Introduction:
The following is a case presentation for a
woman that was treated at my clinic in the spring of 2009. It starts as what seems like a simple case
but proves to be quite the challenge until I delved a little deeper into the
classics, specifically the seminal and possibly the oldest medical text Treatise on Cold Damage (Shāng Hán Lùn), with
further elucidations by the late great Běijīng physician Hú Xī-Shù (胡希恕，1898-1984).
Case:
A 29-year-old female presented at my
clinic with abdominal pain she had been suffering with for four years. Most of her pain was felt in the lower abdomen
and occasionally in the peri-umbillical area.
Pain was occasionally alleviated with warm compresses and with mild
abdominal massage. When asked, she was
not sure whether warm or cool drinks affected the pain but was sure to be more
mindful after our first meeting. The pain was very unpredictable, appearing one
day before meals, the next after without one distinct pattern. She mentioned that she first remembers her
pain starting a couple months after a difficult break up from her fiancé and
several months of instability at her job.
This initial stress had first affected her sleep, which is basically now
under control with the occasional use of sleep medication. Her appetite fluctuated with her moods, as
did her overall energy levels. Bowel
movements were not too affected but had a tendency to be soft. Urination was unaffected. Mild nausea was noted but she felt it was
insignificant since she has always felt slightly nauseous since her break-up. Her tongue was slightly pale with a thin
coating and her pulse was slightly wiry on deep palpation, otherwise they were
both unremarkable. Aside from the above
the symptoms, she was a healthy, active woman, who was at her wits end with
this nagging pain. Various western
medications were tried all to no avail.
I had diagnosed the pattern as a simple Liver-Spleen
disharmony and assumed I could treat this with a basic Qì moving, Spleen
boosting formula such as the Free and Easy Wanderer powder (Xiāo Yáo Sǎn) from
the Imperial Grace Formulary of the Tai Ping Era (He Ji Ju Fang), with the addition of Fructus Amomi (Shā Rén) and Radix Aucklandiae (Mù Xiāng). I prescribed one weeks worth of 5:1
concentrated powders.
The following week she returned to the
clinic and reported that after taking the first dose of herbs there was some
rumbling in her abdomen and within an hour the pain returned slightly worse
than before she came to see me. For the
next couple of days after taking the herbs she felt tired and her abdominal
pain was slightly more pronounced. All
other symptoms remained the same including her tongue and pulse presentations.
In the past when presented with similar
cases of digestive problems due to a Liver-Spleen disharmony when herbal
formulas were prescribed correctly, at least some alleviation of symptoms would
be noted after a few days. Now in this
particular case, with the slight exacerbation of her symptoms and the fact that
she felt weaker, it was clear that I was missing something. Scouring through the pages of the ‘Treatise
on Cold Damage’ I came upon clause 100 where it states;
“In Cold damage, when the Yáng pulse is choppy and the
Yīn pulse is wiry, there should be acute abdominal pain. First administer Xiǎo jiàn zhōng tāng. If there is no reduction (of symptoms), Xiǎo
chái hú tāng governs”.
The use of Minor
centre fortifying decoction (Xiǎo jiàn
zhōng tāng) was definitely justifiable, as her abdominal pain liked the
occasional use of warm compresses and abdominal massage. These two symptoms will usually warrant a
diagnosis of deficiency cold and this is what the above formula treats. With my initial diagnosis, too much stock was
put into her Qì stagnation and the
other symptoms were overlooked. In
addition she had a deep wiry pulse, which is included in the above clause (‘Yīn pulse is wiry’). In the original clause it states that
patients experiencing nausea or vomiting should not take this formula and
although she did experience some nausea, I felt it was fine and was merely a
manifestation of the Qì depression more than anything else. A weeks’ worth of Minor centre fortifying
decoction granules were prescribed with no additions.
