The concept of constitution in Chinese herbal medicine

on 11/11/2009 by Eric Grey in Foundational Science

Established readers : this is one of many reposted articles you will see in the coming months. It is part of the redesign process. I hope you agree that all of these articles are worth another look!

I have to admit to some weirdness around the concept of “constitution.” This is absolutely unfounded, I have no clinical or theoretical information to back up my feeling. I think I’ve just seen this concept be misused. Once you get an idea in your head that a patient is a “Chaihu person,” or a “Bladder CF,” or a “Shaoyang patient,” it seems to be a little difficult to think outside that box. It offends my desire to meet the patient where they are without preconceptions.

Now, don’t get me wrong, I realize that this is part of what WE DO in Chinese medicine in particular and natural medicine in general. We look at the gestalt of the patient, and we make a helpful generalization about their condition and the treatment that is likely to rectify it. We look into past and future and consider how the patient came to be where they are and where they might be going, and treat them based on all of this information. I have no problem with that. But, I find myself a little worried when I persistently think about a person as, say, a “Chaihu” person, even before they come in – and use that lens to view whatever it is they might be presenting with in the current moment.

Before you click on the comment button prematurely – know that this is an attitude that is changing for me. The more patients I see, the more I see really weird cases. These cases involve patients who present with a certain picture that so strongly speaks to a particular treatment strategy but for whom that treatment strategy does not work. Searching for a remedy usually guides me in a very unexpected direction. In retrospect, looking through the patient’s case, I usually see a certain pattern emerge.

Here’s an example from my time in the student clinic.

A patient presenting with very serious symptoms (serious blood stasis, ongoing memory loss, digestive chaos, emotional instability and more) also had a *very* excess pulse – pounding, tight and wiry at all depths with some choppiness throughout. A dong (flicking bean) pulse was found on both sides between the first and second positions. A lot of stasis in the tongue. The supervising doctor and I discussed the case for a while, trying to seek out the best formula. For the next six or eight weeks, we used some variation of Taohe Chengqi Tang + Zhishi Xiebai Guizhi Tang with some incorporation of Guizhi Fuling Wan. We wanted to treat the most excess, the most “outward” of the symptom picture first.

As the treatment progressed, however, it… uh, didn’t. The patient’s symptoms didn’t lessen much, the pulse picture didn’t change. We decided to work from another direction. Following the recommendation from one of my mentors, I used a modification of Shenqi Wan with some additional blood movement incorporated. The patient found almost immediate improvement and continued to improve for the next several months. Later acute episodes found us changing our formula strategy a bit, but Fuzi has always been involved and when the Fuzi is removed, the patient worsens.

Now part of this is just my clinical immaturity and maybe my inability to see signs that, for a more experienced practitioner, would seem obvious. I’m sure there are several of you in the audience shaking your heads sagely – ah yes, of course, Fuzi. But, one could easily see something about “constitution” in this case. I’ve had similar experiences otherwise. It’s not always obvious in the pulse, it’s not always clear in the history, but when you go with it – improvement is found on all levels.

There doesn’t seem to be something that binds these cases together in every case. For instance, I am in no way convinced that if a different person with a similar presentation as above were to come to the clinic that I would be able to resolve their situation in the same way. But, I may be able to look at this person and – over time – learn some basic characteristics that help me to identify patients who might need this approach… this is, to me, constitution.

I’ve been reading the Classicalformulas.com blog over the last couple of months. I’ve also read through the book the blog is affiliated with, Ten Key Formula Families in Chinese Medicine. I enjoyed reading it. One thing I couldn’t quite get into was the classification of people based on their body type. While I, of course, pay attention to body type – I don’t think I’ve gone as far as thinking that a person fell into a certain class of formulas because of that body type. I’d love to hear from anyone who has used, or currently uses, this type of classification. Have you found it works all the time? 90% of the time? Something else?

This is a fascinating topic, in general, and one that I know has a lot of traction out there. So, even if you haven’t read the book above, I’d like to hear your thoughts. What do you think about constitution? Where is the classical support for this method? What have you been learning in your classes and seminars about constitution?

