經方學

Rules of thumb are useful. Being able discern a constitutional type is a broad brushstroke rule of thumb. We can effectively condense experience, and it is often a shortcut to where we are headed. Except for when it is not.

I was working through the diagnosis on a young woman recently and thought I had immediately and accurately slotted her in the gui zhi tribe. She had the fine white skin, sweating, floating pulse and slender build of a cinnamon girl. However, tossing out the usual defining question for this type brought an unexpected response.

“Do you have a sensitivity to drafts?”

The unexpected reply of “what do you mean?” completely threw me.

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Gui zhi types pretty much always answer with an emphatic YES!
Those who do not understand the question are generally not of this constitution. Those with this kind of wei qi deficiency usually are quite aware of any nearby draft; even if it is just a slightly cracked window two rooms away. I’ve taken “what does that mean?” as a rule of thumb to mean they are not this type.

As with any shorthand or rule of thumb, there are those who to whom it does not apply. I could not figure out how she could not be sensitive to wind as she had that pale sweat moisturized skin, and a lack of heat signs.

A different tack was called for, and the question of “do you get cold easily?” brought it all back into focus. “Yes, I get cold because the drafts evaporate my sweat and makes me chilled. It really bothers me.” So there you have it, sensitivity to wind. But, she was focusing on the sweating and it did not occur to her that she was sensitive to wind. It was the fault of the sweat. Still, a gui zhi girl in my book. And moreover a reminder that my clever bits of shorthand are just that; a way of compressing and abbreviating experience. Definitely useful, but not to be confused with the patient’s reality!

This blog usually features translations, case studies, or clinical observations into the workings of Chinese herbal medicine. Today’s post is a bit different. It is a more personal story; my story of the past 24 hours, and an insight into the interaction of wei and xie qi (衛和邪氣).

It started a couple days ago with a stiff neck and rib pain, a slight feeling of fatigue, irritability and mild headache. I wrote it off as a less than restful night of sleep and the stress of a busy clinic. But, by the next day the headache had not receded and the stiffness in the neck more pronounced. While there was no fever, nor a pronounced feeling being chilled, by mid-afternoon it was obvious something was out to get me. I had a clinic partner give me some acupuncture and then had a little nap in the afternoon. That often will kick out some external pathogen, but not today. Mild chills set in, along with achiness, severe headache that was relieved a bit of pressure along the tài yáng channel, along with listlessness and fatigue. In short, it was a job for Kudzu Decoction (gé gën täng).

The first dose (4 grams concentrated granules) did not seem to do much. It was followed a few hours later by a second dose, and off into an achy restless sleep I went. Somewhere in the next couple hours of restless sleep the aches extended through my entire body and there was an odd sense of distention in my muscles, moreover I felt a heat being generated from deep within my core and could feel the fluids and cold being pushed toward the outside of my body. It seemed to take a long time to break a sweat, and in the process the muscle aches grew worse, and there were increasing waves of nausea.

I had a vague sense that this was the so-called struggle between the wei and xie qi, but it was the first time that I recognized that this battle between the qi’s was the reason that I was feeling worse and worse. It is a rather poetic idea that the defensive and pathogenic “battle”, the actual experience was I thought that at any moment I’m on my want to the bathroom to lose the contents of my stomach.

The defensive qi did win, and the pathogen was dragged to the exterior and expelled. But, it was dragged clawing, kicking and screaming to the exterior. It was a terribly uncomfortable process. But, I awoke the next day feeling 90% better. No trace of headache, body aches or fatigue.

Lessons learned?
1) Use of exterior releasing herbs indeed to active the yang wei qi. It comes from deep within the body and has a sticky quality that drags fluids and cold to the surface.
2) The struggle between the defensive wei and exterior pathogenic qi is uncomfortable and causes a worsening of symptoms as the pathogen is dragged to the surface.
3) Recovery comes quite quickly once the pathogen has been expelled.

We all know that translation is rarely a well balanced algebraic equation. Norms, habit, personal preference and worldview all play a role in how meaning crosses between language and culture.

