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IIntroduction: The most commonly misdiagnosed condition in clinical practice is the syndrome of mixed deficiency and excess. Excess syndromes are usually very obvious and can easily mask deficiency syndromes, requiring careful observation and attention to detail. In prescriptions, both aspects must be considered, and the balance between tonifying the right Qi and dispelling pathogenic factors must be controlled to achieve the best therapeutic effect without interference, which is what we need to ponder the most. (Introduction by Yi Yi)
—This article is approximately4000words long, expected reading time10minutes—Analysis of Four Cases of Misdiagnosis
Author/Wu Pingxi
The author has been engaged in TCM teaching and clinical work for over twenty years, experiencing both gains and losses, with many lessons learned. I deeply feel the profound and subtle nature of TCM syndrome differentiation and treatment. If the differentiation is inaccurate, the effect is uncertain; if the differentiation is accurate, the effect is immediate. Therefore, I will record several cases of misdiagnosis and treatment, which may benefit fellow practitioners.01Persistent Diarrhea,Effective with Blood ActivationLi, male, 43 years old, has had diarrhea for 5 years, with 4-5 bowel movements daily. Western medicine diagnosed him with gastrointestinal dysfunction and chronic enteritis. He has been treated with both Western and Chinese medicine in multiple hospitals, with a chaotic medication regimen, sometimes attacking and sometimes tonifying, occasionally effective, but relapsing upon stopping medication.Observing the prescriptions he has taken, they mostly involve strengthening the spleen and draining dampness, harmonizing the stomach and aiding digestion, benefiting fire to generate earth, and even warming yang to treat dysentery, detoxifying and cooling the blood, etc. The prescriptions are numerous and mixed, with no effectiveness.Clinical Diagnosis: The patient has thin skin and a gaunt appearance, a sallow complexion with a slight purplish-black hue, cyanosis of the lips, pale and purplish tongue, white greasy tongue coating, slight distension in the stomach area, does not like to be pressed, appetite is fair, spirit is lacking, urination is smooth, the pulse is weak and choppy.This indicates Qi deficiency with blood stasis, tonifying Qi and strengthening the spleen, transforming dampness to stop diarrhea. Since his appetite is fair, the treatment should focus on dispelling pathogens, so I selected Xuefu Zhuyu Decoction with the addition of Ren Shen (Ginseng) and Huang Qi (Astragalus) for 2 doses, taken 3 times a day, as a trial.
Three days later, upon re-examination, he reported that after taking one dose, the dark purple watery stools increased significantly, abdominal distension disappeared, and the frequency of bowel movements decreased. After taking 2 doses, the stool color turned yellow, and the stool became formed, with 2 bowel movements daily. I increased the dosage of Ren Shen and Huang Qi and continued with the original formula for another 5 doses. One week later, upon re-examination, his complexion showed a rosy hue, appetite increased, spirit improved, and bowel movements were once daily with normal stool quality. I prescribed 5 doses of Shen Ling Bai Zhu San (Ginseng, Poria, and Atractylodes Powder) to consolidate the postnatal Qi. Follow-up after six months showed no recurrence.
02Oral Ulcers, Nourishing Blood and Achieving ResultsZhu, female, 35 years old, first diagnosed in early March 1996.She has had oral ulcers for over a year, with recurrent episodes, causing great distress. Western medicine diagnosed her with chronic oral inflammation, and she had taken large amounts of Vitamin C, Vitamin B2, and antibiotics without effect, then switched to Chinese medicine. Previous doctors prescribed various formulas such as Qing Wei San (Clear the Stomach Powder), Xie Huang San (Drain the Yellow Powder), Dao Chi San (Guide Out the Red Powder), Gan Lu Xiao Du Dan (Sweet Dew Detoxifying Pill), and Zhi Bai Di Huang Wan (Anemarrhena and Rehmannia Pill) without success, and she sought treatment from me.Upon detailed examination: there were over ten ulcers scattered on the oral mucosa, corners of the mouth, and edges of the tongue, some as small as millet and others as large as beans, the tongue was pale and not red, pain was not severe, tongue quality was pale, tongue coating slightly yellow and greasy, pulse was moist and slippery, and weak upon deep palpation, with better spirit, normal urination, and appetite.She mentioned that she usually craved sweet foods and liked spicy flavors, which clearly indicated damp-heat accumulation. However, previous doctors had already prescribed Gan Lu and other formulas, which should have been effective, yet they were not. Why was that?After much thought, I observed that the ulcers were pale and not red, pain was not severe, complexion was sallow, eyelids and nails were pale, tongue quality was pale, and although the pulse was moist and slippery, it was weak upon deep palpation.Considering all symptoms, I pondered for a long time; this must be damp-heat intertwined with toxicity attacking upward as the superficial manifestation, with blood deficiency as the root.Insufficient yin blood leads to a lack of support for yang, floating upwards, combined with damp-heat steaming the oral cavity.
