經方學

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).

Like so many foreigners, soon after I first got to  Taiwan I experienced the joy of illness in a strange land. The lungs are my weak organ system, and given the Brillo pad atmosphere of Taipei, intensely cold AC mixed with murky heat and subtropic humidity, and stress of calling a very foreign country “home” it is not surprising that I came down with one frighteningly nasty respiratory condition.

It is hard enough to stand outside oneself and get enough perspective on how to treat your own condition, and it is even worse when your Americanized “pinyin-speak” rings nothing but confusion into the ears of the local herb store laoban. Luckily a friend, who was also there to study medicine, suggested we go to see this “old doctor” that a friend had recommended. We rode the subway to the “Eternal Harmony” district in search of a cure for my uncommon cold.

Like most Taiwanese clinics it is a storefront affair. Sandwiched in between a tiny lumber shop and bakery on a scooter littered sidewalk we found Dr. Jiang’s clinic, took a number and waited on the bowling alley-like plastic chairs. The TV blared pop Taiwanese music and news. I thought for sure I was going to end up in some hospital.

What little language study I had had in the States was completely useless in Taiwan. Classroom mandarin and real life full tilt language are two completely different animals. My friend translated my discomfort and fever to Doc Jiang. He wrote notes in what I would later come to recognize as a grass style type calligraphy, even the Taiwanese have a hard time reading his writing. I understood nothing of the exchange. It was his assistant that helped me to translate the formula into a language I could understand. And when I did I thought for sure this old doc should have been put out to pasture years ago.

What he prescribed was nothing like I’d been taught in school.

Doc Jiang’s idea of treating a Taiwanese cold was to prescribe, in granule form, five different complete formulas, which were then modified with several single herbs. Had I come up with a formula like that at school I would have had my tuition refunded. I considered flushing those herbs down the toilet, but then figured I was in Taiwan to learn something new about medicine. That this doc’s formula was off my radar was not necessarily a bad a thing. It was just…different…and different is no fun when you are sick. I took the herbs and went to sleep. Slept through the night, and woke the next day feeling 80% better and coughing slippery, wet phlegm from my lungs. I’m the guy who gets the dry cough. Clearly, this doc had a perspective that was worth exploring.

In the years that followed, I would spend a lot of time with Dr. Jiang. I came to find that his way of using herbs was a cross between what he learned from his father on the mainland, and the Japanese influence that is so intertwined with Taiwanese culture.

I came to see that he used formulas much how we would think of individual herbs. And that when treating almost any condition that involved the respiratory system he would see there being some kind of tai yang involvement. There were five herbs that he liked to use to resolve the exterior and clear toxin: jing jie, fang feng, bai zhi, yu xing cao, and a little bitty pinch of xi xin. This was added to any formula that he used to treat colds or allergies. In his way of thinking, opening the exterior would open the Lung. Indeed, there were many cases where I would have focused on clearing Lung heat, or nourishing Lung fluids, but he would simply resolved the exterior and give the qi mechanism a little push. The patient’s own zheng qi would take over and set them right. Elegant!

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.

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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.

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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!

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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.

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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.

Here is the second part of the discussion with Dr. Huang about the use of the classic formulas.

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Q:  You have quite an interest in the history of Chinese medicine; your Master’s thesis was on the doctors of the Menghe current. These doctors were quite skilled practitioners. Can you compare for us the methods of Zhang Zhong-Jing with those of Fei Bo-xiong and the other doctors of the Menghe current?

A:  The Menghe current takes its name from a small town in the southern part of Jiangsu province that was home to successive generations of famous doctors who lived there from the beginning of the 18th century up through the middle of the last century. That area produced many doctors, some of whom became the great doctors of this generation in Shanghai and Nanjing. Later, people would refer to them as the “Menghe current.”

They were country doctors who were skilled in all aspects of medicine. They excelled at treating internal medicine issues, trauma, and laryngology. Not only did they prescribe herbal decoctions, but also performed surgeries, treated skin problems with medicated sticks and used acupuncture. They were excellent clinicians, especially in treating the common illness of their day. For example, infection secondary to trauma, contagious illness, and a common illness of the day, which was a kind of deficiency due to overwork (perhaps what today we would call tuberculosis). The formulas they used for the most part where experiential formulas. They were publicly open about what herbs they used, but rather closed about the amounts. Additionally, they were tightlipped about the presentations treated. Generally, one required the oral teachings of the traditional master/disciple relationship before being able to comprehend these prescriptions.