About Eric Grey

Hi - I'm the founder of Deepest Health. When I'm not writing here, you can find me reaching out to the Chinese Medicine community across the web and in my own backyard. I currently teach Chinese herbs at my alma mater, the National College of Natural Medicine. Additionally, I'm the founder of Watershed Community Wellness, a thriving local clinic in Southeast Portland in Oregon. No matter where I'm working, you'll find my focus on the Classical approach to Chinese medicine laced throughout everything I do.

View all posts by Eric Grey - Website: http://deepesthealth.com

Bonnie says:

11/11/2009

Ah I was hoping people would have started commenting! I get to leave town (and have internet only via my phone for awhile). I know that very often as we peel away layers of symptoms we often get to a very different branch of what is going on. Sometimes it has to do with what the patient brings to the consult–they emphasize things that they think are important. I don’t know how many patients think that something isn’t a symptom because they know it’s a medication side effect. Still–this tells me about their overall picture NOW.

When we start classifying people, there is something nice and tidy for us. However, our mind starts getting frustrated when the person doesn’t stay in their nice little box. Rather than thinking of the constitution as the box, think of finding the right section of the library stacks to find a book–there are still hundreds of books, all different but only one copy of the book you are looking for. Each is unique–they are just classified that this is the closest place they can live.

In research, we very often find books that are helpful to us in parts of the library we never expect to see them, largely because of the way they were classified by the Library of Congress. In the same way, some patients present like they should be one thing, but are really another–it’s not until we read the whole book that we may find out why it was classified to go in one section rather than another.

But wonderful food for thought! I can’t wait to see how everyone else chimes in!

Jason (@allpraxis) says:

11/11/2009

Boxes are seductive things. I know I love when things neat and orderly, but what medical student doesn’t? As a beginning student of CM, I feel like I have to learn about the boxes to have something to work with, even if I know I’ll have to break them later. Oh, and great analogy, Bonnie!

Ross Rosen says:

11/12/2009

Hi Eric,
I think the idea of constitution is very important (of course, not the pigeon-holing part). The roots of our medicine speak strongly to the aspects of astrology and morphology. Indeed, even the triple burner mechanism’s responsibility of siphoning yuan qi to the respective shu points is significant in this regard. Not all shu points get equal amounts. If one is more of a wood morphology-type, BL 18 will get a more substantial portion of yuan qi. It is what sets one’s destiny. Being a wood type may be that person’s lesson in this life. His/her curriculum may depend on it. So, of course we should take that into account. And similarly, of course we shouldn’t be fixated on the fact he/she is a wood constitution and only see this person through that particular lens. But it does to some degree shape one’s personality, one’s challenges, one’s strengths, one’s view of the world and one’s perception.

Another aspect is to understand that people travel through their lives generally in fairly habitual patterns and roadways. Jeffrey Yuen talks about this in terms of the meridian systems. Some people are left lane drivers, others right lane drivers. Some travel the major highways, others travel the side roads, etc. This can also implicate which meridian systems are most active for these individuals. Do they spend their time mostly on the sinew meridians, luo vessels (very emotional), divergent meridians, etc. So I think these are important factors to consider…..

I have read most of the 10 Formula Families book. I wrote a blog post on it not too long ago. I like it.
http://rossrosen.blogspot.com/2009/10/formula-families.html

Michael Max says:

11/12/2009

I don’t think the practice of medicine is about putting people in boxes, asking them to conform to a theory, squeezing them into a category, or taming them into a stereotype. It is more about discovering something about who they deeply are, how they make sense to themselves, and us and the world.

Somehow in this process we need to find a way to focus our clinical eye. Like a navigator needs a compass, we need a way to know that which is steady and that which changes. Constitution, on one hand, can lead us to the trap of dropping people into a box and deciding we are clever for figuring their “type”, on the other hand it can be a powerful way of getting a sense of a patient’s overall disposition and tendencies. It is NOT cast in stone, but neither is it readily malleable. It is a way to help rule out, or rule in certain clinical options. It can help us to make sense of why certain formulas work for some people and not others. It is simply a lens; one of many, that helps us to be effective in our clinical work.

