A 53-year-old woman with a half-year history of paroxysmal abdominal pain, severe watery diarrhea, and a vulnerability to catching colds was successfully managed using a sophisticated synthesis of classical Shanghan (Cold Damage) formulas to simultaneously warm her deficient Spleen and secure her weakened exterior.

Case ID: CHC-0089

Case Summary

This case describes a 53-year-old woman who presented with a six-month history of recurrent, paroxysmal abdominal pain and watery diarrhea containing undigested food. She also suffered from a weak constitution, easily catching colds that triggered sweating and an aversion to wind. The original report documented a conventional diagnosis of paroxysmal abdominal pain and a TCM assessment of a Concurrent Taiyang and Taiyin Disease, driven by Spleen-Stomach Deficiency-Cold, Ying-Wei Disharmony, and Internal Water-Rheum. She was managed by Professor Hu Shiping using a grand synthesis of classical formulas—combining Fuzi Lizhong Tang, Linggui Zhugan Tang, Guizhi Tang, and Yupingfeng San—to comprehensively rebuild her core Yang energy and immune exterior. In a subsequent visit, “incompatible” herbs were boldly utilized to clear stubborn cold-phlegm, resulting in a significant and lasting clinical improvement.

Patient Presentation

• Patient: 53-year-old female (Surname: Zhang).
• Main Complaint: Intermittent abdominal pain for half a year.
• History: The patient sought her initial consultation on July 27, 2022. For the past six months, she had suffered from recurrent, paroxysmal pain in the middle and lower abdomen, accompanied by watery diarrhea containing undigested food (完谷不化). The pain responded well to pressure (喜按). The symptoms were accompanied by an aversion to cold and were noticeably aggravated by eating raw or cold foods. Furthermore, she had a weak exterior; she easily caught colds when exposed to drafts, presenting with an aversion to wind, sweating, nasal congestion, and a runny nose.
• Associated Symptoms: Insomnia, poor appetite, a feeling of abdominal fullness and stuffiness, no desire to eat, and systemic fatigue.

Examination and Diagnosis

• Conventional Diagnosis: Paroxysmal abdominal pain (with chronic diarrhea).
• TCM Tongue and Pulse: The tongue body was pale and puffy with teeth marks on the edges (舌淡胖，边有齿痕), and the coating was white and watery/slippery (苔白水滑). The pulse was sunken, fine, and weak (脉沉细弱), but the right Guan (middle) position was uniquely stringy (右关独弦).

TCM Assessment

The practitioner interpreted the presentation as a Concurrent Taiyang and Taiyin Disease (太阳太阴合病), specifically characterized by Taiyang exterior deficiency, Ying-Wei disharmony, Lung deficiency failing to secure the exterior, Spleen-Stomach deficiency-cold, and internal invasion of water-rheum.

According to the Shanghan Lun (Treatise on Cold Damage), Taiyin disease is characterized by “abdominal fullness and vomiting, inability to eat, severe spontaneous diarrhea, and occasional spontaneous abdominal pain.” This perfectly matched her core digestive symptoms. Her foundational Spleen and Stomach Yang was exhausted (causing the cold aversion, watery diarrhea with undigested food, and the pale/puffy tongue with a watery coating).

Simultaneously, the “mother” (Spleen) failed to nourish the “child” (Lungs), leading to a severe deficiency of her defensive exterior (Taiyang deficiency). This Ying-Wei disharmony allowed external wind and cold to easily invade her body, causing her frequent colds and spontaneous sweating. Furthermore, the uniquely stringy pulse on the right Guan position indicated that Liver Wood was overacting on the deficient Spleen Earth, contributing to the paroxysmal, cramping nature of her abdominal pain.

Treatment Approach

The primary treatment principle was to warm the middle and strengthen the Spleen, scatter cold and transform rheum, harmonize Ying and Wei, support righteous Qi, and secure the exterior (温中健脾，散寒化饮，调和营卫，扶正固表). The strategy was to deploy a massive, multi-formula synthesis to treat both the deep internal cold (the root) and the weak defensive exterior (the branch) at the same time.

