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.

***********************

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!

.

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.

*******************************************************

.

.

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.

*************************************

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.

If you are regular reader of classicformulas.com then you have a pretty good idea of the value that Dr. Huang places on constitution, formula presentation, illness and the interaction between them. If you have worked with these methods yourself in the clinic, it is likely that it has at times sharpened your clinical eye and helped to craft a formula that powerfully changed a patient’s condition. It is equally likely that there have been times when a patient’s constitution seemed to morph between types, and a single formula presentation was impossible to nail down. Our patients continuously challenge us to push wider the doors of our perception and clinical understanding.

.

As mentioned in a previous post, this time in Naning Huang introduced us to another set of filters that can help us to get a glimpse of our patient’s constitutional disposition.

In addition to looking for the herbal family into which they fall, we can also look through the lenses of: deficiency and excess, heat and cold, stagnation of qi or of the blood, and the presence of phlegm or dampness.

When looking through the lens of formula family or herbal presentation does not give us the focus we need to confidently write a prescription, engaging these other eight parameters gives us another corner from which to view the problem.

.

Synchronistically I picked up a book (well, about a dozen actually) from a tiny, but well stocked medical bookstore off Han Zhong Road. One of the participants of this seminar has a theory that if a book has a picture of the author, and that author looks really nerdy, then it is probably a good book. The fellow with the heavy glasses on the cover of Comparing Formula Presentations: Five Steps to Differential Diagnosis in the Treatment of Cold Damage. (方證相對：傷寒辯證論治五步) fit the bill. Partly it was the nerdy guy on the cover, partly it was the plethora of case studies, some from the northern master of the Shang Han Lun, Liu Duzhou (劉度舟) and others from masters of the “Fire God” current (火神派) such as Fan Zhonglin (範中林). All were written with a clear-cut five step process that showed how they targeted at which level(s) the illness was lodged. Thought provoking case studies that weave through warp and woof of level, constitution and presentation; it went into the “buy” pile.

.

It is unseasonably cold in Nanjing at this time, and reading in the comfort of a heated hotel room at the end of the day is all the recreation I want. Browsing the first few pages I was met with a familiar sight. A table of illness parameters that included the eight that Huang has been talking about.

.

Now, anyone even slightly familiar with the study of modern Chinese medicine will certainly have been exposed to these eight parameters. It is part of the basic filter set through which we peculate the confusions and difficulties of our patients. However, we also run the logistics of yin, yang zang and fu, phase transformations and perhaps a few odd perspectives learned from teachers who paid attention to their clinical experience. Somehow, getting back to the basics of what is easily observed, what is concrete and without abstraction, has helped me to re-ground my clinical observation skills.

.

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

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.

.

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.

.

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.

.

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.

.

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.

.

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.

.

.

I will be taking a group to Nanjing next month to study with Dr. Huang. To prepare and brush up my Chinese I’m going over his lecture notes. They are a treasure trove of clinical common sense and revelation. They also help to illuminate why the Gui Zhi Fu Ling Wan I gave to patient with blood stagnation in the lower burner had such an unexpectedly bad reaction. Right disease, wrong constitution.

.

Here is a little snippet from his notes on the importance of differentiating constitution:

.

There is a correlation between treatment efficacy and differences in constitution. The same herbs that are used to treat the same illness in those with differing constitutions will have differing therapeutic effects. Moreover, some prescriptions will merely be useless, while others will cause severe and harmful reactions. Xu Lingtai refers to this phenomenon as “differing kinds of people with the same disease” (病同人異 bìng töng rén yì). To insure the effective use and safety of medicinals the Jing Fang current places special emphasis on the differences between people, by paying attention to and taking into consideration the differences between constitutional types.

It is never as simple as Formula A= Illness B. We must also consider the terrain of our patients.

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

.

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.

.

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.

.

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.

.

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.

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

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

*

How did you learn your Chinese?

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

*

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

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

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

*

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

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

*

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

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

*

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

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

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

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

*

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

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

.

