
Case 3
Name: Chen.
Sex: Female.
Age: 40 years.
Occupation: A peasant.
Chief Complaint: Abdominal distension and diarrhea for 3 years.
History of Present Illness: Three years ago, the patient got abdominal distension and diarrhea from a cold. The stool was formless, loose and looked like soup, accompanied with intermittent abdominal pain. It' s not followed by high fever, nause, vomiting, tenesmus and so on. In the past 3 years, she had been treated by innumerable treatments of TCM and Western medicine, but there was no obvious effect on her. 1 year later, the abdominal distension became severer than before, too much bowel sounds gave her a constant noisy sensation in the abdomen, she became more and more emacited because of her poor appetite. Then she came to me for treatment on February 16,1996.
Physical Examination: The patient was weak and emaciated with a dark grey complexion. The pulse was thready and soggy. The tip of the tongue was fresh red, the root of the tongue was covered with a greasy layer of white fur. There was a kind of special smell in her mouth. There was not other abnormal sign.
Diagnosis: Chronic Enteritis.
Differentiation: It's syndrome of asthenic fire's flaming upward, retention of phlegm in the middle Jiao and downward accumulation of dampness-cold in the lower-Jiao.
Therapeutic Principle: Different treatment according to the theory of Three-Jiao should be used in order to clear away the asthenic fire from the heart and the lung; eliminate pathogenic phlegm from the spleen and the stomach; expell dampness cold evil from the lower Jiao by invigovating the life fire.
Recipe:
DangShen,Pilose Asiabell Root
BaiZhu,Bighead Atractylodes Rhizome
GanJiang,Dried Ginger
HuangLian, Coptis Root
HuangQin,Scutellaria Root
FaBanXia,Pinellia Tuber
ChenPi,Tangerine Peel
HouPu,Magnolia Bark
GouQiZi,Wolfberry Fruit
TuSiZi,Dodder Seed
BuGuZhi,Psoralea Fruit
GanCao,Liquoriee Root
All the above drugs were to be decocted in water for oral taking. She was told to take 5 doses of the above prescription.
Effect Observation: After taking the 5 doses, the bowel sounds were relieved greatly, the stool became formed, the abdominal distension disappeared, the noisy sensation in the abdomen disappeared too. Only occasional bowel sounds could be heard. Then I told her to use the original prescription again and take 5 doses of the prescription.
After 5 days' treatment. No uncomfortable sensation existed. Only the bowel sounds could be heard when she got overexertion or caught a cold. Then she was told to nurse herself well. After 3 months' follow-up, the patient was in good health all along. Then it' s ending.