經方學

This blog usually features translations, case studies, or clinical observations into the workings of Chinese herbal medicine. Today’s post is a bit different. It is a more personal story; my story of the past 24 hours, and an insight into the interaction of wei and xie qi (衛和邪氣).

It started a couple days ago with a stiff neck and rib pain, a slight feeling of fatigue, irritability and mild headache. I wrote it off as a less than restful night of sleep and the stress of a busy clinic. But, by the next day the headache had not receded and the stiffness in the neck more pronounced. While there was no fever, nor a pronounced feeling being chilled, by mid-afternoon it was obvious something was out to get me. I had a clinic partner give me some acupuncture and then had a little nap in the afternoon. That often will kick out some external pathogen, but not today. Mild chills set in, along with achiness, severe headache that was relieved a bit of pressure along the tài yáng channel, along with listlessness and fatigue. In short, it was a job for Kudzu Decoction (gé gën täng).

The first dose (4 grams concentrated granules) did not seem to do much. It was followed a few hours later by a second dose, and off into an achy restless sleep I went. Somewhere in the next couple hours of restless sleep the aches extended through my entire body and there was an odd sense of distention in my muscles, moreover I felt a heat being generated from deep within my core and could feel the fluids and cold being pushed toward the outside of my body. It seemed to take a long time to break a sweat, and in the process the muscle aches grew worse, and there were increasing waves of nausea.

I had a vague sense that this was the so-called struggle between the wei and xie qi, but it was the first time that I recognized that this battle between the qi’s was the reason that I was feeling worse and worse. It is a rather poetic idea that the defensive and pathogenic “battle”, the actual experience was I thought that at any moment I’m on my want to the bathroom to lose the contents of my stomach.

The defensive qi did win, and the pathogen was dragged to the exterior and expelled. But, it was dragged clawing, kicking and screaming to the exterior. It was a terribly uncomfortable process. But, I awoke the next day feeling 90% better. No trace of headache, body aches or fatigue.

Lessons learned?
1) Use of exterior releasing herbs indeed to active the yang wei qi. It comes from deep within the body and has a sticky quality that drags fluids and cold to the surface.
2) The struggle between the defensive wei and exterior pathogenic qi is uncomfortable and causes a worsening of symptoms as the pathogen is dragged to the surface.
3) Recovery comes quite quickly once the pathogen has been expelled.

Focal distention, golmus, pi, call it what you will, the name is not nearly as important as the illness process that it describes. This is one of those concepts upon which there is a wealth of thought and disagreement. Some say it is a sensation the patient has, others say it is the doctor that feels it through palpation. Some doctors differentiate the pathomechanism very carefully, while others simply say it is discomfort in the stomach area, and leave it at that.

Chen Yi-Ren, who was a rather renown Shang Han Lun doctor from Nanjing has quite a bit to say about focal distention. A future posting will contain a detailed translation of his thoughts on this matter. For now, here is a translation of a brief synopsis that written by one of his students.

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Focal distention is an illness presentation where there is an uncomfortable feeling of fullness and distention in the epigastrium. It occurs due to obstruction and stagnation of the Stomach qi. There are many reasons for this; it can be due to:

• Stomach heat
• cold in the middle
• deficiency of the middle with knotted heat
• deficiency of the middle with fluid obstruction
• water accumulation leading to qi stagnation.

These conditions require analysis from a holistic perspective, in this way the correct patho-mechanism can found and proper treatment given.

Heat focal distention is due to Stomach heat leading to qi stagnation; it is treated by using Rhubarb and Coptis to Drain the Epigastrium Decoction (dà huáng huáng lián xiè xïn täng)
Fx: Rhei Radix et Rhizoma (dà huáng), Coptidis Rhizoma (huáng lián), Scutellariae Radix (huáng qín)
Deficiency cold in the middle congeals the qi and causes stagnation, leading to a deficient cold presentation of focal distention; it is treated using Regulate the Middle Decoction (lî zhöng täng)
Fx: Ginseng Radix (rén shën), Zingiberis Rhizoma (gän jiäng), Atractylodis macrocephalae Rhizoma (bái zhú) and Glycyrrhizae Radix (gän câo)

As for the presentations of the three Drain the Epigastrium Decoctions (xiè xïn täng) based on Pinelliae Rhizoma preparatum (zhì bàn xià), Glycyrrhizae Radix (gän câo), and Zingiberis Rhizoma recens (shëng jiäng), these are for presentations of heat focal distention with other concurrent complications.
Chen Yi-Ren summarized this patho-mechanism as

“deficiency of the middle with heat that knots, thus forming focal distention.”

