經方學

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Slow cooked meals are usually tasty and rich in nourishment, often the process of creation is long; you can think of it as a kind of cultivation. Likewise, quality publications take time. Eastland Press has been taking its fine toothed comb through The 10 Key Formula Families; some things can not be rushed. But, we should see it on bookshelves sometime in July. In the meantime, I’ve been arranging interviews with a few practitioners who have a wealth of experience both in Chinese medicine and use of the classic formulas. This first installment is the first part of an interview with the author of The 10 Key Formula Families, Dr. Huang Huang.

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Q: Is constitution changeable? If it is changeable, then under what conditions would changes occur?

A: Constitution is changeable. The primary factors that influence constitutional change are aging, illness, environment, and lifestyle, which includes diet, exercise and use of medications. For example, when some people are young they have a bupleurum constitution, however as they age perhaps they change into a bupleurum/rhubarb constitution. If originally Frigid Extremities Powder (sì nì sân) was effective for these kinds of patients, after their constitution has shifted then perhaps it is Major Bupleurum Decoction (dà chái hú täng) that will be required. There are also those who originally where of a cinnamon twig constitution, however due to their lifestyle they became overweight, and developed problems with their blood sugar and metabolism, in more serious cases there will be heart or kidney disease. Quite likely these patients will appear with an astragalus constitution; for them use Astragalus and Cinnamon Twig Five-Substance Decoction  (huáng qí guì zhï wû wù täng). Additionally, over-treatment or improper use of medicinals also can lead to change of a person’s constitution. For example, if Coptidis Rhizoma (huáng lián) or Rhei Radix et Rhizoma (dà huáng) is taken for an extended period of time it lead to the appearance of the Frigid Extremities Decoction constitution.

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Q: Generally speaking, when people get sick they tend to get sick in line with their constitution. What I mean is there is a correspondence between their constitution and their symptomology. However there are times when a patient’s symptoms are quite different from what one would expect, given their constitution. In this kind of situation, how should one proceed? How does one judge that a patient has fallen ill outside the predilection of their constitution? How to diagnose these cases?

A: To answer this question it is first necessary to clearly understand the theory behind the use of classic formulas. The principle of treating by matching formulas to the patient’s presentation is the core of this theory. Another way to say this is in practice when a certain presentation is seen; use the formula that treats that presentation. This is the principle behind the practice of classic formula medicine.

So, just what comprises a formula presentation? It includes both a patient’s constitution and their illness. Different formula presentations are comprised of varying proportions of constitution and illness. Some formulas targeted toward treating the patient’s constitution. For example, the use of Honey-Fried Licorice Decoction (zhì gän câo täng) is appropriate for treating patients with a thin and blood deficient constitution. While other prescriptions are directed towards an illness. For example, Gardenia and Magnolia Bark Decoction (zhï zî hòu pò täng), which treats a kind of “irritability, with abdominal fullness and a lack of calmness in everyday life” illness. There are other formulations, such as Major Bupleurum Decoction (dà chái hú täng), that are directed both at the illness and constitution. It can be effectively used for the treatment of pancreatitis, cholecystitis, bronchial asthma and gastritis with reflux. It is also effective in treating some systemic body illnesses such as metabolic syndromes and obesity, especially in middle-aged women who have sudden weight gain, left ventricular concentric hypertrophy, constipation, thyroid cysts, uterine leiomyoma, or breast lobular hyperplasia. Taking Major Bupleurum Decoction (dà chái hú täng) can shift their constitution and restore their figure. In summary, using the classic formulas sometimes the formulas are targeted at the illness, at other times it is the person’s constitution that is treated, and there are also times when both are taken into consideration.

In clinic should one come across a patient where there is a discrepancy between their illness and constitution, and it is not possible to clearly diagnose their formula presentation. In that situation, first treat the illness; if the results are less than satisfactory, switch to treating their constitution.

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Q: You have quite an interest in history and have extensively studied the history of Chinese medicine, your Master’s thesis was on the doctors of the Menghe current. These doctors were quite skilled practitioners. Can you compare for us the methods of Zhang Zhong-Jing with those of Fei Bo-xiong and the other doctors of the Menghe current?

For the answer to this question, check back in a couple weeks. If you are not familiar with the Menghe current of medicine, you can go here to learn more.

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That little side trip to Taiwan ate up all my attention there for a while. As promised, here are a few pages from the Extraordinary Views of the Abdomen. Not only that, but there is a bit of discussion from a doctor friend in Beijing that I hope you will find interesting. As ever, please leave your comments or questions in the comments section.