Interventions and Herbal Formulas

• Initial Herbal Formula (July 27, 2022): A 12-herb decoction elegantly fusing four classic formulas: Fuzi Lizhong Tang, Linggui Zhugan Tang, Guizhi Tang, and Yupingfeng San.
  • Warming the Middle and Scattering Cold: Zhi Fu Zi (Prepared Aconite, 10g – decocted first), Gan Jiang (Dried Ginger, 10g), and Bai Zhu (15g) form the core of Fuzi Lizhong Tang to rescue the devastated Spleen Yang and stop the watery diarrhea.
  • Harmonizing Ying and Wei (Exterior): Gui Zhi (Cinnamon Twig, 15g) and a heavy dose of Bai Shao (White Peony, 20g) recreate the dynamic of Guizhi Tang and Xiao Jianzhong Tang. They harmonize the exterior to stop the sweating while softening the Liver to relieve the cramping abdominal pain.
  • Securing the Exterior and Dispelling Wind: Huang Qi (Astragalus, 30g), Bai Zhu (15g), and Fang Feng (Saposhnikovia, 30g) form Yupingfeng San to build an “immunological shield” against future colds.
  • Transforming Rheum and Aiding Digestion: Fu Ling (Poria, 15g) joins to form Linggui Zhugan Tang, leaching out the dampness/water-rheum. Mai Ya (Malt, 20g), Chao Ji Nei Jin (Fried Chicken Gizzard Lining, 10g), and Jing Shan Zha (Hawthorn, 15g) actively digest stagnant food. Zhi Gan Cao (10g) harmonizes.
  • Administration: 14 doses, water decocted, taken warm twice daily.
• Second Visit (August 10, 2022): After 14 doses, the abdominal pain and diarrhea were significantly reduced. However, she still experienced occasional abdominal pain right before a bowel movement, mild bloating after meals, dry mouth, and profuse white sputum. The tongue coating turned from watery to white and greasy, and the pulse became fine and slippery.
  • Formula Adjustment: The presentation shifted slightly to “Painful Diarrhea” (Earth deficiency with Wood overacting) and Stomach cold-phlegm. Professor Hu added components of Tongxie Yaofang (Important Formula for Painful Diarrhea) to suppress the Liver and support the Spleen, and Fuzi Banxia Tang to warm the Stomach and dry the cold phlegm.
  • New Additions: Chen Pi (15g), Jiang Hou Po (15g), and Qing Ban Xia (10g) were added to dry the phlegm and move Qi. Crucially, Wu Mei (Mume, 20g) and Mai Dong (Ophiopogon, 15g) were added to nourish Yin and generate fluids, specifically to prevent the heavy, hot Yang-warming herbs (Fu Zi, Gan Jiang) from drying out the body too much (treating the dry mouth).
  • Administration: 30 doses, manufactured into water-honey pills (水蜜丸) for convenience during the patient’s business travels.

Follow-Up

• Outcome: A phone follow-up confirmed that after taking 15 doses of the second formula, her symptoms were greatly alleviated. Whenever she experienced intermittent mild symptom flare-ups in her daily life, taking the prescribed honey pills consistently brought about immediate improvement and relief.

Why This Case Is Interesting (Clinical Reasoning)

This case beautifully illustrates two hallmarks of advanced classical Chinese medicine: the seamless blending of multiple Shanghan formulas and the bold use of incompatible herbs.

First, by combining Guizhi Tang (Taiyang), Fuzi Lizhong Tang (Taiyin), Yupingfeng San (Wei Qi), and Linggui Zhugan Tang (Phlegm-Fluid), Professor Hu addressed the patient’s entire systemic collapse in a single, unified prescription.

Second, during the follow-up, Professor Hu deliberately prescribed Fu Zi (Aconite) and Ban Xia (Pinellia) together. In traditional TCM pharmacology (the “Eighteen Incompatibilities”), these two herbs are strictly said to clash and are typically forbidden from being combined. However, because the patient’s exact pattern called for both extreme Yang warming (Fu Zi) and aggressive cold-phlegm drying (Ban Xia), Professor Hu followed the classical edict of “having a reason, there is no harm” (有故无殒). He did not rigidly adhere to the theoretical ban, demonstrating that true pattern differentiation always supersedes general pharmacological rules in the hands of a master clinician.

Source Original source: Shenzhen Hospital of Beijing University of Chinese Medicine (Longgang) / Traditional Chinese Medicine Bureau of Guangdong Province Original title: 【以案说医】胡世平：泄责太阳太阴病，经时结合疗效显著 Practitioner: Professor Hu Shiping (胡世平) Publication date: July 29, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation