Nigel Dawes practices shiatsu, acupuncture and Kampo herbal medicine in New York City. This is the second part of classicformulas.com’s discussion with him about the use of abdominal diagnosis as it relates to the application of classic formulas.  Nigel maintains a busy clinical practice in New York and teaches Kampo herbal medicine. He translated a major Japanese text on the clinical application of Kampo in modern society and is working on some follow-up material as well. He recently took a not small amount of time to visit with us at classicformulas.com and share his views on learning medicine, fine tuning our palpation skills and navigating between apparently conflictual clinical points of view.

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Q- Generally speaking, dosing for herbs in China tends to be quite a bit higher than the amounts used in Japanese formulas. What are your thoughts on dosing?

I have a few thoughts on this issue:

1. Classical Formulas (Jing Fang) as a “unit”.

We do not generally modify the dose of an herb or herbs within the formula unit. In other words classical formulas are prescribed as they were written in terms of individual herb dosing as well as in terms of proportions within the formula as a whole.

For Example: In Kampo dosing the formula Gui Zhi Fu Ling Wan (Cinnamon & Hoelen Combination) uses 4g of each of the 5 ingredients (Gui Zhi, Fu Ling, Mu Dan Pi, Bai Shao Yao, Tao Ren) per daily dose.

There are several reasons for this practice. In Kampo training we spend intensive amounts of study on the formulas themselves (primarily classical formulas – Jing Fang). Little time is dedicated to individual herb study in the beginning as the primary objective of training is clinical – to arrive at the ability to accurately assess and treat with a corresponding classical formula or formulas. Only after some years of clinical experience do Kampo practitioners advocate the detailed study of individual herbs within the formula unit. This can be summarized in Dr. Otsuka’s often quoted motto:

“30 Years to become a Kampo practitoner. Ten years to learn the formulas. Ten years to learn to modify. Ten years to write a formula.”

This of course stands out in contrast to the training currently offered in most 5-year bachelor programs in China and TCM schools in Europe and the US where students are expected not only to memorize in excess of 400 individual herbs and more than 300 formulas, but also be able to construct a formula for a patient from scratch after only three years (at least in the US) of training – and that is concurrent with acupuncture study to boot! No wonder many of our MSOM grads lack clinical confidence in prescribing when they first graduate!!

The point being that in Kampo, we do not mess with the original formula structure much if at all, either in terms of individual herb doses or with the proportional amounts of each herb within the formula. There are clinical decisions, which may require “dosing up or down” for smaller or larger patients, metabolic issues, digestive sensitivity, climate etc. But in these cases the herb proportions within the formula are always strictly maintained. For example in the above-mentioned formula we could increase all 5 herbs to 6 or even 8 grams per daily dose or reduce them in the same proportions but we would never alter the individual herb doses such that the proportions were changed. Respect for the synergy of the formulation is key in Kampo and always takes precedence over perceived individual herb action.

2. Smaller is better

In kampo as in many Japanese styles of acupuncture there is an unstated belief that “less is more”. In acupuncture that means finer needles, less vigorous manipulation, non-insertion or “contact” needling, and in Kampo the use of both small formulas and small doses has become the “norm.”

Essentially this is a cultural phenomenon and reference to the medical anthropology literature on this issue would shed light on how and why the Japanese culture developed this tendency for minimalism in medicine and indeed throughout the culture as a whole.

However I feel there are other influences at work here– many of them pragmatic. For example the flow of herbal materials into Japan since the 6th century has, until comparatively recently, been sketchy and often unreliable. Many herbs and particularly animal products commonly used in China simply were not available in Japan on any large scale. Some medical historians have pointed to this as one reason for the Japanese preference for small, simple formulations from the Han dynasty as well as for the very infrequent use of animal products or very large, complex formulations in Ming dynasty China and later. Others have also suggested in the case of animal product use that the Japanese heavily Buddhist-inspired sensibility on this issue, strongly influenced this trend. Be that as it may, Kampo’s predilection for small, low dose formulas without exotic or rare ingredients was already well established by the Edo period and remains till today.

3. Potential textual mis-interpretation

Some scholars have suggested (and I am not qualified to have an opinion on this one) that the units of measurement quoted in the Shang Han Lun and other early classical texts are not clearly understood in today’s weights and measurement scales. They may therefore remain open to interpretation.

