Dr Huang discusses classic formulas, part one|
Slow cooked meals are usually tasty and rich in nourishment, often the process of creation is long; you can think of it as a kind of cultivation. Likewise, quality publications take time. Eastland Press has been taking its fine toothed comb through The 10 Key Formula Families; some things can not be rushed. But, we should see it on bookshelves sometime in July. In the meantime, I’ve been arranging interviews with a few practitioners who have a wealth of experience both in Chinese medicine and use of the classic formulas. This first installment is the first part of an interview with the author of The 10 Key Formula Families, Dr. Huang Huang.
Q: Is constitution changeable? If it is changeable, then under what conditions would changes occur?
A: Constitution is changeable. The primary factors that influence constitutional change are aging, illness, environment, and lifestyle, which includes diet, exercise and use of medications. For example, when some people are young they have a bupleurum constitution, however as they age perhaps they change into a bupleurum/rhubarb constitution. If originally Frigid Extremities Powder (sì nì sân) was effective for these kinds of patients, after their constitution has shifted then perhaps it is Major Bupleurum Decoction (dà chái hú täng) that will be required. There are also those who originally where of a cinnamon twig constitution, however due to their lifestyle they became overweight, and developed problems with their blood sugar and metabolism, in more serious cases there will be heart or kidney disease. Quite likely these patients will appear with an astragalus constitution; for them use Astragalus and Cinnamon Twig Five-Substance Decoction (huáng qí guì zhï wû wù täng). Additionally, over-treatment or improper use of medicinals also can lead to change of a person’s constitution. For example, if Coptidis Rhizoma (huáng lián) or Rhei Radix et Rhizoma (dà huáng) is taken for an extended period of time it lead to the appearance of the Frigid Extremities Decoction constitution.
Q: Generally speaking, when people get sick they tend to get sick in line with their constitution. What I mean is there is a correspondence between their constitution and their symptomology. However there are times when a patient’s symptoms are quite different from what one would expect, given their constitution. In this kind of situation, how should one proceed? How does one judge that a patient has fallen ill outside the predilection of their constitution? How to diagnose these cases?
A: To answer this question it is first necessary to clearly understand the theory behind the use of classic formulas. The principle of treating by matching formulas to the patient’s presentation is the core of this theory. Another way to say this is in practice when a certain presentation is seen; use the formula that treats that presentation. This is the principle behind the practice of classic formula medicine.
So, just what comprises a formula presentation? It includes both a patient’s constitution and their illness. Different formula presentations are comprised of varying proportions of constitution and illness. Some formulas targeted toward treating the patient’s constitution. For example, the use of Honey-Fried Licorice Decoction (zhì gän câo täng) is appropriate for treating patients with a thin and blood deficient constitution. While other prescriptions are directed towards an illness. For example, Gardenia and Magnolia Bark Decoction (zhï zî hòu pò täng), which treats a kind of “irritability, with abdominal fullness and a lack of calmness in everyday life” illness. There are other formulations, such as Major Bupleurum Decoction (dà chái hú täng), that are directed both at the illness and constitution. It can be effectively used for the treatment of pancreatitis, cholecystitis, bronchial asthma and gastritis with reflux. It is also effective in treating some systemic body illnesses such as metabolic syndromes and obesity, especially in middle-aged women who have sudden weight gain, left ventricular concentric hypertrophy, constipation, thyroid cysts, uterine leiomyoma, or breast lobular hyperplasia. Taking Major Bupleurum Decoction (dà chái hú täng) can shift their constitution and restore their figure. In summary, using the classic formulas sometimes the formulas are targeted at the illness, at other times it is the person’s constitution that is treated, and there are also times when both are taken into consideration.
In clinic should one come across a patient where there is a discrepancy between their illness and constitution, and it is not possible to clearly diagnose their formula presentation. In that situation, first treat the illness; if the results are less than satisfactory, switch to treating their constitution.
Q: You have quite an interest in history and have extensively studied the history of Chinese medicine, your Master’s thesis was on the doctors of the Menghe current. These doctors were quite skilled practitioners. Can you compare for us the methods of Zhang Zhong-Jing with those of Fei Bo-xiong and the other doctors of the Menghe current?
For the answer to this question, check back in a couple weeks. If you are not familiar with the Menghe current of medicine, you can go here to learn more.
