By Robin Marchment
I am offering this case study as encouragement for all in our profession as we proceed with often unheralded successes in areas where Western medicine has heroic, but sometimes less acceptable solutions. To quote one of The Lantern editors: “It is always important to remind everyone – ourselves included – what is possible with Chinese medicine.” I was privileged in this case to have the complete confidence of my patient and her faithful compliance with treatment, and especially fortunate to be provided with the report from a post-treatment Western medical screening, which substantiated the results.
The case is all the more rewarding for its confirmation of the efficacy of the classic Chai Hu Tang formulas and their modifications, thereby confirming both the basic principles of Chinese medicine theory and the conceptual brilliance of jing fang (classic formulas). As you will see, the reference in the title to “a bitter taste in the mouth” is as much a reference to the conduct of the surgeon involved as it is to the bitter taste associated with Gall Bladder fire.
History:
On Friday night, October 12, 2007, the patient was admitted to a reputable private hospital in the outer eastern suburbs of Melbourne suffering from acute cholecystitis, otherwise known as a “gallbladder attack”. She had felt nauseous when eating lunch, but put it down to food sensitivity. As the afternoon progressed, the nausea increased and she experienced breathlessness, a hot sensation with intermittent chills, a bitter taste in the mouth and an episode of bilious vomiting alternating with diarrhea that lasted 15–20 minutes, and she experienced severe shooting pain from under the ribs in the front of the body, radiating to the back and legs. She was hospitalised and put on an antibiotic drip. An ultrasound showed enlargement of the gallbladder with thickening of the wall but no stones; it was suggested that they might already have passed.
The pain and the feverish sensation, which was interspersed with chills, gradually subsided by the next day. The patient was advised to have surgery to remove the gallbladder, but did some research and made an informed and carefully considered choice not to have surgery. In the process of arriving at this decision, the patient felt that the surgeon in charge of her case failed to provide relevant information, even when asked, and reported a number of aspects of his management that were less than satisfactory:
a) The surgeon did not explain the potential negative outcomes of surgery and dismissed the patient’s query in an off-hand manner, saying that “we never know what is going to happen – you could be hit by a truck tomorrow”. The patient was disturbed to discover later that up to 30 per cent of cholecystectomies result in post-cholecystectomy syndrome (Davison’s Principles and Practice of Medicine).
b) When the patient tried to discuss the options of acupuncture or herbal medicine with him, the surgeon derided alternative medicine, thus potentially depriving the patient of viable options that have an extensive history of clinical efficacy, confirmed by contemporary research.
c) On the Sunday, two days after admittance to hospital, the patient told the surgeon she did not want the operation. He told her he had an empty spot the next day and would see her in the morning.
d) In spite of having made it clear that she did not want surgery, on the Monday, a nurse came to the patient’s ward to prepare her for anaesthesia. The patient explained there was to be no surgery and was later visited by the surgeon. Rather than respect her decision and provide advice for future management, he told her there was a possibility of her developing cancer and left the room.
In this last meeting, the surgeon failed his patient in two ways: firstly, his comment that she might have cancer was a backlash calculated to frighten her; secondly, he failed to explain that should she have a repeat acute episode in the future, an emergency procedure to remove the gallbladder would involve a major abdominal incision as opposed to key-hole surgery. Does this not leave a bitter taste in the mouth? After discharging herself from the hospital, she saw her family GP who provided her with better information, reassured her that the risk of cancer was very remote, and was supportive of alternative treatment.
Initial consultation: 16.10.2007
The patient came to see me the day after her discharge. She was 41 years old, active, full of energy, normally healthy, with a bright personality, intelligent and talkative. She told me of a serious water contamination problem in her area some two to three months previously, which had resulted in nausea and bronchitis, but which had been dismissed as a possible cause. At the time of the attack, the main symptoms were breathlessness, alternating fever and chills, a bitter taste in the mouth, vomiting and diarrhoea lasting 15-20 minutes, and severe pain radiating from the hypochondrium.
The Western medical reports showed the gallbladder to be distended and non-functional. The bile duct and hepatic ducts were also enlarged.
Her stool was normal, her menstruation regular but dark, with clots, and brown towards the end. She was a bit of a night owl, sometimes feeling anxious and unwilling to sleep, had a dry mouth and occasional nausea. Over the past few months, from time to time, she had experienced tightness in the chest causing difficulty breathing.