Focal distention, golmus, pi, call it what you will, the name is not nearly as important as the illness process that it describes. This is one of those concepts upon which there is a wealth of thought and disagreement. Some say it is a sensation the patient has, others say it is the doctor that feels it through palpation. Some doctors differentiate the pathomechanism very carefully, while others simply say it is discomfort in the stomach area, and leave it at that.

Chen Yi-Ren, who was a rather renown Shang Han Lun doctor from Nanjing has quite a bit to say about focal distention. A future posting will contain a detailed translation of his thoughts on this matter. For now, here is a translation of a brief synopsis that written by one of his students.

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Focal distention is an illness presentation where there is an uncomfortable feeling of fullness and distention in the epigastrium. It occurs due to obstruction and stagnation of the Stomach qi. There are many reasons for this; it can be due to:

• Stomach heat
• cold in the middle
• deficiency of the middle with knotted heat
• deficiency of the middle with fluid obstruction
• water accumulation leading to qi stagnation.

These conditions require analysis from a holistic perspective, in this way the correct patho-mechanism can found and proper treatment given.

Heat focal distention is due to Stomach heat leading to qi stagnation; it is treated by using Rhubarb and Coptis to Drain the Epigastrium Decoction (dà huáng huáng lián xiè xïn täng)
Fx: Rhei Radix et Rhizoma (dà huáng), Coptidis Rhizoma (huáng lián), Scutellariae Radix (huáng qín)
Deficiency cold in the middle congeals the qi and causes stagnation, leading to a deficient cold presentation of focal distention; it is treated using Regulate the Middle Decoction (lî zhöng täng)
Fx: Ginseng Radix (rén shën), Zingiberis Rhizoma (gän jiäng), Atractylodis macrocephalae Rhizoma (bái zhú) and Glycyrrhizae Radix (gän câo)

As for the presentations of the three Drain the Epigastrium Decoctions (xiè xïn täng) based on Pinelliae Rhizoma preparatum (zhì bàn xià), Glycyrrhizae Radix (gän câo), and Zingiberis Rhizoma recens (shëng jiäng), these are for presentations of heat focal distention with other concurrent complications.
Chen Yi-Ren summarized this patho-mechanism as

“deficiency of the middle with heat that knots, thus forming focal distention.”

This is treated by the use of bitter and cold to drain heat, acrid and warm to open knotting, along with sweet and warm to tonify the middle. The three Drain the Epigastrium Decoctions (xiè xïn täng)

Fx: Pinelliae Rhizoma preparatum (zhì bàn xià), Zingiberis Rhizoma (gän jiäng), Coptidis Rhizoma (huáng lián), Scutellariae Radix (huáng qín), Ginseng Radix (rén shën), Glycyrrhizae Radix (gän câo) and Jujubae Fructus (dà zâo)

are actually formed from combining Rhubarb and Coptis to Drain the Epigastrium Decoction (dà huáng huáng lián xiè xïn täng) and Regulate the Middle Decoction (lî zhöng täng) along with minor modifications. As to the rational for removing Rhei Radix et Rhizoma (dà huáng), naturally this is related to the diarrhea from the focal distention’s jumble of cold and heat. As to the removal of Atractylodis macrocephalae Rhizoma (bái zhú) and substitution of Pinelliae Rhizoma preparatum (zhì bàn xià) and Zingiberis Rhizoma recens (shëng jiäng) these are accord with Zhong-Jing’s basic modification methods; as from this line concerning Regulate the Middle Pill (lî zhöng wán)

“For those with frequent vomiting, remove the Atractylodis macrocephalae Rhizoma (bái zhú) and add three liang of Zingiberis Rhizoma recens (shëng jiäng).”

Also the line from Seven-Substance Decoction with Magnolia Bark (hòu pò qï wù täng) states, “For those who vomit, add five he of Zingiberis Rhizoma recens (shëng jiäng).” Methods of decoction and administration are important aspects in the process of treating by differential diagnosis. The decoction and administration methods of the five Drain the Epigastrium Decoctions (xiè xïn täng) each have their own unique clinically valuable characteristics.

