Abdominal Distension #4 (FSF)

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Case from Fei Sheng-Fu (费绳甫)

Mr. Wu from northern Jiangsu [suffered] from Liver wood encroaching the Spleen until only it’s [qi] was present in the abdomen 致成單腹. The abdomen was distended like a drum, the umbilicus protruded outward, the tendons were blue. The back was normal but the waist full. This constituted a dangerous pattern. In this situation [the appropriate strategy] is to curb wood and support earth, unblock with warming [medicinals], and leach out dampness. Prescription was:

Aconiti Radix lateralis preparata (zhì fù zî) 12g
Atractylodis macrocephalae Rhizoma (bái zhú) 4.5g
Poria (fú líng) 9g
Angelicae sinensis radicis Corpus (däng guï shën) 4.5g
Cinnamomi Cortex (ròu guì) 1.5g
Citri reticulatae Pericarpium (chén pí) 3g
Arecae Semen (bïng láng) 4.5g
Magnoliae officinalis Cortex (hòu pò) 3g
Amomi Fructus rotundus (bái dòu kòu) 3g
Citri reticulatae viride Pericarpium (qïng pí) 4.5g
Aurantii Fructus immaturus (zhî shí)) 3g
Benincasae Semen (döng guä zî) 12g
Plantaginis Semen (chë qián zî) 6g
Arecae Pericarpium (dà fù pí) 6g
Sorghum (shú mî) 14 seeds
Coicis Semen (yì yî rén) 30g

** Translated by: Volker Scheid

Volker’s Commentary: Read together with the previous case, this record from FSF’s case histories further illustrates the importance of the middle burner at the centre of the qi dynamic and of fluid metabolism. The situation is described as dangerous because both the qi and yang of the middle burner have collapsed. Movement and transformation have come to a standstill, hence the position of earth is seized by wood. This is visibly manifest in the protruding umbilicus, representing Spleen earth, which is pushed upwards by Liver qi. The treatment therefore is aimed directly and only at the middle burner employing a combined strategy of warming in order to reignite transformative process, acrid downward moving in order to break up stasis, and leaching out of excess dampness from the middle burner. The core formula used for this purpose is modified Bolster the Spleen Drink (shí pí yîn), which in turn builds on True Warrior Decoction (zhën wû täng) and Three-Substance Decoction with Magnolia Bark (hòu pò sän wù täng). Even here, however, FSF takes account of the role and relation between Liver and Lungs, qi and blood. This explains his use of Angelicae sinensis Radix (däng guï) , on the one hand, and of Benincasae Semen (döng guä zî) and Coicis Semen (yì yî rén) on the other, which together with Amomi Fructus rotundus (bái dòu kòu) and Magnoliae officinalis Cortex(hòu pò) suggest the intention of Three-Seed Decoction (sän rén täng).

Thus, like his grandfather, FSF skillfully interweaves cold damage and warm pathogen strategies to realize the principles of harmonization and moderation even in a strongly warming and draining prescription.”

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  • Matthew VW

    Could one approach involving a triple burner issue involve nourishing Kidney yang by supplementing Kidney Yin/Jing? This would calm the aggravated Kidney yang which is directly involved in the control of the Triple Burner qi. The water channels would then be controlled appropriately. If necessary, the earth element could than be supported. What do you think? It has been said that there are many angles that one could approach a situation. I guess it all depends upon the “best approach.” What do you think about creative approaches? This involves an emotional/mental involving the metal element. (The metal element being creativity)

    • Jason Blalack

      Thanks for the comment and I will do my best to give you my two cents. One of the best ways to approach case studies is not try to guess what you would do, but more importantly try to figure out why this famous doctor did what he did. Quite simply, you’ll never know if the strategy is correct.

      However we can think through your theory and evaluate that. First, I do not understand why you consider this a triple burner issue and want to address the Kidney yang through supplementing Kidney Yin and Jing. From the case itself it says that this is a wood and earth pattern, therefore it makes sense to address it from this perspective as Fei does. I see no reason to look beyond that.

      I would like to discuss the idea that’there are many angles to approach a given situation.’I am actually not inclined to think this way and do believe there is a “best approach.” Actually, Qin Bo-Wei discusses this and points out that doctors may actually consider different symptoms as starting points for their diagnostic process, however if one’s methodology is sound then everyone in the end should come up with the same diagnosis.

      Of course, if you compare diagnostic results from a strict cold damage practitioner, a strict warm disease and another Earth School practitioner then most likely they all will have different approaches. However, it is my opinion that there is one superior approach; however it is impossible to know which one. However Qin’s point is that doctors that are schooled in a well-rounded Chinese medicine approach will have access to all of these approaches, and should be able to systematically figure out which one is best. Hence 10 doctors should come up with the same answer. Formulas will of course vary much more than diagnosis and treatment principles.

      Too often in the West we hear that if you get 10 practitioners in the room you will get 10 diagnostic answers and all of them can be correct. Because we favor creativity over core theoretical knowledge and rigor we often see all sorts of diagnostic and pathodynamic ideas emerge when explaining cases. Hence everyone can be right and we get 10 correct answers. I think this is incorrect and only further perpetuates a lack of rigor that we often see here in the West.

