經方學

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.

One of the first concepts we hear upon walking through the gate of Chinese medicine is that of excess and deficiency (xu虛 & shi實). Deceptively simple at first glance, this is one of the foundations of accurate diagnosis that tends to become more slippery as time goes on and we see patients in the clinic with strange mixes of symptoms. All the practitioners here in Nanjing have at least 10 years of experience, and like anyone seeking mastery,  some of us are still working on refining the basics as a way to sharpen our clinical eye.

Today’s guest post comes from one of the participants of the Nanjing seminar. It gives us a fresh insight into issues of excess and deficiency and the use of Ma Huang.

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The single most important thing I learned in the first week of studying with Dr. Huang in Nanjing is his explanation of “shi”and “xu”, most often translated as”excess” and “deficiency”. The usual translation to German is “Fülle” and “Leere”, which literally brought into English is expressed as “fullness” and “emptiness”.

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Even though we are used to the relational nature of terminology in Chinese medicine, it never was really satisfying when teachers spoke about a Gui Zhi Tang situation as “exterior deficiency”, while at the same time saying that there was no “real deficiency”, but only compared to the Ma Huang Tang situation, which is “exterior excess”. And on the other hand both the Ma Huang Tang and Gui Zhi Tang situations are “excess” in relation to, lets say: Yu Ping Feng San or Gui Zhi Jia Fu Zi tang conditions.

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Dr. Huang provided us with a new perspective by switching the focus to movement and function. On every level of the body there are doors, which have to open and close in appropriate ways, for example at the exterior of the body, the doors are the pores. If they stuck close (in other words don’t open properly) this is “shi”, if they stuck open (in other words: don’t close properly) this is “xu”. So in a Gui Zhi Tang Situation “Xu” means: the exterior doors are stuck open, and in a Ma Huang Situation “Shi” means: the exterior doors are stuck close.

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Ma huang is the primary herb used to open glands, which are considered to be one kind of door, like the sweat glands of the skin. Therefore it is used for acne to open the pores which are clogged shut. It can be used as well as to help release eggs of the ovaries, or for insufficient lactation. Whether a formula (like Gegen tang) is appropriate, depends on the constitutional body type and if the formula presentation fits with the disease presentation. Another example of how Dr. Huang uses Ma Huang for problems with glands is Zhen Wu Tang together with Ma Huang Fu Zi Gan Cao Tang and Dang Gui Shao Yao San for hypothyroidism.

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Furthermore the opening function of Ma Huang is also used for other “closed” types of problems, for example Bi-Syndrome. Dr. Huang even uses it together with Wen Dan Tang for patients with schizophrenia, who are mentally locked in by the use of anti-psychotic drugs.

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I’m sure that the new perspectives provided by Dr. Huang will allow us to expand the use of herbs and formulas even further.

Perhaps practicing medicine is much like forest management, fiddling around with the economy of a large developed country, or arranging a 100 table banquet. There are individual issues; the overpopulation of a certain insect, corruption in a key business sector, unrelenting fever, or who should sit next to who. There are hot spot issues, the fly in the soup, bark blight and leaf mold, mortgages foreclosures, or a sudden inability to digest. These are the issues that command attention, the issues that lead to a mobilization of action. A call for change and remediation.

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Then there is the forest of trees, streams, soils and how they sway and grow with the seasons. There are the vast web-like connections between businesses, those who buy, who sell and those who speculate. In business there is an ongoing organic symphony of exchange that mimics the process of respiration and digestion. In most any process, depending on where we shine the light of intention, issues of overall constitution or specific ailment can be brought into relief and focus.

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So it is with medicine as well. We can focus on specific issues or complaints, or we can pay attention to the overall terrain in which our patient’s lives unfold. There are formulas that are very good at treating certain problems over the range of a number of constitutions. These prescriptions target disease. There are other formulas that adjust a patient’s constitution; these do not directly treat illness, but instead adjust the internal environment. It is the difference between spraying a chemical cocktail on blighted leaves, and changing the nutrient balance of the surrounding soil, so that a tree has access to the constituents it needs to ward off opportunistic invasion. Sometimes seating two people together at a banquet provides more catalyst for change than a dozen business meeting. You just have to be sure you are getting the right people together.

So it is with the formulas that adjust constitution.

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One of the participants here in this Nanjing seminar pointed out a line from The Ten Key Formula Families, that I had not completely understood:

The range of practical clinical uses of Bu Zhong Yi Qi Tang is unusually wide. Furthermore, the broader a formula’s range of indications, the more important it is to be rigorous in grasping when and how it should be used.

Simply put, constitutional formulas can be quite effective in treating a variety illness, so long as one grasps the constitutional underpinnings of the problem. The more issues a formula is capable of treating, the more rigorous one must be in correctly determining the patient’s constitution. Because these prescriptions are capable of treating a wide range of disease, it is easy to make the mistake of thinking these formulas can treat a certain illness in all people. They key here is that they do in fact treat a wide variety of disease, but the key is they only do within the scope of a certain constitution.

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Ma huang can be used effectively to treat amenorrhea in those with an Ephredra/Cold constitution. But, it will only bring about agitation in those with a Bupleurum/Stagnation constitution. For spotting between periods in women with a Heat/Excess constitution forget the stop bleeding herbs; bring on the huang lian jie du tang.

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Obviously, we are dealing with strong medicinals here, and a scatter shot approach is not recommended. The key to effective and safe use of these terrain regulating constitutional prescriptions hinges on one’s ability to discern constitution.

Like those magic eye pictures, where when the vision is loosened just so a completely three dimension image appears. Learning to acquire an clinical gaze that is soft enough to take in the entire landscape of a patient’s presentation, and sharp enough to see clearly the shape and structure of dysfunction, is an acquired skill. Usually facilitated by guidance from an experienced teacher who has both the skill and inclination to share it. Dr. Huang is just such a teacher.

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Our class here in Nanjing uses The Ten Key Formula Families as a starting point. Unlike our last trip to Nanjing two years ago, he is not teaching the book; it is simply background for his current way of thinking and approaching clinical work. The ten constitutional types he introduced in that work have been expanded to include a number of other medicinals, and are now elements of a broader structure that helps us to better understand the predilections and disposition of our patients.

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While there is still a sharp focus on the patient’s constitution based on the herbal formula family they fall into, he also casts a broader net of discernment using the parameters of cold, heat, deficiency, excess, qi stagnation, blood stagnation, phlegm and dampness. Like the crosshatch pattern of a sieve, it gives us a finer granularity with which to shift a patient’s complaints and constitution into a formula that fits the lock of their dysfunction.

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Watch for more posts from Nanjing, as the lessons from the classes, observations from the clinic, and discussions over foot massages make their way to these pages!

If any of you have inclination toward reading Chinese, then you probably are familiar with Pleco software. Yes, that is their logo on the iPhone app in the picture. No, it is not yet available. But, from participating in the beta-test I can tell you that if you have an iPhone in your pocket, and have some kind of relationship with the Chinese language, this application is going to rock your world.

Unlike the PDA versions, you use your finger to write directly on the screen. The word lookup is blinding fast and startlingly accurate. The handwriting input system is also smart enough to differentiate simple and traditional characters on the fly. While the initial release will not support flashcards, an update that does will not be far behind.

For a glimpse at the magic click here.