經方學

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We learn about in our Chinese medicine textbooks, a certain kind of insubstantial mix of phlegm and qi that collects in the throat... 咽喉異物感Plum Pit Qi.

It is a pretty little diagnosis. Sounds very….Asian…Sounds very beautiful, and somehow exotic, but I have yet to have have a patient Western, or Asian, walk into my clinic and say “I have plum pit qi.”

Dr Huang talks about this particular condition as a subjective feeling on the part on the patient where there is some kind of odd sensation involving the throat. It could be that there is a feeling that something is stuck in the throat, something that can neither be swallowed or coughed out. It could be a bit of phlegm, or an irritation or tickle that constantly has someone clearing their throat.

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Or, it could be some kind of issue that causes problems with speaking, or leaves people with a feeling of chest stuffiness, that the breathing is somehow off, or the words that one seeks to speak come out not quite right, or that somehow something is causing the functions that run through the throat to not quite work so smoothly.

This kind of presentation could have its roots in either an emotional issue, or some physiological process that has gone astray. It really does not matter the origin, what matters is the patient has arrived at this juncture in their state of health, and there are formulas that treat it, and treat it well.

As practitioners, it is our job to figure this stuff out, to take what our patients say, express, or leave out, and see if matches what we know about the particular uses of an herb or formula. Ban xia hou po tang, is the formula that is famous for treating “plum pit qi.” But, if we can begin to see under the iceberg of “an odd feeling in the throat”, we can begin to see a whole constellation of patterns and situations where this formula may be of benefit.

And it helps if you understand something about Ban Xia Constitution, which was talked about here.

If you are a reader of The Lantern, then you perhaps have already seen this interview with Dr. Huang. If you are not a reader of The Lantern, and you are the kind of practitioner that would rather read the Classics, than sift through modern research. If you are the kind of person that prefers to noodle through the thoughts and clinical experience of seasoned doctors, instead of following the latest on how MRI’s say acupuncture works. Then The Lantern is certainly worth your time and money!In the last issue, they published this interview which came from an afternoon discussion of medicine, and in particular, the origins of his book The Ten Major Formula Families. It is a good introduction, not only to his particular style of clinical reasoning, but also touches on the history of this method of treatment.Of course, if you would actually like to sit down with Dr Huang and discuss medicine, that is also a possibility. We have just a couple more spaces left in the fall trip to Nanjing.Come join us!

It takes practice this abdominal diagnosis method. It is not just a matter of feeling where there is tension, or where the patient experiences discomfort. Getting a sense of how differences in skin, moisture, innate muscular tension, where there is fullness, and how emptiness can be easily not found are all part of the process.

The more I touch patient’s abdomens, the more I approach it with a sense of inquire and curiosity, rather than with the demand to find something, the more I discover patterns and presentations that at times lead to a clear sense of a patient needs, and at other times leads to further questions.

Here is part two of the abdominal palpation article that Steve Clavey and I did last year. It originally was written in Japanese, translated to Chinese where I found it in Taiwan, and then appeared for the first time in English in The Lantern, which of course, you are already subscribed to.

What? You haven’t yet?  Well, then click below, and remedy that situation!

Through the miracle of MP3, I’ve been having discussions with Dr. Huang on my morning walks to work. Actually, re-listening to the discussions we had in Nanjing. But, since words in Chinese have this sneaky way of going transparently through my ears when engaged in thinking and making sense, listening again to our conversations yields all kinds of new information.I have recently begun to translate the Ma Huang (麻黃類方) chapter, and in the Ma Huang Constitution it includes the sign of “aversion to cold.” People with the Gui Zhi Constitution also have that. So, I asked Huang about it.

This feeling of aversion to cold, is it different for Ma Huang and Gui Zhi types? 

His answer was surprising to me in that it had little to with the patient’s subjective sense, and more to do with an intersection of their feelings and objective perception of the practitioner.

Yes, they are different. The Ma Huang type has sensitivity to cold, but there is a lack of sweating, their skin is course and even sandy looking. Those Gui Zhi types, they also dislike cold, but their skin is fine, moist, and tends to be pale. 

It is not helpful to simply go on what the patient says. People all have different ways of experiencing themselves and body. Of course, listen to a patient’s subjective experience, but then back it up with your own objective observation. There is a more dimensional image that emerges when the observable and reported mutually inform each other.I rather like this approach of Dr Huang’s. That there are concrete physical signs that help us to differentiate a patient’s particular constitution. It is this background, along with the various signs and symptoms that help us to to determine how best to help a patient.It is not just a matter of what symptoms are present, but more importantly, the kind of person that is having those symptoms.

It is not common in the practice of acupuncture to use palpation as a method of gathering information to help one decide on a course of treatment. In herbal medicine, this has been a much less used method. At least here in the United States.

When living in Taiwan, I came across a book called the Medical Dictionary of Kampo Diagnosis and Treatment, (漢方診療醫典 Han Fang Zhen Liao Yi Dian), it was written by Dr. Otsuka Yoshinori, a Japanese practitioner of Chinese medicine, and translated into Chinese. It is a fine collection of the author’s clinical experience, written in a refreshingly candid fashion. Most interesting to me, was a section in the front, where he outlines a variety of abdominal patterns which indict which classic formula would be appropriate.

Abdominal signs are discussed in both the Ling Shu and Su Wen in the Yellow Emperior’s Internal Classic. While it appears abdominal diagnosis was a part of Han dynasty medical practice, and indeed there are lines in the Shang Han Lun that mention palpatory abdominal findings, it fell out of favor in later years. In Japan, however, that portion of the tradition has been preserved, and is part of the Kampo (漢方 han fang) tradition, where abdominal signs are the confirmation for prescribing various formulas.

