Abdominal Distension #3 (5 visits) (FBX)
Original case by: Fei Bo-Xiong ((费伯雄)
[1st Visit]: Qi deficiency with fullness of the middle [burner]. The abdomen is distended and resistant to palpation. Both flanks are acutely painful, with focal distension and a stifling sensation in the chest and diaphragm. On getting up [in the morning] the patient feels well, but in the afternoon the stifling feeling becomes worse and the mood depressive. The stools are loose. The pulse is deep and wiry on the right, and wiry and rapid on the left. [Treatment will not be successful] unless one regulates and extends [the qi dynamic].
Citri reticulatae Pericarpium (chén pí)3g, Pogostemonis/Agastaches Caulis (huò xiäng gêng) 4.5g, Polyporus (zhü líng) 9g, Poria rubra (chì fú líng) 9g, Arecae Pericarpium (dà fù pí) washed in alcohol 6g, Perillae Caulis (zî sü gêng), 6g, Alismatis Rhizoma (zé xiè) 6g, Amomi Fructus rotundus (bái dòu kòu) (pounded and with kernels removed) 2 pcs, Asari Radix et Rhizoma (xì xïn) 0.6g, burnt Atractylodis Rhizoma(cäng zhú) 3g, Trichosanthis Pericarpium (guä lóu pí) 9g, Toosendan Fructus (chuän liàn zî)6g, Zingiberis Rhizomatis Cortex (shëng jiäng pí) 6g
2nd Visit: The abdominal distension is reduced and more comfortable, and the chest also feels more relaxed. I follow the above strategy with some modifications.
Paeoniae Radix alba (bái sháo) 6g, Aurantii Fructus (zhî ké) 3g, Schisandrae Fructus (wû wèi zî) 1.5g, Glycyrrhizae Radix preparata (zhì gän câo) 1.8g, Trichosanthis Pericarpium (guä lóu pí) 9g, Zingiberis Rhizomatis Cortex (shëng jiäng pí) 6g, Perillae Caulis (zî sü gêng), 6g, Pogostemonis/Agastaches Caulis (huò xiäng gêng) 6g, houpi 4.5g, Bupleuri Radix (chái hú) 9g, Acanthopanacis Cortex (wû jiä pí) 6g, Arecae Pericarpium (dà fù pí) washed in alcohol 9g, Citri reticulatae Pericarpium (chén pí) 3g, Mori Cortex (säng bái pí) 9g, Poriae Cutis (fú líng pí) 9g, Corydalis Rhizoma (yán hú suô) 6g
3rd Visit: The abdominal distension continues to be dispersed, the pulse also is gradually coming to 醒 [awakening-JB], the tongue coating has changed, from which the generally [positive] momentum [of the treatment] can be determined. I continue with clearing and dredging.
The previous prescription plus Adenophorae Radix (nán shä shën) 6g, Glehniae Radix (bêi shä shën) 6g, honey-fried Farfarae Flos (kuân döng huä) 6g, Benincasae Exocarpium (döng guä pí) 9g, Aucklandiae Radix (mù xiäng) 1.5g, Amomi Fructus (shä rén) 3g, Akebiae Caulis (mù töng) 4.5g Citri reticulatae viride Pericarpium (qïng pí) 3g, Zanthoxyli Pericarpium (huä jiäo) 2.4g
4th Visit: The abdominal distension has further decreased from the previous visit, chest and upper abdomen are also more comfortable. Only, the [patient’s] strength remains insufficient so that he finds it difficult to walk. [The appropriate strategy] is to support earth and build up the original [qi].
Angelicae sinensis Radix (däng guï) 6g, Chuanxiong Rhizoma (chuän xiöng) 3g, burnt Atractylodis macrocephalae Rhizoma (bái zhú) 4.5g, Poriae Cutis (fú líng pí) 9g, honey-fried Astragali Radix (huáng qí) 4.5g, Citri reticulatae Pericarpium (chén pí) 3g, Zingiberis Rhizoma recens (shëng jiäng) 1 slice, Dendrobii Herba (shí hú) 9g, Citri reticulatae Exocarpium rubrum (jú hóng) 2.4g, fried Paeoniae Radix alba (bái sháo) 4.5g, Dipsaci Radix (xù duàn) 9g, Glycyrrhizae Radix preparata (zhì gän câo) 3g, Zanthoxyli Pericarpium (huä jiäo) 3g, Jujubae Fructus (dà zâo) 3 pcs
5th Visit: The abdominal distension has been removed, the qi dynamic has also been woken up. Merely walking is still [made difficult] by lack of strength. I continue [treatment] by building up earth and nourishing yin.
