經方學

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.

.

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.

.

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.

.

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.

.

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.

.

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

The back of Richard Goodman’s book says it best “Why not go deeper?”

I ran into Rick back in 2005. He was just arriving in Taiwan, I was on my way back to the USA; he rented the penthouse studio that overlooked Eternal Harmony City and the Xin Dian river that I’d been living in for the past year plus. Our paths crossed again when I purchased his book. Journeys through Chinese into medicine have a way of crisscrossing from time to time.

Anyone who has read the Mitchell/Wiseman/Feng translation of the Shang Han Lun knows that there are appendixes in the back that are a treasure trove of translation gold. Especially, for understanding the Chinese of The Discussion of Cold Damage.

Rick Goodman gives us some basic vocabulary, and more importantly, grammatical parsing that helps us to crack the code of Classic Chinese. Is it a comprehensive text that spills out all the gems of the Nei Jing, Nan Jing, and Jia Yi Jing? Of course not, the process of learning Chinese can in no way be captured in one book. Does it give us some keys that coax open those doors? Absolutely! It is a clearly written, carefully explained text that gives the reader access to the treasure house of Chinese medicine. Indeed, this book will give the dedicated reader an opportunity to go deeper.

Rick also has a second volume of what will be a three part series that will be published soon. Get the details here on his blog.

Thanks Rick for your contribution!

How is it that you ended up in Taiwan to pursue your study of language and medicine?

It had to do with Andy Ellis, I met him when still in school and through our association started to study the Chinese language. It is difficult to study Chinese in the US. Andy suggested that as I did not have family or other commitments I might consider going to Asia, as being immersed in a Chinese speaking environment would be good for my acquisition of Chinese.

When I first arrived in Taiwan I spent time doing medicine in the clinics of some people that Andy knew. It was after being there for a year that I met Nigel and really got into the language.

*

Many people think that the formulas and theory found in the Shang Han Lun are only applicable to cold climates. Taiwan can be quite hot and humid. How did you see the doctors there applying the “classic formulas” there?

I got pretty sick after getting to Taiwan. It was primarily a digestive system problem. At the time I had no idea what was going on, and felt so bad that I almost went home. But, it turned out to be a Ban Xia Xie Xin Tang presentation. It was a slam-dunk diagnosis for the doc that I saw. The formula worked very quickly, as I took the herbs and felt magically better. My condition was not the result of the classic exterior pattern that had been purged, as is described in the Shang Han Lun. It was just disharmony between self and environment. These classic formulas have a broader scope of utility than we learn in school. The Taiwanese docs used them in all kinds of creative ways. Problems being caused only by cold is not true in clinical reality.

You have to try and understand the patho-mechanism. Understand not just symptoms, but what do those symptoms represent. What kind of picture is being painted? One thing I’ve found helpful, it is purely my own mental noodling, is to think of the lines of the Shang Han Lun as kind of a clinical notebook. There is more utility to it when you think of the lines illustrating a certain situation and understand that the way it is described is not the only way it can happen. It is an image of that kind of patient.

I’ve found this at times when reading case studies of the Masters. You read their cases and the patient does not have the usual symptoms, but they have the patho-mechamism; based on that they prescribe.

*

It was you who laid that first copy of 10 Key Formulas Families in Chinese Medicine on me in Beijing in 2002. How did you come across that book in the first place? When you are looking for resources in Chinese, what do you look for?

Sometimes I look for a specific author I like, for example Liu Du-Zhou. I am interested in his perspective, so I read whatever he writes.

The other thing is that sometimes there are specific books based on content. If there is a Shang Han Lun or Jin Gui book that I have not seen before, I will give it a look. I also like case studies, so I browse those and I like the jing fang books, where there are cases that trace a case to a line of the text.

I also enjoy the more classic works. Even though the older authors can be more difficult to read, they are interesting. I like to read texts from 500 years ago that have case studies and see how their treatments compare with modern methods.

One of the best ways to visit bookstores is to go with one your Chinese teachers and see what they like and follow their suggestions!

*

I’ve heard a number of discussions about using classic formulas to “unstuck” a pathogen. In fact, sometimes knotty and intractable problems can be due to this issue. Can you give us some insight into knowing when we are dealing a stuck pathogen? And tell us a bit about how pathogens get stuck? How about a case to illustrate the point?

For me, a key indicator that I’m dealing with this situation is when someone describes a situation where in a broad sense they can tell you when the problem started. They say something like “I never used to get headaches, but last year in the spring it seems things are different, and now…”

If they articulate that kind of progression it is a good indication that something got stuck. It does not need to be a traumatic event. They may not always remember right away what was the triggering incident, sometimes later they remember something happened.