A week later she
returned to report that there had been a significant reduction of pain and
there were even a couple days where she would forget about her stomach and go
about her day pain-free. Her energy was slightly improved but she still felt
quite tired most days. Another two weeks
of the same formula were prescribed.
Two weeks later
she returned feeling great. There was an
even greater reduction in the pain (about 80%) and her energy levels were “not
a hundred percent, but getting better”.
Another two weeks worth of formula with the addition of Radix Astragali (Huáng Qí) were
prescribed in hopes that the condition would resolve.
Another two weeks
past and she returned feeling essentially the same as before. Most of the abdominal pain was alleviated except
for a few occasions and her energy levels were slowly improving.
xiǎo chái hú tāng
was prescribed for ten days according to the rule of Clause 100, in the Treatise
on Cold Damage where it states;
“If there is no reduction in symptoms, xiǎo
chái hú tāng governs”.
Hú Xī-Shù offers his interpretation of this passage
in his ‘Discussion and Elucidation on Cold Damage’ (越辩越明释伤寒)[1];
“No reduction of symptoms namely means that after taking xiǎo jiàn
zhōng tāng the abdominal pain is not completely resolved. Now because both xiǎo jiàn zhōng tāng and
xiǎo chái hú tāng symptoms exist, we must first treat the interior and
afterwards the exterior. Since xiǎo jiàn
zhōng tāng only treated half the condition, we must follow up with xiǎo chái hú
tāng to affect a complete resolution of symptoms”
Ten days later my patient returned pain free. She had
not had any abdominal discomfort in over eight days. Her energy has improved and she reported an
overall greater sense of wellbeing. This
was followed with another two weeks of Minor Buplureum decoction (xiǎo chái hú tāng) to consolidate her
condition by resolving Qi stagnation and further supplementing her Spleen and
she was discharged. On follow up almost
one year later, she has not had any major problems with her stomach and the
only time she has any discomfort is following days of overindulgence in foods
that are known triggers for her.
Afterthoughts:
In retrospect I believe that my initial diagnosis of
a Liver-Spleen disharmony was correct, it was my focus and choice of medicinals
that failed to offer a quick resolution of symptoms. As we can see from clause
100 and from the perspective of Hú Xī-Shù, it is clear that the deficiency (of
the central burner) must be addressed first and afterwards the stagnation. As Xú Líng-Tāi says in his Categorization of
Formulas from the Discussion of Cold Damage (伤寒论类方) regarding Minor Centre Fortifying Decoction[2];
“The Yáng Qì
of the office of the centre (burner) is deficient, thereby allowing wood to
overwhelm earth”
What this means to me is that Minor Centre Fortifying
Decoction would in fact address a Liver-Spleen disharmony with emphasis on
supplementation. Once we are able to bank up and entrench earth, wood would no
longer be able to exploit, and as per the original clause, we follow up with a
formula to harmonize Liver and Spleen, resolve Qi stagnation and supplement the
Spleen such as Minor Buplureum decoction (Xiǎo
chái hú tāng).
According to Kē Qín (a Qing dynasty Shang Han expert), Minor Centre Fortifying decoction is a great centre harmonizing pain-relieving formula[3] and proved to be just that in this case.
I believe this case to be a bit of an anomaly as it
fit almost too perfect with Zhāng Zhòng Jǐng’s original line and even responded
to his predictions. I used to believe
that practicing the classics in this day and age was far too difficult and that
pre-modern conditions had nothing to do with the complex, modern maladies our
patients present with today. As I
continue to study the classics and apply them in my day to day practice, I find
that when we truly begin to look at our cases from a different lens we find
these patterns that Zhāng Jī and the great physicians after his time spoke
about and are offered numerous opportunities to utilize them and bring them to
life.
[1]胡希恕越辩越明释伤寒， 冯世纶， 中国中医药出版社， 2009.
[2]伤寒论类方 , 徐灵胎, 清, 公元1759年.
[3]伤寒论翼, 柯琴, 清
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