經方學

Rules of thumb are useful. Being able discern a constitutional type is a broad brushstroke rule of thumb. We can effectively condense experience, and it is often a shortcut to where we are headed. Except for when it is not.

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 my 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!

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.

Today we have another guest post from a member of the group that journeyed to Nanjing this past November to study jing fang with Dr. Huang. Bernd Schleifer is a practitioner from Munich who has an active practice, and weak spot for good books on medicine written in Chinese.

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Reading the Ten Key Formula Families I always tried to create a picture in my mind of how these people might look. Working with Dr. Huang in the hospital was great, because a lot of those pictures really came to life.

As it was written before I was also very impressed by his use of Ephedrae Herba (má huáng) for acne. By seeing those introverted, closed-in Ephedra type acne patients, with their silent voices and reduced expression, the idea of using a warm and acrid herb to open them up was striking to me.

Another very interesting thing for me to see was his view of the Pinellia constitution and his extensive use of Pinelliae Rhizoma preparatum (zhì bàn xià) for different emotional issues. Using Warm the Gallbladder Decoction (wën dân täng) for anxiety disorders or waking up with fright was not new to me. But apart from that my idea of a person with bàn xià issues was more one of a slow reacting, plump or puffy person; more the phlegmy kind of thing, as it is also described in the Ten Key Formula Families book.

To my surprise it was often the funniest and most entertaining people in the clinic that were labeled as Pinellia constitution!

Later on in the lecture Dr. Huang explained that he distinguishes between a bàn xià heat and a bàn xià cold type. In general these are people with round faces and round eyes. However, the cold ones are more dull and slow; while the hot ones are very talkative, have lively quick moving eyes, mood swings and are very expressive with their emotions like actors or other performing artists. Most of them don’t have serious health problems, but loads of strange complaints that they feel in their body. That’s why they are kind of full-time patients, or like Dr. Huang said “those people are always at the hospital”.

Additionally I observed a funny thing in the clinic; it was almost always the bàn xià types who after saying goodbye would came back once or twice, just to ask another question or get reassurance that all of their complaints had been considered within the formula. It might have been their anxiety issues, their muddle-headedness due to the phlegm, or their vast variety of subjective problems that moved them to behave that way.

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.

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.

This entry is a guest post from Australia’s Greg Bantick. It is a case study that reminds us how easy it is to dream into what we think our patients think and feel and how stepping back and getting a clear view their presentation can help to leverage their innate resources and healing process.

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72 year old, male patient. First visit, in November ’05.

Initial observations: About 5’ 11”, thin, wiry build. Alert, but with a hesitant gaze; collapsed, weary sitting posture; quietly spoken with an unanimated, tired voice; sluggish gestures; deeply troubled and really wanting relief.

Chief complaints his words: general debility, chronic constipation, sharp abdominal pain on and off since he was in his teens.

From questioning: sharp, stinging epigastric pain, with spasms and visibly quivering from Ren 12 up to ribs. Sharp radiating pain to the rib sides is strong enough to make him jump, with the right side being worse. The pain is aggravated by deep breathing, constipation, frustration and stress; eating tomatoes, salt, and especially oily, greasy foods. Contrarily he has a deep, gnawing, constant hunger. All of these were made much worse since the bitter breakup of a relationship last year. In the months after breakup he was hospitalized for two weeks with cholelithiasis and he is now waiting for a cholecystectomy. The pain is relieved by relaxation, and the hunger with dry, bland biscuits. He also complains of long-term chronic constipation years, and will often go without a bowel movement for 4 – 5 days. When he does go the stools are loose, greasy, smelly and dark.

Secondary complaints: Frequent, often daily, dull temporal headaches, Or less often they can be sharp, unilateral, mostly on the right side when right side rib pain worse. Left side around Sp 9 had a boil like lump, now several small lumps, pricking pain, feels “like a maggot running around in it”. Right side thigh, UB channel sciatica, when sitting on hard seats or when sitting a long time.

Other observations: Broken sleep due to acid reflux, sleep easily disturbed by noise and also because he has to urinate 2 -3 times a night. Very tense abdomen especially midline above navel. Many long surgical scars on the abdomen, including one from around Ren 9-14. Most of the abdomen is tender to light touch, making him wince when palpated.