As to the diagnosis and treatment of other focal distention presentations, they too need to be examined from a holistic perspective with concrete analysis; there is not just one way of draining the epigastrium.

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The most exciting phrase to hear in science, the one that heralds the most discoveries, is not “Eureka!”, but “That’s funny…”
~Isaac Asimov

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We have these kinds of opportunities all the time in our clinical work. The pulse that does not feel quite like any pulse we have felt before. The odd reaction a patient has to a formula. The strange way that an acupuncture point that seems unrelated to a person’s problem, when palpated suddenly unfreezes a stuck joint.

Moments of discovery, more often than not first manifest as a head scratching annoyance. If we are quick enough and can turn it to curiosity, we have the opportunity to learn something new.

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One of our astute readers pointed out some discrepancies between the description of the astragalus constitution as it is written in The 10 Key Formula Families, and how it was presented in one of Huang’s recent lectures. This prompted a little email discussion with him about how his thinking has changed since the original publishing of the book in Chinese nearly 15 years ago.

As we all know, the more clinical experience we have, the more refined our ability to differentiate and treat disease.

What follows is Huang’s current thinking about the astragalus constitution.

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Q: How does one differentiate the Astragali Radix (huáng qí) constitution?
A: From the following five aspects, one can differentiate and understand the astragalus constitution.

1. Physical appearance and build: the physique of these people tends toward being overweight, however their muscles are flabby; while the skin lacks elasticity it also however is relatively moist. These people’s abdomen is soft, the abdominal muscles are weak and there is an accumulation of flesh and fat, and the navel is sunken. When palpated there is no feeling of resistance, nor is there a feeling of pain or distention on the part of the patient. This is called the “astragalus belly.” The tongue body for the most part is pale red, or pale and flabby, or purple and dark.

2. Appetite and digestion: These people have a good appetite and can eat a large quantity of food without feeling bloated or pain. Some experience a feeling of abdominal fullness, however more of a soft heavy feeling than one of distention. Taking large amounts of Astragali Radix (huáng qí) can control the appetite. The lower legs of these people are often edematous.

3. Daily activity: These people easily feel fatigued and sweat profusely. They are easily dizziness and short of breath, especially when exercising they feel like their ambition is not equal to their ability.

4. Commonly experienced illnesses: These people are inclined toward edema, especially in the feet. Their hands and feet have a tendency to get numb, and are prone to getting infections and ulcerations. They tend toward illnesses such as diabetes, hypertension, arteriosclerosis, coronary heart disease, vertebrobasilar insufficiency, spinal disc herniation, cervical spine disease, bone spurs, adhesive capsulitis, problems due to the sequel of stroke, or obesity.

5. Other factors: the possibility of seeing the astragalus constitution in those who are of advanced age, undergone chronic illness, are fatigued, lack physical exercise, have poor nutrition, or thoughtlessly take large amounts of prescription medication is high.

Q: What kinds of people should be cautious about the use of Astragali Radix (huáng qí)?

A: Astragali Radix (huáng qí) should be used with caution, and large amounts may not be used in prescriptions for those who have white complexions and thin physiques with tight musculature whose throats are often red, swollen and painful, and who have constipation. If this herb is used incorrectly it can result in adverse side effects of abdominal distention and reduction in appetite.

If you drift on over to the Pleco website you will see that as of December 18th the new Pleco dictionary for the iPhone will be available at the App Store.

I’ve been using this software as part of the beta testing program for the past six weeks. It is brilliant.

If you have an iPhone (or iPod Touch) and noodling through Chinese is part of your way of engaging Chinese medicine, do consider this as one of the tools of the trade. You could schlep around several dictionaries, or just have a Pleco product in your pocket. In addition to the iPhone, they have software that runs on the Palm and Windows Mobile platforms. Excellent software from a savvy software company that has the very best tech support in the known universe.

又方便又實用!

UPDATE 12/18—  The new Pleco for iPhone has a basic level that is FREE. Visit the Pleco website for more information, or visit Apple’s App Store to download it, and take it for a drive.