As to Zhang Zhong-Jing’s classic formulas, not only are the formulas a part of the public domain, their formula presentations are both comparatively clear and concrete; they are one of the standards within Chinese medical science. The Menghe current of medicine really cannot compare with the classic formulas. For those who study Chinese medicine, it is still best to begin with a study of the classic formulas.

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Q:  There are some who say that for complex and longstanding problems correspondingly large and complex formulas must be employed. Contrarily, the classic formulas usually use a small amount of herbs and are rather simple. Please share with us how they can treat relatively serious, chronic conditions, such as cancer, heart disease, or the complications associated with diabetes.

A:  It must clearly be stated that treating serious illness does not necessarily require the use of large prescriptions. However, the reality is that in clinic many patient’s conditions are complicated, single use of one or two classic formulas cannot take into account the entire situation. What to do? In my experience, make use of combining formulas together. What I mean by combining formulas is to take several classic formulas and use them together as a way to expand the scope of that is treated. Patients with chronic and complicated conditions can be treated in this way.

Let me give an example, I when treating patients with diabetes I often use Astragalus and Cinnamon Twig Five-Substance Decoction  (huáng qí guì zhï wû wù täng) combined with Cinnamon Twig and Poria Pill (guì zhï fú líng wán). When treating cancer I commonly combine Minor Bupleurum Decoction (xiâo chái hú täng) with Five-Ingredient Powder with Poria (wû líng sân), or Honey-Fried Licorice Decoction (zhì gän câo täng) with Ophiopogonis Decoction (mài mén döng täng). Also, in the treatment of the elderly with hypertension who have suffered a stroke I combine Bupleurum plus Dragon Bone and Oyster Shell Decoction (chái hú jiä lóng gû mû lì täng) with Cinnamon Twig and Poria Pill (guì zhï fú líng wán), or with Gardenia and Magnolia Bark Decoction (zhï zî hòu pò täng). To treat bronchial asthma I usually use the combination of Major Bupleurum Decoction (dà chái hú täng) with Cinnamon Twig and Poria Pill (guì zhï fú líng wán). All that being said, within the classic formulas there are some large formulations that can be used to treat complex and complicated disease. For example Warm the Gallbladder Decoction (wën dân täng) has 11 herbs, it can be used to treat irregular periods and amenorrhea. There is also Chinese Yam Pill (shû yù wán) which has 21 different medicinals, it can be used to the treat the side effects of chemotherapy by regulating the constitution.

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Q:  I think most people would agree it is better to prevent illness than to treat it. How can we use the classic formulas to promote wellness?

A:  Generally the classic formulas are primarily used for treating illness, if there is no illness then they are not prescribed; especially they are not prescribed for long term use. However, from the perspective of Chinese medicine the space between illness and health does not have clearly defined limits.

Many people have a propensity to contract an illness or tendency toward certain kinds of disorders; this is actually what I am referring to when I talk about constitution.

Furthermore, after establishing a person’s constitution and overall state of health, they can take herbs or formulas that are appropriate for their body type.

For example, those with a Ginseng constitution can regularly take some Ginseng Radix (rén shën), or Honey-Fried Licorice Decoction (zhì gän câo täng) or Generate the Pulse Powder (shëng mài sân). Those with an Astragalus constitution can regularly use Astragali Radix (huáng qí), or take Astragalus and Cinnamon Twig Five-Substance Decoction  (huáng qí guì zhï wû wù täng) or Jade Windscreen Powder (yù píng fëng sân). That being said, however, medicinal substances are medicine. Medicine cannot be used as food.

Another way to say this is that is not necessary to ingest classic formulas everyday as a way to stay healthy; herbs should only be taken in those times when the body feels run down, or when a formula presentation manifests. The use of classic formulas for “wellness” has to do with their ability to the treat presentations that manifest when the body is out of balance.

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Q:  Chinese medicine has experienced much development over the past 2000 years that for which we have a written history. Many skilled doctors over the ages have added their contributions. What is it that makes the classic formulas unique, what is that makes them particularly distinctive?

A:  The distinctive qualities of the classic formulas are quite clear. First, they have been used for a long time, thus we have accumulated a lot of experience concerning their usage. Most of the classic formulas have been developed from single medicinals. From these single medicinals have developed various formulas, which bring out different characteristics the herbs. Understanding, development and usage of these formulas has come through the slow process of thousands of years of clinical trial and application, along with our predecessors’ practical experience. It has not been from one single person, or even one era, but from the painstaking effort of countless scholars and doctors over time that has solidified our understanding of this body of knowledge.

As an example there is Cinnamon Twig Decoction (guì zhï täng), just who actually created this prescription no one really knows. Certainly it was not one of the formulas that Zhang Zhong-Jing himself developed, but instead came from this collecting and arranging of various texts that contained the experiential prescriptions of doctors that had come before him.

Secondly, these are important prescriptions for treating illness. Many of these formulas contain rather fierce, strong acting medicinals, which have a notable effect on the body. It is said “medicinals with an effect that people notice are required in the treatment of disease.” Light acting herbs like Ephedrae Herba (má huáng) or Cinnamomi Ramulus (guì zhï), strong acting ones like Rhei Radix et Rhizoma (dà huáng) and Aconiti Radix lateralis preparata (zhì fù zî), those with toxins such as Aconiti Radix preparata (zhì wü tóu) or Crotonis Semen (bä dòu) and those which result in severe reactions like Genkwa Flos (yuán huä) and Knoxiae Radix/Euphorbiae pekinensis Radix (dà jî) are examples of such herbs. One of the distinctive characteristics of the classic formulas is the usage of these strong acting medicinals. They are different from the pairing of herbs used by later generations. Many of which are tonics herbs such as Rehmanniae Radix preparata (shú dì huáng), Ginseng Radix (rén shën), Dendrobii Herba (shí hú); or flowers like Chrysanthemi Flos (jú huä), Rosae rugosae Flos (méi guï huä), Magnoliae officinalis Flos (hòu pò huä); or food grade herbs like Luffae Fructus Retinervus (sï guä luò), Nelumbinis Folium (hé yè), Lablab Semen album (bái biân dòu), Soybean (huáng doù), or medicinal foods such as beef, deer sinew, sheep kidney or pig liver.

Thirdly, there is a strict regiment to the combining of herbs in the classic formulas. Change one herb and the name of a formula also changes, even changing the amount of one herb used will result in a formula with a new name. The formula function and illnesses treated also shift along with these changes in herbs or amounts. This is an expression of the tight relationship between how a formula is constituted and its effect; it shows the classic simplicity and beauty of structure and function.

Fourth, the effects of using classic formulas to treat illness are relatively clear, concrete and observable. The formulas recorded in the Shang Han Lun and Jin Gui Yao Lue, although they appear to be relatively simple, they all originate from clinical experience and as such are both practical and objective. So long as an experienced clinician explains the formulas and how they are used, the code for what they treat and scope of use can be cracked. Therefore, it is of benefit to pass along this kind of concrete understanding.

Later generations of doctors used formulas that treat illness from the conceptual point of view of “yin or yang deficiency,” “fluid loss, “ blazing fire,” “excess above with deficiency below,” “various wind disturbances,” and “five taxations and seven injuries”, the parameters for their usage are rather vague in comparison to the clear cut presentations treated by the classic formulas.

Lastly, the classic formulas use a small amount of inexpensive and commonly found herbs. They are suitable for the masses and of benefit in that they reduce medical costs for the country.

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That little side trip to Taiwan ate up all my attention there for a while. As promised, here are a few pages from the Extraordinary Views of the Abdomen. Not only that, but there is a bit of discussion from a doctor friend in Beijing that I hope you will find interesting. As ever, please leave your comments or questions in the comments section.