History: As we spoke, he became more talkative and engaged with a remarkable ability to view his life objectively, and with a dry sense of humor. He has faced many difficult challenges in his life. In the interest of brevity, I will only mention a few that influenced my thinking. The abdominal scars were the result of several unnecessary surgeries up to age 19, performed at the insistence of his mother who suffered Munchausen by proxy syndrome. In his late twenties, he became a bank manager in a small town. He married, had 4 children, and lived happily in their small community. Much later, when his children were adults, he learnt from a friend that none of them were his. They were all fathered by his wife’s various lovers, and the reason she was late for their wedding was that she was having a “quickie” with the best man, then his best friend. Later, during his second marriage, in his sixties, he was kicked and beaten; including several kicks and blows to his abdomen. The beating was at the hands of his new wife’s son and daughter in law, following a dispute over her money. His wife was beaten too.

P: thin, deep, collapsing on pressure. ST and GB pulses had a rising up, floating sensation

T: thin, tending pale, moderately thick, dirty white coat

Diagnosis: focal distention in the epigastrium with counterflow of ST qi

My thinking: The patient had tried acupuncture with limited success. He was willing to give it another try, but had been referred to me primarily for herbs. I suggested we do both as I thought acupuncture, plum blossom hammer and moxa locally for the scarring would be useful. I was uncertain of my ability to help with his heavy burden, both psychological and physical. I thought that the pain in the abdomen, given its onset and duration, must be contributed to by the scar tissue, and was uncertain if herbs would help so long after the surgeries. I felt confused and saddened hearing his story, thus making it difficult to feel clear about my diagnosis. It felt easier to go with Liver qi constraint invading the Stomach based on the pain radiating into the hypochondria, long term frustration and anger (although in conversation he did not seem bitter, I just couldn’t imagine he wasn’t), aggravation by oily, greasy foods and temporal headaches all seemed to fit that diagnosis. Other factors made me go in a different direction. In thinking of his history and the impact on his health, I was drawn to a wider view of treating the qi mechanism.

Some key indicators to me;

-the main belly symptoms were on, or originated near the midline

-qi movement was unsmooth; there was pain in the epigastrium, tension in the abdomen depression and irritability, alternating constipation and loose stools

-qi was rising; reflux, headaches, poor sleep, sensitivity to noise, gnawing hunger, much rumination, constipation

-qi was sinking: frequent urination at night

Initially I was thinking I would need to use strong qi and blood moving herbs, especially in treating the scar tissue. I was also uncertain of his ability to digest and persevere with raw herbs. Given the duration, I was thinking this was going to be a long course of treatment. I was not confident that I had understood the case well and was tempted to write a long formula trying to address everything. In the end, I decided on a modification of Pinellia Decoction to Drain the Epigastrium (bàn xià xiè xïn täng) based on the midline focal distention and stomach symptoms and because I wanted to adjust the qi mechanism and harmonize counterflow. Aside from the other indicators for the formula I was thinking;

Pinelliae Rhizoma preparatum (zhì bàn xià) 9g and Zingiberis Rhizoma (gän jiäng) 6g; for their acrid flavors, which penetrate the qi and disperse. To dissipate epigastric focal distention and improve the ascending and descending of qi.

Scutellariae Radix (huáng qín) 6g, Coptidis Rhizoma (huáng lián) 3g; bitterness clears heat and drains downwards. Coptidis Rhizoma (huáng lián) clears heat in the heart, further encourages the descending action, clears heat and calms the spirit.

Ginseng Radix (rén shën) 6g, Glycyrrhizae Radix preparata (zhì gän câo) 6g, Jujubae Fructus (dà zâo) 6 pieces; Glycyrrhizae Radix (gän câo) is sweet and neutral. Jujubae Fructus (dà zâo) and Ginseng Radix (rén shën) are sweet and warm. One reason for epigastric focal distention is due to inhibition of the descending and ascending movements of qi. These sweet medicinals harmonize the center, freeing both above and below.

+ Salviae miltiorrhizae Radix (dän shën) 6g; one of my favorite herbs, it is bitter and slightly cold. It invigorates the blood, dispels stasis, clears heat, soothes irritability, as well as nourishes the blood and calms the spirit.