When I saw her at the initial consultation, she still felt queasy with occasional nausea, her tongue was small with stasis spots in the centre; the coat was white and slightly greasy, with none on the sides. Her Kidney pulse was weak and fine, the Liver pulse was knotted and the Spleen pulse wiry yet empty. I had known this patient for many years, and it is of interest to note that she had always had an underlying “fire” constitution, manifesting as great enthusiasm and excitement, rapid speech and an unwillingness to sleep at night. This constitutional base would have contributed to the development of fire in the Gall Bladder channel. As a sensitive and informed person, she was alert to health concerns, which heightened her anxiety.
The bitter taste experienced a few days before was evidence of fire generated by constraint in the Gall Bladder. The lingering nausea was a direct result of the Gall Bladder and Liver disharmony harassing the Stomach. The wiry pulse indicated stagnation and was a reflection of the Liver and Gall Bladder disharmony; the emptiness of the Spleen pulse showed qi deficiency not only due to “Wood attacking Earth”, but equally due to the failure of the Liver and Gall Bladder to support the transformation and transportation function of the Spleen. In addition, the menstruation showed evidence of pre-existing stasis (clots) and deficiency (the brownish colour of the menses at the end). The location of the stasis spots in the centre of the tongue may seem anomalous; however, although the tongue margins are generally regarded as relating to the Liver and Gall Bladder, Chinese medical theory generally ascribes the Gall Bladder to the middle jiao, and therefore, although the location of the disease is primarily the Gall Bladder, we should not necessarily expect the stasis spots to occur at the tongue margin.
The patient’s signs and symptoms (breathlessness, alternating fever and chills, nausea and a bitter taste) pointed to a shao yang disharmony or Xiao Chai Hu Tang (Minor Bupleurum Decoction) pattern. This, interestingly, coincided with the Western view of the pathology as being an inflammation of the gallbladder having disturbed the proper function of the digestive system.Translated into Chinese medicine terms this can be interpreted as Gall Bladder fire having disrupted the middle qi dynamic. The treatment principle was to harmonise the shao yang by calming the Liver, harmonising the middle qi, clearing fire and toxicity from the Gall Bladder and invigorating blood. Although Da Chai Hu Tang (Major Bupleurum Decoction) is a formula often used for cholecystitis, treatment must be according to the pattern and not the disease name: the pulse was wiry but not forceful, the diarrhoea and vomiting were transitory with the stool returning to normal after the attack, and there being no further vomiting. The tongue coat was not yellow, and even on the day of the attack there was no irritability, the episode of diarrhea and vomiting was limited, and the pain and distension was focused in the chest and hypochondrium rather than the epigastrium. Based on this presentation, Xiao Chai Hu Tang was indicated rather than Da Chai Hu Tang.
Acupuncture points used during the course of treatment were: Zusanli (ST-36) and Sanyinjiao (SP-6) to descend qi, cool blood, calm the mind and harmonise the middle and support the zheng qi; Yanglinquan (GB-34) and Taichong (LIV-3) to clear heat from the Liver and Gall Bladder and to spread qi and eliminate stagnation; Neiguan (P-6) to harmonise the Liver and Spleen and ease nausea, and also to ease anxiety; Yintang to calm the mind. Ququan (LIV-8) was also used on one occasion to nourish Liver yin.
All formulas were dispensed from single concentrated granules but the equivalent raw herb dose has been given to avoid any confusion that may be caused by concentration ratios. The initial herbal formula was given for five days as follows:
Chai Hu 6g Bupleuri Radix
Huang Qin 7.5g Scutellariae Radix
Ban Xia 12g Pinelliae Rhizoma
Chen Pi 4g Citri reticulatae pericarpium
Dang Shen 5g Codonopsis Radix
Long Dan Cao 6g Gentianae Radix
Pu Gong Ying 22g Taraxaci Herba
Wu Wei Zi 5g Schisandrae Fructus
Zhu Ru 8g Bambusae Caulis In Taeniam
Dan Shen 4g Salviae Miltiorrhizae Radix
Yu Jin 10g Curcumae Radix
Sheng Jiang 4g Zingiberis Rhizoma Recens
Zhi Gan Cao 2.5g Glycyrrhizae Radix Prep.
