Stroke in an Obese Man: Twisted Mouth and Paralyzed Arms?
What the patient searches for: mouth pulled to one side / numb hands and feet / both hands cannot move / paralysis on one side / sudden stroke / are fat people more prone to stroke?
Medical terms: stroke (meridian pattern) · phlegm-heat generating wind · cerebral infarction / cerebral hemorrhage
Opening scene: Doctor Zhu Danxi looks at the person first
Doctor Luo Dalun says Doctor Zhu Danxi had a wonderfully distinctive habit when seeing patients — he looked at the person first, at the patient’s constitution. This case opens with just three words in the original text: 一肥人 — "an obese man."
💬 Note from Doctor Luo: Notice that Zhu Danxi had already tied constitution to stroke — this is his trademark. He always said "fat, pale people carry heavy phlegm-dampness" — people who are very overweight, fair-skinned, and not used to physical labor are sure to have heavy phlegm-dampness inside them, and they are far more prone to this illness. Look at today’s stroke wards: aren’t fat people everywhere? A thousand years ago, Zhu Danxi had already seen it clearly.
Who was the patient? Fat, fair-skinned, and not used to work
The patient was a textbook "fat, pale person": very fat, pale skin, and he did no physical labor.
💬 Note from Doctor Luo: "Fat, pale people carry heavy phlegm-dampness" — that is Zhu Danxi’s own words. When a person gets heavy and doesn’t move, the food he takes in cannot be fully transformed and transported, so it turns into phlegm-dampness piling up in the body. When people like this develop problems, phlegm-dampness is almost always at the center of it.
What were his stroke symptoms? A twisted mouth, numbness of the hands and feet, and "left and right both useless" (左右俱废).
💬 Note from Doctor Luo: The twisted mouth means his mouth was pulled to one side and his face skewed; the numb hands and feet mean his limbs felt wooden and lost sensation; and the most serious sign is "left and right both useless" — note, this was not paralysis on just one side, it was both hands useless, completely unable to move, with motor function severely restricted. What does that tell you? That his phlegm-heat was extremely heavy and clogging badly.
Doctor Zhu Danxi’s judgment was decisive: this man was heavy with phlegm-dampness, and phlegm-dampness had to be treated as the leading factor — resolving phlegm first. Then he wrote out a string of phlegm-resolving herbs.
What is stroke? The Huangdi Neijing already knew
To understand Zhu Danxi’s formula, you first have to know how Chinese medicine came to understand this disease. Doctor Luo Dalun walked through the whole development of that understanding.
💬 Note from Doctor Luo: What we call stroke today maps closely onto modern medicine’s cerebral hemorrhage and cerebral infarction. Chinese medicine recognized this disease very early. The Huangdi Neijing (Yellow Emperor’s Inner Classic) already put forward the ideas — names like da jue (great reversal), bo jue (sudden reversal), pu ji (sudden collapse), and pian ku (one-sided withering) are all old names for stroke. The Su Wen (Plain Questions) says: "When blood and qi race upward together, this is great reversal" — blood and qi surge up at the same time and the person collapses on the spot; that is the acute form of stroke.
But knowing about it was one thing; treating it was something medicine developed only slowly.
💬 Note from Doctor Luo: Before the Tang and Song dynasties, physicians basically believed that stroke was caused by insufficient upright qi with vacuous channels, attacked by external wind — wind evil blowing in from outside — so treatment focused on supporting upright qi and dispersing wind. That way of thinking ruled for many years. It was not until the Jin-Yuan era that understanding took a great step forward.
The four great Jin-Yuan physicians: three different views
In the Jin-Yuan era, the great physicians Liu Hejian, Li Dongyuan, and Zhu Danxi each had their own theory of stroke.
💬 Note from Doctor Luo: Liu Hejian (Liu Wansu) said the problem was insufficient kidney water with blazing heart fire — kidney yin deficiency was the key: water could not control fire, so fire suddenly flared up. Li Dongyuan said it was qi deficiency — "the form is replete while qi is failing; the root disease arises from the self": the person is very heavy (the form replete), yet his qi is insufficient, and qi can no longer govern that heavy form, so illness arises. Zhu Danxi, for his part, championed damp phlegm transforming into heat and generating wind — he believed phlegm-dampness was the crucial factor in this disease. Such people usually overeat rich, fatty delicacies; put in today’s terms, they have high blood lipids and thick, sticky blood.
