A 46-year-old man with a three-year history of severe tinnitus, accompanied by profound fatigue, cold intolerance, and impotence, was successfully managed using a Spleen and Kidney-tonifying herbal strategy that notably utilized classically “incompatible” herbs to break through the severe cold-phlegm pathology.

Case ID: CHC-0082

Case Summary

This case describes a 46-year-old man who presented with a three-year history of chronic tinnitus that had recently escalated to a constant, deafening cicada-like noise, severely disrupting his sleep. Despite seeking numerous treatments from various hospitals and renowned practitioners, his condition remained refractory. The original report documented a conventional diagnosis of tinnitus and a TCM assessment of Tinnitus driven by Spleen and Kidney Yang Deficiency with Internal Retention of Phlegm-Turbidity. He was managed by Professor Hu Shiping using a highly specialized approach that intentionally combined Zhi Fu Zi (Prepared Aconite) and Fa Ban Xia (Pinellia)—two herbs classically considered incompatible—to aggressively warm his exhausted Yang energy and clear the heavy, sticky phlegm blocking his sensory orifices, resulting in a complete clinical recovery.

Patient Presentation

• Patient: 46-year-old male (Surname: Li).
• Main Complaint: Tinnitus sounding like cicadas, unceasing day and night, severely worsening over the past month.
• History: The patient sought consultation on September 19, 2023. Three years prior, without any obvious trigger, he developed a low-pitched tinnitus accompanied by a heavy, groggy head. The condition progressively worsened into a loud, cicada-like ringing. One month prior to the visit, the noise became unceasing day and night, severely impacting his sleep and causing deep distress. Previous Chinese and Western medical treatments had all failed.
• Associated Symptoms: Profound fatigue, aversion to cold with cold limbs, impotence (阳事不举 – failure to achieve an erection), profuse sweating (especially upon exertion), a sticky sensation in the mouth, heavy and foul breath, poor sleep, and loose, unformed stools (2-3 times daily). His hearing remained relatively normal.

Examination and Diagnosis

• Conventional Diagnosis: Tinnitus.
• TCM Tongue and Pulse: The tongue body was pale and puffy (舌淡胖) with a thick, white, and greasy coating. The pulse was sunken and slow/moderate (脉沉缓).

TCM Assessment

The original practitioner interpreted the presentation as Tinnitus driven by Spleen and Kidney Yang Deficiency with Internal Retention of Phlegm-Turbidity (耳鸣 – 脾肾阳虚，痰浊内停).

According to the holistic principles of Chinese Medicine, the Kidneys open into the ears, and the Spleen is the root of acquired constitution that nourishes the sensory orifices. In this 46-year-old patient, his Kidney Yang was severely deficient, failing to vaporize fluids and warm the body (directly causing the cold limbs, slow pulse, and impotence).

Because the “fire could not warm the earth” (Kidney Yang failing to support Spleen Yang), his Spleen lost its ability to transport fluids, leading to the generation of internal dampness and phlegm-turbidity. This sticky turbidity manifested as his loose stools, thick/greasy tongue coating, sticky mouth, and foul breath. Finally, because the Spleen could not ascend clear Yang to the head, this heavy, turbid phlegm rose and physically blocked the ear orifices, causing the deafening tinnitus and groggy head. Furthermore, his profuse sweating was a clear sign of Yang deficiency failing to secure the exterior pores.

Treatment Approach

The primary treatment principle was to warm and tonify the Spleen and Kidneys, ascend the clear and descend the turbid, resolve phlegm and drain dampness (温补脾肾，升清降浊，化痰利湿). The strategy required a bold approach to simultaneously ignite the body’s core fire and aggressively dry the deep, sticky phlegm clogging his sensory pathways.

Interventions and Herbal Formulas

• Initial Herbal Formula (September 19, 2023): A 17-herb decoction modifying Fuzi Banxia Tang, Banxia Baizhu Tianma Tang, and Erxian Tang.
  • Warming Spleen and Kidney Yang: Zhi Fu Zi (Prepared Aconite, 15g – decocted first), Xian Mao (15g), and Xian Ling Pi (Epimedium, 15g) powerfully warm the body’s foundational Yang to restore metabolic fire and treat the impotence.
  • Transforming Phlegm and Calming Wind: Fa Ban Xia (Pinellia, 15g) aggressively dries dampness and cuts through thick phlegm, while Tian Ma (Gastrodia, 30g) calms internal wind to stop the dizziness/heavy head.
  • Strengthening Spleen and Leaching Dampness: Bai Zhu (15g), Cang Zhu (15g), Chen Pi (15g), Fu Ling (20g), and Ze Xie (20g) form a massive Spleen-fortifying matrix to dry dampness, regulate Qi, and flush the turbidity out through the urine.
  • Arousing Spleen and Clearing Turbidity: Huo Xiang (15g) and Pei Lan (15g) aromatically awaken the Spleen and directly clear the sticky, foul breath.
  • Securing the Exterior and Unblocking: Huang Qi (Astragalus, 30g) boosts Qi to stop the sweating. Gui Zhi (15g) warms the meridians. Wu Gong (Centipede, 2 pieces) and Bai Ji Li (Tribulus, 30g) unblock the deep collaterals and direct the medicine to the sensory orifices and genitals. Gan Cao (5g) harmonizes.
  • Administration: 14 doses, water decocted, taken warm morning and evening.
• Second Visit (October 10, 2023): After taking 6 doses, the frequency and severity of the tinnitus drastically reduced, allowing him to rest normally. His fatigue improved, the sticky mouth and foul breath completely disappeared, and his stools became formed. His sexual function (impotence) was also gradually recovering. However, he still experienced profuse sweating.
  • Formula Adjustment: Because the sticky damp-turbidity was successfully cleared, the aromatic Huo Xiang and Pei Lan were removed. Duan Mu Li (Calcined Oyster Shell, 20g) was added to strongly astringe the pores and stop the sweating. (14 doses prescribed).
• Third Visit (October 25, 2023): Following the second course of herbs, the excessive sweating was completely relieved. The tinnitus and aversion to cold had entirely disappeared, and his sexual function had returned to a good state.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is Professor Hu Shiping’s intentional use of “incompatible herbs” (反药 – Fan Yao) to break a severe pathological stalemate.

In classical TCM pharmacology (the “Eighteen Incompatibilities”), Fu Zi (Aconite) and Ban Xia (Pinellia) are strictly stated to clash and are traditionally forbidden from being used in the same formula. However, Professor Hu recognized that this patient suffered from a profound combination of severe Yang collapse (requiring the extreme heat of Fu Zi) and deep, stubborn cold-phlegm (requiring the extreme drying power of Ban Xia).

As historically demonstrated by Zhang Zhongjing’s Fuzi Jingmi Tang and Sun Simiao’s Da Wuyin Wan, when the pathogenesis precisely matches “cold accumulation and phlegm-fluid retention,” combining these two “rigid” herbs creates a highly synergistic effect that forcefully unblocks the Yang and clears the turbidity. This case beautifully demonstrates the classical tenet that “when there is a reason [a proper clinical indication], there is no harm” (有故无殒)—successfully curing a refractory, multi-system illness where standard treatments had failed.

Source Original source: Shenzhen Hospital of Beijing University of Chinese Medicine (Longgang) / Traditional Chinese Medicine Bureau of Guangdong Province Original title: 【以案说医】胡世平：脾肾同调治耳鸣，反药有故无殒施 Practitioner: Professor Hu Shiping (胡世平) Publication date: August 11, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation