Many kinds of pulsations can occur on the abdomen. Here, Nigel helps me tease this all apart.
I am also trying to understand pulsations in general. It seems they can be caused by:
1. water – which in turn could be more Kidney (Zhen Wu Tang), Spleen (Bai Zhu/Sheng Jiang type formulas) or excess water (Wu Ling San type) – all of which over lap. Am I missing something in terms of what could cause water accumulation/splash sounds?
Yes this is right. Water accumulation causes the Qi to stagnate (or vise versa) leading to pulsations. In this mechanism, the pulsations are a result of impediment (by a Yin substance) to the normal downward flow of Qi in the abdomen. This is a case of the influence of the more material (Yin water) dominating that of the immaterial (Yang Qi).
In deficient patients often as you say Spleen tonics may be used: Si/Liu Jun Zi Tang family for example.
Where accumulation from middle Jiao Qi depletion predominates and fluid stasis is secondary, Xiang Sha Liu Jun Zi Tang may apply, but where stagnant fluids are the major evidence in a similar case, Fu Ling Yin may be preferable.
Ren Shen Tang (aka. Li Zhong Tang) will govern in cases that are colder, though apart from nausea and excessive salivary activity (drool), this formula does not evidence many Water Nobose symptoms. This is unlike Huan Fu Hua Dai Zhe Shi Tang, another Ren Shen formula, where these are clearly evidenced by repeated hiccup, vomiting and acid reflux. In this case, these upward signs are settled in part by the Dai Zhe Shi. In similar cases where cold stasis in the stomach is more in evidence, with water nobose signs such as vomiting of clear liquids, headache and stiff neck and upper back muscles, Wu Zhu Yu Tang is appropriate. Wu Zhu Yu Tang is yet another Ren Shen formula very similar to Li Zhong Tang, but whose action in this case is rendered much more warming by the inclusion of the powerfully warming Evodia fruit.
Basically, the more the presence of cold, the more stasis there will be. The more Stasis (initially of Qi) there is, the more likely fluids are to collect and get stuck in the Stomach (“the sea of fluids”) and upper intestines, further impeding normal downward flow and giving rise to nobose. (Nobose is rebellious upsurge and refers to an ‘uncomfortable sensation of heat, congestion or mounting pressure in the upper body, especially the head, often with visible flushing in the face’. Taken from Kampo Treatment for Climacteric Disorders: A Handbook for Practitioners). Thus, all these formula examples include evidence of the splash sound in Fukushin (abdominal palpation).
The primary clinical decision in selecting from among these formulas, is to establish the following:
- The degree of cold that may be part of the etiology
- Whether the stasis is due to deficiency or the other way around, and
- The strength of the patient’s constitution.
In formula terms, this will determine whether you can simply remove the obstruction (see the paragraph on Pinellia formulas below) and having lifted the impediment to normal middle jiao Qi function, simply wait for the flow of Zhen (True) Qi to be restored. In this case one would not need the explicit Qi tonics such as Ren Shen. If there is evidence of underlying root depletion of the middle jiao Qi however then Ren Shen formulas will be called for. Where there is clear evidence of cold stasis (as opposed simply to Yang depletion resulting in stasis and cold) then warming formulas will be required and Ren Shen alone will be insufficient, as evidenced by several examples above.
Where Tai Yin or Shao Yin level dysfunction is concerned, the resulting Qi stasis in the middle or lower jiao will always include increased water accumulation (due to diminished Yang activity) resulting in pulsations (the Jing Mai or vessels are constricted by the surrounding fluid creating localized pressure giving rise to a pulsing sensation).
Ren Shen and/or Fu Zi formulas are indicated in such cases often combining together is such examples as Fu Zi Li Zhong Tang or Si Ni Tang jia Ren Shen. These are Tai Yin and Shao Yin patterns whereas Wu Zhu Yu Tang would be an example of a Shao Yin/Jue Yin pattern formula with cold water accumulation in the stomach and pulsations on the abdomen as well as a splash sound. Cold water accumulations in the lower intestines with watery diarrhea and pulsations and a splash sound on the abdomen of course matches the Zhen Wu Tang SHO.