Eric says:

11/12/2009

I like the idea of a lens, Max, I think I used the same word in my post. It feels precisely like that – suddenly, with the right lens, things come into greater focus. It’s helpful as a student (as Jason mentioned) but also as a practitioner. I think my struggle will be to avoid jumping to conclusions too quickly, and to let all the information come in before I think myself too clever.

I really appreciate all the comments on this post and hope to read more!

Eric

Michael Max says:

11/12/2009

I find for myself that one of the tricks is not to get too attached to the lenses, methods or filters we use in the process of doing our work. Use what is useful when it is appropriate.

In clinical work we need to arrive quickly at some kind of conclusion, otherwise how can we treat our patients? I find I rarely have enough information to completely understand the patient’s condition, but I usually can get enough to get started. This is where constitution can come in very handy!

CTK says:

11/12/2009

I love to look at the way I practice. I find myself using my intuition to guide me. But where did all of this intuition come from? From internalizing what my teachers taught me…and truly believing in what was passed down to me.

I like to look at the way someone describes their pain (for example) and the way they hold their arm. Points and ideas start popping into my head right away!

…but it is definitely a balance between the verbal information of what the patient is giving you versus (or plus or minus) what we as practitioners pick up on.

G. Michael Reynolds says:

11/12/2009

I am very impressed with the homeopathic constitution picture painted by Luc De Schepper. Each individual remedy’s picture is so fully fleshed out that it becomes somewhat easy to be able to view their constitution and the pathological layers that sit on top of it, obstructing their natural state of being. While this doesn’t IMMEDIATELY translate into a CM treatment protocol, it does give one a wealth of necessary information for understanding the patient, which of course is the vital thing for getting any sort of real progress with the case. This I think is primarily due to the Jungian psychoanalysis emphasis, which of course points toward Leon Hammer and Dragon Rises Red Bird Flies.

I like what the late Dr. Edward Whitmont said about all this, that we are dealing with Form that existed before form. We are trying to perceive that a priori Form and assist its never-ending efforts to exert itself upon the physical terrain it has been assigned to. That’s the real point of all this talk about constitution, right?

Z'ev Rosenberg says:

11/13/2009

I also think constitution is important. In rapidly shifting exterior conditions, constitution can provide an anchor, as people tend to get sick in repeatable patterns. some get sore throats right away, some diarrhea and bloating, etc. However, these patterns can also shift into unknown territory quickly, and then we really need to know our theory, such as six channel differentiation of SHL/JGYL. I enjoy the ‘Ten Formula Families’ text a lot, but was disappointed that he doesn’t really go into six channel theory behind his work. I prefer Arnaud Versluy’s work because he bases everything on six channel theory, and it seems to work much better for how I practice.

Anonymous says:

11/16/2009

Hi Z’ev,

I agree with you that the constitution is important. Without considering the individual’s body constitution we are not truly working on a holistic level. I believe Chinese medical theory is very much about holism, since it is about how everything in the body is connected, and how the body is connected to, and a reflection of nature. Constitution is a major reason why two people who get sick at the same time and in the same place can manifest with different symptoms. Everybody’s body will respond different to a pathogen and present different symptoms based on what the individual’s terrain is like. Ultimately, I think we need to understand the disease pattern in relation to the body’s constitution or else we are not fully practicing medicine the way the sages intended it to be- holistic. This seems to be one of the weaknesses of the SHL approach, as I feel it doesn’t explain individual constitutions, but focuses on pattern differentiation. In my opinion, we need to focus on the disease pattern (tips and branches), but we must understand them in relation to the constitution (the trunk and roots). If we only understand one or the other, or see them as separate, then I don’t think we are fully understanding the whole picture, and thus the results of the treatment will not be as good as they should be.

Michael Max says:

11/17/2009

Sometimes I think Huang’s work is like a Macintosh computer; elegant, powerful, and easy to use. Because, in some ways what he teaches lacks a peek at the underlying mechanics of what is going on. I think it is there, in that he has thought about it and used it to form his clinical methods. But, if you really want to get deeper into how it relates with various levels, other resources will need to be accessed.

Huang himself has studied long and hard, and his clinical methods are based on a number of sources, including some from Japan. Like him, to really go deeply into our work we will need to study and pull from different streams of thought.