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Major Bupleurum Decoction (dà chái hú täng)

This is a drawing of the dà chái hú täng presentation. It indicates the presence of chest and hypochondriac fullness, epigastric urgency with muscle spasms, and when palpated deeply the abdominal tissue has a feeling of strength.
Additionally, there could be hard lumps that influence the ability to breath as the upper abdomen has clumping with a slight feeling of fullness; there can also be abdominal pain. If only one side of the hypochondria or the epigastrium is painful, if there is pain in the area around the navel, or if there is an indistinct and unfixed feeling of distention and pain, these also can be seen as part of the presentation.

This formula is Minor Bupleurum Decoction (xiâo chái hú täng) with the Ginseng Radix (rén shën) and Glycyrrhizae Radix (gän câo) removed, and the additions of Paeoniae Radix alba (bái sháo), Aurantii Fructus immaturus (zhî shí), Rhei Radix et Rhizoma (dà huáng) and a double dose of Zingiberis Rhizoma (gän jiäng).
It is used to treat patient’s those abdomen is large; they are referred to as dà chái hú types.

In this formula the meaning of epigastric urgency is that there is focal distention and hardness in the epigastrium, which is the result of a process of gradual internal accumulation that over time becomes an interior excess condition. Both fluids and qi stagnate outside of the Stomach, leading to continual vomiting. Thus, Bupleuri Radix (chái hú), Pinelliae Rhizoma preparatum (zhì bàn xià), Scutellariae Radix (huáng qín) and Jujubae Fructus (dà zâo) are used. Paeoniae Radix alba (bái sháo) is used to treat the fullness, pain and urgency aspects of the presentation. Additionally, Aurantii Fructus immaturus (zhî shí) and Rhei Radix et Rhizoma (dà huáng) are added to treat what is between the interior and exterior (枳實，大黃可及於內外 zhî shí dà huáng kê jí yú nèi wài).

This phrase: 枳實，大黃可及於內外 zhî shí dà huáng kê jí yú nèi wài, is interesting in that it indirectly refers to the shào yáng as the space between. In discussions with a friend, who teaches at the Beijing TCM University and has an incurable taste for the classics, she brought forth this gem; “the illness is in the shào yáng which means it is half interior and half exterior, at the same time it has already entered into the organ level of the yáng míng. So using Minor Bupleurum Decoction (xiâo chái hú täng) addresses shào yáng illness, while the two additional herbs treat the yáng míng.

The Classics state: tài yáng illness that for 10 days, the patient was erroneously purged for two or three days. In the four to five days afterward a xiâo chái hú täng presentation persists; first use Minor Bupleurum Decoction (xiâo chái hú täng) to treat it.

Commentary: As the illness has already passed from the tài yáng level [to the shào yáng], the patient has been ill for 12 days without any further changes in their condition. After being ill for a long time, following and treating according to the presentation is what masters the problem. In this case the patient was erroneously given purgative medicinals. After one course results were not seen so a second and third course were given which caused diarrhea. Four to five days after this mistaken treatment there was still a xiâo chái hú täng presentation. One does not have to be a stickler for the number of days a patient has been ill, it is enough prescribe the herbs based on the observing the manifestations of the xiâo chái hú täng presentation.

Ceaseless vomiting with tightness and pressure pain sensitivity in the epigastrium, a sense of constraint with slight irritability, [the illness has] not yet resolved. Giving Major Bupleurum Decoction (dà chái hú täng) to purge it can bring about the cure.

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When there is just vomiting and tightness in the chest, it is appropriate to continue using Minor Bupleurum Decoction (xiâo chái hú täng). When there is irritability that then turns into a feeling of constraint with irritability Minor Bupleurum Decoction (xiâo chái hú täng) will not be able to resolve it. This kind of tightness in the epigastrium with pressure pain sensitivity accompanied by feeling of constraint with irritability is indicative of a condition of internal accumulation. If it is not purged, it will be difficult to cure.

As there continues to be ceaseless vomiting, this cannot be said to be an Order the Qi Decoction (chéng qì täng) condition, but rather it falls within the scope of the bupleurum formula family. Therefore adding Aurantii Fructus immaturus (zhî shí) and Rhei Radix et Rhizoma (dà huáng) to Minor Bupleurum Decoction (xiâo chái hú täng) to purge [address the yáng míng aspect of the presentation] will bring about the cure. Additionally, to treat the vomiting, the amount of Zingiberis Rhizoma recens (shëng jiäng) is increased. As previously mentioned, vomiting and irritability are seen as being part of the Minor Bupleurum Decoction presentation.

