The Leaking Wine Cup
A Gynecology Case from Wáng Xùgāo
A couple of weeks back, I posted a couple of discussions on gynecology; I’ve had this case staring at me since that time, not sure what to do with it. I figure someone else might find it interesting, so onto the mulch pile it goes. It is a case from Wáng Xùgāo Lín Zhèng Yī Àn (Wáng Xùgāo's Clinical Records). The case report genre is an important part of the process by which our medicine is transmitted through the generations, and gives us a window not only into our forebears’ clinical reasoning and treatments, but sometimes also into their thoughts, doubts, and frustrations. Wáng’s case here shows us a little of all that. Here’s my working version, there were plenty of rough spots for me in this one but I think I got the drift.
The Case
陸 營分有熱，則經至而淋漓；衛分有寒，則脈小而遲緩。脾為營之本，胃為衛之源。經至而舌苔反布，胸無痞悶，是胃陽虛而無氣以化濁也。擬醒胃陽以攝脾陰為法。
歸芍六君子加神麯。
Lù [Patient’s name]: There is heat in the yíng aspect, as a result menstruation arrives but it is dribbling; there is cold in the wèi aspect, as a result the pulse is small as well as tardy and slack. The spleen is the root of the yíng, the stomach is the origin of the wèi. Menstruation arrives but the tongue coating is contrarily spread out, there is no glomus or oppression in the chest, this is stomach yáng vacuity and so there is no qì to transform turbidity. Follow the method of awakening stomach yáng to contain spleen yīn.
Guī Sháo Liù Jūn Zǐ [Chinese Angelica and Peony Six Gentlemen Decoction], adding Shén Qū [Massa Medica Fermentata].
[Mulch comments: Guī Sháo Liù Jūn Zǐ is Liù Jūn Zǐ Tāng with Dāng Guī and Bái Sháo added. ]
又 經行過多，血氣兩衰，肝腎失固，麗翁所論包括盡矣。然治病之道，有相機從事之權。夫舌白多痰，胃有濁也。咽乾色紅，陰虛而火浮也。脈細遲緩，中氣不足也。考古人腎虛有痰濁者，金水六君煎；氣虛而上有浮火者，生脈四君子。合而參之，似覺不可擅易，還祈曬政。
大熟地 半夏 五味子 歸身炭 陳皮 於朮 茯苓 麥冬 人參 穀芽 建蓮肉
Later on: There is excessive menstruation, blood and qì both debilitated, liver and kidney fail to secure, the Lì Wēng treatise covers all of this. It is like this, in the course of treating disease, there are mutual mechanisms that need to be handled pragmatically. Her tongue is white [meaning] a lot of phlegm, thus there is turbidity in the stomach. Her throat is dry and colored red, [indicating] yīn vacuity with floating fire. The pulse is thin, tardy and slack, which is insufficiency of central qì. In cases of kidney vacuity with phlegm turbidity, our forebears tried Jīn Shuǐ Liù Jūn Jiān [Metal and Water Six Gentlemen Decoction]; and in cases of qì vacuity with upper burner floating fire, Shēng Mài Sì Jūn Zǐ [Pulse-Restoring Four Gentlemen]. Putting [the case] together and examining it, it seems different, but I dare not change it; still I’m praying the sun will shine upon these affairs.
Dà Shú Dì [Rx Rehmanniae Praeparata], Bàn Xià [Rz Pinelliae], Wǔ Wèi Zi [Fr Schisandrae], Guī Shēn Tàn [Rx Angelicae Sinensis Carbonisatus], Chén Pí [Pc Citri Reticulatae], Yú Shù [Rz Atractylodis Macrocephalae], Fú Líng [Poria], Mài Dōng [Tuber Ophiopogonis], Rén Shēn [Rx Ginseng], Gǔ Yá [Fr Oryzae], Jiàn Lián Ròu [Sm Nelumbinis].
[Mulch comments: “Lì Wēng” “麗翁” is possibly a misprint, referring to 李翁醫記, Lǐ Wēng Yī Jì, or Medical Records of Lǐ Wēng. Jīn Shuǐ Liù Jūn Jiān is a formula from Jǐng Yuè Quán Shū; it is like Six Gentlemen Decoction but Rén Shēn and Bái Zhú are swapped out for Shú Dì Huáng and Dāng Guī; in this prescription you can see elements of that formula as well as Shēng Mài Sǎn and Sì Jūn Zǐ Tāng, with rice sprouts and lotus seeds added.]