Explanation:
This combination of herbs satisfied the dual objective of harmonising the Stomach to ease the nausea, and relieving toxic fire from the Gall Bladder in order to eliminate what, from the Western perspective, would be described as inflammation. Given the severity of the pain and other symptoms, there was naturally also some degree of anxiety; by alleviating the anxiety, recovery could be enhanced. The herbs in the core formula serve to restore the qi dynamic by dispersing stagnant qi and harmonising and strengthening the middle qi: Chai Hu (Bupleuri Radix) and Huang Qin (Scutellariae Radix) both enter the Gall Bladder, soothe the Liver and clear heat; Ban Xia (Pinelliae Rhizoma) and Sheng Jiang (Zingiberis Rhizoma Recens) harmonise the Stomach; Dang Shen (Codonopsis Radix) strengthens the middle qi and thus supports the zheng qi.
The modifications aimed to clear toxicity, reduce swelling, ease the nausea and relieve anxiety: Long Dan Cao (Gentianae Radix), and Pu Gong Ying (Taraxaci Herba) drain toxic fire from the Liver and Gall Bladder because Huang Qin by itself would have been inadequate; Wu Wei Zi (Schisandrae Fructus) conserves and generates fluids consumed by the fire and also calms the mind; Zhu Ru (Bambusae Caulis In Taeniam) assists Ban Xia (Pinelliae Rhizoma) and Sheng Jiang (Zingiberis Rhizoma Recens) in harmonising the Stomach to reduce nausea; Dan Shen (Salviae Miltiorrhizae Radix) and Yu Jin (Curcumae Radix) both enter the Liver and invigorate blood, thereby reducing the swelling in the gallbladder and restoring its function. Wu Wei Zi (Schisandrae Fructus), Yu Jin (Curcumae Radix) and Dan Shen (Salviae Miltiorrhizae Radix) have all been shown by modern research to restore the function of the liver and gallbladder, moderate enzyme levels and all have the additional action of calming the mind, thus enhancing the overall effect of the treatment.
Second consultation: 22.10.2007.
The day after the initial consultation (and before finishing the five-day course of herbs), the patient had seen a gastro-enterologist who was of the opinion that a stone had probably already been passed. He told her that the wall of the gallbladder was still thickened, the gallbladder was not functional, and that more stones could develop. At this second consultation, she reported that she felt thirsty, had slight nausea on waking and that her sleep had improved. The tongue coat was still greasy and the sides of the tongue uncoated. The pulse was moderate and wiry, fuller on the left hand side and deep on the right hand side, reflecting the disharmony between Liver and Spleen. A formula similar to the first one was dispensed for 10 days as follows:
Chai Hu 3.5g Bupleuri Radix
Bai Shao 7g Paeoniae Radix Alba
Huang Qin 6.5g Scutellariae Radix
Shi Chang Pu 10g Acori Tatarinowii Rhizoma
Qing Pi 5g Citri Reticulatae Viride Pericarpium
Dang Shen 6g Codonopsis Radix
Fu Ling 10g Poria
Ji Nei Jin 9g Gigeriae Galli Endothelium Corneum
Bai Jiang Cao 15g Patriniae Herba
Yu Jin 10g Curcumae Radix
Jin Qian Cao 14g Lysimachiae Herba
Da Huang 2g Rhei Radix et Rhizoma
Zhi Gan Cao 3g Glycyrrhizae Radix Prep.
Explanation:
The essence of the formula was unchanged, but more focus was given to reducing the toxic swelling of the gallbladder and eliminating stagnation, the objective being to restore function and forestall the formation of more stones. Shi Chang Pu (Acori Tatarinowii Rhizoma) replaced Ban Xia (Pinelliae Rhizoma) to harmonise the middle and resolve turbidity: this herb is indicated for fullness in the chest and epigastrium and also calms the mind. Qing Pi (Citri Reticulatae Viride Pericarpium) was added to break stagnant qi and dissipate clumps; it is useful for distension or pain in the hypochondrium. Fu Ling (Poria) was added to tonify the Spleen and resolve damp. Ji Nei Jin (Gigeriae Galli Endothelium Corneum) reduces food stagnation and secures essence. Bai Jiang Cao (Patriniae Herba) clears toxic heat, dispels stasis, reduces swelling and eases pain. Jin Qian Cao (Lysimachiae Herba) clears damp-heat in the Liver and Gall Bladder, reduces toxic swelling and expels stones. Da Huang (Rhei Radix et Rhizoma) was given to invigorate blood and purge toxicity, but the dose was kept small because there was no constipation.