Slow cooked meals are usually tasty and rich in nourishment, often the process of creation is long; you can think of it as a kind of cultivation. Likewise, quality publications take time. Eastland Press has been taking its fine toothed comb through The 10 Key Formula Families; some things can not be rushed. But, we should see it on bookshelves sometime in July. In the meantime, I’ve been arranging interviews with a few practitioners who have a wealth of experience both in Chinese medicine and use of the classic formulas. This first installment is the first part of an interview with the author of The 10 Key Formula Families, Dr. Huang Huang.

.

Q: Is constitution changeable? If it is changeable, then under what conditions would changes occur?

A: Constitution is changeable. The primary factors that influence constitutional change are aging, illness, environment, and lifestyle, which includes diet, exercise and use of medications. For example, when some people are young they have a bupleurum constitution, however as they age perhaps they change into a bupleurum/rhubarb constitution. If originally Frigid Extremities Powder (sì nì sân) was effective for these kinds of patients, after their constitution has shifted then perhaps it is Major Bupleurum Decoction (dà chái hú täng) that will be required. There are also those who originally where of a cinnamon twig constitution, however due to their lifestyle they became overweight, and developed problems with their blood sugar and metabolism, in more serious cases there will be heart or kidney disease. Quite likely these patients will appear with an astragalus constitution; for them use Astragalus and Cinnamon Twig Five-Substance Decoction  (huáng qí guì zhï wû wù täng). Additionally, over-treatment or improper use of medicinals also can lead to change of a person’s constitution. For example, if Coptidis Rhizoma (huáng lián) or Rhei Radix et Rhizoma (dà huáng) is taken for an extended period of time it lead to the appearance of the Frigid Extremities Decoction constitution.

.

Q: Generally speaking, when people get sick they tend to get sick in line with their constitution. What I mean is there is a correspondence between their constitution and their symptomology. However there are times when a patient’s symptoms are quite different from what one would expect, given their constitution. In this kind of situation, how should one proceed? How does one judge that a patient has fallen ill outside the predilection of their constitution? How to diagnose these cases?

A: To answer this question it is first necessary to clearly understand the theory behind the use of classic formulas. The principle of treating by matching formulas to the patient’s presentation is the core of this theory. Another way to say this is in practice when a certain presentation is seen; use the formula that treats that presentation. This is the principle behind the practice of classic formula medicine.

So, just what comprises a formula presentation? It includes both a patient’s constitution and their illness. Different formula presentations are comprised of varying proportions of constitution and illness. Some formulas targeted toward treating the patient’s constitution. For example, the use of Honey-Fried Licorice Decoction (zhì gän câo täng) is appropriate for treating patients with a thin and blood deficient constitution. While other prescriptions are directed towards an illness. For example, Gardenia and Magnolia Bark Decoction (zhï zî hòu pò täng), which treats a kind of “irritability, with abdominal fullness and a lack of calmness in everyday life” illness. There are other formulations, such as Major Bupleurum Decoction (dà chái hú täng), that are directed both at the illness and constitution. It can be effectively used for the treatment of pancreatitis, cholecystitis, bronchial asthma and gastritis with reflux. It is also effective in treating some systemic body illnesses such as metabolic syndromes and obesity, especially in middle-aged women who have sudden weight gain, left ventricular concentric hypertrophy, constipation, thyroid cysts, uterine leiomyoma, or breast lobular hyperplasia. Taking Major Bupleurum Decoction (dà chái hú täng) can shift their constitution and restore their figure. In summary, using the classic formulas sometimes the formulas are targeted at the illness, at other times it is the person’s constitution that is treated, and there are also times when both are taken into consideration.

In clinic should one come across a patient where there is a discrepancy between their illness and constitution, and it is not possible to clearly diagnose their formula presentation. In that situation, first treat the illness; if the results are less than satisfactory, switch to treating their constitution.

.

Q: You have quite an interest in history and have extensively studied 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?

For the answer to this question, check back in a couple weeks. If you are not familiar with the Menghe current of medicine, you can go here to learn more.

.

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.

.

.

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.

…

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.