This does seem very possible to me and may account for quite some variation in interpretation when it comes to dosages. After all, if our post-modern world has taught us anything in historical terms it is that there can be no absolute account of past events (especially from 2000 years ago). The role of subjective analysis may be more useful to us here than any attempt at discerning some “absolute” truth.

4. Quality Control Issues

A final point I would make on this issue is a commercial one (that nonetheless has immediate clinical implications) and has to do with modern quality control standards in the herbal manufacturing industry, which in Japan is entirely controlled by big Pharma.

Whatever our personal stance regarding the activities of the pharmaceutical industry and its products, the fact remains that when it comes to manufacturing and selling prepared herbal formulations (in freeze-dried 5:1 ratio granular extract form in Japan’s case) the large R & D budgets these companies enjoy combined with the very strict quality control requirements of the government regulatory agencies (Ministry of health in Japan) ensure a certifiably high grade product. Herbs are sold and regulated in Japan (and in Taiwan though not currently in China) as “Ethical Drugs” (an FDA category). In other words they are subject to the same rigorous assays, testing and other commercial manufacturing and production standards as pharmaceutical drugs. They are not considered “food” as they are at this point in the US.

The point here with regard to dosing is that any individual herbal product whether a single dose, a package or an entire batch, can claim (and document) the very highest quality in terms of meeting assay requirements of active ingredients present, absence of additives or contaminants, accurate labeling and all the many other aspects that define quality control of herbs.

This cannot be said at this point for the raw herb market as it is extremely hard to determine quality on sight and even harder sometimes to establish the source of the herbal material, it’s cultivation method, harvesting, preparation and so on. We are not trained pharmacists ,let alone botanists – how can we be expected to confirm the medicinal quality of raw herbs we purchase for our patients? Not so the mega pharmaceutical giants who dispatch highly trained specialists to the Hong Kong markets and elsewhere to do their selection and purchasing. Not to mention it is a well-known fact that China reserves its best quality product for the export market.

My final point then is that, though the dosing may be smaller in Japan than elsewhere (sometimes by as much as two thirds), we should take into account the possibility that the quality of the herbs themselves may be far superior and therefore more potent than many of the raw herb prescriptions filled in mainland China and elsewhere.

 

Q- In addition to Otsuka’s system for determining which herbs would be useful for a patient, there are also abdominal diagnosis systems for acupuncture. Leaving those aside for the moment, have you found in your clinical experience that certain abdominal findings from Otsuka’s system that lead you to checking for the effectiveness of certain points?

This is something that, as an acupuncturist also, I have been working on for a while. I should say though that consistent with two things I mentioned earlier, I try in general:

a) not to mix traditions and
b) to approach channel-based (exterior) and substance-based (interior) problems differently– often with different disciplines.

This said, the way I tend to use the Kampo abdominal findings in regard to influencing acupuncture point selection is as follows:

1. I think in point groupings not in terms of individual points (in much the same way as Kampo practice focuses on formulas not individual herbs.)
2. I arrive at those point groupings not by identifying the Zang-Fu pattern suggested by the formula prescription and matching point selection accordingly (the standard TCM approach). But, rather by identifying and reflecting on the functional targets of the formula that I have selected and trying to match a point grouping accordingly.

Example:
Let’s say the formula prescription was Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Combination) based on an abdomen pattern that included both Kyo Kyo Ku Man (Xiong Xie Ku Man 胸脇苦満), Ri Kyu (Li Ji 裏急) and Do Ki (Dong Qi 動悸).

A point formulation that comes to mind in this case would be what is often termed the “8-Gate yangming treatment”. Namely:

Du20, Yintang, Li4, Liv3, Li10, St36

The rationale here is that:

a. Kyo Kyo Ku Man (Hypochondriac obstruction and distress) reflects in Kampo the need for Chai Hu formulas with the function of promoting proper flow of qi and blood through the Liver system (hence the “outer” 4-Gates, Li4 and Liv3)
b. Ri Kyu (Muscular tension or spasm in the abdominal wall, primarily in the m. rectus abdominis) indicates the need for softening (Bai Shao Yao), moistening (Da Zao, Zhi Gan Cao,) warming and circulating (Sheng Jiang, Gui Zhi) through sweet stimulation of the Middle Jiao digestive function (hence the 4 “inner” gates, Li10 (Li11 can be used instead) and St36.
c. Do Ki (Pulsations along the abdominal aorta) indicate the need for settling the Qi downwards, not by cooling or anchoring it (as with minerals) but by warming, softening and relaxing the vessels achieved by Gui Zhi and Da Zao in particular (hence the use of “calming” points such as Du20 and Yintang).