This is treated by the use of bitter and cold to drain heat, acrid and warm to open knotting, along with sweet and warm to tonify the middle. The three Drain the Epigastrium Decoctions (xiè xïn täng)

Fx: Pinelliae Rhizoma preparatum (zhì bàn xià), Zingiberis Rhizoma (gän jiäng), Coptidis Rhizoma (huáng lián), Scutellariae Radix (huáng qín), Ginseng Radix (rén shën), Glycyrrhizae Radix (gän câo) and Jujubae Fructus (dà zâo)

are actually formed from combining Rhubarb and Coptis to Drain the Epigastrium Decoction (dà huáng huáng lián xiè xïn täng) and Regulate the Middle Decoction (lî zhöng täng) along with minor modifications. As to the rational for removing Rhei Radix et Rhizoma (dà huáng), naturally this is related to the diarrhea from the focal distention’s jumble of cold and heat. As to the removal of Atractylodis macrocephalae Rhizoma (bái zhú) and substitution of Pinelliae Rhizoma preparatum (zhì bàn xià) and Zingiberis Rhizoma recens (shëng jiäng) these are accord with Zhong-Jing’s basic modification methods; as from this line concerning Regulate the Middle Pill (lî zhöng wán)

“For those with frequent vomiting, remove the Atractylodis macrocephalae Rhizoma (bái zhú) and add three liang of Zingiberis Rhizoma recens (shëng jiäng).”

Also the line from Seven-Substance Decoction with Magnolia Bark (hòu pò qï wù täng) states, “For those who vomit, add five he of Zingiberis Rhizoma recens (shëng jiäng).” Methods of decoction and administration are important aspects in the process of treating by differential diagnosis. The decoction and administration methods of the five Drain the Epigastrium Decoctions (xiè xïn täng) each have their own unique clinically valuable characteristics.

As to the diagnosis and treatment of other focal distention presentations, they too need to be examined from a holistic perspective with concrete analysis; there is not just one way of draining the epigastrium.

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.

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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.

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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.

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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.

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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.

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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.

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!

We know from the texture of our lives that the Chinese yin/yang theory of opposites attracting and mutually transforming into one another is one of the ways that life grows, unfolds, and transforms. It is somehow comforting to know that moments of despair will in time tranform, and that present frustrations can be the inspiration to questions that lead us to wider view of the world.

But, on a less grand scale, opposites as they are currently constellated can give us deeper insight and understanding into the present situation. Anyone who has studied even a little of the six warp of the Shang Han Lun will easily recognize the da huang presentation of excessive heat that burns the tongue coating into a dry yellow-black, turns the stool into a dry compacted mass, and causes thirst as a rescue signal to replace the fluids that are pouring out as sweat.

Ever stop to think about what is the opposite of this kind of presentation?

It is the presentation for gan jiang! Check it out:

• Vomiting of saliva or phlegm fluid. Clear, thin and odorless stool and urine.

• Abdominal distention and pain, nausea and vomiting, or coughing.

• The mouth is moist and there is a lack of thirst, aversion to cold with a desire for warmth, listless and dispirited.

• Pale or pale red tongue, with a greasy coating; the coating is usually white and greasy, grey-black and greasy, or white and glossy. (This is the ginger tongue)

Notice here that both the da huang and gan jiang presentation include signs of abdominal distention and pain. As is so often the case with Chinese medicine, we can not even begin to consider what herbs to use from a single symptom, the entire gestalt must be considered.

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

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

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

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

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

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

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