Third consultation: 26.10.2007.
The third consultation was brought forward in response to some uncomfortable symptoms. The patient reported a sensation of blockage in the epigastrium, which then descended to the lower jiao. She experienced tightness in the chest causing difficulty breathing. This was a stronger version of what she had experienced from time to time over the previous six months, in response to eating animal protein or hard-to-digest food. The breathlessness had eased that morning. The tongue was slightly red, and the coat was dirty in the centre. The pulse was slippery but not strong and was tight on the right hand side. She had taken only a few days of the herbs. To the remaining herbs I added:
Bing Lang 10g Arecae Semen
Hou Po 8g Magnoliae Officinalis Cortex
Zhi Shi 8g Aurantii Fructus Immaturus
Da Huang 4g Rhei Radix et Rhizoma
Yin Chen 8g Artemisiae Scopariae Herba
These herbs combined with those remaining made eight days of formula.
Explanation:
These herbs regulate qi and have a descending action. Bing Lang (Arecae Semen), Zhi Shi (Aurantii Fructus Immaturus) and Sheng Da Huang (Rhei Radix et Rhizoma) purge and drain downwards and eliminate food stagnation by unblocking the bowels; Hou Po (Magnoliae Officinalis Cortex) transforms damp and descends rebellious qi, thus easing nausea and the stifling sensation in the chest; Yin Chen (Artemisiae Scopariae Herba) clears damp-heat from the Liver and Gall Bladder and also resolves nausea and a stifling sensation in the chest.
Fourth consultation: 5.11.2007.
The patient reported that the herbs took effect a couple of days after the last visit, producing two stools a day instead of one, but not urgent. The stool seemed to contain dark brown granules resembling coffee grounds. There was no more chest tightness or breathing difficulties.
She had lost 4kg since the gallbladder attack due to queasiness, which was now easing. The tongue was pale red, the coat was slightly greasy in the centre of the tongue, but the sides were uncoated. The pulse was deep and wiry. I prescribed 10 days of formula very similar to the previous one:
Chai Hu 4g Bupleuri Radix
Bai Shao 8g Paeoniae Radix Alba
Huang Qin 7g Scutellariae Radix
Dang Shen 10g Codonopsis Radix
Ban Xia 10g Pinelliae Rhizoma
Xiang Fu 10g Cyperi Rhizoma
Yu Jin 8g Curcumae Radix
Bai Jiang Cao 12g Patriniae Herba
Bing Lang 10g Arecae Semen
Yin Chen 12g Artemisiae Scopariae Herba
Ji Nei Jin 8g Gigeriae Galli Endothelium Corneum
Jin Qian Cao 20g Lysimachiae Herba
Da Huang 4.5g Rhei Radix et Rhizoma
Gan Cao 2g Glycyrrhizae Radix
Explanation:
Xiang Fu (Cyperi Rhizoma) was added to regulate the Liver qi and support the digestion. Zhi Shi was omitted.
Fifth consultation: 15.11.2007.
The patient had had some stress during the week and had eaten some goat’s cheese that caused a painful knot in the gallbladder region. Shan Zha (Crataegi Fructus) 10g was added to the previous formula and 10 days worth was dispensed.
Explanation:
Shan Zha (Crataegi Fructus) resolves food stagnation and invigorates blood; it has also been found to metabolise fats and cholesterol.
Sixth consultation: 7.12.2007.
The patient reported feeling good for the past three weeks, with the exception of having knots in the hypogastrium for one to two days after eating a lamb chop. She also found she felt sluggish after eating yoghurt. The same formula as for the fifth consultation was dispensed for 10 days.
Seventh consultation: 21.12.2007.
The patient reported feeling generally well, but had been nauseous two days previously, and occasionally felt tender in the region of the gallbladder. Ten days of formula were prescribed as follows:
Chai Hu 4g Bupleuri Radix
Bai Shao 8g Paeoniae Radix Alba
Huang Qin 6g Scutellariae Radix
Shi Chang Pu 8g Acori Tatarinowii Rhizoma
Cang Zhu 6g Atractylodis Rhizoma
Hou Po 8g Magnoliae Officinalis Cortex
Yu Jin 10g Curcumae Radix
Bing Lang 10g Arecae Semen
Ji Nei Jin 8g Gigeriae Galli Endothelium Corneum
Jin Qian Cao 20g Lysimachiae Herba
Bai Jiang Cao 12g Patriniae Herba
Fu Ling 10g Poria
Zhi Shi 8g Aurantii Fructus Immaturus
Da Huang 4.5g Rhei Radix et Rhizoma
Gan Cao 2g Glycyrrhizae Radix
Explanation:
This formula is a composite of earlier formulas, focusing on harmonising the Stomach and clearing toxic heat and swelling from the gallbladder. Fu Ling (Poria) was included to benefit the Spleen. The use of Cang Zhu and Hou Po reflect their function in the formula Ping Wei San (Calm the Stomach Powder).
