian of Xing Ren and two qian of Gan Cao in one package.

Though this illness had lasted for more than a week, the patient was robust and the patho-mechanism and the formula composition were identical.  I knew it had to work.   I told the father that “ After giving your son the herbs, there should be a sweat and the fever will follow the sweat and recede.”  The boatman was leaving so I had to pack up and after several days I arrived home to Shang Hai.  There was not enough time to make an inquiry after that.

Arriving at school, I received instruction on case records from Professor Lu Yuan-Lei.  Unexpectedly he read my case and afterwards said: “The pathogenesis is that of the Da Qing Long Tang pattern but that is not what was used.  What formula is this?  From the dosages and proportion of the herbs we could say this is Da Qing Long.  However, the ingredients are not the standard.  This is Ma Xing Shi Gan Tang jia Gui Zhi or perhaps Ma Huang Tang with Shi Gao.  It could go either way.”  He also said “Jiang and Zao are indispensible in this formula and so they should not be removed.”  My teacher’s words were correct and then he showed a completely different opinion: “Zhong Jing is extremely strict, not only about the dosages in his formulas.  He is also clear that changing one herb change a formula to be as different as two opposite poles.  There are too many examples of this in the Shang Han Lun to enumerate.”  As to the validity of this inner truth, there need be no effort to convince.  I repeated these words to professor Zhang Ci-Gong章次公。 He said “Dr. Lu’s words are really true.  I would like to know this wise man.  After the herbs, what formula then?”  I said “I did not give herbs afterwards.”  He then said “ For a serious disease like this, you give a strong formula and yet you do not plan for how to treat the aftermath?”  I suddenly heard the teacher’s words like cold consecrated water being sprinkled on my head.  I suddenly wanted to know the outcome but I couldn’t!

At summer vacation I returned and met with the Lei family.  The father said “My son took one boil of the herb and after a while there was a profuse sweat.  The fear of cold and fear of heat and the thirst that was difficult to bear decreased by more than half.  In the night he took the second boil but the sweating was not like the one in the daytime.  The fever did not further recede.  The family saw that the herbs were inexpensive and also effective.  They again gave one package.  After taking these he sweat even more than the day before and did not stop even though the fever had cleared.  He also felt an extreme aversion to cold with cold limbs.  He felt like ice from head to toe.  His four limbs were cramping and he fell into a kind of stupor.  He could not speak and was like this day and night.  He continued like this until he died.”  I sobbed at this shocking news.  Although my heart was smashed to pieces, I could not say a word.

Considering the illness that is related to this formula, I could see Zhang and Lu’s words are authenticated.  Looking back I can see that for the first dose, Da Qing Long Tang was the correct formula.  Yet even though the formula pattern was correct, death was not avoided.  It is not that the herbs in this formula are deadly.  It was the application of them that was deadly.  This was a serious disease that required strong herbs.  But I did not observe the rules for safety vs. danger.  Ma Huang is able to cause a person to sweat but too much sweating plunders the Yang.  I gave 6 qian of Ma Huang combined with Gui Zhi.  How was this going to guard against a big sweat?  Moreover, in regard to the method after taking the herbs, the Shang Han Lun clearly warns that “If there is recovery, sweating once again will damage the Yang.”  I did not tell them that they should not repeat the herbs if there was sweating.  This lead to a situation in which they gave herbs after the sweating and the Yang was damaged leading to death.  This formula should not be taken again with these dosages because it can damage the Yang.  One must give advanced notice about the conditions and safety measures for after taking these herbs.  One should prepare a Si Ni type formula beforehand and give this to the patient, being prepared for any contingency because cold limbs with a pulse on the verge of expiring can be cured.  This failure to carry out the above plan caused a gross error and was due to my own barbaric ignorance.

中医杂志1981; (8): 24