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基本資料
病人資料： 曾某，男/40歲。運輸公司負責人。
過往史：否認藥物、食物敏感。否認有長期病患史。
現病史：
胃脹不舒4月許，食後尤甚。素有胃病史，常因工作繁忙而食不定時。訴於今年4月許因應酬爆食火鍋海鮮(病人用語)，使胃病復發。初見脹痛噯氣，就診西醫，查有胃炎，予消炎止痛藥。藥後痛去，但脹滿未除。因不欲再服西藥，經友人介紹前來就診。
治療
8.8.2021 初診
胃脹不舒4月許。
刻診上腹只脹不痛，按之略緊。報喜溫喜按，得溫稍解。脹滯食後尤甚。神清。語速快，聲高。體形偏瘦。眠安，常1AM就寤，易入睡，無夢。納可，有飢餓感，多噯氣，偶泛酸。多飲熱。無胸脅苦滿，偶有口干，無口苦，無眼干澀，無頭痛頭暈。大便日1行，成形，偶溏，量常，質軟，多矢氣，偶腹脹。小便量多色淡，清長，偶夜尿1次。少汗出。怕冷，手足冰涼，足部尤甚。偶腰酸軟。舌質紅，尖紅，苔薄白；脈弦，略緊。囑宜飲食清淡以養胃，忌寒食冷飲以無伐脾陽。
診斷：胃痞病(寒痞)。脾胃虛寒，脾虛肝旺，腎陽不足。治以疏肝扶脾，溫胃散寒，溫腎助脾之法。
治療：處方中藥濃縮藥粉(下同)如下：
白朮，白芍，防風，陳皮，厚朴，檳榔，佛手，補骨脂，吳茱萸，製附子(炮附子)，肉桂，炙甘草。4天，餐後早晚各1服。
方義：以痛瀉要方柔肝扶脾，以陳皮、厚朴、檳榔及佛手行氣運脾，並以補骨脂、吳茱萸(四神丸主藥)、製附子及肉桂等溫補脾腎，炙甘草補氣及和諸藥。
13.8.2021 二診
報藥後胃部不舒、噯氣, 身冷減。有少上火現象, 兩日後自罷。餘證同前, 泛酸未除，稍調方藥續治。舌脈同上。擬方如下：
白芍，防風，陳皮，厚朴，檳榔，佛手，補骨脂，吳茱萸，製附子(炮附子)，炙甘草，肉桂，海螵蛸，浙貝母，女貞子，墨旱蓮。5天，餐後早晚各1服。
方義：因方藥應證而症狀減，故不更方。因見上火現象，當減或去溫藥，然若如此，則寒邪難去，因見上火之象能自罷，在平衡二者的情況下，故酌加二至丸以補肝腎之陰，陰足則火不易上浮。另加烏貝散以對治泛酸之症。
20.8.2021 三診
報藥後持續改善, 痞脹已去。手腳不溫仍在，泛酸小減，依前法小調方藥續治，稍加溫脾腎之藥。舌紅，苔薄白；脈弦而緩。擬方如下：
白芍，防風，陳皮，厚朴，檳榔，補骨脂，吳茱萸，黃連，製附子(炮附子)，乾薑，炙甘草，肉桂，海螵蛸，浙貝母，淫羊藿，杜仲。5天，餐後早晚各1服。
方義：主證痞脹已去，但手足不溫、泛酸仍見，在守方之餘，酌加溫脾腎之淫羊藿、杜仲及干薑，及取左金丸之方義加黃連合吳茱萸，以免胃熱生火。
由於主證已罷，他證亦減，故囑咐病人在盡劑後，如無其他不適，可以不用再就診，另囑其要額外注意飲食及作息。
病理概要
胃痞，又名心下痞。其主要症狀是心下，即指胃脘部滿悶不舒。胃痞一症，常見病因如飲食失宜內傷脾胃、情志失調臟腑失和，又或因於傷寒誤下等。其病機總以脾胃氣機升降不和所致，即如《傷寒論》所云「但滿而不痛者，此為痞。」及「按之自濡，但氣痞耳。」── 此兩者都表明胃痞是脾胃氣機失調而形成的痞塞的表現，故治法重在調理脾胃，升清降濁，使中氣樞轉順暢，則痞症自消。
在辨證方面，明‧張景岳在《景岳全書．痞滿》中的論述可供參考，其謂「痞者痞塞不開之謂，滿者脹滿不行之謂。蓋滿則近脹，而痞則不必脹也。所以痞滿一證，大有疑，辨則在虛實二字。凡有邪有滯而痞者，實痞也；無物無滯而痞者，虛痞也。有脹有痛而滿者，實滿也；無脹無痛而滿者，虛滿也。實痞實滿者，可散可消；虛痞虛滿者，非大加溫補不可。此而錯用，多致誤人。」換言之，辨清胃痞病的寒熱虛實是治療的基本而又關鍵的第一步。
思路及體會
見患者身形，聞其聲調語速，知其職業作息，另合脈象，得患者為肝急之人的印象。身無熱象，雖誤傷飲食，中焦受累，但亦不見實邪，故斷為脾胃虛寒，脾虛肝旺之證；另見一派寒象如小便清長、怕冷、手足冰涼，足部尤甚等，亦見脾腎之陽不足。由於病及肝、脾及腎三臟。在肝旺脾虛方面，心中起方逍遙散及痛瀉要方。前者治及肝脾(如方歌所言：肝鬱血虛脾氣弱，調和肝脾功效卓)，但此方需有柴胡疏肝白芍柔肝，但餘藥都偏於補(證亦不見明顯血氣虛之象)；又鑑其運脾之力不足，故改選用以陳皮白朮為主藥，運脾補脾力較大的痛瀉要方合其他行氣藥如行氣(有說破氣)較強之檳榔，以消脹滿。另脾腎二臟，取四神丸之義合其他溫藥以散寒及溫脾腎。
雖謂「寒者熱之」，但要對應機體，做到恰到好處，用藥不會太過不及，又非易事 ── 溫補太過，則見上火；不及則寒邪留連。事實上，前一個以溫補治泄瀉的病案也出現上火的現象，這個情況也同樣出現，只是這個兩日後自罷。上一個因是久病，見上火，又見苔薄黃，故要更方(由理中丸改為小建中湯)以免助火生熱。但慮及此患者，發病時間短，上火尚能自罷，苔白，並且寒邪較重，若減或去溫藥，則寒邪稽留，病情或會拖延。故在不減溫藥的前題下，想及滋陰之法，陰足則火熱不易上浮。於此，又想及能「三陰並補」的六味地黃丸，唯地黃粘膩滯胃之性，用於已見脹滿，運化不力的脾胃，實非上策，故只能退而選用同樣具有滋陰作用的二至丸。至三診，在平調寒熱方面，則以2:1之左金丸代之。