Follow-up: The patient had an ultrasound in March 2008. The findings were as follows:
The gallbladder is of normal appearance. There is no evidence of cholelithiasis or cholecystitis. The gallbladder wall is not thickened and there is no free pericholecystic fluid. Murphy’s sign is negative.
The liver demonstrates a normal homogeneous echotexture with no focal abnormality. The common bile duct is not dilated, measuring 3mm and there is no evidence of hepatic duct dilation.
The spleen, pancreas and kidneys are of normal size and appearance. The right kidney measure 10.4 and the left 9.2 cm in bipolar length. No hydronephrosis or focal intrarenal lesions demonstrated.
No free fluid is seen in the abdomen.
Conclusion: Normal examination.
Reflections:
The Western protocol for cholecystitis is cholecystectomy, this being based on the perceived probability of repeated attacks. In this case, the patient had the satisfaction of avoiding surgery and its after-effects, and also of procuring treatment that completely restored the function of the liver and gallbladder, thus minimising the risk of potential attacks in the future. This case demonstrates the efficacy of Chinese medicine when used according to age-old principles and is an example of a classic formula being adapted for contemporary clinical application.
In the formulas used above, the essence of both Xiao Chai Hu Tang and its cousin Da Chai Hu Tang can be seen. Of these, Da Chai Hu Tang is more commonly indicated for the treatment of cholecystitis.
In prescribing, however, I considered Xiao Chai Hu Tang as the core formula because the tongue coat was not yellow, the pulse wiry but not forceful, the stool was normal and there was no irritability. At the second visit, I added Bai Shao in order to soften the Liver and relax spasm, as well as to preserve the yin in the presence of so many draining herbs; Da Huang and Zhi Shi were added for their draining effect. Although I was not consciously influenced by that formula, these three herbs are ingredients of Da Chai Hu Tang. I did not consciously consider this as a concurrent pattern of shao yang and yang ming, nevertheless, Da Huang may be seen not as purging accumulation from the intestines, as in a yang ming fu excess pattern, but as draining accumulation from the shao yang Gall Bladder via the yang ming Intestines. This is a different way of explaining the use of Da Chai Hu Tang in the treatment of cholecystitis.
The original use of Xiao Chai Hu Tang for a shao yang disorder, as developed by Zhang Zhong-Jing in the Shang Han Lun (Discourse on Cold Damage), was expanded in that text and its range of application has further expanded since that time. The original text also advocates its use for concurrent patterns where the shao yang pattern predominates. Modern applications cover a vast range of disorders and include the treatment of cholecystitis.
Cholecystitis can fall into a concurrent pattern of shao yang and yang ming, where the shao yang symptoms are accompanied by constipation. Da Chai Hu Tang addresses the symptoms of both patterns.
Many thanks to Robin Marchment for permission to reprint this article, which is a real case from her clinical practice. Thanks also to Steven Clavey and The Lantern journal where this article was first published (Volume V, Issue 3).
Robin is registered as a herbalist and acupuncturist with the Chinese Medicine Registration Board. She runs a private practice in Melbourne and is the trusted family physician of many long-term clients. She completed a four-year honours arts degree at Monash University in 1969 followed by a pre-masters.
In later years she obtained an advanced diploma and a degree in acupuncture at ACNM before embarking on a diploma of languages and then completing two years of herbal studies at SSNT. Fluent in Mandarin, she completed two post-graduate internships in China, focusing on paediatrics and gynaecology. She was also first woman in Australia to hold a black belt in taekwondo and was a full-time instructor for 30 years, being awarded 6th dan in 1995.
Robin presents lectures on Chinese Medicine, and is the author of Chinese for TCM Practitioners, Gynaecology Revisited: Obstetrics and Gynaecology for Practitioners of Chinese Medicine, and with Dr Greta Young, co-authored Shang Han Lun Explained.