經方學

One of the first concepts we hear upon walking through the gate of Chinese medicine is that of excess and deficiency (xu虛 & shi實). Deceptively simple at first glance, this is one of the foundations of accurate diagnosis that tends to become more slippery as time goes on and we see patients in the clinic with strange mixes of symptoms. All the practitioners here in Nanjing have at least 10 years of experience, and like anyone seeking mastery,  some of us are still working on refining the basics as a way to sharpen our clinical eye.

Today’s guest post comes from one of the participants of the Nanjing seminar. It gives us a fresh insight into issues of excess and deficiency and the use of Ma Huang.

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The single most important thing I learned in the first week of studying with Dr. Huang in Nanjing is his explanation of “shi”and “xu”, most often translated as”excess” and “deficiency”. The usual translation to German is “Fülle” and “Leere”, which literally brought into English is expressed as “fullness” and “emptiness”.

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Even though we are used to the relational nature of terminology in Chinese medicine, it never was really satisfying when teachers spoke about a Gui Zhi Tang situation as “exterior deficiency”, while at the same time saying that there was no “real deficiency”, but only compared to the Ma Huang Tang situation, which is “exterior excess”. And on the other hand both the Ma Huang Tang and Gui Zhi Tang situations are “excess” in relation to, lets say: Yu Ping Feng San or Gui Zhi Jia Fu Zi tang conditions.

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Dr. Huang provided us with a new perspective by switching the focus to movement and function. On every level of the body there are doors, which have to open and close in appropriate ways, for example at the exterior of the body, the doors are the pores. If they stuck close (in other words don’t open properly) this is “shi”, if they stuck open (in other words: don’t close properly) this is “xu”. So in a Gui Zhi Tang Situation “Xu” means: the exterior doors are stuck open, and in a Ma Huang Situation “Shi” means: the exterior doors are stuck close.

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Ma huang is the primary herb used to open glands, which are considered to be one kind of door, like the sweat glands of the skin. Therefore it is used for acne to open the pores which are clogged shut. It can be used as well as to help release eggs of the ovaries, or for insufficient lactation. Whether a formula (like Gegen tang) is appropriate, depends on the constitutional body type and if the formula presentation fits with the disease presentation. Another example of how Dr. Huang uses Ma Huang for problems with glands is Zhen Wu Tang together with Ma Huang Fu Zi Gan Cao Tang and Dang Gui Shao Yao San for hypothyroidism.

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Furthermore the opening function of Ma Huang is also used for other “closed” types of problems, for example Bi-Syndrome. Dr. Huang even uses it together with Wen Dan Tang for patients with schizophrenia, who are mentally locked in by the use of anti-psychotic drugs.

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I’m sure that the new perspectives provided by Dr. Huang will allow us to expand the use of herbs and formulas even further.

Perhaps practicing medicine is much like forest management, fiddling around with the economy of a large developed country, or arranging a 100 table banquet. There are individual issues; the overpopulation of a certain insect, corruption in a key business sector, unrelenting fever, or who should sit next to who. There are hot spot issues, the fly in the soup, bark blight and leaf mold, mortgages foreclosures, or a sudden inability to digest. These are the issues that command attention, the issues that lead to a mobilization of action. A call for change and remediation.

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Then there is the forest of trees, streams, soils and how they sway and grow with the seasons. There are the vast web-like connections between businesses, those who buy, who sell and those who speculate. In business there is an ongoing organic symphony of exchange that mimics the process of respiration and digestion. In most any process, depending on where we shine the light of intention, issues of overall constitution or specific ailment can be brought into relief and focus.

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So it is with medicine as well. We can focus on specific issues or complaints, or we can pay attention to the overall terrain in which our patient’s lives unfold. There are formulas that are very good at treating certain problems over the range of a number of constitutions. These prescriptions target disease. There are other formulas that adjust a patient’s constitution; these do not directly treat illness, but instead adjust the internal environment. It is the difference between spraying a chemical cocktail on blighted leaves, and changing the nutrient balance of the surrounding soil, so that a tree has access to the constituents it needs to ward off opportunistic invasion. Sometimes seating two people together at a banquet provides more catalyst for change than a dozen business meeting. You just have to be sure you are getting the right people together.

So it is with the formulas that adjust constitution.

