經方學

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.

Eastland Press just released an herb index to The 10 Key Formula Families in Chinese Medicine as a PDF.

For those of you that would like a copy you can either go to Eastland’s site and get a copy, or simply click HERE to download a copy.

I am considering adding a discussion forum to the site. If anyone has a comment or suggestions about that, please leave a comment.

Another great interview is coming soon coming your way. Stay tuned!

It has been a long journey and I am delighted to share the news that The 10 Key Formula Families in Chinese Medicine is now available. You will be able to find it at the usual outlets, and of course from Eastland Press. To help celebrate the occasion Eastland Press is offering a discount on the book from now, until the end of August.

From Huang’s forward to the Chinese edition:

While there are no less than dozens of formula categories in Chinese medicine, large and small, in this book we will discuss ten key families. While becoming familiar with theses formula categories and their constituent herbs, will not enable the reader to have complete mastery over all aspects of Chinese medicine. It will however, allow practitioners to grasp the rules in general for using Chinese herbal formulas, to understand the basic principles of Chinese medicine’s differentiation of patterns as a basis for treatment, and to handle these with ease in the clinic. Thus, laying down a firm foundation for the further study of Chinese medicine.

It is deceiving how much time and effort is required to dig the English out of one thin, little book on Chinese medicine; nor is it a solitary endevor. The assitance of my editor, Dan Bensky; the ongoing conversations both in person and by email with Dr. Huang; the patients that have visited Yong Kang clinic over the past few years and various collegues who have proofed the material and offered up their insights and suggestions, all of them share the responsibily for this book making its way into English. All have played a role in helping me to bring Dr. Huang’s words and ideas to the Western reader. I owe a deep debt of gratitude to all who have helped bring this project to fruition.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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

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

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

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

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

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

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

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

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

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

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

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