Zhu Danxi laid out the whole causal chain in the Dan Xi Xin Fa (Teachings of Danxi): damp earth generates phlegm.
💬 Note from Doctor Luo: Zhu Danxi said the deepest root is spleen deficiency — when the spleen is deficient, damp earth generates phlegm; when phlegm accumulates, heat is generated inside it; phlegm generates heat, and heat generates wind. This phlegm-heat, clogged in the body, produces the stroke. So the core of Zhu Danxi’s thinking can be compressed into four words: phlegm-heat is the key. The path "eating too well → spleen deficiency → phlegm → heat → wind → stroke" — a chain every modern person knows intimately — he explained it seven hundred years ago.
Then came Zhang Jingyue in the Ming dynasty: "internal injury and accumulated depletion" settled it
Later, the Ming-dynasty physician Zhang Jingyue explained the problem thoroughly.
💬 Note from Doctor Luo: Zhang Jingyue stated plainly: external wind has much less to do with this disease; it is chiefly internal wind — an "internal injury with accumulated depletion" (内伤积损): the body’s interior has been hollowed out too severely, it can no longer transform and transport, kidney qi and kidney essence are insufficient, and that gives rise to deficient wind stirring internally. He explicitly demanded that the disease be considered from internal causes — a huge advance. To this day we agree: this illness really is tied to the body’s depletion. A person with normal qi and blood, in the full vigor of youth, does not simply have a stroke. Look at stroke patients — aren’t most of them elderly?
Who is prone to stroke? Six causes, ranked
Doctor Luo Dalun says that when Zhu Danxi discussed this disease, he was really teaching us how to prevent it. He summed up the causes of stroke in a list, and every item hits modern people square on.
💬 Note from Doctor Luo: Number one, insufficient upright qi. As a person ages, upright qi grows weaker and weaker — this is the most fundamental cause; so after middle age you absolutely must take precautions. The age of stroke keeps getting younger because everyone eats too well and there are too many disease factors around, but the rule that older people have higher rates hasn’t changed. Number two, excessive consumption of upright qi — worrying all day, working overtime day and night, indulging in excess. In Zhu Danxi’s own case records, he wrote about men who had just taken young concubines — even four or five of them — and drained their kidney essence until they fell ill: when kidney essence is insufficient, either yang deficiency or yin deficiency results; with yin deficiency, deficient fire races upward and liver wind stirs internally, and stroke becomes easy.
Number three: rich, fatty food and lack of exercise.
💬 Note from Doctor Luo: In the old days when people went hungry, stroke rates were much lower. Today we eat too well, and rich, fatty food slowly wears the spleen and stomach down. When spleen qi is insufficient, transformation and transport fail, and turbid phlegm is generated internally; the more turbid phlegm, the more deficient the spleen — mutual causation, a vicious circle. People like this go for a check-up today and their blood viscosity is certain to be high, their lipids certain to be disordered. Zhu Danxi lived in a settled, peaceful time when some people ate chicken and fish every day and grew fat on rich food, wearing out their spleens — that is why he talked about "stroke in the fat man," because fat people are sure to have eaten well. Add a blood-stasis constitution to that kind of obesity and the blood vessels clog easily — the stroke rate shoots up. That is why Zhu Danxi kept hammering on two things: strengthen the spleen and resolve phlegm-dampness — that is the top priority in prevention.
Number four: poor emotional state.
💬 Note from Doctor Luo: Many stroke patients have terrible tempers. Frequent rage, liver yang surging upward, liver qi swelling — blood and qi rush upward all at once, and stroke follows easily. I once treated a patient in the Northeast whose lung condition was improving very slowly, and I couldn’t find the reason no matter how I searched — until we chatted and his wife told me he flies off the handle at the slightest thing; if anything doesn’t go exactly his way, he explodes. I told him that’s a weakness of us Northeasterners — go learn from the Southern husbands, don’t treat a hot temper as a virtue. A violent temper and blazing fire are extremely dangerous stroke factors.
Number five: changes in the outer climate — scorching summer heat, or severe cold that congeals qi and blood, can both trigger a stroke. Number six: alcohol.
💬 Note from Doctor Luo: A tiny bit of alcohol is fine — it even invigorates blood and unblocks channels. But drinking too much is dangerous: blood circulates too fast, bleeds somewhere, forms stasis, and mixed with a stasis-prone constitution, problems come easily. All these factors swirling together are what make a person have a stroke.