Glycyrrhizae Radix preparata (zhì gän câo) 3g, Jujubae Fructus (dà zâo) 3 pcs, Zingiberis Rhizoma recens (shëng jiäng) 2 slc, Codonopsis Radix (dâng shën) 6g, Moutan Cortex (mû dän pí) 6g, Pinelliae Rhizoma preparatum (zhì bàn xià) 4.5g, Corni Fructus (shän zhü yú) 6g, Poria (fú líng) 9g, burnt Atractylodis macrocephalae Rhizoma (bái zhú) 6g, Achyranthis bidentatae Radix(niú xï),6g, Citri reticulatae Exocarpium rubrum (jú hóng) 3g
** Translated by: Volker Scheid
Volker’s Commentary: This is one of a small number of case records by FBX documenting a succession of visits. The case series is also instructive regarding the amount of information supplied at each successive stage. This focuses almost entirely on those symptoms that are actually treated, i.e. considered most important by the physician, rather than on the overall picture. Thus, we only learn on the fourth visit that the patient feels weak and has difficulty in walking, while the precise nature of the pulse and tongue signs are left implicit throughout. It is expected that the experienced reader will be able to deduce them from the presentation. Yet, they are nevertheless important to the clinician in as much as that they confirm changes taking place in the body beyond surface symptoms and signs.
The strategies employed over the course of the five visits narrated here follow a conventional pattern that gradually moves from a focus on draining pathogenic qi to one of tonifying deficiency. At the first visit, the elimination of water qi excess by promoting the qi dynamic of the Triple Burner through the Lungs, Spleen/Stomach and particularly the Bladder is the clear priority. For this purpose, a combination of Five-Ingredient Powder with Poria (wû líng sân), Five-Peel Drink (wû pí yîn), and Calm the Stomach Powder (píng wèi sân) are used. Flank pain indicating stagnation in the Liver channel is cleared by means of Toosendan Fructus (chuän liàn zî), a herb that drains excess from the Liver channel via the Small Intestine; while Asari Radix et Rhizoma (xì xïn) is added to an overall somewhat cooling formula to support the fire of the gate of vitality.
At the second visit, once the edema has been reduced, the focus shifts to the Lungs and middle burner via a modification of Minor Bluegreen Dragon Decoction (xiâo qïng lóng täng). This is complemented by a more forceful regulation of Liver qi by means of combining Frigid Extremities Powder (sì nì sân) with Melia Toosendan Powder (jïn líng zî sân), allowing clear yang to rise and turbid yin to be directed downward.
The role of the Lungs as the upper source of water, and by implication yin, is emphasized in the third prescription, with the inclusion of tonifying herbs for the upper burner. This further enhances the curtailing of Liver qi by exploiting the controlling relationship of the five phases cycle. Zanthoxyli Pericarpium (huä jiäo) here is a specific herb for cold water qi in the Liver channel.
During the fourth visit, the focus of tonification shifts to the middle burner and constructive blood, with a formula based on Tangkuei and Peony Powder (däng guï sháo yào sân); while the fifth formula moves this focus even further inward towards the Liver visceral system by way of combining Six-Gentleman Decoction (liù jün zî täng) with a modified Six-Ingredient Pill with Rehmannia (liù wèi dì huáng wán).
Viewed together this case series underlines the sophistication of FBXs strategic thinking and his ability to view and address a pathological process from different positions. The emphasis on the bowels, as places through which stuff is moved, is gradually substituted by one on the viscera, as places where essences are stored. At the same time, the treatment also moves in a circular fashion following the qi dynamic from an initial focus on the lower burner Bladder, as the organ where water is transformed and excreted, to one on the upper burner, where water is collected. From there, it moves downward again via tonification first of the Lungs and the jin fluids, then the qi, constructive and blood, and finally the Liver.
This emphasis on treating the Liver is another very interesting aspect of the case. At the most simple level, this can be explained symptomatically: initially because of pain in the flanks as a manifestation that water qi is obstructing the Liver channel; and later because of the association between Liver blood and the muscles and sinews. A more sophisticated understanding is that water and qi, fire and blood continuously produce and interpenetrate each other, and that this movement and interpenetration is facilitated by the function of the organ systems. Just as the Lung qi controls the movement of water downward, Liver blood reigns in the upward rushing of yang qi. Obstruction, constraint and blockage in one system will have repercussions in the other and vice versa. Hence, even as the treatment process focuses on water qi, it always also addresses ministerial fire and blood. Furthermore, precisely because it is located in the middle burner, anchoring both the ascending and directing downward of qi, water and fire, the functions of Spleen/Stomach earth are crucial to the water metabolism. This is succinctly summarized one generation later by Tang Zonghai in Discussion of Blood Patterns:
“Blood is produced from Heart fire and stored below in the Liver. Qi is produced from Kidney water and is controlled above by the Lungs. In between, the activator of the rising and falling is the Spleen.”
Finally, this sequence of treatment episodes convincingly showcases FBX’s intent as well as ability to break through existing boundaries in the Chinese medical tradition. Almost all prescriptions used are built around formulas from the Discussion of Cold Damage, often combined with formulas from the Song or Jin-Yuan periods. However, the thinking that informs their composition, specifically the emphasis placed on the functions of the Triple Burner and the Lungs in regulating the water metabolism are clearly borrowed from the warm pathogen disorder current and physicians such as Ye Tianshi and Xue Shengbai. The ingenuity of this synthesis was unique at the time, and is not seen often in the case record literature even today.
** For more reading on Fei Bo-Xiong, please look for Volker’s upcoming book from Eastland Press. Its working title is, “Menge Medicine, Vol. 1, Fei Boxiong’s Refined Medicine Remembered with Commentaries and Fei Family Case Histories”