Let me give you an example; this is a case at the very beginning of this kind of a process. I had a student a few years ago who had gone out and eaten a heavy meal that included ice cream. It was unusual for her to eat in this way. She felt bad after that and got constipated. It felt like food stagnation, so we tried Preserve Harmony Pill (bâo hé wán) and those kinds of formulas, nothing worked. When I took a further at her one of the interesting things was she had only mild discomfort in abdomen. I gave her Frigid Extremities Decoction (sì nì täng) with Cannabis Semen (huô má rén), which cleared the problem right up with one bag of herbs. This illustrates that some cold got lodged in the abdomen, causing damage to the yang qi, which in turn reduced peristalsis. Warming the yang to dispel cold did the trick.

*

For many of us, it is quite daunting to approach studying the Shang Han Lun. Can you give us some advice on getting started? How to approach this text in a way that will help us deepen our practices?

A couple of key points. First, don’t ignore the source text. It may be confusing and daunting, but if you have some of this in your head, it will be useful in the clinic when you see patients. As you are working you can ask yourself “does this line match this patient?” If the material is in your head, you are more likely to see it.

Concerning the use of formulas, it is best to use them with minimal modification until you understand how they work. That way you can tell if you if are right or not.

Finally, I want to again point out that it is essential to know what the underlying patho-mechanism is. This helps you to understand the patient and the course of their illness.

How did you develop your interest in the Shang Han Lun?

My interest in the Shang Han Lun was a result of my search for source materials in Chinese medicine, and my fascination with medical anthropology. Perhaps it has something to do with my Jewish background, as in Talmudic scholarship there is a strong incentive toward accessing source material and commentaries. I’ve always had the incentive to dig into the classical literature of Chinese medicine, but it took many years to find reliable translations.  I also began studying medical Chinese relatively late, about ten years ago.
When I first heard of the Shang Han Lun the translations that were available, such as OHAI’s Treatise on Febrile Disease or the New World Press translation were not very good.  I couldn’t make the text work for me. The Mitchell, Wiseman and Feng’s translation allowed me to finally immerse in the text, as it includes glossaries, and the Chinese, Pinyin and English translation are all pegged to each other.

*

How did you learn your Chinese?

I began with a tutor ten years ago, Fred Wong, and then continued mostly on my own.  I utilized such texts as Paul Unschuld’s How to Read Chinese, and the Wiseman Chinese Medical Chinese series and Paradigm Press character series.

*

Are there any kinds of issues that you think the classic formulas are particularly well suited for treating?

Quite frankly, everything; the classic formulas of the Shang Han Lun and Jin Gui Yao Lue are the essence of simplicity, but they can treat rather complex patterns by specific modifications or combining with other prescriptions from the texts. You can think of the classic formulas as the trunk of the great tree of Chinese herbal prescriptions. The Shang Han Lun is the template for later schools of thought and prescriptions, such as the Spleen/Stomach current and Warm Disease current.

I usually do not modify the formulas very much. These classic formulas tend to be good for cases that require finding the key to specific qi transformations.  For example, using Si ni san to treat dribbling urination by unblocking qi transformation in the San Jiao channel. Sometimes I combine a couple formulas together. They are really quite elegant in the way a simple addition or subtraction can shift the emphasis of the prescription.

*

The use of classic formulas is more about matching a formula to a particular presentation, than it is about considering the Zang/Fu. Much of the schooling in modern Chinese medicine schools revolves around Zang/Fu diagnosis. How do you reconcile these two approaches in your clinical work?

I see it as having different prisms, which allow you to observe different phenomena. I call it the “Picasso Principle”, in that one can view a patient from several angles at the same time.  The Shang Han Lun provides other views of symptomatic phenomena effecting our patients, by seeing a continuum of change of medical conditions through a six channel warp or gradation.

*

What are your thoughts about constitution and the treatment of illness?

I think it is both important and quite under-emphasized in modern TCM. For me, constitution is about observing the manner in which people tend to get ill. It comes from both their constitution and any changes brought about due to damage to the system over time, from illness, medications, poor diet, or emotional taxation. People get habituated to how they get sick, stuck in specific patterns; addressing constitution helps in these situations.

*

Many people believe that the classic formulas of the Shang Han Lun are only for treating acute illness or the aftermath of acute illness. However many doctors use these classic formulas to treat chronic illness as well. Can you give us an example of using a Shang Han Formula to treat a chronic condition.

It is important to remember that the original name of the book was Shang Han Za Bing Lun, or Treatise on Cold Damage and Complex (Miscellaneous) Ilnesses. And do keep in mind that the Jin Gui Yao Lue is very much focused on chronic illness. There are sections on gynecology, water swelling diseases, skin problems, malaria-like disorder, and diseases of taxation.