      I agree with Qin Bo-Wei, there’s a correct way of thinking when approaching diagnosis. Anyone should be able to follow this process and come up with the same diagnosis. We do not need to be overly creative and make up our own theoretical constructs, but follow what others have done in the past.

      I would love to hear other peoples’ opinion on this topic…

  • Giusi

    I think this is a bit of a tricky one because, as Jason said, to a certain extent it is impossible to find out what approach is best so you might argue that all are. However, I believe that there should be an area of agreement which allows some flexibility. You might use different words to make your diagnosis but ultimately we should be doing pretty similar things when it comes to treatment principles and strategies. To go back to the first comment, I think the whole kidney approach is far out and I don’t see any connection to the original text. In my opinion, that is reading something that is not there and perhaps it is more humble to try to understand the intentions of the original author first and only then question it.

  • Matthew VW

    Mr. Guisi,

    My intentions were not to arrogantly question the original author’s expertise. I was simply posing a question that came to me intuitively. I am still learning and am trying to see where my thoughts are in relation to those that are much more skilled than I am. The idea was posed with the intent of learning and not proving anything. However, I do see where you are coming from and appreciate your suggestions as well.

  • Douglas Eisenstark

    Jason, your comments about the fuzziness of 10 different diagnosis seems unfair here. In this case we have 3 different aspects to a diagnosis and a combination of 3 or more formula ideas. As one of those formulas includes, or is “built upon”, Zhen Wu Tang, then it is a matter of which aspect of the diagnosis to emphasize. In fact, here all are taken equally, I have no doubt that it worked and glad for everyone but doesn’t seem to be a case of an elegant and straight forward solution.

    • Jason Blalack

      Hi Doug,

      I am glad we can talk about this idea and maybe I can clarify or change my point of view. However, I am really not sure of your point and would like some further explanation on your idea. There are two aspects to discuss. 1. The diagnosis, 2. the formula.

      The diagnosis is very straightforward, and in my opinion the formula fits the diagnosis quite well. My comment specifically is referring to diagnosis. Since we do not have much information about this case this issue is hard to discuss, however the diagnosis is given to us. The diagnosis is Liver encroaching the Spleen. This really is a single diagnosis. Of course there is always additional aspects to treat when one writes the formula and designs the treatment principles. For example, damp often occurs in such patterns, therefore he states one must 1. Curb wood, 2. Support Earth (by warming), and 3. Leach out dampness. These principles fit perfectly with the diagnosis and constitute a single idea.

      However, even if there happens to be multiple aspects of a case there should be a rationale thinking for this process of naming them. That is, 10 doctors should not come up with 10 diagnosis. Once the diagnosis is set, each doctor may select different herbs and may choose to emphasize different aspects of the diagnosis/treatment principle. This is quite normal. However, I do not consider these separate diagnosis (maybe that was not clear before). For example, I consider a “separate/different” diagnosis, something along the lines of, Kidney yin and yang deficiency, liver qi constraint leading to heat, damp heat in the middle burner, etc.

      It is hard to imagine how anyone could come up with these (diagnosis) in this case (because there is not much information and the diagnosis is given), but the point is important for cases when more thorough information is given. Too often, people base their whole diagnosis around only one or two symptoms, instead of seeing the interrelationship of these to the underlying pathodynamic. Hence we arrive at very differing approaches. One will treat the Heart and another the Stomach and another the Liver. This I feel is incorrect. There is a correct answer.

      It’s also quite normal to take multiple formula’s ideas/herbs and combine them into one formula addressing the full presentation. This is precisely how I practice and find that it is extremely flexible in addressing the individual and not just the pattern. The key is staying focused on the treatment principles, within that one can have quite a bit of individual expression due to their knowledge base and personal style.

      I have no comment about the formula’s “elegance”, however I do like, and it makes complete sense to me. It has a clear focus based on the diagnosis and treatment principles.
      So I guess I should ask, do you think in such a case you (or any case) one could have ten different diagnosis that are correct? If so, please explain bit. However, if I have missed your point, please feel free to elaborate.

  • Douglas Eisenstark

    It’s a matter of what one considers diagnosis. Is it a listing of “everything wrong” or the key that triggers all the other symptoms. So a matter of ben and biao in many cases. What I mean by elegance is finding the latter and treating this. So in Volker’s description there is the start of a core formula yet the final formula then ends up treating the branches as well.
    One could also see elegance in treating along the 5 phases whereas the obvious is relegated in a sense to biao and a different phase is the core. So my disagreement is with your statement. “Too often, people base their whole diagnosis around only one or two symptoms, instead of seeing the interrelationship of these to the underlying pathodynamic. Hence we arrive at very differing approaches. One will treat the Heart and another the Stomach and another the Liver. This I feel is incorrect. There is a correct answer.”
    Obviously writing formulas based on symptoms is not great however I see a disconnect with your following sentence.
    Don’t get me wrong, there is a place for elegance and there is a place for “down and dirty’. As I said before I’m sure the patient got better with this formula and I applaud the doctor who wrote the formula.

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