The differentiation is blood deficiency leading to heat transformation, damp toxicity attacking upward. The treatment should nourish blood, clear heat, transform dampness, and detoxify. I prescribed Dang Gui Bu Xue Tang (Angelica Blood Nourishing Decoction) combined with Gan Lu Xiao Du Dan, with modifications, and since she lived nearby, I instructed her to take 1 dose. Three days later, she called to say that all oral ulcers had healed after just one dose, expressing immense gratitude. I instructed her to take 2 more doses of the original formula to ensure complete recovery, and follow-up after 2 months showed no recurrence.
03Abdominal Distension, Benefit Qi and ResolveZhang, male, 40 years old, a factory manager, was introduced to me in July 1995.He has experienced abdominal distension for over a year, which begins at night when he sleeps. He feels distension upon pressing his abdomen, which radiates to his sides and back. Pressing his sides and back, his stomach and navel area also feel distended, but not painful, leading to tossing and turning in bed, making it difficult to sleep. He must press his abdomen with a pillow and bend over to feel slightly better.Every morning after bowel movements, the distension subsides, just like a normal person, but he feels dizzy, and cannot press on both sides of his temples, working as usual, but feeling slightly fatigued, with normal appetite and smooth urination.He had undergone relevant examinations in two hospitals in our city, but the cause was unclear. He had taken dozens of doses of Western and Chinese medicine aimed at regulating Qi, activating blood, resolving distension, and purging, but the distension persisted. Recently, he also experienced this symptom during afternoon naps, severely affecting his rest, causing him distress. Upon inquiry, I learned that his factory was on the verge of bankruptcy, leading to emotional distress, with fluctuating moods; upon examination, the tongue was pale with a thin coating, and the pulse was wiry and long.Thus, I diagnosed him with liver Qi stagnation, liver wood invading earth, and disharmony between liver and stomach, as the saying goes: “If the stomach is not harmonious, one cannot sleep peacefully.” The treatment should soothe the liver, harmonize the stomach, and resolve distension.I selected Chai Hu Shu Gan San (Bupleurum Powder to Spread the Liver) with the addition of Fo Shou (Buddha’s Hand), Yu Jin (Curcuma), and Hou Po (Magnolia Bark), and instructed him to take 3 doses, one dose daily.Several days later, upon re-examination, he reported that after taking the medicine, he experienced more frequent bowel movements, but the distension did not decrease, and he developed oral ulcers, with no other changes.I asked for the formulas used by previous doctors and my own, and after a long silence, I thought the basic prescriptions were appropriate, so why was there no effect?Upon careful examination of his symptoms:The tongue was slightly pale, with abdominal distension, and every time he lay down, the symptoms would occur. He had to press on his abdomen with his hand and cover it with a pillow, bending over to get a moment of sleep. Although his pulse was wiry and long, it was weak upon deep palpation.As the ancients said: “Stagnation of Qi must lead to distension, and excess must resist pressure.” Now the patient likes to press, so it is not excess; however, treating it as excess would violate the principle of treating deficiency. Using pungent and drying herbs would further damage Qi and Yin, leading to oral ulcers. Therefore, I diagnosed it as Qi deficiency with distension.The treatment should tonify Qi and strengthen the spleen, while also soothing the liver and resolving depression. I selected Wu Wei Xiang Gong San (Five Flavor Unique Function Powder) with the addition of Huang Qi (Astragalus), Mei Gui Hua (Rose), and He Huan Hua (Mimosa Flower), with a slight addition of Chai Hu and Yu Jin, and instructed him to take 3 doses.
Several months later, upon re-examination, his symptoms had significantly reduced, from experiencing symptoms every time he lay down to only having them around 5 AM the next morning, with less distension, still preferring to press. The original formula was effective, and I maintained the same method, increasing the dosage of Ren Shen and reducing the pungent herbs, and continued with 3 doses. One week later, he happily reported that all symptoms had disappeared, as the formula was effective, and he took 5 doses on his own, sleeping soundly and feeling revitalized.