Today we have another guest post from a member of the group that journeyed to Nanjing this past November to study jing fang with Dr. Huang. Bernd Schleifer is a practitioner from Munich who has an active practice, and weak spot for good books on medicine written in Chinese.

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Reading the Ten Key Formula Families I always tried to create a picture in my mind of how these people might look. Working with Dr. Huang in the hospital was great, because a lot of those pictures really came to life.

As it was written before I was also very impressed by his use of Ephedrae Herba (má huáng) for acne. By seeing those introverted, closed-in Ephedra type acne patients, with their silent voices and reduced expression, the idea of using a warm and acrid herb to open them up was striking to me.

Another very interesting thing for me to see was his view of the Pinellia constitution and his extensive use of Pinelliae Rhizoma preparatum (zhì bàn xià) for different emotional issues. Using Warm the Gallbladder Decoction (wën dân täng) for anxiety disorders or waking up with fright was not new to me. But apart from that my idea of a person with bàn xià issues was more one of a slow reacting, plump or puffy person; more the phlegmy kind of thing, as it is also described in the Ten Key Formula Families book.

To my surprise it was often the funniest and most entertaining people in the clinic that were labeled as Pinellia constitution!

Later on in the lecture Dr. Huang explained that he distinguishes between a bàn xià heat and a bàn xià cold type. In general these are people with round faces and round eyes. However, the cold ones are more dull and slow; while the hot ones are very talkative, have lively quick moving eyes, mood swings and are very expressive with their emotions like actors or other performing artists. Most of them don’t have serious health problems, but loads of strange complaints that they feel in their body. That’s why they are kind of full-time patients, or like Dr. Huang said “those people are always at the hospital”.

Additionally I observed a funny thing in the clinic; it was almost always the bàn xià types who after saying goodbye would came back once or twice, just to ask another question or get reassurance that all of their complaints had been considered within the formula. It might have been their anxiety issues, their muddle-headedness due to the phlegm, or their vast variety of subjective problems that moved them to behave that way.

There is a section in Comparing Formula Presentations: Five Steps to Differential Diagnosis in the Treatment of Cold Damage on formulas, presentation, and illness. Unlike the way Huang writes, the author of this book writes in a condensed, specific fashion and is very clear about where within the six warp the illness is located. The more I read it, the more there appears to be spaces to read between the lines. There are areas compact in meaning, but with pointers to other presentations which when combined together gives a three-dimensional texture to the illness and context in which it is found. Obviously, it is easier to formulate a more effective treatment when the one has a clear idea of what is being treated and the terrain in which it is found.

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Let’s take a look at how the entry of a very simple little formula, Zingiberis Rhizoma and Aconiti Radix Decoction (gän jiäng fù zî täng), is written and use it to tease apart its associated presentation and illness, along with a read between a few of the lines.

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Formula: Zingiberis Rhizoma and Aconiti Radix Decoction (gän jiäng zhì fù zî täng) is Frigid Extremities Decoction (sì nì täng) with the Glycyrrhizae Radix (gän câo) removed, however the dosage [of each ingredient] is relatively larger. Note: unprepared Aconiti Radix lateralis (fù zî) is called for.

Presentation: Internal Yin/ Tai Yin Level

Irritability and restlessness with general disquiet. Non-acute Frigid Extremities Decoction (sì nì täng) presentation with relatively severe cold due to deficiency.

Disease:

No vomiting- this condition has no relation to a shao yang presentation.

No thirst- this condition has no relation to a yang ming presentation.

Deep and minute pulse with no significant heat in the body, the body feels cold with reversal cold of the hands and feet- Tai Yin Level

There are no exterior presentations; the irritability is not related to an unresolved exterior presentation. During the day the patient is irritable and unable to sleep, however in the night they calm down.** — This is extreme yin cold irritability, not the deficiency irritability with insomnia that is treated by Gardenia and Prepared Soybean Decoction (zhï zî chî täng).

