Strategy in Chinese Medicine: Timing and Momentum, pt. 2

 

Last week we began by exploring the concept of timing in acupuncture. This week we’ll move on to herbs.

Timing in Herbology

Timing is equally important in herbology, as knowing where in the system the disease currently is will dictate what formula you prescribe and what modifications have to be made (I discuss this in an upcoming free PDF entitled “Beginners Guide to Acute Respiratory Disease”).

For this, the Six Conformation model used by Zhang Zhongjing (called the Six Channel Model in TCM) is without question the most powerful tool we have at our disposal, telling us where the disharmony is, what its nature is, and what principles are required to fix it.  This applies in acute as well as chronic cases. For example – If the problem is diagnosed as a Cold invasion of the channels of Taiyang we know several things at once:

  1. We know that since the invasion has penetrated into the channel that the surface is open, which removes the need for the pure surface opening action of Ma Huang Tang.
  2. We know that Taiyang is a Yang conformation. Therefore, our efforts are going to be centered on expelling the Cold pathogen and that if resolved correctly there won’t be any long term consequences of the invasion having taken place (as opposed to an invasion of the Yin conformations which tends to leave the need for a significant cleanup operation after being resolved).
  3. We know that according to the Five Phase (or Five Element) model Taiyang is associated with Cold Water of the North. Taiyang invasions tend to be accompanied by all over muscular aches of varying degrees (depending on the situation). If we envision the Taiyang channels (UB/SI) as being rivers of cold water coming down from the mountains to nourish the plains (read about Mt. Kailash for the ultimate example of this) we can see that when those rivers get more cold, they freeze over and stop flowing. The Chinese characters for pain 疼痛 (teng tong) indicate a state of cold and of obstruction of movement, much like the frozen river analogy. This tells us that we need to “melt the ice” by warming up the channels and re-establishing uninterrupted flow.

The formula that answers all of these requirements is Gui Zhi Tang. If given on time (meaning before the pathogen passes on to, say, the Shaoyang level) the patient will recover quickly. Aside from the diagnostic timing, however, the Shang Han Lun tells us about another necessary element of timing.  An all important feature of timing and momentum in Chinese herbalism is the method and length of time to apply treatment.

The text that introduces Gui Zhi Tang makes very clear that the formula must be prescribed under very specific conditions. One of them is the instruction to give the decoction to the patient warm, then have them bundle up to await sweating. However it also makes very clear that once the patient sweats the formula must be stopped immediately.

The danger here (one that I have seen happen many times and have even experienced personally) is that the patient over-sweats and suffers damage to their Yang Qi, thus creating a different or more complex condition that now has to be treated.  In a Gui Zhi Tang type situation, over-sweating can lead to a combined Taiyang-Shaoyin condition of external invasion with underlying Yang deficiency (needing a formula such as Gui Zhi Jia Fu Zi Tang).

Strength and Focus

The other side of this is the question of strength and focus. A principle that Heiner Fruehauf often points out is that you must have not only the right formula with the right herbs, but also of sufficient quality and enough of them.

A practice of a lot of TCM-trained herbalists (including those from China and even those who have been in practice since the early days of the PRC) is one of adjusting downward individual herb dosages in formulas for the purposes of safety or according to someones weight. This is especially true for Shang Han Lun formulas, which seem overly aggressive in comparison with modern “gentle” formulas.

TCM herbalists will take a formula like the aforementioned Gui Zhi Tang and begin stripping it of its curative power by ratcheting downward the dosages of the warming herbs Gui Zhi and Sheng Jiang by as much as half, then playing around with the amounts of Da Zao, Bai Shao, and Zhi Gan Cao according to some paradigm known only to themselves. The result is the equivalent of cooking a complex dish in the kitchen while randomly choosing ingredient amounts and never tasting the results. This results in a grossly ineffective formula (I’ll save a critique of the practice of ingredient carpet-bombing for another time).

