The Art of Palpating the Abdomen for the Purpose of Prescribing Chinese herbal formulas
This is a guest post from recent National College of Natural Medicine (NCNM) graduate, Kumiko Shirai. She is a fine herbalist already and obviously has an expertise in the (almost) lost art of abdominal diagnosis. I have seen this work in action and can attest to its amazing effectiveness! Please enjoy the article. There are more guest articles to come! -Eric
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Japanese abdominal diagnosis, known as fukushin 腹診 is an art form of medical practice that is virtually lost in modern practice of Chinese medicine. There are two major schools and types of abdominal diagnosis, Nanjing and Shanghan Lun schools, which separates into the Japanese schools of acupuncture and the schools of herbalism respectively. There are many modern books written on acupuncture style of abdominal diagnosis, which is also referred to as hara diagnosis, however books written on herbal prescription style of fukushin are difficult to find.
In the studies of Japanese style of herbal prescriptions, kampo, 漢方 which is mostly based on Han Dynasty formulas from the classical texts of the Shanghan Lun and the Jingui Yaolue, one can find many abdominal patterns and findings for almost every formula. It appears, though it is not certain, that Zhang Zhongjing used abdominal palpation as part of his diagnostic tools. And there are many Japanese scholars who have elaborated and perfected their practices of fukushin for the purpose of herbal prescriptions based on Zhang Zhongjing’s classical texts.
The concept and significance of the abdomen are different in Japan from what exists in Western cultures. It was not too long ago that Japanese people commonly said, “I am going to go see a doctor to get my abdomen examined.” In Japanese culture, the abdomen or hara is central. Alternatively, the nervous system and mind seem to be central in Western cultures. But, when we think about it, the Japanese idea makes a lot of sense. The abdomen is physically a central part of the body, containing many of the vital organs. Japanese people also believe that hara is the seat of the soul, where self-consciousness is anchored. On the other hand, from pathological sense, the abdomen is where people hold emotional stress, affecting their digestive problems as well as other physical discomforts. For this reason, in Japanese medicine, the hara becomes a pivotal part of the body during the examination, diagnosis, and treatment.
In fukushin, abdominal patterns are named after herbal formulas such as “Xiao Chaihu Tang pattern” or “sho” in Japanese, which already gives a diagnosis and a treatment plan. On the other hand, in the Nanjing school of abdominal diagnosis, abdominal patterns are named after theoretical diagnostic concepts such as “Liver qi overacting on Spleen”. The difference between Nanjing style of theoretical approach versus Shanghang Lun style of clinical approach is interesting in that it shifted the clinical practice of kampo in Japanese medical history. One of the most influential Japanese scholars, Todo Yoshimasu (1702-1773), emphasized mastering clinical skills rather than understanding theories. He claimed that “proof is always more convincing than logic,” accentuating the importance of the practice of palpation, and to treat what is obvious by carefully examining the abdomen. For this reason, Todo inspired many practitioners to practice palpation during the examination. However, Japanese scholars did not ignore fundamental theories of Chinese medicine completely, and fukushin is still very much based on theory as well.
In order to give an herbal formula based on abdominal diagnosis, one must understand the architecture of the formulas first. There are eight therapeutic methods in the study of herbal prescriptions, however, it is important to break up each method into further smaller groups, understanding the function of the pivotal herb or herbs in each formula. The key herb in a formula may not always be the emperor of the formula, though often times it is. For example, in the purging method, there can be different causes for accumulation in the middle burner hence requiring different approaches and treatment plans. While Dahuang (in Da Chengqi Tang) treats fullness caused by middle burner accumulation due to qi stagnation causing heat, Mangxiao (in Tiaowei Chengqi Tang) treats accumulation of the middle burner due to dryness of the intestines, and Taoren and Mudanpi (in Dahuang Mudanpi Tang) treat fullness by breaking up blood stasis, hence moving both qi and blood. As a consequence, these three formulas, which share a common category of method, will have different abdominal patterns and imply different treatment plans.
In closing, I want to emphasize that examining a person’s center is not only theoretically appropriate but also clinically helpful in the process of assessment, diagnosis and finally planning a treatment. Hence, Chinese medicine practitioners, are encouraged to cherish the art form of practicing this medicine by observing and touching each patient and interpreting such information as holographic representation of the body.