Q: You have quite an interest in the history of Chinese medicine; your Master’s thesis was on the doctors of the Menghe current. These doctors were quite skilled practitioners. Can you compare for us the methods of Zhang Zhong-Jing with those of Fei Bo-xiong and the other doctors of the Menghe current?
A: The Menghe current takes its name from a small town in the southern part of Jiangsu province that was home to successive generations of famous doctors who lived there from the beginning of the 18th century up through the middle of the last century. That area produced many doctors, some of whom became the great doctors of this generation in Shanghai and Nanjing. Later, people would refer to them as the “Menghe current.”
They were country doctors who were skilled in all aspects of medicine. They excelled at treating internal medicine issues, trauma, and laryngology. Not only did they prescribe herbal decoctions, but also performed surgeries, treated skin problems with medicated sticks and used acupuncture. They were excellent clinicians, especially in treating the common illness of their day. For example, infection secondary to trauma, contagious illness, and a common illness of the day, which was a kind of deficiency due to overwork (perhaps what today we would call tuberculosis). The formulas they used for the most part where experiential formulas. They were publicly open about what herbs they used, but rather closed about the amounts. Additionally, they were tightlipped about the presentations treated. Generally, one required the oral teachings of the traditional master/disciple relationship before being able to comprehend these prescriptions.
As to Zhang Zhong-Jing’s classic formulas, not only are the formulas a part of the public domain, their formula presentations are both comparatively clear and concrete; they are one of the standards within Chinese medical science. The Menghe current of medicine really cannot compare with the classic formulas. For those who study Chinese medicine, it is still best to begin with a study of the classic formulas.
Q: There are some who say that for complex and longstanding problems correspondingly large and complex formulas must be employed. Contrarily, the classic formulas usually use a small amount of herbs and are rather simple. Please share with us how they can treat relatively serious, chronic conditions, such as cancer, heart disease, or the complications associated with diabetes.
A: It must clearly be stated that treating serious illness does not necessarily require the use of large prescriptions. However, the reality is that in clinic many patient’s conditions are complicated, single use of one or two classic formulas cannot take into account the entire situation. What to do? In my experience, make use of combining formulas together. What I mean by combining formulas is to take several classic formulas and use them together as a way to expand the scope of that is treated. Patients with chronic and complicated conditions can be treated in this way.
Let me give an example, I when treating patients with diabetes I often use Astragalus and Cinnamon Twig Five-Substance Decoction (huáng qí guì zhï wû wù täng) combined with Cinnamon Twig and Poria Pill (guì zhï fú líng wán). When treating cancer I commonly combine Minor Bupleurum Decoction (xiâo chái hú täng) with Five-Ingredient Powder with Poria (wû líng sân), or Honey-Fried Licorice Decoction (zhì gän câo täng) with Ophiopogonis Decoction (mài mén döng täng). Also, in the treatment of the elderly with hypertension who have suffered a stroke I combine Bupleurum plus Dragon Bone and Oyster Shell Decoction (chái hú jiä lóng gû mû lì täng) with Cinnamon Twig and Poria Pill (guì zhï fú líng wán), or with Gardenia and Magnolia Bark Decoction (zhï zî hòu pò täng). To treat bronchial asthma I usually use the combination of Major Bupleurum Decoction (dà chái hú täng) with Cinnamon Twig and Poria Pill (guì zhï fú líng wán). All that being said, within the classic formulas there are some large formulations that can be used to treat complex and complicated disease. For example Warm the Gallbladder Decoction (wën dân täng) has 11 herbs, it can be used to treat irregular periods and amenorrhea. There is also Chinese Yam Pill (shû yù wán) which has 21 different medicinals, it can be used to the treat the side effects of chemotherapy by regulating the constitution.
Q: I think most people would agree it is better to prevent illness than to treat it. How can we use the classic formulas to promote wellness?
A: Generally the classic formulas are primarily used for treating illness, if there is no illness then they are not prescribed; especially they are not prescribed for long term use. However, from the perspective of Chinese medicine the space between illness and health does not have clearly defined limits.
Many people have a propensity to contract an illness or tendency toward certain kinds of disorders; this is actually what I am referring to when I talk about constitution.
Furthermore, after establishing a person’s constitution and overall state of health, they can take herbs or formulas that are appropriate for their body type.