This is one example formula and I could offer many more. But sometimes associations can be literal and related again to the overall function of a particular formulation both of herbs and points. An example of this might be:

Shi Quan Da Bu Tang (Ginseng and Dang Gui Ten Combination – literally: “the ten great tonifying decoction”). Miriam Lee comes to mind when I use this formula with a patient as she very often advocated her so-called “Great Ten Point Combination” comprising:
Li10 (or 11), Lu7, Li4, St36, Sp6 (or Liv3). When considered as a unit, this point combination clearly aims at an overall qi and blood nourishing effect with the use of a Lung point to target the Wei Qi (matching the effect of Huang Qi in the herbal formula which carries the very same name).

This is the kind of thinking I employ when trying to “translate” herbal diagnostic information into my acupuncture practice.

 

Q- What are your thoughts on constitution? Is this something that informs your clinical work and if so, how?

In Kampo practice constitutional analysis forms a major part of the assessment process. It often influences treatment strategies even more powerfully than the presenting signs and symptoms.

Tai Shitsu (Ti Zhi 体質), literally the “root” of the person, is a composite reflection of a person’s behavior, body type, personality, tendency towards disease and response to treatment. I my experience, this is an aspect of diagnosis that is only accurately observed in a patient over time. Learning more about their likes and dislikes, their lifestyle, family, chosen profession, relationships as well as palpating their pulse and abdomen on a regular basis and carefully observing their responses to treatment (both immediate and long term) gradually allow the clinician to come to a better understanding of what we might call “constitution.”

In Kampo, this is usually expressed in terms of an over-arching Kyo (Xu 虚) or Jitsu (Shi 實) type with a “moderate” constitutional type in the middle. Formulas are always referred to in the literature as being “for the strong, weak or moderate constitution.” Check for example: Commonly Used Chinese Herbal Formulas, Hong Yen Hsu, Publ. Oriental healing Arts and you will easily find this type of referencing (he studied in Japan with Dr. Otsuka and was himself heavily influenced by the Kampo system).

“Qi”, “Blood” or “Fluid” types are considered constitutional subcategories, each with their own tell-tale signs and qualities.
Furthermore, there are two specific sub-divisions of constitutional typing which include:

a. Hie Sho (leng zhi zheng 冷え症) – those people who by nature are ALWAYS cold even in the absence of any yang-damaging cold pathogen. In the vernacular we might refer to these types as having “poor circulation” and of course endocrine issues (such as hypothyroidism) can be a factor here.
b. I Cho Kyo Jyaku (wei chang xu ruo 胃腸虚弱) – those people who are known to suffer from especially weak gastrointestinal functioning. Possibly caused by traumatic damage to the gut – viruses, parasites, eating disorders, poor in-utero nutrition, immune or allergic tendencies etc.

This is a fascinating area of practice for me and I cannot elaborate here in any meaningful way without a lot more space. Suffice to say that this way of thinking clinically influences just about every choice I make in treatment approaches to any given condition. Conversely, neglecting to take into account the constitutional aspect of the presentation as a whole has often led me into difficulty especially when it comes to herbal prescribing.

Take myself for example. I discovered early on that, even when I may enter the taiyang stage and at its worst I may have horrible muscle and joint aches, chills and fever, a cracking headache and a tight, floating pulse, though I may feel the need to simply “sweat it out” I simply cannot tolerate Mahuang Tang. I usually get stomach cramps, nausea, palpitations, jitteriness and my mouth feels as dry as leather. If it’s early stage taiyang I can usually get away with a dose or two of Ge Gen Tang but the formula of choice for colds and flu for me in the taiyang stage is Gui Zhi Tang or modifications of it.

Simply put Mahuang is way too drying for my already dry body type and way too stimulating for my qi-type constitution. Without the mitigating influence of something like Ge Gen I cannot tolerate its effect on my gut and my nervous system. I could give countless examples from my practice of this need to consider constitution as part of the overall diagnostic picture where many times dosing has to be altered accordingly, or more commonly another formula is used.