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Major Bupleurum Decoction (dà chái hú täng)

This is a drawing of the dà chái hú täng presentation. It indicates the presence of chest and hypochondriac fullness, epigastric urgency with muscle spasms, and when palpated deeply the abdominal tissue has a feeling of strength.
Additionally, there could be hard lumps that influence the ability to breath as the upper abdomen has clumping with a slight feeling of fullness; there can also be abdominal pain. If only one side of the hypochondria or the epigastrium is painful, if there is pain in the area around the navel, or if there is an indistinct and unfixed feeling of distention and pain, these also can be seen as part of the presentation.

This formula is Minor Bupleurum Decoction (xiâo chái hú täng) with the Ginseng Radix (rén shën) and Glycyrrhizae Radix (gän câo) removed, and the additions of Paeoniae Radix alba (bái sháo), Aurantii Fructus immaturus (zhî shí), Rhei Radix et Rhizoma (dà huáng) and a double dose of Zingiberis Rhizoma (gän jiäng).
It is used to treat patient’s those abdomen is large; they are referred to as dà chái hú types.

In this formula the meaning of epigastric urgency is that there is focal distention and hardness in the epigastrium, which is the result of a process of gradual internal accumulation that over time becomes an interior excess condition. Both fluids and qi stagnate outside of the Stomach, leading to continual vomiting. Thus, Bupleuri Radix (chái hú), Pinelliae Rhizoma preparatum (zhì bàn xià), Scutellariae Radix (huáng qín) and Jujubae Fructus (dà zâo) are used. Paeoniae Radix alba (bái sháo) is used to treat the fullness, pain and urgency aspects of the presentation. Additionally, Aurantii Fructus immaturus (zhî shí) and Rhei Radix et Rhizoma (dà huáng) are added to treat what is between the interior and exterior (枳實，大黃可及於內外 zhî shí dà huáng kê jí yú nèi wài).

This phrase: 枳實，大黃可及於內外 zhî shí dà huáng kê jí yú nèi wài, is interesting in that it indirectly refers to the shào yáng as the space between. In discussions with a friend, who teaches at the Beijing TCM University and has an incurable taste for the classics, she brought forth this gem; “the illness is in the shào yáng which means it is half interior and half exterior, at the same time it has already entered into the organ level of the yáng míng. So using Minor Bupleurum Decoction (xiâo chái hú täng) addresses shào yáng illness, while the two additional herbs treat the yáng míng.

The Classics state: tài yáng illness that for 10 days, the patient was erroneously purged for two or three days. In the four to five days afterward a xiâo chái hú täng presentation persists; first use Minor Bupleurum Decoction (xiâo chái hú täng) to treat it.

Commentary: As the illness has already passed from the tài yáng level [to the shào yáng], the patient has been ill for 12 days without any further changes in their condition. After being ill for a long time, following and treating according to the presentation is what masters the problem. In this case the patient was erroneously given purgative medicinals. After one course results were not seen so a second and third course were given which caused diarrhea. Four to five days after this mistaken treatment there was still a xiâo chái hú täng presentation. One does not have to be a stickler for the number of days a patient has been ill, it is enough prescribe the herbs based on the observing the manifestations of the xiâo chái hú täng presentation.

Ceaseless vomiting with tightness and pressure pain sensitivity in the epigastrium, a sense of constraint with slight irritability, [the illness has] not yet resolved. Giving Major Bupleurum Decoction (dà chái hú täng) to purge it can bring about the cure.

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When there is just vomiting and tightness in the chest, it is appropriate to continue using Minor Bupleurum Decoction (xiâo chái hú täng). When there is irritability that then turns into a feeling of constraint with irritability Minor Bupleurum Decoction (xiâo chái hú täng) will not be able to resolve it. This kind of tightness in the epigastrium with pressure pain sensitivity accompanied by feeling of constraint with irritability is indicative of a condition of internal accumulation. If it is not purged, it will be difficult to cure.

As there continues to be ceaseless vomiting, this cannot be said to be an Order the Qi Decoction (chéng qì täng) condition, but rather it falls within the scope of the bupleurum formula family. Therefore adding Aurantii Fructus immaturus (zhî shí) and Rhei Radix et Rhizoma (dà huáng) to Minor Bupleurum Decoction (xiâo chái hú täng) to purge [address the yáng míng aspect of the presentation] will bring about the cure. Additionally, to treat the vomiting, the amount of Zingiberis Rhizoma recens (shëng jiäng) is increased. As previously mentioned, vomiting and irritability are seen as being part of the Minor Bupleurum Decoction presentation.