In the line from the Discussion of Cold Damage that describes the use of Major Bupleurum Decoction (dà chái hú täng) it uses the word “can treat” (與 yù), it does not use the commonly seen phrase “masters it” (主之 zhû zhï), should [this formula not work] and there is condition of genuine internal excess, then the appropriate treatment is with a prescription from the Order the Qi (chéng qì) family. However, as this is slow moving kind of tài yáng illness, it cannot be impatiently treated as a yáng míng illness with aggressive medicinals where purging will immediately about the cure. Adding a little Aurantii Fructus immaturus (zhî shí) and Rhei Radix et Rhizoma (dà huáng) to gently drain will cure the problem. As it says in the original text, one should know if Stomach presentation is excessive or not, otherwise purging is of no benefit.

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Andy Ellis is one of the significant contributors to our field. He is the co-author of The Fundamentals of Chinese Acupuncture, Fundamentals of Chinese Medicine, and Grasping the Wind. Author of Notes from South Mountain, and part of the team that has given us the latest edition of Eastland Press’s Formulas and Strategies. He is the founder of Springwind Herb Company; not only does he find time to teach and practice, but he manages to mix it up on a basketball court several times a week as well.

While our paths often cross in Taipei, this time we had to catch up on online.

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How did you manage to find your way to Taiwan in the 80′s, and what was your motivation at the time?

I first went to Taiwan in 1983 to further my studies in acupuncture. I had studied with Dr. So at the New England School of Acupuncture for a year or so and then Dr. So got ill. I wanted to learn the real thing and since China was not accessible at that time I opted for Taiwan. At that time I had no intention to study herbs but when I got to Taiwan I realized that Chinese medicine there was largely herbal. There were, and still are, herb shops in every neighborhood.

You have spent time both in Taiwan and Mainland China. How would you say the medicine traditions differ between these two places?

It is hard to characterize an entire population. There are many traditions in Taiwan and many in Mainland China. In herbal practice there has been a great influence by Japan in Taiwan. The most obvious one being the use of concentrated granules. Like the Japanese, Taiwanese doctors emphasize formulas from the Discussion of Cold Damage (傷寒論 Shang Han Lun) and the Restoration of Health from the Myriad Diseases (萬病回春 Wan Bing Hui Chun). In modern mainland China the Restoration of Health from the Myriad Diseases is largely ignored. The Cultural Revolution, which had a large influence on China also influenced the medicine. Much of the spiritual nature was removed and a more dialectical approach was substituted for primarily political reasons. That is not to say that there were not many wonderful schools of thought that survived this purging but it was definitely an influence and can be seen in the modern writings.

Both Taiwan and China seem to feel a need to have their medicine be taken seriously by the West. They have taken slightly different approaches to gaining this approval. That is a long topic perhaps for another discussion.

Dr. Shi was a real influence for you. What about your time with him informs the way you approach medicine today?

Dr. Shi was the kind of doctor that I had hoped I would find in China. His unending patience and kind manner set an example that my better self recognized immediately. His approach to the medicine was not dogmatic and he felt truly that he was the fortunate recipient of a tradition that dated back to the early Han. Anyone who spent time with him gleaned immediately that he felt privileged to be able to help others with the information and tradition that had been handed down to him. I can only hope to emulate his manner and the unending study he engaged in order to help his patients.

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Andy’s book about Dr. Shi, not only is part of his contribution to us in the West, but also passes along some of the essence of Dr. Shi’s experience, learning and teaching. You can download THIS pdf file that contains a few pages from the book; it gives  a glimpse into the mind of Dr. Shi. Andy is making the book available at a 10% discount to the readers of classicformulas.com.

Click HERE to go directly to the Springwind site, at the checkout page simply enter classicformulas in the coupon space. This book not only gives great clinical tips, it also gives you a taste of how a gentleman/doctor thinks and works. We don’t have many books like this.

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It may not be a trip to China, but it is an opportunity
to engage the mind of a true doctor of the art!