04Palpitations During Sleep, Resolving Phlegm for PeaceJia, male, 40 years old, first diagnosed on December 6, 1990.He has experienced palpitations for six months, worsening over the past two months. Due to work fatigue, half a year ago, one night he fell into a state of sleep rather than deep sleep, suddenly feeling his heart racing violently, startling him awake and causing him to fall to the floor, injuring his forehead. At that time, he thought it was a nightmare and did not pay attention.After that, it became more frequent, almost every night before falling into deep sleep, in a state of semi-sleep, he would feel his heart pounding, as if it would burst out, at which point he would feel short of breath, with a terrifying sense of impending death, followed by a scream, and he would wake up, sometimes sitting up in shock, sweating profusely, or even falling to the ground. Each episode lasted only a moment, about 1-2 seconds, and he would immediately wake up, but his heart would continue to race.If he could fall asleep, he could sleep until dawn, but later, he also experienced this during afternoon naps. He felt terrified, fearing sleep, and sought medical help. He had undergone relevant examinations in several local hospitals, but no abnormalities were found. ECG monitoring showed normal heart function, suspected to be functional cardiac arrhythmia, and medication did not alleviate the symptoms, so he sought treatment from TCM. Previous doctors often used methods to nourish the heart and calm the spirit, harmonizing the heart and kidney, and activating blood to dispel stasis, but to no avail, so he sought treatment from me.Clinical Diagnosis: The complexion was yellow-black with luster, muscles were well-developed, spirit was fair, tongue quality was slightly red, tongue coating was white and greasy with slight yellow, pulse was slow and slippery yet wiry, and he enjoyed sports, particularly martial arts and basketball. He reported that during intense activities like playing ball or cycling, he felt no discomfort, no heart fatigue or palpitations, but only during sleep did he experience symptoms. During episodes, he was clear-headed, with no family history of epilepsy, normal urination, and fair appetite.This indicates palpitations due to the yang not communicating with the yin, leading to unrest of the heart spirit. The treatment should focus on strongly calming the yang, settling the spirit, and tranquilizing the heart. I selected Zhu Sha An Shen Wan (Cinnabar Tranquilizing Pill) combined with Ci Zhu Wan (Magnetite Pill) with modifications, to be taken 3 times a day for 3 doses. Three days later, upon re-examination, he said he had not finished one dose, and the frequency of episodes had increased, forcing him to take 2 doses, but the symptoms worsened, with 7-8 episodes during sleep before he could fall asleep, leading him to fear and stop the medication. This was also likely due to unclear differentiation.Having practiced medicine for over twenty years, I had never seen such a case; it was indeed peculiar. Upon careful consideration of the symptoms: the patient was strong, enjoyed sports, had a penchant for smoking and drinking, was irritable, and had a yang excess constitution, with slightly yellow and thick greasy tongue coating, wiry and slippery pulse, bitter mouth and dry throat, and experienced dry heaving after eating flour-based foods, indicating disharmony between the liver and stomach, phlegm-heat disturbing the heart, leading to palpitations.This aligns with the ancient saying: “All diseases are caused by phlegm.”The treatment should clear heat, transform phlegm, soothe the liver, and harmonize the stomach, with the formula Huang Lian Wen Dan Tang (Coptis Warm Gallbladder Decoction) with modifications:Prescription
Ban Xia (Pinellia) 10g, Zhu Ru (Bamboo Shavings) 10g, Chen Pi (Aged Tangerine Peel) 10g, Fu Ling (Poria) 15g, Yuan Zhi (Polygala) 9g, Shi Chang Pu (Acorus) 9g, Yu Jin (Curcuma) 12g, Dan Shen (Salvia) 12g, Huang Lian (Coptis) 6g, ginger and jujube as guides.
3 doses, one dose divided into 3 parts daily, and advised him to abstain from smoking and drinking, and to manage anger.
After taking the medicine, he felt comfortable, the sensation of chest tightness disappeared, the number of startling episodes during sleep decreased, and he could nap peacefully, with the tongue coating becoming thinner.As the effect was satisfactory, I continued with the original formula for another 3 doses. After completing the doses, he was able to sleep soundly, with occasional episodes, and the bitter mouth and dry heaving had disappeared. I continued with the original formula with slight adjustments, totaling 15 doses, and all symptoms resolved, with follow-up after one year showing no recurrence.DiscussionClinical cases of difficult and miscellaneous diseases are complex and varied. In summary, conditions caused by deficiency, phlegm, and stasis are particularly prominent, often intertwined and persistent, making it challenging for practitioners. The first three cases of misdiagnosis and ineffective treatment were primarily due to unclear understanding of the root cause, mixing the superficial and the deep. All of these cases were fundamentally deficient, leading to excess due to deficiency, with a mixture of deficiency and excess, making them difficult to treat.Li Shicai said:
“The method of syndrome differentiation places the greatest importance on the pulse.”
“The method of pulse differentiation is based on deep observation.”
This is indeed a valuable experience.