This speaks to the strong belief within the modern Koho-Ha (Classical) school of Kampo, which Dr. Otsuka championed, namely that the patient’s healing response must not be too violent or uncomfortable. Such an approach interestingly is in direct opposition to that of some other notable Kampo physicians amongst whom Todo Yoshimazu 吉益東洞(1702-1773) stands out in particular. He advocated his theory of Manbyo ichidoku setsu 万病一毒説 literally: “All disease is caused by a single toxin” referring to the idea that all treatment needs to start with identifying and eliminating at all cost the disease-causing entity within the system. This required using harsh purgatives, diaphoretics and other draining treatments that often induced a strong Men gen (眄)瞑 眩 or “Healing Crisis.” Todo considered this a “requirement” of the treatment process whilst Dr. Otsuka claimed such cathartic reactions constituted “improper treatment.” Interesting differences of opinion even in this case within the same current of Japanese Kampo!

 

Q- What advice would you have for our readers who would like to learn more about how to use abdominal diagnosis in their clinical work? Obviously, taking some of your workshops would be a good idea, but what else can they do to start cultivating these skills?

The usual anecdote applies: “you can’t learn practical skills from a book.” Not to mention in the case of abdominal diagnosis in the Kampo tradition we simply don’t have much available in English on this subject. Dr. Otsuka’s 1956 text, recently published in English by Churchill Livingstone in 2010, is perhaps an exception though the abdomen section is rather small. I am currently at work on a comprehensive text on this topic but it probably won’t be out for a while……!

Best thing to do is get to a seminar wherever you can, or at least get hold of a copy of Miki Shima’s video on this topic – which is not bad and shows a very similar system of palpation to Dr. Otsuka’s.

In the final analysis, please feel free to contact me personally and for practitioners in the NY area you are always welcome to come and shadow in my office. I also offer internships in my office by invitation.

My personal hope is that this kind of invaluable work will gradually gain favor with practically-minded clinicians and there will be a future generation of teachers and practitioners using abdominal diagnosis for the prescription of herbs. It will just take a little time.

 

This is the second part of an interview with Arnaud. Here we discuss the connections between “illness, pulse, presentation and treatment”,  more on the use of abdominal palpation, constitution, and the importance of matching presentation with prescription.
For those of you who live in the American midwest, beginning in February of 2011 there will be a special opportunity to study with Arnaud as he will bring his 10 month course of study to Chicago. This course, which is open to both practitioners and students of Chinese medicine, involves one weekend a month of classes. More information is available at the Institute of Classics in East Asian Medicine.

In your clinical reasoning, how do you synthesis the pulse, abdominal signs and patient’s main complaint?

The Shanghan Lun chapter headings are almost a mathematical code for our clinical work flow: disease, pulse, signs, and treatment (bing mai zheng zhi 病脈證治). One first establishes with which disease (病 bing) conformation one is treating. For example, if a patient is suffering from body aches and a floating pulse, then the disease is established as being a Taiyang disease.

But that information alone is not sufficient to treat with herbs since Taiyang disease has many expressions and treatments. As such one needs to look at the second and actually most decisive piece of evidence; the pulse (脈 mai). So for example, when the pulse is also soft or moderate (緩 huan), then one knows that the patient is suffering from Taiyang disease plus Wind Strike (中風 zhong feng). Here the outcome of the Taiyang disease of the Wind Strike persuasion is the treatment (治 zhi) with Cinnamon Twig Decoction (guì zhï täng).

Lastly, Zhang Zhongjing instructs us to reference the finding of Cinnamon Twig Decoction (guì zhï täng) with the primary symptoms (證 zheng) alleged to be treatable with Cinnamon Twig Decoction (guì zhï täng), for example stiff neck, aversion to wind, mild sweating, etc. This is done for two reasons. One, if one or more of these signs are present, then our therapy with the chosen formula has been confirmed. And two, investigating the accompanying symptoms will qualify and focus the treatment to be more comprehensive and appropriate. If for example a Cinnamon Twig Decoction (guì zhï täng) patient also displays signs of panting and chest fullness, then according to Zhang Zhongjing one needs to add Magnoliae officinalis Cortex (hòu pò) and Armeniacae Semen (xìng rén) to form the modification formula Cinnamon Twig Decoction plus Magnolia Bark and Apricot Kernels (guì zhï jiä hoù pò xìng zî täng). Undoubtedly, Cinnamon Twig Decoction can treat an asthma patient’s wind strike common cold, but Cinnamon Twig Decoction plus Magnolia Bark and Apricot Kernels will also address their tendency for asthmatic breathing, thus making the treatment more personalized and comprehensive. As such, the workflow is: disease (病 bing) plus pulse (脈 mai), qualified by signs and symptoms (證 zheng), equals treatment (治 zhi) with a formula (方 fang) and possible original modification.