In the line from the Discussion of Cold Damage that describes the use of Major Bupleurum Decoction (dà chái hú täng) it uses the word “can treat” (與 yù), it does not use the commonly seen phrase “masters it” (主之 zhû zhï), should [this formula not work] and there is condition of genuine internal excess, then the appropriate treatment is with a prescription from the Order the Qi (chéng qì) family. However, as this is slow moving kind of tài yáng illness, it cannot be impatiently treated as a yáng míng illness with aggressive medicinals where purging will immediately about the cure. Adding a little Aurantii Fructus immaturus (zhî shí) and Rhei Radix et Rhizoma (dà huáng) to gently drain will cure the problem. As it says in the original text, one should know if Stomach presentation is excessive or not, otherwise purging is of no benefit.

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Andy Ellis is one of the significant contributors to our field. He is the co-author of The Fundamentals of Chinese Acupuncture, Fundamentals of Chinese Medicine, and Grasping the Wind. Author of Notes from South Mountain, and part of the team that has given us the latest edition of Eastland Press’s Formulas and Strategies. He is the founder of Springwind Herb Company; not only does he find time to teach and practice, but he manages to mix it up on a basketball court several times a week as well.

While our paths often cross in Taipei, this time we had to catch up on online.

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How did you manage to find your way to Taiwan in the 80’s, and what was your motivation at the time?

I first went to Taiwan in 1983 to further my studies in acupuncture. I had studied with Dr. So at the New England School of Acupuncture for a year or so and then Dr. So got ill. I wanted to learn the real thing and since China was not accessible at that time I opted for Taiwan. At that time I had no intention to study herbs but when I got to Taiwan I realized that Chinese medicine there was largely herbal. There were, and still are, herb shops in every neighborhood.

You have spent time both in Taiwan and Mainland China. How would you say the medicine traditions differ between these two places?

It is hard to characterize an entire population. There are many traditions in Taiwan and many in Mainland China. In herbal practice there has been a great influence by Japan in Taiwan. The most obvious one being the use of concentrated granules. Like the Japanese, Taiwanese doctors emphasize formulas from the Discussion of Cold Damage (傷寒論 Shang Han Lun) and the Restoration of Health from the Myriad Diseases (萬病回春 Wan Bing Hui Chun). In modern mainland China the Restoration of Health from the Myriad Diseases is largely ignored. The Cultural Revolution, which had a large influence on China also influenced the medicine. Much of the spiritual nature was removed and a more dialectical approach was substituted for primarily political reasons. That is not to say that there were not many wonderful schools of thought that survived this purging but it was definitely an influence and can be seen in the modern writings.

Both Taiwan and China seem to feel a need to have their medicine be taken seriously by the West. They have taken slightly different approaches to gaining this approval. That is a long topic perhaps for another discussion.

Dr. Shi was a real influence for you. What about your time with him informs the way you approach medicine today?

Dr. Shi was the kind of doctor that I had hoped I would find in China. His unending patience and kind manner set an example that my better self recognized immediately. His approach to the medicine was not dogmatic and he felt truly that he was the fortunate recipient of a tradition that dated back to the early Han. Anyone who spent time with him gleaned immediately that he felt privileged to be able to help others with the information and tradition that had been handed down to him. I can only hope to emulate his manner and the unending study he engaged in order to help his patients.

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Andy’s book about Dr. Shi, not only is part of his contribution to us in the West, but also passes along some of the essence of Dr. Shi’s experience, learning and teaching. You can download THIS pdf file that contains a few pages from the book; it gives  a glimpse into the mind of Dr. Shi. Andy is making the book available at a 10% discount to the readers of classicformulas.com.

Click HERE to go directly to the Springwind site, at the checkout page simply enter classicformulas in the coupon space. This book not only gives great clinical tips, it also gives you a taste of how a gentleman/doctor thinks and works. We don’t have many books like this.

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It may not be a trip to China, but it is an opportunity
to engage the mind of a true doctor of the art!

One of the great things about hanging out with experienced doctors, especially guys like Chang Bu-Tao, is that you get to see how a tuned and savvy doc works. Doc Chang’s ample waiting room empties and refills like a Zen bamboo water pipe; seeing 200 patients in a day is not uncommon. He is one of the senior docs in Taipei city with over 20 books to his name, students from down the street and across the world, and a reputation that drifted far, far out from his fourth floor clinic just south of Peace and Harmony East Road.

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Like all experienced doctors, he has this ways of using the classic formulas in ways that don’t quite match the first glanced at list of actions and functions in our formula books. This is a darned good reason to read the Discussion of Cold Damage (傷寒論 Shäng hán lùn) and the works of various authors who have gone deep into that tradition.