《素問‧至真要大論》中，歧伯提出了「谨察阴阳所在而调之，以平为期，正者正治，反者反治」的治病原則。以上述兩病案為例，「以平為期」當中的加減進退，在臨床上實踐起來，又殊非易事！
Basic Information
Patient Information
Mr. Zeng, male, 40 years old. Transport company manager.
Medical History
Denies medication or food allergies. Denies a history of chronic illness.
Present Illness
Experienced discomfort and bloating in the stomach for about 4 months, especially after meals. Has a history of gastric problems, often irregular eating due to busy work schedule. Reports that around April of this year, his gastric issues flared up after overeating hotpot and seafood (patient’s wordings). Initially experienced bloating and belching, sought medical attention from a western doctor, diagnosed with gastritis, prescribed anti-inflammatory and pain relief medication. Pain subsided after medication, but bloating persisted. Due to reluctance to take western medicine again, came for consultation based on a friend’s recommendation.
Treatment
8.8.2021 First Consultation
Complains of bloating in the upper abdomen, not painful, slight tightness upon palpation. Reports slight relief with warmth and slight relief upon pressure. Bloating worsens after meals. Clear consciousness. Speaks rapidly and loudly. Lean physique. Sleeps well, wakes up at 1 AM, easily falls asleep, no dreams. Appetite good, feels hungry, belches frequently, occasionally experiences acid reflux. Prefers warm drinks. No chest or rib discomfort, occasional dry mouth, no bitter taste, no dry or itchy eyes, no headaches or dizziness. Bowel movement once a day, formed stool, occasionally loose, normal frequency and quantity, soft stool, frequent passing of gas, occasional abdominal bloating. Urinates frequently, clear and copious, occasionally nocturia once a night. Sweats less. Cold intolerance, cold hands and feet, especially cold feet. Occasionally experiences lower back soreness. Tongue slightly red with thin white coating; pulse wiry and slightly tight. Advised to consume bland diet to nourish the stomach, avoid cold and chilled foods to prevent spleen yang deficiency.