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One of the participants here in this Nanjing seminar pointed out a line from The Ten Key Formula Families, that I had not completely understood:

The range of practical clinical uses of Bu Zhong Yi Qi Tang is unusually wide. Furthermore, the broader a formula’s range of indications, the more important it is to be rigorous in grasping when and how it should be used.

Simply put, constitutional formulas can be quite effective in treating a variety illness, so long as one grasps the constitutional underpinnings of the problem. The more issues a formula is capable of treating, the more rigorous one must be in correctly determining the patient’s constitution. Because these prescriptions are capable of treating a wide range of disease, it is easy to make the mistake of thinking these formulas can treat a certain illness in all people. They key here is that they do in fact treat a wide variety of disease, but the key is they only do within the scope of a certain constitution.

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Ma huang can be used effectively to treat amenorrhea in those with an Ephredra/Cold constitution. But, it will only bring about agitation in those with a Bupleurum/Stagnation constitution. For spotting between periods in women with a Heat/Excess constitution forget the stop bleeding herbs; bring on the huang lian jie du tang.

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Obviously, we are dealing with strong medicinals here, and a scatter shot approach is not recommended. The key to effective and safe use of these terrain regulating constitutional prescriptions hinges on one’s ability to discern constitution.

Like those magic eye pictures, where when the vision is loosened just so a completely three dimension image appears. Learning to acquire an clinical gaze that is soft enough to take in the entire landscape of a patient’s presentation, and sharp enough to see clearly the shape and structure of dysfunction, is an acquired skill. Usually facilitated by guidance from an experienced teacher who has both the skill and inclination to share it. Dr. Huang is just such a teacher.

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Our class here in Nanjing uses The Ten Key Formula Families as a starting point. Unlike our last trip to Nanjing two years ago, he is not teaching the book; it is simply background for his current way of thinking and approaching clinical work. The ten constitutional types he introduced in that work have been expanded to include a number of other medicinals, and are now elements of a broader structure that helps us to better understand the predilections and disposition of our patients.

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While there is still a sharp focus on the patient’s constitution based on the herbal formula family they fall into, he also casts a broader net of discernment using the parameters of cold, heat, deficiency, excess, qi stagnation, blood stagnation, phlegm and dampness. Like the crosshatch pattern of a sieve, it gives us a finer granularity with which to shift a patient’s complaints and constitution into a formula that fits the lock of their dysfunction.

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Watch for more posts from Nanjing, as the lessons from the classes, observations from the clinic, and discussions over foot massages make their way to these pages!

If any of you have inclination toward reading Chinese, then you probably are familiar with Pleco software. Yes, that is their logo on the iPhone app in the picture. No, it is not yet available. But, from participating in the beta-test I can tell you that if you have an iPhone in your pocket, and have some kind of relationship with the Chinese language, this application is going to rock your world.

Unlike the PDA versions, you use your finger to write directly on the screen. The word lookup is blinding fast and startlingly accurate. The handwriting input system is also smart enough to differentiate simple and traditional characters on the fly. While the initial release will not support flashcards, an update that does will not be far behind.

For a glimpse at the magic click here.

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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.

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

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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.

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.

The back of Richard Goodman’s book says it best “Why not go deeper?”

I ran into Rick back in 2005. He was just arriving in Taiwan, I was on my way back to the USA; he rented the penthouse studio that overlooked Eternal Harmony City and the Xin Dian river that I’d been living in for the past year plus. Our paths crossed again when I purchased his book. Journeys through Chinese into medicine have a way of crisscrossing from time to time.

Anyone who has read the Mitchell/Wiseman/Feng translation of the Shang Han Lun knows that there are appendixes in the back that are a treasure trove of translation gold. Especially, for understanding the Chinese of The Discussion of Cold Damage.

Rick Goodman gives us some basic vocabulary, and more importantly, grammatical parsing that helps us to crack the code of Classic Chinese. Is it a comprehensive text that spills out all the gems of the Nei Jing, Nan Jing, and Jia Yi Jing? Of course not, the process of learning Chinese can in no way be captured in one book. Does it give us some keys that coax open those doors? Absolutely! It is a clearly written, carefully explained text that gives the reader access to the treasure house of Chinese medicine. Indeed, this book will give the dedicated reader an opportunity to go deeper.

Rick also has a second volume of what will be a three part series that will be published soon. Get the details here on his blog.

Thanks Rick for your contribution!

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.