When stroke actually happens: first tell "meridian stroke" from "organ stroke"
After the causes, Doctor Luo Dalun said that when a stroke really occurs, Chinese medicine first sorts it into two situations: meridian stroke (中经络) and organ stroke (中脏腑).
💬 Note from Doctor Luo: Meridian stroke is mainly a problem of the limbs — the arms and legs are not nimble, but the mind stays clear. This is relatively lighter; some people recover on their own within a day or two, others in two or three weeks. But remember, meridian stroke is still an important warning — it can develop into something worse. Organ stroke is serious: consciousness is affected, the person becomes clouded or comatose, and the illness is generally grave. So never take meridian stroke lightly.
Then weigh excess and deficiency: the closed pattern and the collapse pattern
Stroke must also be divided into the closed pattern (bi zheng) and the collapse pattern (tuo zheng). Doctor Luo said he had covered this before but would stress it again because it is absolutely crucial.
💬 Note from Doctor Luo: What does the closed pattern look like? Jaws clenched, limbs in spasm, breathing coarse with a loud rattling sound — this is usually an excess pattern. The closed pattern further splits into yin and yang: in yang closure, the face is flushed red, even the eyeballs are red, and a foul odor pours from the mouth — the jaws are clamped so tight you have to pry them open, and inside the smell is strong; the tongue is red with a yellow greasy coating. This is an excess pattern with damp-heat, and you must quickly transform the phlegm-heat and open the qi mechanism of the organs. In yin closure, the person is also rigid, but the tongue is swollen and the face pale. The two can transform into each other: when upright qi fails, yang closure can turn into yin closure.
And what about the collapse pattern?
💬 Note from Doctor Luo: In the collapse pattern the hands fall open, the mouth hangs slack, the breath is faint, the eyes are closed, and there is loss of urinary and bowel control — the urine can no longer be held at all. Zhu Danxi called it "urine pouring out on its own" (尿自出). This is the case we talked about last time — that elderly gentleman in his sixties kept on rich food whose urine simply streamed down by itself. The collapse pattern means upright qi has already scattered outward, extremely dangerous; it needs ginseng decoction to rush the qi back. So with the same word "stroke," the excess pattern calls for resolving phlegm and clearing heat, while the collapse pattern calls for urgently replenishing original qi — completely opposite directions. Get that wrong and you are in serious trouble.
Zhu Danxi’s formula: from the first herb on, everything resolves phlegm
Back to the obese patient. Doctor Luo Dalun broke Zhu Danxi’s prescription down herb by herb.
💬 Note from Doctor Luo: Look at what he wrote — bei mu (fritillaria; both the Sichuan and Zhejiang varieties are cool-natured and specifically clear phlegm-heat), gua lou (Trichosanthes fruit, resolves phlegm-heat), nan xing (Arisaema, resolves phlegm), ban xia (Pinellia, resolves phlegm), chen pi (aged tangerine peel, resolves phlegm and regulates qi) — this opening string is all phlegm-resolving herbs, especially for clearing phlegm-heat. Then he added bai zhu (Atractylodes) to tonify the spleen — why? Because the root of phlegm-dampness lies in spleen deficiency and too much rich food; the spleen must be tonified. On top of that came huang qin, huang lian, and huang bai (Scutellaria, Coptis, and Phellodendron) to drain phlegm-heat — this man’s tongue was certainly red with a yellow greasy coating; resolving phlegm alone was not enough, pairing it with clearing heat works far better.
Beyond resolving phlegm and clearing heat, Zhu Danxi added a group of wind-dispelling, channel-unblocking herbs.
💬 Note from Doctor Luo: qiang huo (Notopterygium), fang feng (Saposhnikovia), jing jie (Schizonepeta), wei ling xian (Clematis), plus bo he (mint) and gui zhi (cinnamon twig) — these wind-dispelling herbs do two jobs: first, wind can overcome dampness, helping carry the dampness away; second, herbs like Clematis unblock the channels — your channels are so blocked that nothing moves, so they have to be opened up. Then gan cao (licorice), and tian hua fen (Trichosanthes root) to moisten dryness — for fear that all the wind-dispelling would be too drying and injure yin. There is also bai fu zi (Typhonium), an important herb for resolving phlegm and dispelling wind. Here a warning is essential: bai fu zi (Typhonium) is not the same herb as fu zi (aconite) — bai fu pian (prepared aconite slices) is the processed product of aconite. Some people mix them up at the pharmacy, take Typhonium thinking it is aconite, and end up dizzy and reeling — Typhonium carries a slight toxicity and has side effects; it must only be used under the guidance of a Chinese medicine practitioner.