There are however many cases of water accumulation in the abdomen that do not require such a firm hand in terms of strengthening or warming with Ren Shen or Fu Zi. Regulating the Qi flow and promoting normal fluid transformation in the middle jiao may be all that is required formula examples of which include: Ping Wei San where “abdominal thunder” (borborygmus) is a cardinal sign; or in similar cases where there is counterflow (nausea, palpitations, dizziness and other anxiety signs): Ling Gui Zhu Gan Tang, Ling Gui Gan Cao Tang and other such “running piglet formulas” evidence of what Kampo calls: Water Nobose. In cases of cold constraint leading to Water Nobose signs similar to those mentioned above but including more of a tendency for epigasrtric pain, acid reflux, nausea and vomiting, An Zhong San will apply, again a formula with no Ren Shen.
Further example formula groupings that often include splash sounds in the abdomen contain Ban Xia, a herb used to free up a subjective feeling of obstruction (glomus) “under the heart”, a symptom confirmed in Kampo abdominal diagnosis by the finding: Shin Ka Hi Ko (Subjective and Objective Epigastric Obstruction). The action of this herb can encourage the downward movement (drainage) of both stagnant Qi and fluids in the upper intestinal tract. Example formulas in this group would include Ban Xia Hou Pu Tang, where the glomus may also be experienced in the chest or throat along with multiple anxiety symptoms. There is also Xiao Ban Xia Tang, used frequently in Japan for morning sickness when this Sho is identified (it’s composition being 3 of the 5 herbs of Ban Xia Hou Pu Tang minus the Zi Su Ye and Hou Pu). There are also a well-known “family” of formulas containing Ban Xia that come to mind here: Ban Xia Xie Xin Tang (and the common modifications of this formula such as Gan Cao Xie Xin Tang and Sheng Jiang Xi Xin Tang). However, interestingly these formulas do also contain Ren Shen and therefore do assume not only Qi and fluid stasis in the middle jiao but also some degree of deficiency also.
In Tai Yang cases of cold attack to the stomach, intestines and sometimes bladder Wu Ling San is indicated and there are plenty of pulsations on that abdomen! In this formula Sho of course the predominant signs confirming water nobose include nausea (exacerbated by drinking water though there is thirst), headache, facial edema and reduced urinary output or urinary block.
There are also Liver Patterns which will cause accumulation of Qi and in the long term water also. Ascites from Liver disease is an obvious western example of this. So Yin Chen Wu Ling San, Chai Ling Tang and even Chai Pu Tang (in certain watery asthma cases) will all have abdomens with Kyo Kyo Ku Man (hypochondria painful fullness) and water splash sounds as well as pulsations.
2. Deficiency with a tight abdomen (Gui Zhi and Ren Shen type formulas)
These pulsations are usually directly related to pure Qi disturbances and largely occur in dry, deficient types. I mentioned this earlier regarding Gui Zhi Jia Long Gu Mu Li Tang for example. Thus formulas that are basically Gui Zhi Tang derivatives are almost always marked by pulsations on the abdomen. (I notice Dr. Huang Huang in his book Zhang Zhong-jing’s Clinical Application of 50 Medicinals
mentions about Gui Zhi in the very first line that it “descends and settle the Qi”. Thus a typical counterflow Qi running piglet formula such as Ling Gui Gan Cao Tang has an abdomen full of pulsations. It is not exclusively true to say though that Gui Zhi formulas are always and only suited to dry counterflow conditions. Ling Gui Zhu Gan Tang for example is the exception here and in addition to pulsations will also often have a splash sound in the abdomen. However, this formula Sho is characterized by other Water Nobose signs such as dizziness, vertigo, heavy head, headache and balance problems.