** Line 61 of the Shang Han Lun:

For irritability and restlessness with inability to sleep during the day, but calm and quiet at night without vomiting or thirst, no exterior presentation, a sinking, faint pulse, and no great fever [in a patient] who has had sweating induced after purging, Ginger and Aconite Accessory Root Decoction Pill (gän jiäng fù zî täng) masters it

Zingiberis Rhizoma (gän jiäng) and Aconiti Radix lateralis (fù zî) warm the middle and eliminate cold. Zingiberis Rhizoma (gän jiäng) leans toward treating cold fluids rebelling upwards; Aconiti Radix lateralis (fù zî) more toward treating tenesmus due to cold fluids. Together these herbs warm above and below, it is an important prescription that warms the middle and eliminates cold.

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Between the lines:

First looking at the formula, Frigid Extremities Decoction (sì nì täng) is made of three herbs, two that warm the interior and one that harmonizes. Not only is the harmonizer removed, but unprocessed Aconiti Radix lateralis ( fù zî) is called for as well. From this alone we know we are dealing with an internal presentation of severe cold.

Turning to the presentation, all the charts in this book specify which of the six warps are addressed by the formula. More interesting in my mind is that it also differentiates between external and internal yang, and external and internal yin. I see this as a way of helping us to further understand the character of the illness. In the case of Zingiberis Rhizoma and Aconiti Radix Decoction (gän jiäng fù zî täng) we are dealing with a problem at the inner yin aspect of the tai yin warp. What kind of illness is this? Judging from the herbs being used to treat it, it would appear it is an issue having to do with a profound depletion of the yang leading to severe internal cold.

For the sake of comparison let’s take a look at True Warrior Decoction (zhën wû täng). This formula treats illnesses that straddle the exterior yin aspect of the shao yin and interior yin aspect of the tai yin warps. Judging by the herbs that comprise this formula there are going to be issues of cold, pain and fluid metabolism. As there is an aspect of this illness presentation that touches on the shao yin, we can infer that there likely will be issues that relate to the kidney or heart. Indeed, issues of water metabolism are a key True Warrior Decoction (zhën wû täng) issue.

When prescribing herbs and going through the mental gymnastics required to find the right medicinals, it is useful to be able to rule out entire formula families, thereby being able to concentrate our attention on the realm of potentially beneficial herbs. Using the lack of symptoms is helpful here. In this case “no vomiting” and “no thirst” means we can disregard the shao yang and yang ming levels as the disease has no relation or connection those warps. There is something very elegant and clinically useful here, as it gives us a kind of shorthand for understanding a patient’s condition.

The next line describes a “sinking and minute pulse with no significant heat in the body, the body feels cold with reversal cold of the hands and feet” and then classifies this as a tai yin level condition. There are numerous conditions that could show with a sinking and minute pulse. Here it is the reversal cold of the hands and feet along with signs of internal cold that tips it into the tai yin level.

In discussing irritability and restlessness the author is using the vocabulary of context and presentation via the process of comparison. These symptoms can arise from a number of different etiologies. He is very clear that “there are no exterior presentations, so the irritability can not being coming from an unresolved exterior” more interesting is that “during the day the patient is irritable and unable to sleep, however in the night they calm down.” We often think of irritability being due to a condition of excess. Untold doses of Rambling Powder (xiäo yao sän), Frigid Extremities Powder (sì nì sân) and Bupleurum Powder to Dredge the Liver (chái hú shü gän sân) are prescribed for patients with irritability, however in this case not only has the exterior been ruled out, but we also know the illness has no connection with the shao yang warp either. The key here is that the patient is irritable in the day, but calms down at night. But, this is not the calm of contentment and wellbeing; it is they appear of calm due to severe depletion of the yang. During the daytime the patient’s depleted yang receives some assistance from the yang qi of the day. It gives them enough “oomph” to contend with the overwhelming yin cold of their condition, but they are seriously depleted and thus irritable and fussy. At night when the yin qi is ascendant they sink back into quiet and calm. This is a false condition of quiet, as the patient’s yang qi is extremely weak. Really they are more in a stuporous state than one of true calm.