For example, those with a Ginseng constitution can regularly take some Ginseng Radix (rén shën), or Honey-Fried Licorice Decoction (zhì gän câo täng) or Generate the Pulse Powder (shëng mài sân). Those with an Astragalus constitution can regularly use Astragali Radix (huáng qí), or take Astragalus and Cinnamon Twig Five-Substance Decoction (huáng qí guì zhï wû wù täng) or Jade Windscreen Powder (yù píng fëng sân). That being said, however, medicinal substances are medicine. Medicine cannot be used as food.
Another way to say this is that is not necessary to ingest classic formulas everyday as a way to stay healthy; herbs should only be taken in those times when the body feels run down, or when a formula presentation manifests. The use of classic formulas for “wellness” has to do with their ability to the treat presentations that manifest when the body is out of balance.
Q: Chinese medicine has experienced much development over the past 2000 years that for which we have a written history. Many skilled doctors over the ages have added their contributions. What is it that makes the classic formulas unique, what is that makes them particularly distinctive?
A: The distinctive qualities of the classic formulas are quite clear. First, they have been used for a long time, thus we have accumulated a lot of experience concerning their usage. Most of the classic formulas have been developed from single medicinals. From these single medicinals have developed various formulas, which bring out different characteristics the herbs. Understanding, development and usage of these formulas has come through the slow process of thousands of years of clinical trial and application, along with our predecessors’ practical experience. It has not been from one single person, or even one era, but from the painstaking effort of countless scholars and doctors over time that has solidified our understanding of this body of knowledge.
As an example there is Cinnamon Twig Decoction (guì zhï täng), just who actually created this prescription no one really knows. Certainly it was not one of the formulas that Zhang Zhong-Jing himself developed, but instead came from this collecting and arranging of various texts that contained the experiential prescriptions of doctors that had come before him.
Secondly, these are important prescriptions for treating illness. Many of these formulas contain rather fierce, strong acting medicinals, which have a notable effect on the body. It is said “medicinals with an effect that people notice are required in the treatment of disease.” Light acting herbs like Ephedrae Herba (má huáng) or Cinnamomi Ramulus (guì zhï), strong acting ones like Rhei Radix et Rhizoma (dà huáng) and Aconiti Radix lateralis preparata (zhì fù zî), those with toxins such as Aconiti Radix preparata (zhì wü tóu) or Crotonis Semen (bä dòu) and those which result in severe reactions like Genkwa Flos (yuán huä) and Knoxiae Radix/Euphorbiae pekinensis Radix (dà jî) are examples of such herbs. One of the distinctive characteristics of the classic formulas is the usage of these strong acting medicinals. They are different from the pairing of herbs used by later generations. Many of which are tonics herbs such as Rehmanniae Radix preparata (shú dì huáng), Ginseng Radix (rén shën), Dendrobii Herba (shí hú); or flowers like Chrysanthemi Flos (jú huä), Rosae rugosae Flos (méi guï huä), Magnoliae officinalis Flos (hòu pò huä); or food grade herbs like Luffae Fructus Retinervus (sï guä luò), Nelumbinis Folium (hé yè), Lablab Semen album (bái biân dòu), Soybean (huáng doù), or medicinal foods such as beef, deer sinew, sheep kidney or pig liver.
Thirdly, there is a strict regiment to the combining of herbs in the classic formulas. Change one herb and the name of a formula also changes, even changing the amount of one herb used will result in a formula with a new name. The formula function and illnesses treated also shift along with these changes in herbs or amounts. This is an expression of the tight relationship between how a formula is constituted and its effect; it shows the classic simplicity and beauty of structure and function.
Fourth, the effects of using classic formulas to treat illness are relatively clear, concrete and observable. The formulas recorded in the Shang Han Lun and Jin Gui Yao Lue, although they appear to be relatively simple, they all originate from clinical experience and as such are both practical and objective. So long as an experienced clinician explains the formulas and how they are used, the code for what they treat and scope of use can be cracked. Therefore, it is of benefit to pass along this kind of concrete understanding.
Later generations of doctors used formulas that treat illness from the conceptual point of view of “yin or yang deficiency,” “fluid loss, “ blazing fire,” “excess above with deficiency below,” “various wind disturbances,” and “five taxations and seven injuries”, the parameters for their usage are rather vague in comparison to the clear cut presentations treated by the classic formulas.
Lastly, the classic formulas use a small amount of inexpensive and commonly found herbs. They are suitable for the masses and of benefit in that they reduce medical costs for the country.