I recently found some books here in China on “jing fang,” one in particular that goes through the Shang Han Lun line by line and “decodes” it as which level of illness it is describing. I’m not sure we have anything quite like this in English. But, if we do, it would be a good place to dig in. Maybe Z’ev has some recommendations.

Z'ev Rosenberg says:

11/17/2009

Michael,
Can you give us a short survey of the SHL text you uncovered plus title, etc.? Sounds fascinating.
It is very interesting that not only Huang Huang, but historical figures like Todo Yoshimasu in Japan, had a very practical, hands-on view of the SHL, but others were more theoretical in their approach. It appears to be a text flexible enough to allow different approaches to the material. What someone from the China trip with Huang Huang told me was that he felt that a very practical approach to the SHL was necessary. However, I don’t think he understood that Westerners don’t ‘grok’ six channel theory, it is not innate to us as it may be to him or other Chinese practitioners. Or perhaps he has just absorbed and assimilated six channel theory to the point where it is part of his core ‘software’ approach. I personally like using the theory to ground my diagnosis as to location, depth, progression and direction of disease patterns, rather than just a ‘here-now’ approach. In my understanding, such rubrics as six channel allow us to see the progression of disorders, and see more complex conditions as combination diseases.

brandon brown says:

11/18/2009

Hi all,

I’m glad to see a post about this eric. I’m actually writing my thesis on the topic (specifically the 4 fires), so i’ll share much more when I’m done. But an interesting starting point is Ling Shu 64, where the 25 types of people are introduced.

Z'ev Rosenberg says:

11/19/2009

There is also a section at the beginning of the Jia Yi Jing on constitution, it may well be derived from Ling Shu 64, I’ll check. However, the constitutional archetypes of Ling Shu/Jia Yi Jing are different from those that Huang Huang postulates from the Shang Han Lun, and seemingly from Kampo influences.

Michael Max says:

11/19/2009

Z’ev

I just posted something on http://www.classicformulas.com about the book. Actually, it will be part of a series as the more I dig into this book, the more I am finding some really interesting stuff. It talks about BOTH channel level and formula presentation. Plus it is full of case studies that in essence use a bit of both approaches to diagnose.
Michael

G. Michael Reynolds says:

11/20/2009

One of my students appeared the other day at a tea session with Huang Huang’s work. Wow, this families thing is really spreading if it’s made it al the way out here!

Dragon Blogger says:

12/20/2009

Though I don’t practice CM, I do read reviews of products and sometimes try unique methods to treat ailments I suffer from on occasion, this was the first time I found this blog and you have incredibly detailed and useful information.

Cosinensis says:

12/22/2009

Some classification is surely necessary, although terms like “Chaihu person” are ridiculous indeed.

Dean Campbell says:

09/28/2011

Eric,
I have come to CM via an Ayurvedic background which has a strong constitution model. It seem that CM practitioner often, like you describe don’t feel comfortable with a constitutional model. From my background I don’t quite understand this challenge. In Ayurveda we use it all the time without reservations, it doesn’t lock us into a box, it simple narrows thing down a bit. It really is helpful in simple understanding “where” someone is coming from….in that if their constitution is different than your, most likely their perspective/world view is much different than your own. Just a tool, not a burden. Thanks for the article, good stuff.

Eric Grey says:

09/29/2011

Dean,

Thanks for your comments – most appreciated! I don’t think that my personal reservation has so much to do with being locked in a box, but more of a question of the reality of the designation. Am I incorrectly placing a constitutional diagnosis on a person and, thus, treating them incorrectly? I have seen practitioners do this, and have also seen them hold so tightly to their constitutional diagnosis that they cannot change treatment strategies even when it is harming the patient! I believe strongly in the existence and operation of archetypes, and believe the constitutional concept to be basically sound. It seems that it would need to depend on a fairly rigorous diagnostic model that is systematized and agreed upon. Because things like body type/facial diagnosis and other typical hallmarks of a constitutional method are not as well developed (or taught) in contemporary Chinese medicine education – it makes many of us wary.

At least, that’s my take.

Thanks again for your comment!

Eric

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