3. Fullness in the middle (Ban Xia Hou Po Tang) or Chest.
Again these are primarily Qi disturbances in this case marked more by accumulation than by counterflow. The Xie Xin Tang group as well as many of the Chai Hu formulas I mentioned above would fit this category where pulsations may or may not be accompanied by splash sounds, epigastric or hypochondriac tightness.
4. Kidney weakness (pulsations in the lower abdomen)
Here the mechanism is Kidney weakness leading to cold water accumulation, leading to pulsations (as in for example Zhen Wu Tang), or Kidney weakness failing to communicate with heart leading to counterflow Qi pulsations as in Gui Zhi Jia Long Gu Mu Li Tang or even Kidney weakness leading to a failure to moisturize the blood causing blood deficiency and stasis pulsations disrupting the circulatory system and leading to cardiac signs as in Zhi Gan Cao Tang.
And you could add a #5, which of course is the whole Oketsu group of formulas both for excess and deficient patterns in which pulsations almost always occur on the abdomen as a result of constrained Qi flow, due to Oketsu. Da Huang Mu Dan Pi Tang, Tao He Cheng Qi Tang, Da and Xiao Cheng Qi Tang, Tiao Wei Cheng Qi Tang – these formulas for the Jitsu (Excess) blood stasis patient all have pulsations on the abdomen. Gui Zhi Fu Ling Wan and Zhe Chong Yin, the two main non-Da Huang blood stasis formulas used in kampo also have abdominal pulsations. Not to mention all the many derivatives of Si Wu Tang which also have pulsations and often blood stasis signs around the navel area. These deficient patterns reflect an underlying blood deficient root, though pulsations will accompany the branch pattern manifestations related to blood stasis.
I am looking through the book KAMPO: A Clinical Guide to Theory and Practice and class materials and it is difficult to find a summary of what pulsations mean in terms of diagnosis. Am I on the right track?
Definitely on the right track. You might summarize pulsations into the standard triple grouping in Kampo as in Qi, Blood and Fluid related pulsations. One could genralize and suggest that pure Qi pulsations tend to occur on the midline in the upper portions of the abdomen (fire area in Nan Jing), Fluid pulsations occur Ren 12 to the navel (Earth area in NJ) and Blood pulsations occur around and below the navel (Water area in NJ). You could also expect Qi pulsations as the most Yang and therefore insubstantial to be subject to the most frequent and immediate changes. For example the pulsations of
some Ling Gui Gan Cao Tang types or Gui Zhi Jia Long Gu Mu Li Tang types may diminish or even disappear in the course of a single acupuncture treatment or reappear with an upsetting thought or feeling. They are whimsical and never really completely resolve. However the Yin pulsations – related to dysfunctions at the water and blood levels – are a different matter. Slow to change but ultimately resolvable. When the blood stasis of a patient taking Tao He Cheng Qi Tang for example improves so too will the pulsations and this change can be lasting.
In the book Cardiac pulsations are talked about. Is there a category of pulsations that occur in the chest? Are these felt by the patient or the practitioner?
Well, technically 動悸 (Doki -throbbing pulsations) are the pulsations experienced by the patient in the abdomen and palpable by the practitioner as well. 心悸 (Shin Ki -heart pulsations) are cardiac pulsations primarily experienced by the patient. Shin Ki can potentially also be palpated by the practitioner at the apical pulse (more or less on the left side of the chest in or around the 5th intercostal space). In western terms we might relate these findings to:
a) 動悸 (Doki) – any and all manner of vascular pulsations both subjectively and objectively felt usually along the trajectory of the abdominal aorta. These most commonly will occur in disorders of the nervous system indicating an autonomic nervous imbalance but may also have structural implications (eg: aneurism).
b) 心悸 (Shin Ki) – these relate to actual heart arrhythmias including palpitations, tachycardia, fibrillations etc.