又 肝腎與脾胃同治，經漏仍然不止。左脈稍覺有力，原得歸、地之功；右脈更覺細微，脾氣虛衰不振。許學士謂補腎不如補脾，蓋謂脾胃虛者言之。今心跳食少，心脾不足可知。經血如漏卮不息，衝任不得不固；腹中微痛，氣虛且滯，不得不補，不得不通。仿黑歸脾法。
熟地炭 黃耆（炒焦） 茯神 棗仁 白芍 廣木香 歸身炭 冬朮 人參 陳皮 炙草
Afterward: The liver and kidney along with the spleen and stomach were all included in the same treatment, but still the menstrual spotting did not stop. The left pulse feels like it has a little more strength, as a result of the effects of the [Dāng] Guī and Dì [Huáng]; the right pulse feels more thin and weak, this is the spleen qì vacuous, debilitated and devitalized. Learned master Xǔ said that supplementing the kidney is inferior to supplementing the spleen, this can be said about cases of spleen and stomach vacuity. Now her heart is jumping and there is little appetite, so heart and spleen insufficiency is evident. The menstrual blood is like a leaking wine cup which won’t cease, there is no option but to secure the chōng and rèn; there is slight pain in the abdomen, the qì is both deficient and stagnant, so there is no option but to supplement, and there is no option but to unblock. Imitate the Hēi Guī Pí [Black Spleen-Returning Pills] method.
Shú Dì Tàn [Rx Rehmanniae Praeparata Carbonisatus], Huáng Qí (Chǎo Jiāo) [Rx Astragali Usta / scorch-fried Astragalus], Fú Shén [Poria Pararadicis], Zǎo Rén [Sm Zizyphi Jujubae], Bái Sháo [Rx Paeoniae Alba], Guǎng Mù Xiāng [Rx Aucklandiae], Guī Shēn Tàn, Dōng Shù [Rz Atractylodes Macrocephalae Praeustum/ Frostbitten Bái Zhú], Rén Shēn, Chén Pí, Zhì Cǎo [Rx Glycyrrhizae Praeparata].
[Mulch comments: Hēi Guī Pí Wán is Guī Pí Wán with Shú Dì added. You can see the formula here, with some additions and subtractions - Yuǎn Zhì / Rx Polygalae taken out, Bái Sháo and Chén Pí put in – and some charring and scorching of ingredients for blood-stanching effect.]
淵按：既云固衝任，而無固衝任之藥。仍用歸脾，恐漏仍不止。古人治崩漏急證，自有專方，如血餘、棕炭、百草霜、倒掛塵等，殊有效驗。且脈小遲緩，其漏未必屬熱，或脾腎陽虛，不能固攝其血，尤非固而兼溫不效，未可見血即以為熱也。
Yuān [Wáng’s student, who collected and edited the cases] comments: Securing chōng and rèn was previously mentioned, but there are no medicinals [included here] that secure the chōng and rèn. Still he uses Guī Pí [Spleen-Returning Pill], for fear that the spotting will not stop. The ancients would treat urgent patterns of flooding and spotting, of course they had special formulas, [with ingredients] like Xuè Yú [Crinis / hair], Zōng Tàn [Petiolus Trachycarpi Carbonisatus / charred palm frond], Bǎi Cǎo Shuāng [Fuligo Herbarum Ustarum], Dào Guà Chén [beam dust], and the like, which were remarkably effective. Moreover, the pulse was small, tardy, and slack, so her spotting did not necessarily pertain to heat, or to spleen and kidney yáng vacuity which could not secure and contain her blood, especially as securing and simultaneous warming had no effect, and it is not clear why the bleeding could be considered to be due to heat.
[Mulch comments: Dào Guà Chén is dust collected from the beams of old houses, which is then burnt to ashes and sifted in with the other ingredients. I was unable to find a pharmaceutical name for it. It has a variety of uses in addition to stanching bleeding.]
Epilogue
I wonder how the case turned out. Often in these collections, we just see signs and symptoms, maybe a brief description of the pathomechanism and a treatment principle, and list of prescription ingredients. We are never certain of the outcome; perhaps we assume the best, that the patient was quickly cured. In these more extended examples, like the case here, with follow-ups, we get a better sense of just how difficult it must have been to practice in those days - circumstances were often dire and patients had nowhere else to turn.
That’s all I have for now. As always, thanks for reading.
Note: this publication is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Wáng, X, & Fāng, R. (1897). Wáng Xùgāo lín zhèng yī àn. https://jicheng.tw/tcm/book/%E7%8E%8B%E6%97%AD%E9%AB%98%E8%87%A8%E8%AD%89%E9%86%AB%E6%A1%88/index.html