If you read the Shang Han Lun/Jin Gui commentaries, you will find it is talking about all kinds of approaches to treatment and strategies, not just external contractions/wai gan. Really, it is a template for getting into a deeper level of understanding and application of medicine.

The other thing to remember about the Shang Han Lun is that it treats those illnesses that have become complex because they did not resolve, or were aggravated (huai bing) by inappropriate treatment. Purging/precipitation is not just about the misuse of da huang. Modern use of laxatives, or the currently popular colon cleansers, which purge people when they are in the midst of a tài yáng illness.  These products, or enemas, are recommend for the common cold.  Or large doses of Vitamin C which cause diarrhea. Another example would be the excessive use of diuretics that dry people out and as a result cause tremors and shaking. These are examples of the “mistakes” that Zhang Zhong-Jing talks about that can be reinterpreted in line with modern treatments or lifestyle.

*

Any tips you have for our readers on ways of approaching the study of the Shang Han Lun and Jing Gui Yao Lue?

First of all, while it is important to read the book itself, and re-read it again and again; in addition, it is essential that you find a teacher who has experience. We are fortunate these days that there is are people like Arnaud Versluys who has developed extensive courses on both the Shang Han Lun and Jin Gui Yao Lue, and quality translations like the Mitchell/Wiseman/Ye translation. Soon we will have a Wiseman/Ye translation of the Jin Gui Yao Lue as well. To really make the material yours, constant review and study are required. I remember seeing Miki Shima at a conference once a few years ago. His copy of Mitchell’s translation was beaten and battered and had the cover torn off; the margins were filled with his own notes and observations. This kind of constant review, this kind of going back over the material again and again as we gain more experience is essential to unlocking its wealth.

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.

.

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!

.

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!

Most Westerner’s exposure to the Shang Han Lun is that is an an old book that has something to do with the common cold, and the various complications that result. We get a smattering of it in acupuncture school, but it is a book that really has nothing to do with acupuncture. It does, however, have a lot to do with herbal medicine.

I am no expert in the Shang Lan Hun, but I have been fortunate enough to have teachers and friends who are. And Dr. Huang is no slouch when it comes to this classic text of herbal medicine. In fact, he reads it not as a book about the progression of acute infectious disease, he reads it as a manual of how to use herbs to treat a wide wide range of issues.

My time in Nanjing is winding down, three weeks goes by in the blink of an eye. We share a home-cooked meal and discuss history. He loves history, and in fact, history of medicine and medical theory is what his Master’s study was about.

“War is a catalyst for medical advancement”, he says.

Of course, this is true. Plastic surgery got its start in treating the injuries of WWII, and most people are aware of the advances in prosthetics that has resulted from America’s current adventure in Iraq.

The late Han dynasty was a turmoil of war and upheaval. The usual story is that Zhang Zhong Jing, the author of the Shang Han Lun cultivated his skill because so many people were suffering the resulting effects of scarcity, injury and want. Dr. Huang agrees on this point, but his opinion has a twist.

“Those days were not so different from now, all the good stuff went to the army. The best of the food, clothing and medical care too. ZZJ, a doctor of his skill and talent was most likely an army doctor. All the good ones were.”

It is never boring around being around Dr Huang. He has bright quick eyes, iconoclastic opinions, a distaste for the status quo, and a fierce dedication to helping people get better. He is a rare voice in committee approved and sanctioned China. It is never a dull moment.

“Gui Zhi Tang (Cinnamon Twig Decoction)”, he says with a smile as he knifes through golden ginger that is on its way to becoming the soup for our lunch.
“You know, it is not just for colds and those miscellanious sweating conditions.”

Think about it this way. Imagine a soldier who has seen battle, he is beat and weary. Probably in a state of shock from the bloodshed and watching his friend’s head rolling about on the ground. Imagine exposure to the elements, days of not eating well, no real rest. He stumbles into camp, half death and starving. What do you do?

He is certainly not in a state to eat much solid food. He has lost blood and is cold and without vital energy. His spirit is disordered, anyone’s would be after this kind of experience.

Now, think about Gui Zhi Tang. Cinnamon and ginger to warm, peony to nourish the blood and calm the heart, licorice to settle the frayed nerves, and plums to build the digestion. Chase it down with a nice easy to digest bowl of rice gruel, and have a nap.

The thing about Dr. Huang is that he makes a lot of sense, even when he is talking about medicine in ways I’ve never heard or imagined.

I’m thinking Gui Zhi Tang would be the perfect thing for those people that get lost in the woods for a few days.