The author goes further here and says that this irritability is one that is due to extreme yin and cold and is not a case of deficiency irritability that would be treated by Gardenia and Prepared Soybean Decoction (zhï zî chî täng). Again, we are seeing how comparison between presentations helps to clarify our clinical gaze. The author assumes the reader has the ability to decode a Gardenia and Prepared Soybean Decoction (zhï zî chî täng) presentation and know what that means. For those of us that think only in zang/fu terms we can be quickly be lead astray. This is not the heat of floating yang due to yin deficiency. It is a yang ming level heat in the stomach and chest that is without constipation. It is heat, but as it is only heat and not accompanied by constipation; it is therefore not considered to be excess.

So, what does the irritability of an extreme yin cold condition look like, other than an inability to sleep during the day? I suspect these patients have a fragility about them. One thing for sure, it will no doubt be a type of irritability that will respond favorably to Aconiti Radix lateralis preparata (zhì fù zî), which is interesting as that is not exactly the first herb most would consider in the treatment of irritability.

Finally there is an explanation about how the dried ginger and aconite treat cold fluids that are rebelling upward, or being forced downward. The tai yin warp is associated with the digestion, and these two herbs target the middle and warm it. Once again the author is emphasizing the involvement of the tai yin warp for this formula’s presentation.

This all may seem like a hall of mirrors, and it is if you don’t have a compass by which to steer. But like any system, the six warp, once you learn to make sense of the landscape, can bring a startling clarity to your clinical work.

If you are regular reader of classicformulas.com then you have a pretty good idea of the value that Dr. Huang places on constitution, formula presentation, illness and the interaction between them. If you have worked with these methods yourself in the clinic, it is likely that it has at times sharpened your clinical eye and helped to craft a formula that powerfully changed a patient’s condition. It is equally likely that there have been times when a patient’s constitution seemed to morph between types, and a single formula presentation was impossible to nail down. Our patients continuously challenge us to push wider the doors of our perception and clinical understanding.

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As mentioned in a previous post, this time in Naning Huang introduced us to another set of filters that can help us to get a glimpse of our patient’s constitutional disposition.

In addition to looking for the herbal family into which they fall, we can also look through the lenses of: deficiency and excess, heat and cold, stagnation of qi or of the blood, and the presence of phlegm or dampness.

When looking through the lens of formula family or herbal presentation does not give us the focus we need to confidently write a prescription, engaging these other eight parameters gives us another corner from which to view the problem.

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Synchronistically I picked up a book (well, about a dozen actually) from a tiny, but well stocked medical bookstore off Han Zhong Road. One of the participants of this seminar has a theory that if a book has a picture of the author, and that author looks really nerdy, then it is probably a good book. The fellow with the heavy glasses on the cover of Comparing Formula Presentations: Five Steps to Differential Diagnosis in the Treatment of Cold Damage. (方證相對：傷寒辯證論治五步) fit the bill. Partly it was the nerdy guy on the cover, partly it was the plethora of case studies, some from the northern master of the Shang Han Lun, Liu Duzhou (劉度舟) and others from masters of the “Fire God” current (火神派) such as Fan Zhonglin (範中林). All were written with a clear-cut five step process that showed how they targeted at which level(s) the illness was lodged. Thought provoking case studies that weave through warp and woof of level, constitution and presentation; it went into the “buy” pile.

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It is unseasonably cold in Nanjing at this time, and reading in the comfort of a heated hotel room at the end of the day is all the recreation I want. Browsing the first few pages I was met with a familiar sight. A table of illness parameters that included the eight that Huang has been talking about.

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Now, anyone even slightly familiar with the study of modern Chinese medicine will certainly have been exposed to these eight parameters. It is part of the basic filter set through which we peculate the confusions and difficulties of our patients. However, we also run the logistics of yin, yang zang and fu, phase transformations and perhaps a few odd perspectives learned from teachers who paid attention to their clinical experience. Somehow, getting back to the basics of what is easily observed, what is concrete and without abstraction, has helped me to re-ground my clinical observation skills.

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Basics, like a black dress and simple string of pearls, never go out of style.