What I did not expect is that the practice would grow as quickly as it has. And so I am seeking an associate to join the clinic here in St. Louis, MO.

Yong Kang Chinese Medicine Clinic is located in the delightful and accessible neighborhood of Kirkwood. We draw patients from both St. Louis city and county, as well as from southern Illinois.

St Louis offers a low cost of living, access to the arts, spectacularly vivid weather, an increasingly diverse community, some nice restaurants and the City Museum. It also is in a region that up till recently has not been exactly open to acupuncture.

That, however, has changed and Chinese medicine is rapidly becoming THE alternative treatment of choice.

Do you want to build a practice, and built it fast? Do you like the idea of a cash-only business? Does it sound appealing to practice in a community that is very supportive of new practitioners? Would you like to see patients with difficult and challenging health concerns? Do you happen to have a weak spot for frozen custard? Then this opportunity just might be for you.

Interested? Visit the clinic website to get a taste for what we have going on here. Like what you see?
Follow up with an email.

The American Midwest is desperately in need of more Chinese medicine practitioners.
You can make a difference here!

An excerpt from Deciphering the Shang Han Lun, by Chang Bu-Tao (張步桃)

A Mr. Li had a motorcycle accident and was taken to the emergency room and then into surgery. After surgery he was taken to the intensive care unit for observation. His older sister was one of my students, she come to the clinic, told me about his condition and asked me to write a prescription for him.

I used Bupleurum plus Dragon Bone and Oyster Shell Decoction (chái hú jiä lóng gû mû lì täng) with the additions of Salviae miltiorrhizae Radix (dän shën), Nelumbinis Folium (hé yè) and Notoginseng Radix (sän qï) to invigorate the blood and transform stasis. Additionally, Acori tatarinowii Rhizoma (shí chäng pû) and Polygalae Radix (yuân zhì) were added to open the orifices and awaken the brain. After being administered the herbs, the very same day he revived and awoke. Furthermore, could use his fingers to rub his nose; this provided endless surprise to the rehabilitation doctors.

Afterwards, acupuncture was also used and Mr. Li patiently continued to take herbs. As of this writing there are no signs of him having been in a serious accident.

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As students of Chinese medicine we spend countless hours memorizing an endless parade of signs and symptoms that should lead us to selecting an effective formula. Our exams have questions that must be answered correctly, our teachers have expectations for us learning the fundamentals, which will make us safe for public consumption. In an effort to orient ourselves in the Chinese medicine universe we litanize pulses, tongues and indications. It is all a necessary process, and it prepares us for the confusing constellation of patterns and presentations of our patients that come to us for help.

Study prepares us to think with a different kind of pattern language. It gives us a method of inquiry and a set of lenses with which to view the balance of illness and wellness. But, how do we get from the textbook descriptions of Bupleurum with Dragon Bone and Oyster Shell to treating brain damage due to trauma. In a word; experience.

This is one of the reasons why Chinese medicine bookstores in Asia have an abundance of case studies books. Case studies can act as a catalyst that furthers our development as doctors. They help us to navigate between knowing and discovering,  as they force us to open up our thinking.

About this project
Walk into any reasonably sized bookstore in China and you will find shelves full of the experience of Chinese medicine doctors. Case studies are the bones and blood of furthering one’s skill as a doctor. We all gain a foundation, a skeletal structure from our textbooks and first years in medical school. But it is the actual application, the use and practice of medicine that allows us to distill meaning from our experience.

Here in the West we have plenty of books that teach us how-to, books that are rich in theory and heavy with fundamentals; we all need a foundation from which to work. But to really understand how medicine unfolds in the clinic, how to engage the conversation between patient and practitioner, connect the dots between symptom and treatment, and navigate between knowing and discovering, it is within the case study literature where we really see medicine come alive.

Chinese medicine is both vast and deep. This book seeks to bring into focus one aspect: the use of the classic formulas of the Shang Han Lun and Jin Gui Yao Lue in modern practice.

Why the focus on classic formulas?
There is not just one way to read the Shang Han Lun; its 398 lines have multiple interpretations and there is a plethora of ways to apply its methods. Formulas that were used 1,800 years ago for a single purpose now have multiple applications in modern life. Just as a single substitution or changing the amount of one herb can profoundly change the function of a formula, so too does clinical perspective have a deep impact on how prescriptions are chosen and modified.

Through the window of case studies, this book seeks to allow the reader a glimpse into the contributor’s clinical reasoning, to throw light on how they gather information and distill its meaning, and to share their perspective on how the lines of the Shang Han Lun and Jin Gui can be applied to understanding the use of these ancient formulas in the modern clinic.

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Who will be contributing?
This is not just a look at how the jing fang are used in the West. Invitations to contribute will be distributed to China, Taiwan, Japan, Singapore, Europe, Australia and New Zealand, and other countries where there are stories of innovative use of the classic formulas.

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The goal is to improve our clinical results
We are not looking to prove the classic formulas are effective, or that Chinese medicine is useful. We already know that from our clinical work. This book, which unfolds the practice of medicine via case study, gives us a glimpse into the mind and clinical reasoning of the seasoned practitioner. It will help us to understand how to sort out what is important, as it maps out a method of inquiry and intervention. The classics have given us a common set of prescriptions, but the ways in which they are clinically applied in modern practice are as unique and varied as the practitioners themselves.

This is an invitation to contribute to a work that will give the reader a diamond-faceted look at the clinical application of the classic formulas, an opportunity to contribute a more multi-dimensional view of those formulas in modern clinical use. As well, it is an opportunity to add to the discussion that has been going on for 1800 years now about how to help our patients with these often simple, but effective formulas.

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Would you like to join us?
If you would like to submit a case study for review and inclusion, please write and let us know of your interest. You will be sent a submission package that details format, writer’s guidelines, timetables and other pertinent information.

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 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.

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.

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.