+ Aurantii Fructus immaturus (zhî shí) 6g; is bitter and acrid and slightly cold. It breaks up qi stasis in epigastrium and abdomen

Cooking instructions: cook each packet in 10 cups of water, cook down to 6 cups, remove ingredients and cook again until 4 cups remain. Take 1 cup in the morning and evening over the course of two days.

Second visit one week later. His pain was markedly reduced, and with a complete lack of sharp pain episodes. Reduced frequency and intensity of reflux, and bowel movements were regular for the first the days of taking the formula. No change to headaches or gnawing hunger. He looked more relaxed and energetic, but complained of being more irritable. He described some episodes where he had gotten angry. I considered this a step in the right direction as his qi was moving, he was not depressed, and could more easily acknowledge his anger.

P: thin, deep, stronger. No floating quality. Liver pulse weak on pressure. Continued acupuncture and the original formula.

Third visit one week later. Only one short, painful abdominal spasm that radiated toward the right side, otherwise no pain. No reflux and now sleeps through the night. Less gnawing hunger, able to eat a wider range of foods and enjoying eating. Frequency of headaches reduced, less irritability, more energy and he was clearly happier. Lumps at Sp 9 were minimal. Still tending toward constipation. P: less thin and tight, the liver pulse was stronger. Continued acupuncture and the formula adding Ophiopogonis Radix (mài mén döng) 6g, to moisten the intestines, clear heat and irritability, as well as supplement and preserve Stomach yin and Rhei Radix et Rhizoma (dà huáng) 3g, as its bitterness and cold clear heat and it also resolves blood stasis.

Fourth visit one week later. No epigastric or abdominal pain, no gnawing hunger, only one headache, much less irritable, more energy and a happier disposition. Missed a bowel movement one or two days, but didn’t feel uncomfortable not having gone. I continued to see the patient a few more times with continued improvement, until he moved interstate. During this time I also saw his second wife. They reconciled and were going to buy a place in the country and grow organic vegetables and herbs. Both were happier and healthier. As far as I know he has not needed the surgery.

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I see many patients with mood disorders, most of them with histories of real difficulties and trauma. While often being touched by their willingness to share so personally and deeply, I am sometimes thrown by the depth of their suffering. It can be hard to reduce their narrative to an easy syndrome differentiation. I sometimes doubt mine, and my medicines ability to heal and bring real change in these peoples lives. However, when I do my best to follow our elders and their understanding of qi medicine, and I borrow their ideas as encapsulated in their formulas, I am often really surprised at how effective our medicine can be. I also learn that adjusting the qi mechanism clearly resolves physical problems and also soothes deep emotional hurt as well. Many other SHL formulas share with Pinellia Decoction to Drain the Epigastrium (bàn xià xiè xïn täng) its simple, gentle and elegant construction, which focuses on adjusting and harmonizing the qi mechanism.

Every now and then I like to pull something off my Chinese shelf and give it a read. Sometimes I just open to a page and start reading, sometimes I browse the table of contents for some inspiration on a challenging clinical case. Today, it was the former motivation and as I was feeling a bit homesick for Taiwan, I figured a bit of a re-read of some of Dr. Jiang’s stuff would be the antidote. It is good to be reminded of the basics; like how to treat the Liver.

Doc Jiang had a bunch of books in print and a few more that were always in the process of being written. At the age of 98 he was as active and sharp as anyone in their 60’s, and he always had some kind of writing project going. Here are a few pages of his outline for treating the Liver.

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METHODS FOR TREATING LIVER PRESENTATIONS

Method: Dredging the Liver and regulating qi. When Liver qi stagnates on its own in the Liver channel, with primary symptoms of focal distention and fullness in the chest and abdomen along with stabbing pain in the hypochondria. The formula to use is Aucklandia to Smooth the Qi Decoction (mù xiäng shùn qì täng).

Method: Soften the Liver and nourish the Blood. Used for blood deficiency where the Liver has lost its softness due to lack of nourishment. The key symptoms seen are throat dryness, and lack of moisture on the tongue with a thin and weak pulse. The formulas to use are Linking Decoction (yï guàn jiän) or a modified version of Four-Substance Decoction (sì wù täng).