If you wish to add abdominal diagnosis into this equation, then these findings would also be a part of the signs and symptoms (證 zheng) that will confirm or further inform the initially obtained treatment strategy. For example, the abdominal findings of tension and mild pulling in the erectus abdominis, or the present of mild abdominal fullness, might confirm either the basic presentation for Cinnamon Twig Decoction (guì zhï täng), or its modification with Magnoliae officinalis Cortex (hòu pò).
Many practitioners in the West think of the Shanghan Lun being used specifically for the treatment of acute illness. Recently, in Taiwan I came across a book from Japan that was very specific in the use of the classic formulas to treat chronic illness. They usually broke it into a three-stage process. First, treat the presentation; second, as the condition changes and the pathogen begins to move, treat what the presentation has changed into. Finally (usually) some kind of tonifying formula is used. What are your thoughts on this?

I do not believe that the Shanghan and the Jingui should be regarded as separate entities, the same way my left and my right legs are both mine. Shanghan or “damage by cold” is the old Han dynasty name for what we would now call “external contraction” (外感 waigan). As such, formulas of the Shanghan Lun can treat all illnesses that are caused by an external atmospheric or climacteric influence with which the body’s protective qi could not keep a balance. It does not matter whether this illness is still in its acute phase of less than 12 days or whether this illness has now become “stuck” in one conformation or more. The formulas of the Shanghan Lun re-balance the physiology of the body’s primary six functions, as they are abstractly represented by the six conformations.

When an illness does not originate from a purely climacteric condition with which the body could not maintain balance, and thus comes from a purely internal emotional cause that disrupted the function of its related organ from within; or a disease caused by a non-external/non-internal cause such as trauma, food poisoning, childbirth, etc, then the treatment will be recorded in the Jingui Yaolue. As such, when both books are studied together, the practitioner can treat any illness possible.

As for the example you bring up, I do generally agree with the workflow suggested. The exterior presentation of the illness is always conditioned by the internal environment of the patient. If a patient has Shaoyin yang deficiency, then that patient is very likely to experience Taiyang cold aversion. When a patient has Jueyin blood deficiency internally, then such a patient is prone to Shaoyang patterns when invaded by wind cold. The beauty of Zhang Zhongjing’s system is that this is already taken into account per the formulas. We do not need to second-guess this. And as such, indeed one has to treat the exterior presentation when an acute illness strikes and follow-up by stabilizing and rectifying the internal insufficiency or imbalance once the exterior condition has effectively been resolved.
What are your thoughts about constitution and the treatment of illness?

I think people have differing views on constitution. I do not regard constitution as something pre-natal, or genetic, simply because if that were to be the Chinese medicine concept of “constitution”, then I would have no way of ever making a difference at that level.

In my view, constitution is the interior condition of the solid organs, which store and supply the essential building blocks for life. In other, more Shanghan Lun friendly terms the constitution of a patient refers to the condition of the yin conformations. As I mentioned before, when a patient contracts an acute illness, the clinical manifestation will be conditioned by the interior state of these conformations. For example, patients with a weak Taiyin conformation and a tendency towards having abdominal fullness, looser stools, low appetite, and such, will upon exterior contraction of a Taiyang disease more often present with a Minor Bluegreen Dragon Decoction (xiâo qïng lóng täng) pattern, rather than for example a Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction (má xìng shí gän täng) pattern. This is because of their lack of yang in the Earth domain and the presence of damp under the Heart. Thus, resulting in a wet productive cough, rather than the dry panting state of Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction (má xìng shí gän täng) patterns. This goes for every conformation, and every formula. The Tian lineage of Shanghan Lun to which I belong has a very clear system of recognizing interior-exterior relationships between patterns and formulas, and it is something we use constantly in clinic.
Is there anything else you would like to share with our readers?

The study and practice along the classical tenets of the Shanghan Lun and Jingui Yaoyue is more difficult in the beginning stages than the regular institutionalized TCM approach, but in the long run everything is a lot easier and there will be nothing that you cannot comprehend and therefore treat. Just work hard and persevere and results will be guaranteed. Focus on the classics!