One of the great things about hanging out with experienced doctors, especially guys like Chang Bu-Tao, is that you get to see how a tuned and savvy doc works. Doc Chang’s ample waiting room empties and refills like a Zen bamboo water pipe; seeing 200 patients in a day is not uncommon. He is one of the senior docs in Taipei city with over 20 books to his name, students from down the street and across the world, and a reputation that drifted far, far out from his fourth floor clinic just south of Peace and Harmony East Road.

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Like all experienced doctors, he has this ways of using the classic formulas in ways that don’t quite match the first glanced at list of actions and functions in our formula books. This is a darned good reason to read the Discussion of Cold Damage (傷寒論 Shäng hán lùn) and the works of various authors who have gone deep into that tradition.

Dr. Chang has his own way of thinking about Formula Families, and sees Puerariae Radix (gé gën) as being a family of its own. Here are a couple gems from his book that explains Shang Han Lun formulas.

Treatment of spasms:
Because Puerariae Radix (gé gën) functions to control tremors, when used together with Paeoniae Radix alba (bái sháo), Jujubae Fructus (dà zâo), and Glycyrrhizae Radix (gän câo) its ability to relief spasms is even more pronounced. As written in the Yellow Emperor’s Inner Classic “sour astringes, bitter dries dampness, sweetness relaxes tightness…,” [thus we understand how] Glycyrrhizae Radix (gän câo), Jujubae Fructus (dà zâo), and Paeoniae Radix alba (bái sháo) have the effect of softening and relaxing tightness. For tightness and pain in the head, shoulders and neck, and especially for numbness due to problems with the facial nerves use of Puerariae Radix (gé gën) with peony, dates and licorice works rapidly to relax these symptoms and improve the patients condition.

Treatment of allergic rhinitis:
Kudzu Decoction (gé gën täng) can be used to good effect in the treatment of allergic rhinitis and sinus infections. Taiwan has the typical climate of an island, as it is surrounded by ocean it is usually quite humid; especially so in March when it is still bothersomely on the cool side and frequently drizzles. Due to these environmental factors there is an increase in the instances of the common cold and allergic rhinitis. Western medicine commonly uses antihistamines to treat allergic rhinitis. Although it is effective, drowsiness is one of the side effects.

I remember one year during the Chinese New Year going on a group tour to New Zealand. At that time the tour leader experienced a flare up of allergic rhinitis and was quite uncomfortable. One of the members of the tour happened to have some antihistamines, which he gave to the tour leader. This resulted in our leader constantly dozing off wherever we went. If these drugs were taken before driving, it was difficult to avoid nodding off while driving, which was quite a danger to the safety of all involved.

For nasal allergies due to climatic factors, I use Kudzu Decoction (gé gën täng) as the primary formula, and add the anti-allergy medicinals Schizonepetae Herba (jïng jiè), Saposhnikoviae Radix (fáng fëng), Cicadae Periostracum (chán tuì) and Coicis Semen (yì yî rén); the clinical effect is quite good. Should the patient also have itchy eyes, then add Equiseti hiemalis Herba (mù zéi) as well.

Treatment of sties:
Sties are a type of ophthalmologic disease. Because people these days often eat rich, fried or roasted foods and as they rely on the computer and spend long hours staring at the screen, visual acuity diminishes and there are pathological changes to the tissue of the eyes. Sties are one result of these changes.

Western medicine uses surgical procedures to treat this problem. We Chinese doctors, however, use the thought process found in the Yellow Emperor’s Inner Classic to differential illness. In the Inner Classic we find that the blood vessels that go from above to below are considered to belong to the tài yáng meridian. Those which go from below to above belong to the yáng míng meridian, and those that radiate sideways are associated with illnesses of the shào yáng meridian. In line with these relationships we select a formula representative of the yáng míng meridian; Kudzu Decoction (gé gën täng). Which is then modified with ophthalmologic medicinals such as Celosiae Semen (qïng xiäng zî), Cassiae Semen (jué míng zî), Leonuri Fructus (chöng wèi zî), and Plantaginis Semen (chë qián zî). It is quite good for treating sties!

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.

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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!

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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!