Native Dosage

An absolute fact in Chinese herbology is that each herb we use behaves differently in both different dosages and different ratios within each formula. Each herb also has what I think of as a “native dosage”, meaning the amount that you are most likely to see it prescribed at effectively. For example, Gui Zhi at 9g, Chai Hu at 24g, Ban Xia at 12g, etc. Going away from these amounts (without very good reason) usually translates into outright failure in my experience. If you need Gui Zhi Tang, you also need Gui Zhi at 9g. If you need Xiao Chai Hu Tang, you need Chai Hu at 24g. Going away from this is a good way to not be successful vs. the condition you are treating.

When you change the dosage of herbs you change the functional emphasis of that herb within its formula. The best example of this principle in my opinion is with Fu Zi. Fu Zi in most TCM clinics-if used at all-is used at a very low dosage, usually in the range of 3-6g. The fear is that because Fu Zi is so “toxic” that more than a small amount will give the patient headaches, nosebleeds, hot flashes, etc.

Paradoxically, Fu Zi in this small amount causes its energy to rush outward to the exterior and to the head, causing the very situation that they were trying to avoid in the first place. However, once the dosage crosses a certain line (around 18g in my experience) its entire behavior changes. Now instead of warming the Yang and sending it rushing outward and upward, it grabs the Yang qi of the body and causes it to descend into storage (the lower Dantian in Qigong parlance) where it is now able to recharge. Rather than feeling hyperactive, patients on the receiving end of recharge formulas like Qian Yang Dan (in which I usually use 30g of Fu Zi) have the overwhelming urge to go to sleep, which is exactly the aim of the formula.

Ratio

Finally, one must account for the ratios of herbs in formulas. In the Shang Han
Lun there is an army of formulas that are essentially Gui Zhi Tang with one ingredient changed in some way. This small shift significantly changes the impact of the formula.

For example, if in the case of Gui Zhi Tang you increase Gui Zhi to 15g you now have the formula Gui Zhi Jia Gui Tang.  Now, instead of treating a case of the common cold, the formula treats the anxiety disorder known as Running Piglet Syndrome. The increased Gui Zhi stokes the Fire of the Heart.  The Heart, in turn, is now able to descend and overcome the amassed cold in the Lower Jiao.  This amassed cold was what the patient’s Yang qi was counterflowing away from –  causing the Running Piglet sensation.  Problem solved.

Another example starting with Gui Zhi Tang.   If we remove Bai Shao altogether we get the formula Gui Zhi Qu Shao Yao Tang, which treats conditions of fullness in the chest and skipping pulse.  These symptoms  point toward Upper Jiao blockage as well as deficiency of the Heart itself. Removal of sour flavored Bai Shao also removes the formulas restraints on the Wood energy of the body (due to Bai Shao’s affinity with Metal and Metal’s husband-wife relationship with Wood).  Wood is now more  able to feed the Fire energy (due to Mother-Son relationship) and release the body’s Earth energy (again, husband-wife relationship) which makes up half the Middle Jiao!

Formula Strength

There is also the question of amount of herbs taken. Zhang Zhong Jing was very clear on the necessary amounts to be taken for all of the formulas in his book, as well as specific preparation instructions. A close inspection of the Shang Han Lun’s preparatory methods reveals formulas that are orders of magnitude more concentrated than their modern descendants, using significantly less water both at the start of decocting as well as the final dose.

In both individual herb dosages as well as the total amount to be taken, these formulas were very much built upon the idea of the right intervention at the right time and in concentrated strength. It’s no good to just try and push a boulder any old way in hopes that it will move. You have to push at the right spot (the fulcrum) and use sufficient force  in order to accomplish the task.

The point here is that as herbalists we absolutely must know what our herbs do inside and out, right down to the effects of differing amounts. This will prevent the useless (and potentially dangerous in the hands of the over-enthusiastic) practice of trying to assign random amounts and percentages to our formula components.

Next week we’ll begin tackling the issue of momentum.



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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