Medical Case of Professor Huang Shipei: With an 89-Year-Old Patient – Would You Dare Use 20g of Dahuang?

黄仕沛系广州市名中医，广州中医药大学兼职副教授，南京中医药大学客座教授，十三行国医馆名誉馆长，当代经方临床大家，著名经方学者。学术上独尊经方，推崇“方证对应”，临床以大剂著称，著有《黄仕沛经方亦步亦趋录》、《黄仕沛经方亦步亦趋录（续）》、《梦回伤寒四大金刚》、《黄仕沛经方师传录》。

Professor Huang Shipei is a renowned traditional Chinese medicine (TCM) doctor in Guangzhou, a part-time associate professor at Guangzhou University of Chinese Medicine, a visiting professor at Nanjing University of Chinese Medicine, and an honorary director at the Thirteen Halls National Medical Museum. He is a contemporary expert in classical formulas (Jingfang) and a famous scholar in the field. Academically, he exclusively focuses on classical formulas, advocating the “correspondence between formula and symptoms” approach. His clinical practice is notable for using large doses, and he has authored several books, including “Huang Shipei’s Follow-up Records of Classical Formulas,” “Huang Shipei’s Follow-up Records of Classical Formulas (Continued),” “Dreaming of the Four Great Masters of Shanghan,” and “Huang Shipei’s Record of Teaching and Transmission of Classical Formulas.”

何某，女性，89岁。因有老年性痴呆病史，长期居住老人院。2010年7月13日开始出现食入即吐，腹胀满，大便秘结，当时无寒战发热，无腹痛、呕血、黑便等不适。即由家属送至我市某三甲医院住院，行血常规，WBC：11.98*109/L，NE：84.7%，腹部CT：不完全性肠梗阻。因患者高龄，不能耐受手术，暂予禁食，抗感染，补液支持为主，并予桃核承气汤及开塞露，灌肠。

Case Study:

He, female, 89 years old.

Senile dementia, long-term resident in a nursing home.

From July 13, 2010, she started experiencing vomiting immediately after eating, abdominal distension and fullness, as well as constipation. No chills, fever, abdominal pain, hematemesis, or melena were reported. Her family took her to a tertiary hospital in our city, where she was admitted. Blood tests showed WBC: 11.98*10^9/L and NE: 84.7%. Abdominal CT indicated partial intestinal obstruction. Due to her advanced age and inability to tolerate surgery, she was treated with fasting, antibiotics, fluid infusions, and given Taohe Chengqi Tang to open the stoppage as well as enemas.

灌肠后，可解少量硬便，但如是治疗十余日后，患者食入即吐及腹胀满症状未见好转，家属要求转我院继续治疗。入院时患者暂无呕吐，腹胀满而不痛，复查腹平片仍提示不全肠梗阻，仍予禁食及补液。

Following the enema, she was able to pass a small amount of hard stool. However, after over ten days of treatment, her symptoms of vomiting after eating and abdominal distension did not improve, and her family requested a transfer to our hospital for further treatment. Upon admission, she had no vomiting but had abdominal fullness and distension without pain. Abdominal X-ray still indicated partial intestinal obstruction, so fasting and fluid infusions were continued.

主管医师与黄仕沛教授短信联系，问其能否继续予承气汤类中药内服及灌肠，黄师认为此患者无腹痛，以胀满为主，非痞、满、燥、实、坚的大承气汤证。此患者老年体虚，虽腹胀、便秘、呕吐，但无明显腹痛，其肠梗阻的主要原因考虑为肠麻痹引起，动力不足所致。而此患者在外院已反复攻下而不愈，其虚证更明显。虽有便秘等可下之证，但并非具大承气汤痞、满、燥、实、坚之证，更不是第106条“热结膀胱，其人如狂……但少腹急结”下焦瘀血的桃核承气汤证。可试以厚朴生姜半夏甘草人参汤合小承气汤。

The attending physician contacted Professor Huang Shipei via text message, asking whether the patient could continue taking a Chengqi Tang type of formula and the enemas. Professor Huang believed that this patient, who mainly suffers from bloating without abdominal pain, does not exhibit the symptoms typically treated by a Da Chengqi Tang pattern, such as glomus, fullness, dryness, and hardness. This elderly patient is physically weak and although experiences bloating, constipation, and vomiting, does not have obvious abdominal pain. The primary cause of the patient’s intestinal obstruction is likely intestinal paralysis, resulting in insufficient motility. The patient has undergone repeated purgative treatments at another hospital without recovery, which has further weakened her condition. Although there are symptoms of constipation that might suggest a purgative treatment, the patient does not exhibit the specific symptoms required for Da Chengqi Tang [such as] glomus, fullness, dryness, and hardness, nor the pattern described in line 106 of the Shanghan Lun [where it states] “Heat accumulation in the bladder, causing the person to be manic… with a tense and firm lower abdomen,” which would indicate a Taohe Chengqi Tang pattern of static blood in the lower burner. He suggested trying a combination of Houpo Shengjiang Banxia Gancao Renshen Tang and Xiao Chengqi Tang:

处方：

法夏24g，炙甘草12g，党参30g，厚朴25g（后下），生地45g，生姜15g，枳实30g，大黄20g（后下）。服第1剂药后，次晨解黑褐色烂便1次，量约100ml，并予开塞露，灌肠后，又解黑褐色烂便1次，量约200ml。如是共服药5天，每天均有大便解出，腹胀消。本欲复查腹平片评价患者肠梗阻情况，因患者痴呆，近日精神好转后，烦躁乱动，不能配合拍片，暂未予。尝试予少量进食，食后无呕吐。得泻后，改予小柴胡汤，处方：柴胡24g，黄芩15g，法夏24g，党参30g，大枣15g，炙甘草15g，厚朴（后下）20g，枳实20g。住院15天，可进食，无呕吐，大便每日可解，予出院。

Formula

Banxia 24g
Zhi Gancao 12g
Dangshen 30g
Houpo 25g (added later)
Shengdi 45g
Shengjiang 15g
Zhishi 30g
Dahuang 20g (added later)

After taking the first dose, the next morning, she passed about 100ml of blackish-brown loose stool. After another enema, she passed about 200ml of blackish-brown loose stool again. She continued this treatment for five days, with daily bowel movements and reduced abdominal distension.

We originally planned to conduct an abdominal X-ray to assess the patient’s intestinal obstruction. However, due to the patient’s dementia and recent improvement in mental state, the patient became agitated and restless, making it difficult to cooperate for the imaging, so it was temporarily postponed. We attempted to give the patient a small amount of food, and there was no vomiting after eating. After the patient had a bowel movement, we switched to Xiao Chaihu Tang.