The translation of this material on abdominal palpation and formula selection was a collaborative effort with Steve Clavey, editor of the fine Australian English language journal on Chinese medicine, The Lantern, where this article was first published. Get it here: SHL Abdominal Patterns I

While Michael Max and Steve Clavey retain the copy write on this article, it may be downloaded for individual use.

Watch for part two, coming to this blog in the near future!

Will Cooper writes:

“By the presentation, prescribe the herbs” as being the rationale and foundation of Dr. Huang’s approach to treatment. Dr. Huang obviously has decided for himself what is meant by “presentation”, but do we know what the original author meant by that use of the word?

In a sense, yes, it is “root.” I was talking with him the other day, and told me about an insight he had at one point. That what originally he was seeing as “symptoms” in a patient was not really “symptoms” at all. It was just who they were.

Let’s take for example a “gui zhi” constitution person. They tend to have fair and fine skin, generally are thin and wispy, they are prone to stomach aches, they tend to sweat easily.

Now, you can look at their tendency to sweat and think “qi deficiency” or you could look at it and think “gui zhi people, they just are like that.”

…a more Japanese concept of the root is, “the root of the person, i.e., the background of who they are”, and that being resonant with the French concept of “terrain”, as being the background of who someone is as well. I remember when Volker Scheid was visiting us at SIOM, and he worked people up, it seemed that he utilized this approach also.

When he worked me up, he saw me as a “yang ming” type constitution, for example, and he used this ‘lens’ or perspective of what sort of constitution/terrain I had to then view my signs/symptoms/complaints, which then informed the herbal prescription he gave me.

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Yes, I think Dr. Huang is looking at it more like this.
Constitution, or as is said in Chinese 體質 (tî zhì), or the French concept of Terrain. If we use that lens to view our patients illnesses (or health for that matter) we come up with a different picture. It is another way of looking.

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Gui zhi people have a tendency to get sick in a certain way. Their illness tends to be different from, say, a shi gao person. Where this gets interesting is when the gui zhi person gets sick like a shi gao person, then you know you have an unusual problem on your hands.

I think one of the contributions of Dr. Huang’s work is bringing this concept of constitution, and its affinity toward the function of key herbs, into play.

Actually, there is a triangular  relationship that he uses. It involves Herbs, Person (constitution), Illness. But, more about that in another post!

It is not uncommon in life that failure opens a gate that otherwise would not have appeared. I’d gone to Beijing in the fall of 2002 to study with a Shang Han Lun doctor I’d been introduced to, but my Chinese just was not yet up to the task. It took jaw grinding days to read a few paragraphs, and my listening ability was like trying to tune in a broken radio. I gave up.

About that time Craig Mitchell was in Beijing, and sympathetic to my situation he encouraged me by handing me a thin book titled The Ten Major Formula Families (十大類方 shí dà lèi fäng). Told me that this Chinese stuff takes time, keep at it, and in the meantime read this. It is kind of an Idiot’s Guide to the Shang Han Lun. It’s a fun read, and has some really interesting ideas.

It has taken a few more years for the black holes in my understanding of Chinese to generate light and understanding. He was right, it is a fun read, and there are some tremendously interesting ideas. But, it is not an quite an idiot’s guide. In fact, it is a concise, thoughtful and clinically useful text. In it, Dr Huang looks at the “jing fang” the classic formulas of the Shang Han Lun and Jin Gui Yao Lue, not from the perspective of illness patterns and disease progression, but from the point of view of herb confirmations and formula presentations. In essence, he has taken the way we usually consider practicing Chinese herbal medicine, and turned it on its ear.

As Dr Huang says:

“In my practice I look at the what. I look at what kind of person is sitting in front of me. What is the condition of their muscular, their skin, their manner and eyes. This is how I come up with what kind of constitution they have. I then look to see what kind of signs and symptoms with which they present. Instead of tying all these to some abstract concept like liver fire, spleen xu, or qi stagnation, I map them to the well known functions of herbs that have been used in China for thousands of years.”

There is a saying in Chinese that sums this up:
“By the presentation, prescribe the herbs”
(對證下藥 duì zhèng xià yào).
That is what is helpful!

I’ve been thinking for a while that I would like to see this book in English. Last fall when I was traveling in China, I tossed it in my pack as the read on the train book. One day a Chinese friend asked me why the book was interesting to me. I told her it was one of the best books I’d read in any language on prescribing herbs. One day I’d love to translate it. She gave me a funny look and asked “So, what’s stopping you?”

Uh, the author’s permission to do so?
Um! Let’s call him and see if he would like to have it read by the English speakers of the world.
Twenty minutes, and a big dose of “yuan fen” later, I was talking to Dr Huang on the phone. Thus, began the journey of the “shi da lei fang” into English.

I’m spending most of the month of April here in Nanjing, sitting in Dr Huang’s clinic, attending his classes and discussing the book. This book might be thin compared to some of the tomes that have been written about our medicine, but in fact, it is the flower of tradition of looking at “jing fang” the classic formulas, from the perspective of the “herbs being the key.”

This website is dedicated to bringing that tradition to English speaking practitioners in the West. There will be occasional excepts from the book that I think are of clinical use, portions of discussions I’ve had with Dr Huang, and my own thoughts about herb confirmations and formula presentations as they relate to our daily clinical work.
I invite your comments and discussions. And most of all, hope that this information will serve to inform your practice in ways that allow you to help more people.