The formula also contains two items doctors still use today: zhu li (bamboo sap) and jiang zhi (ginger juice).
💬 Note from Doctor Luo: Zhu li is the sap roasted out of bamboo, and it resolves phlegm. To this very day we still use bamboo sap to treat phlegm-heat stroke, and in fairly large doses — the results are excellent, it truly has the power to turn the tide. Zhu Danxi had his own rule of thumb: "for patients with strong qi who can eat, use jing li (sap of the chaste tree); for patients with deficient qi who eat little, use zhu li (bamboo sap)." Then a little ginger juice is added — phlegm is warmed to transform; warmth is what dissolves it — the ginger juice warms the channels and lets them open. The medicine was also taken with wine to invigorate blood and unblock the channels. If the phlegm-heat was very heavy, Zhu Danxi would sometimes add hong hua (safflower) and quan xie (whole scorpion) to invigorate blood and unblock the channels; and if the patient’s upright qi was insufficient, he would add ren shen (ginseng) to support it. That is the complete strategy of Zhu Danxi for this kind of stroke: resolve phlegm-heat as the main line, unblock the channels and dispel wind as support, and keep an eye on upright qi at every step.
One more fierce trick: the vomiting method
In treating stroke, Zhu Danxi also had a technique that sounds drastic to modern ears — the induced vomiting method (tu fa).
💬 Note from Doctor Luo: Zhu Danxi wrote about it specifically: "Hemiplegia is by and large due to phlegm" — when half the body cannot move, when the arms and legs will not work, it is mostly because phlegm is blocking the channels, and the phlegm is sure to be abundant. "When phlegm is copious and thick, with a twisted mouth, crooked eyes, and inability to speak, the method calls for vomiting" — when there is a lot of phlegm, a very thick tongue coating, and a rattling sound in the throat, with the mouth and eyes distorted and speech lost, the first thing to consider is the vomiting method.
How was it done? Zhu Danxi’s method is quite interesting.
💬 Note from Doctor Luo: He had shrimp boiled with ginger and scallion, had the patient first suck the shrimp, then drink the broth, and then provoked vomiting — bringing the wind-phlegm up and out. That was his method at the time; nobody uses it that way today. But the vomiting method has an iron rule: deficient people must not be made to vomit — when upright qi is already badly insufficient, vomiting weakens it further and that is disastrous. Only an excess pattern qualifies — abundant phlegm and saliva, a red face. If the face is pale and the breathing faint, never use the vomiting method; first tonify, tonify properly. After the vomiting method has brought the phlegm out, following up with phlegm-resolving herbs works even better.
Doctor Luo’s reminder: stroke can be prevented
The case is done, and Doctor Luo Dalun brings the conversation back to today: stroke — whether cerebral hemorrhage or cerebral infarction — is a major killer that endangers health, and its disability rate is very high. Some patients really do end up bedbound and unable to move; others walk with a limp and need someone to hold them up.
💬 Note from Doctor Luo: In the history of Chinese medicine’s understanding of stroke, Zhu Danxi played a connecting role between past and future — he dug out the phlegm-dampness thread. And how does Chinese medicine develop? It is precisely these great physicians thinking one by one, with later generations combining their experience, that gradually produced a correct understanding of a disease. The experience of the ancient physicians deserves our serious study.
How to prevent it? Doctor Luo Dalun’s answer comes in three sentences:
💬 Note from Doctor Luo: Stay emotionally positive — don’t fly into a rage at every little thing; liver yang surging upward is the great enemy of stroke. Eat lightly — don’t let rich, fatty food drag the spleen and stomach down; strengthen the spleen and resolve phlegm-dampness — this is exactly what Zhu Danxi taught. Don’t over-consume yourself — worry, staying up late, indulgence: each one hollows out your upright qi. Do these three things and you can greatly lower your risk of stroke. A stroke does not arrive suddenly — every one of its causes has been piling up day after day.
Compiled from Doctor Luo Dalun’s explanation of a case by Doctor Zhu Danxi, from Dan Xi Zhi Fa Yao Xin (《丹溪治法心要》).