Dr. Chang has his own way of thinking about Formula Families, and sees Puerariae Radix (gé gën) as being a family of its own. Here are a couple gems from his book that explains Shang Han Lun formulas.

Treatment of spasms:
Because Puerariae Radix (gé gën) functions to control tremors, when used together with Paeoniae Radix alba (bái sháo), Jujubae Fructus (dà zâo), and Glycyrrhizae Radix (gän câo) its ability to relief spasms is even more pronounced. As written in the Yellow Emperor’s Inner Classic “sour astringes, bitter dries dampness, sweetness relaxes tightness…,” [thus we understand how] Glycyrrhizae Radix (gän câo), Jujubae Fructus (dà zâo), and Paeoniae Radix alba (bái sháo) have the effect of softening and relaxing tightness. For tightness and pain in the head, shoulders and neck, and especially for numbness due to problems with the facial nerves use of Puerariae Radix (gé gën) with peony, dates and licorice works rapidly to relax these symptoms and improve the patients condition.

Treatment of allergic rhinitis:
Kudzu Decoction (gé gën täng) can be used to good effect in the treatment of allergic rhinitis and sinus infections. Taiwan has the typical climate of an island, as it is surrounded by ocean it is usually quite humid; especially so in March when it is still bothersomely on the cool side and frequently drizzles. Due to these environmental factors there is an increase in the instances of the common cold and allergic rhinitis. Western medicine commonly uses antihistamines to treat allergic rhinitis. Although it is effective, drowsiness is one of the side effects.

I remember one year during the Chinese New Year going on a group tour to New Zealand. At that time the tour leader experienced a flare up of allergic rhinitis and was quite uncomfortable. One of the members of the tour happened to have some antihistamines, which he gave to the tour leader. This resulted in our leader constantly dozing off wherever we went. If these drugs were taken before driving, it was difficult to avoid nodding off while driving, which was quite a danger to the safety of all involved.

For nasal allergies due to climatic factors, I use Kudzu Decoction (gé gën täng) as the primary formula, and add the anti-allergy medicinals Schizonepetae Herba (jïng jiè), Saposhnikoviae Radix (fáng fëng), Cicadae Periostracum (chán tuì) and Coicis Semen (yì yî rén); the clinical effect is quite good. Should the patient also have itchy eyes, then add Equiseti hiemalis Herba (mù zéi) as well.

Treatment of sties:
Sties are a type of ophthalmologic disease. Because people these days often eat rich, fried or roasted foods and as they rely on the computer and spend long hours staring at the screen, visual acuity diminishes and there are pathological changes to the tissue of the eyes. Sties are one result of these changes.

Western medicine uses surgical procedures to treat this problem. We Chinese doctors, however, use the thought process found in the Yellow Emperor’s Inner Classic to differential illness. In the Inner Classic we find that the blood vessels that go from above to below are considered to belong to the tài yáng meridian. Those which go from below to above belong to the yáng míng meridian, and those that radiate sideways are associated with illnesses of the shào yáng meridian. In line with these relationships we select a formula representative of the yáng míng meridian; Kudzu Decoction (gé gën täng). Which is then modified with ophthalmologic medicinals such as Celosiae Semen (qïng xiäng zî), Cassiae Semen (jué míng zî), Leonuri Fructus (chöng wèi zî), and Plantaginis Semen (chë qián zî). It is quite good for treating sties!

One of the really interesting things about use of the “jing fang” is that the change of a single herb, or even the amount of an herb used, can have a significant impact on the function of the formula.

A friend of mine who has shelves full of books concerning the Shang Han Lun once mentioned over tea and cookies that because the classic formulas are not made of many herbs, it is easy to understand how a small change can have significant results. Thus, studying and using the prescriptions from the Shang Han Lun and Jin Gui Yao Lue are a great way to both save your patients money, as these prescriptions tend not to be expensive, and for you as the practitioner to hone your skill in understanding how the change of a single herb can have profound clinical effects.

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As Dr. Huang says, this is part of the “beautiful attraction of the Classic Formulas.”

It is rare that I find really amazing books about Chinese medicine. The vast majority of mind opening books in my collection have been recommended to me by someone else. I am ever in the debt of others who also walk this path. Recently, over a plate of dumplings, Gabriel Fuentes and I were discussing medicine in Taiwan. Taiwan is a goofy place as it is possible to be a well skilled doctor and not have a license. For that matter, it is possible to study for years and years abroad with deeply skilled doctors, but if you don’t have the pedigree of a Taiwanese diploma; no license for you. However, if you have the “stuff” to be a doctor, you open a clinic anyway. If you have the ability to help people; they will come to you.  I just love Taiwan!