- Example 1
The patient’s pulse was deep and choppy, complexion yellow with black, tongue pale and purplish, skin thin and gaunt, indicating blood stasis without a doubt.Upon investigation, it was due to prolonged illness leading to spleen deficiency, insufficient Qi, and when Qi is insufficient, blood circulation is weak, causing stasis in the stomach and intestines, thus affecting the blood aspect, leading to smooth urination;Qi deficiency and blood stasis, with Qi stagnation causing distension;spleen deficiency and weak Qi, leading to poor transformation and transportation, making it difficult to separate clear from turbid, hence persistent diarrhea. This is what is meant by “long illness entering the collaterals,” so I used methods to activate blood and tonify Qi, achieving effectiveness.
- Example 2
Oral ulcers are quite common in clinical practice, especially due to accumulated heat in the heart and spleen or damp-heat steaming. This is the usual case.The patient had a penchant for spicy and sweet foods, with slightly yellow and greasy tongue coating, and slippery pulse, indicating damp-heat. Using Gan Lu alone without effect is understandable.However, her nails, tongue quality, and eyelids were pale and not red, and the oral ulcers were pale and not red, indicating blood deficiency, which is a variation.Failing to seek the root cause in differentiation is not the correct treatment, which is to say, focusing on the usual while ignoring the variations, rarely achieving effectiveness.Thus, I used Dang Gui Bu Xue Tang to nourish blood and clear heat to consolidate the root, and Gan Lu Xiao Du Dan to clear heat, drain dampness, transform turbidity, and detoxify to treat the superficial symptoms, addressing both root and branch, hence achieving results with one dose.
- Example 3
Abdominal distension leading to insomnia is primarily due to Qi stagnation, but both deficiency and excess can cause Qi stagnation. Reviewing the reasons for previous misdiagnosis, it was due to unclear differentiation between deficiency and excess.The “Zheng Zhi Hui Bu” states:
“Qi distension is caused by emotional stagnation, leading to fullness and oppression in the chest and abdomen.”
The patient was a factory manager with poor performance, and it is evident that emotional distress was unspoken; the distension moved to the chest and sides, and pressing on both sides of the temples caused pain, indicating that the foot Shaoyang meridian starts at the outer canthus of the eye and runs along the side of the body, while the foot Jueyin meridian passes through the lower abdomen and distributes to the sides, indicating liver Qi stagnation and obstruction of Qi movement.Both previous doctors and I during the initial diagnosis overlooked this and ignored the root cause.Now the patient, due to labor, consumes Qi, and due to thinking, Qi becomes stagnant, leading to weak central Qi, insufficient propulsion, and difficulty in Qi movement, compounded by liver Qi stagnation, hence the distension;“Sleep is fundamentally Yin.”When Yang interacts with Yin, one can sleep; now, Yang Qi is deficient, and Yin Qi is excessive, with excessive Yin rejecting Yang, leading to Qi stagnation, hence the distension when lying down; the symptoms belong to deficiency, hence the preference for pressing, bending over to sleep; waking belongs to Yang, and daytime also belongs to Yang. When Yang is sufficient, Qi moves, allowing the stagnant Qi to be released, leading to peace in the body. Therefore, I focused on tonifying Qi while assisting in soothing the liver, achieving effectiveness.
- Example 4
Palpitations during sleep are indeed rare in clinical practice. I used calming and tranquilizing formulas without any effect, which was a significant error.The “Xue Zheng Lun: Zheng Chong” states:
“When there is phlegm in the heart, it obstructs the heart Qi, leading to palpitations.”
This patient had a penchant for smoking and drinking, leading to damp accumulation and phlegm obstruction of heart Qi, compounded by a naturally strong liver, easily affecting the spleen, “the spleen is the source of phlegm.” Over time, phlegm accumulated and disturbed the heart.The “Lai Zheng Zhi Cai: Bu Mei Lun” states:
“When Yang Qi moves automatically, one can sleep; when Yin Qi is still, one wakes up.”
When Yang does not enter Yin, they mutually reject each other, disturbing the spirit, hence the palpitations; phlegm turbidity is Yin, and sleep is a function of Yin. When Yin is excessive, it rejects Yang, leading to disturbances at the moment of sleep.As Lin Peiqin stated in the “Lai Zheng Zhi Cai: Phlegm and Drink”:
“Following the rise and fall of Qi, it reaches everywhere; in the lungs, it causes cough; in the stomach, it causes vomiting; in the heart, it causes palpitations… it changes in myriad ways, and many strange cases are attributed to phlegm.”
Thus, I used formulas to clear heat, transform phlegm, harmonize the stomach, and calm the spirit, achieving peace.
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