Diagnosis:
Gastric distension (cold type). Spleen and stomach deficient in yang qi, spleen deficiency with liver hyperactivity, kidney yang insufficiency. Treatment aims to soothe the liver, tonify the spleen, warm the stomach, dispel cold, and warm the kidneys to assist the spleen.
Treatment:
Prescribed concentrated Chinese herbal powder (same for subsequent prescriptions) as follows:
Atractylodes macrocephala, Paeonia lactiflora, Saposhnikovia divaricata, Citrus reticulata, Magnolia officinalis, Areca catechu, Citrus medica, Psoralea corylifolia, Evodia rutaecarpa, Aconitum carmichaelii (processed), Cinnamomum cassia, Glycyrrhiza uralensis. 4 days, 1 pack after breakfast and dinner.
Treatment Principle:
Aiming to gently soothe the liver and tonify the spleen, using
Citrus reticulata, Magnolia officinalis, Areca catechu, and Citrus medica to move qi and invigorate the spleen, supplemented by Psoralea corylifolia, Evodia rutaecarpa (main ingredients of Si Shen Wan), Aconitum carmichaelii, and Cinnamomum cassia to warm and tonify the spleen and kidneys, with Glycyrrhiza uralensis for harmonizing effects.
13.8.2021 Second Consultation
Reported slight improvement in stomach discomfort and belching after medication, reduced sensation of coldness. Experiences mild symptoms of excessive internal heat, resolved spontaneously after two days. Other symptoms remain the same, acid reflux not alleviated, slight adjustment to prescription medication continued. Tongue and pulse unchanged. Prescription as follows:
Paeonia lactiflora, Saposhnikovia divaricata, Citrus reticulata, Magnolia officinalis, Areca catechu, Citrus medica, Psoralea corylifolia, Coptis chinensis, Aconitum carmichaelii (processed), Zingiber officinale, Cinnamomum cassia, Sepia esculenta, Glehnia littoralis, Ligustrum lucidum, Nelumbo nucifera (processed). 5 days, 1 pack after breakfast and dinner.
Treatment Principle:
No change in prescription as symptoms improved with current medication. Due to slight signs of excessive internal heat, consider reducing or eliminating warming herbs; however, doing so might exacerbate lingering cold evil. As the symptoms of excessive internal heat resolved spontaneously, maintaining balance between the two, hence adding herbs to nourish liver and kidneys’ yin, as strengthening yin prevents excessive yang rising. Additionally, adding Sepia esculenta to address symptoms of acid reflux.
20.8.2021 Third Consultation
Continued improvement reported after medication, distension in the stomach has resolved. Coldness in hands and feet persists, acid reflux slightly improved. Continued minor adjustment to prescription medication to further address spleen and kidney deficiency. Tongue slightly red with thin white coating; pulse wiry and relaxed. Prescription as follows:
Paeonia lactiflora, Saposhnikovia divaricata, Citrus reticulata, Magnolia officinalis, Areca catechu, Psoralea corylifolia, Evodia rutaecarpa, Coptis chinensis, Aconitum carmichaelii (processed), Zingiber officinale, Cinnamomum cassia, Sepia esculenta, Glehnia littoralis, Epimedium brevicornu, Eucommia ulmoides. 5 days, 1 pack after breakfast and dinner.
Treatment Principle:
Main symptoms of gastric distension have resolved, but coldness in hands and feet and mild acid reflux persist. In addition to maintaining the previous prescription, herbs to warm the spleen and kidneys are slightly increased. Tongue and pulse findings guide adjustments.
Summary of Pathology
Gastric distension, also known as epigastric fullness, refers to a feeling of fullness and discomfort in the epigastric region. Gastric distension can be caused by improper diet leading to spleen and stomach disharmony, emotional imbalances affecting organ function, or complications arising from improper treatment of febrile diseases, among other factors. The underlying pathology often involves disharmony in the ascending and descending functions of spleen and stomach qi, as described in the “Discussion on Cold Damage” where it states, “If there is fullness without pain, this is called distension” and “Palpation feels dampness, indicating gas distension.” These descriptions indicate that gastric distension is a manifestation of stagnation and obstruction due to imbalances in spleen and stomach qi. Therefore, treatment focuses on regulating spleen and stomach function, promoting the ascending and descending movements of clear and turbid qi, and restoring smooth flow of middle qi to alleviate the distension.
