經方學

Focal distention, golmus, pi, call it what you will, the name is not nearly as important as the illness process that it describes. This is one of those concepts upon which there is a wealth of thought and disagreement. Some say it is a sensation the patient has, others say it is the doctor that feels it through palpation. Some doctors differentiate the pathomechanism very carefully, while others simply say it is discomfort in the stomach area, and leave it at that.

Chen Yi-Ren, who was a rather renown Shang Han Lun doctor from Nanjing has quite a bit to say about focal distention. A future posting will contain a detailed translation of his thoughts on this matter. For now, here is a translation of a brief synopsis that written by one of his students.

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Focal distention is an illness presentation where there is an uncomfortable feeling of fullness and distention in the epigastrium. It occurs due to obstruction and stagnation of the Stomach qi. There are many reasons for this; it can be due to:

• Stomach heat
• cold in the middle
• deficiency of the middle with knotted heat
• deficiency of the middle with fluid obstruction
• water accumulation leading to qi stagnation.

These conditions require analysis from a holistic perspective, in this way the correct patho-mechanism can found and proper treatment given.

Heat focal distention is due to Stomach heat leading to qi stagnation; it is treated by using Rhubarb and Coptis to Drain the Epigastrium Decoction (dà huáng huáng lián xiè xïn täng)
Fx: Rhei Radix et Rhizoma (dà huáng), Coptidis Rhizoma (huáng lián), Scutellariae Radix (huáng qín)
Deficiency cold in the middle congeals the qi and causes stagnation, leading to a deficient cold presentation of focal distention; it is treated using Regulate the Middle Decoction (lî zhöng täng)
Fx: Ginseng Radix (rén shën), Zingiberis Rhizoma (gän jiäng), Atractylodis macrocephalae Rhizoma (bái zhú) and Glycyrrhizae Radix (gän câo)

As for the presentations of the three Drain the Epigastrium Decoctions (xiè xïn täng) based on Pinelliae Rhizoma preparatum (zhì bàn xià), Glycyrrhizae Radix (gän câo), and Zingiberis Rhizoma recens (shëng jiäng), these are for presentations of heat focal distention with other concurrent complications.
Chen Yi-Ren summarized this patho-mechanism as

“deficiency of the middle with heat that knots, thus forming focal distention.”

This is treated by the use of bitter and cold to drain heat, acrid and warm to open knotting, along with sweet and warm to tonify the middle. The three Drain the Epigastrium Decoctions (xiè xïn täng)

Fx: Pinelliae Rhizoma preparatum (zhì bàn xià), Zingiberis Rhizoma (gän jiäng), Coptidis Rhizoma (huáng lián), Scutellariae Radix (huáng qín), Ginseng Radix (rén shën), Glycyrrhizae Radix (gän câo) and Jujubae Fructus (dà zâo)

are actually formed from combining Rhubarb and Coptis to Drain the Epigastrium Decoction (dà huáng huáng lián xiè xïn täng) and Regulate the Middle Decoction (lî zhöng täng) along with minor modifications. As to the rational for removing Rhei Radix et Rhizoma (dà huáng), naturally this is related to the diarrhea from the focal distention’s jumble of cold and heat. As to the removal of Atractylodis macrocephalae Rhizoma (bái zhú) and substitution of Pinelliae Rhizoma preparatum (zhì bàn xià) and Zingiberis Rhizoma recens (shëng jiäng) these are accord with Zhong-Jing’s basic modification methods; as from this line concerning Regulate the Middle Pill (lî zhöng wán)

“For those with frequent vomiting, remove the Atractylodis macrocephalae Rhizoma (bái zhú) and add three liang of Zingiberis Rhizoma recens (shëng jiäng).”

Also the line from Seven-Substance Decoction with Magnolia Bark (hòu pò qï wù täng) states, “For those who vomit, add five he of Zingiberis Rhizoma recens (shëng jiäng).” Methods of decoction and administration are important aspects in the process of treating by differential diagnosis. The decoction and administration methods of the five Drain the Epigastrium Decoctions (xiè xïn täng) each have their own unique clinically valuable characteristics.

As to the diagnosis and treatment of other focal distention presentations, they too need to be examined from a holistic perspective with concrete analysis; there is not just one way of draining the epigastrium.