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Over those dumplings I found out about this guy, Dr. Zhang,  who is rumored to be good with the pulse, and spot-on with herbs. A bunch of both students and licensed doctors ride up into the mountains outside of Taichung to study with him, and they have written down the methods and clinical reasoning of this guy.

The great thing about knowing how to read Chinese is that you get access to material as far away from English as Taipei is from Tennessee.

One of the collections of notes concerns dui yao, the pairing of herbs. While these herbal couplets are useful when thinking about any formulation, the changes they make to a “jing fang” formula are even more pronounced. Here is a taste of Dr. Zhang Guo-Yang’s work. I hope you find it helpful in your clinical practice!

We should see The 10 Key Formula Families out in print sometime in March. I am hoping you will find it as interesting to read, as I found it to translate. More importantly, I trust it will give you another lens to focus clinical reality.

Dr. Huang’s emphasis on constitutional types and herb presentations is a useful clinical tool that helps us to navigate the at times confusing world of herbal medicine.

Eastland Press and I are delighted to offer you a free eBook that gives a basic introduction to the 10 Key Formula Families. Just sign up for our spam-free mailing list, then follow the link to your free eBook.

Wat Po temple in Bangkok is said to be dedicated to the healing arts.

Check out these images from one of the side pavilions.

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I am ever reliant on the knowledge, guide and good will of others. This book Extraordinary Views of Abdominal Patterns (腹證奇覽 fù zhèng qí lân) originally caught my attention when friend asked me to pick up a few copies for him on one of my trips to Taiwan. I snagged a copy for myself at the time, and like The 10 Key Formula Families have been reading it over a period of time. The more I read, the more interesting it becomes.

As this book also focuses on the classic formulas, it is not surprising that there are tie-ins to some of the clinical considerations that Dr. Huang tends to stress. More interesting, this book gives clear and concise abdominal presentations that help the practitioner to focus their clinical perception through the use of their hands and consider the objective physical presentation of the patient’s abdomen.

I asked Nigel Dawes, one of the foremost western practitioners of Japanese Kampo, about this book. He had this to say:

The book you are referring to, 腹證奇覽 Fuku Shoh Ki Ran  (Extraordinary Views of Abdominal Patterns, is one of the most famous Edo Period (1600 - 1862) Japanese texts on Fukushin (abdominal diagnosis) it was written around 1800 by 稻葉克文禮  Inaba Katsubunrei who was born around 1805.

It seems the book had a great influence in spreading the importance of Fukushin in the practice of Kanpo.  Little is known about Inaba and a positive date of birth or hometown is not even known.

He was said to be an orphan and had minimal education, but he decided nonetheless to become a doctor. So he looked for a way to train without being able to read/write. He met a doctor, who was an expert in Fukushin. This doctor was not a direct student of Todo Yoshimasu, (perhaps the most celebrated of the Kanpo doctors of the Edo period in Japan), but was an admirer of his.

It is said that Inaba wrote Fuku Sho Ki Ran by having his students transcribe his dictations.

The content of this book is quite complimentary to that of The 10 Key Formula Families, watch for occasional excerpts here that will help you to add palpatory diagnosis to your clinical repertoire.

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There is a great saying in Chinese 一步一步來; 
keep putting one foot in front of the other.

It is good advice for any endeavor, but especially apropos for those projects that span years, or for journeys where the destination can barely be imagined, let alone seen, from the point of departure.

Five years ago The Ten Key Formula Families made its way into my hands. Two years ago I received Dr Huang’s permission to translate it into English. This past week my final proofing was completed, and it is now in the hands of my publisher, Eastland Press.

Look for it in the first quarter of 2009. It should be available soon after we have celebrated the year of Ox here in China.

滑 hua

It means slippery.
Like ice is slippery.
Or like summer oil coated roads in Seattle, when they get their first misting of a fall rain.

In Chinese medicine we use 滑 to describe a kind of pulse that has a certain feeling of phlegmy force. But, it is also used to describe a coating on the tongue.

Describing the slippery coating on the tongue (tongue not in cheek) is a rather slippery issue.

As with most everything in Chinese medicine (and language for that matter) it depends on context. The slippery tongue coat can be a slightly greasy, slightly glossy, almost shellacked like coating. Like the one often seen in the presentation for ban xia formulas. But, the tongue coating in dried ginger formulas is also often described as slippery, but here it is actually a bit more of a slimy coat.

Consulting the Chinese dictionary tells us that slippery also can mean glossy, as in shiny.

It would be convienant if there was always a one to one corraspondence between words, between languages, a gold standard  firm and unchanging rule. But, language is, well, more slippery than that.