Method: Warm and Open the Liver Channel. Used for Bulging Qi disorders (疝氣 shàn qì). Symptoms seen include cold pain in the lower abdomen and weighted pain. The formula to use is Conduct the Qi Decoction (dâo qì täng).

Method: Dredge the Liver and Disperse Stagnation. Used for Liver qi stagnation that does not reach its destination, the qi mechanism is kinked up, with symptoms of pain in both costal margins being seen. The formulas to use are a modified version of Rambling Powder (xiäo yao sän) or Bupleurum Powder to Dredge the Liver (chái hú shü gän sân).

Method: Tonify the Liver and Nourish Blood. Used for Liver deficiency with dry blood. Symptoms seen include tightness under the hypochondriac which manifests when excessively hungry, and is exacerbated when fatigued. The formula to use is Hua’s Decoction to Tonify the Liver (huá shì bû gän täng).

Method: Calm the muscles and quiet rebellion. Used for rebellious Liver qi rising upward with symptoms hiccup from counterflow, high-pitched voice along with a sense of urgency to the speech. The formula to use is Inula and Haematite Decoction (xuán fù dài zhê täng).

Method: Clear and drain Liver fire. Used for excessive heat in the Liver channel. Symptoms seen include hypochondriac pain, bitter taste in the mouth, and a distended feeling in the ears with a loss of hearing. The formulas to employ are Gentiana Decoction to Drain the Liver (lóng dân xiè gän täng) or Tangkuei, Gentian, and Aloe Pill (däng guï lóng huì wán).

Method: Dredge the Liver and harmonize the collaterals. Used for stagnated and depressed Liver qi with disharmony in the channels and collaterals. Symptoms seen include hypochondriac pain and swellings in the body. The formulas to use are Inula Decoction (xuán fù huä täng) or Calm the Liver and Dredge the Collaterals Pill (píng gän shü luò wán).

Method: Regulate the Liver and Spleen. Used for Liver and Spleen qi stagnation with symptoms of hypochondriac pain and upper abdominal fullness. The formula to employ is a modification of Rambling Powder (xiäo yao sän).

Method: Bank the Earth and drain the Liver. Used for when the Liver takes advantage of the Spleen, resulting in symptoms of abdominal pain. The formula to use is Important Formula for Painful Diarrhea (tòng xiè yào fäng).

Method: Drain the Liver and harmonize the Stomach. Used for when the Liver takes advantage of the Stomach, resulting in the Stomach losing harmony and its ability to descend, resulting in symptoms of abdominal pain and vomiting of sour fluids. Use the formula Two-Aged [Herb] Decoction (èr chén täng) combined with Left Metal Pill (zuô jïn wán).

Method: Dredging the Liver with bitter, acrid and sour. For use in treating Liver qi rushing upward to the Heart; resulting in pain in the chest, upper abdominal and hypochondriac regions. The formula to use is Melia Toosendan Powder (jïn líng zî sân).

Method: Restrain the Liver and drain the Lung. Used in the treatment of Liver qi rushing upward into the Lung, resulting in the Lung qi not being able to descend. There are symptoms of hypochondriac pain along with coughing and wheezing. Use a combination of formulas that restrain the Liver and drain the Lung.

Method: Regulate the Liver and pacify the Blood. Used for vigorous Liver wood where the wood fire trespasses on metal. Symptoms of hypochondria pain and coughing of blood are seen. Use a modification of Rambling Powder (xiäo yao sän).

Method: Nourish the Liver, clear heat and pacify the spirit. Used for unsettled Liver and Gallbladder where there are symptoms of fitful sleep. The formula to employ is Sour Jujube Decoction (suän zâo rén täng).

Method: Clear and pacify the Liver and Gallbladder. Used to treat deficiency wind of the Liver and Gallbladder, with symptoms of insomnia with fright. The formula to use is Mother-of-Pearl Pill (zhën zhü mû wán).

Method: Moisten yin to descend fire. Used for Liver and Kidney yin deficiency with a lack of movement due to qi stagnation. Symptoms of hypochondriac pain, chest and abdominal distention, and a tongue lacking moisture are seen. The formula to use is Linking Decoction (yï guàn jiän).