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Tags: abdominal diagnosis, asian medicine, clinic, Diagnosis, formulas, japanese medicine, patterns, schools, shang-han-lun, study, TheoryRelated posts
The nuts and bolts of the Chinese medicine awareness experiement
In two articles, Abdallah and I have begun to lay out the foundations for a project that is, in some ways, the extension of the Year of Sagely Living. There hasn’t been much discussion generated around those two articles. There are two possible reasons for this and they both come down to our failure to express the essence of the project appropriately. I will offer two articles - one today and one tomorrow - that attempt to explain the project clearly and also highlight its importance.
First, here, I’d like to just lay out in very clear prose what it is we are proposing and, briefly, why.
Record of a journey
Blogging is, at its best, the record of some person’s (or people’s) particular way through life. Even when the blog isn’t personal, it represents a particular take on some particular aspect of the experience of living. Deepest Health has always been mostly about exploring Classical Chinese medicine from the perspective of one student, myself. In this journey, I’ve revealed my own struggles and a-ha moments. I’ve also attempted to share the knowledge I’ve gained in my schooling in an effort to make good information about Chinese medicine more available. As I grow and change, so does the blog.
I’ve walked across a threshold in my study - the threshold from theory to practice. In doing so, I’ve learned deeply the importance of rock-solid theory. More than that, I’ve learned about the inseperability of theory and practice. They inform and shape one another. One of the places where theory and practice interpenetrate for me is in the realm of Chinese medical symbolism. What I’ve learned about the symbols of Chinese medicine from a few professors, most overtly Heiner Fruehauf, is the way that Chinese medicine is actually built on a system of symbols and a method of symbolic perception and thinking that is at least somewhat alien to contemporary Western consciousness. I’ve tried to make that way of thinking and perceiving less alien for myself and, through my blog, for you.
In clinic, I don’t think that much about the Chinese medicine organ clock. But, I do think a lot about symbols. I think about the symbolism of the pulse. About how to read it, how to match it up with patient experience. I think about how the pulses are written about in Classical texts and the deep symbolic meaning present in every character. I think about the symbol of the human face, a microcosmic representation of the whole body. I consider the symbolic diagnostic methods of Worsley style five element acupuncture. I wonder about the concise descriptions of symptoms patterns in the Shang Han Lun, and begin to understand the deep symbolic nature of the characters that make up those descriptions. I see how all of my professors seek to understand this way of thinking, seek to incorporate it into their practice, despite how they feel about more overt conversations about the subject.
There is no class that can teach me how to think symbolically. There is no seminar that can rearrange your mind so you think less analytically and more holistically. There is only lived experience. There is only gentle but persistent effort. Nature and patients as teachers.
Wait, didn’t I say this was going to be clear?
Yes, yes yes… To provide a “why” for the rambling “what” above, please accept the following. I believe that by teaching myself to think symbolically, to deeply perceive the infinite richness of patients and nature and the world at large, I will gain information that will make me a better clinician. There are lots of ways to teach myself these skills. There are lots of layers to be unfolded. The project that Abdallah and I are proposing is simply to record our journey to gain this particular way of thinking and perceiving. Just as everything it will grow and change, but here are the essential elements:
So what is this going to look like?
Records of our efforts in the form of text articles : This is more of the same as far as Deepest Health is concerned. You can expect frequent reports on how our efforts are progressing. Sometimes this will come in the form of an article about a formula or an herb, something like you’ve seen here before. But, it will attempt to go deeper by incorporating multi-sensory lived experience. Sometimes it might be a new type of article that reports back on a specific experience along the lines of what I’ve described above. For instance, if one week I find myself especially attracted to understanding the Chinese medicine concept of fire, I might write an article about all of my multifaceted research on the subject. This could incorporate lines and interpretation of those lines from various Classical texts. It could incorporate my own musings about patients and myself as related to fire. It might posit connections between lines in the Classical texts, formulas that I have recently prescribed and some aspect of popular culture that makes clear some important relationship. It could involve a series of photographs around Portland as well as a recording of some firedancers on a mountaintop. Which brings me to the next point…
Multimedia integration : What we are proposing is that only by laying open ALL of our senses are we able to really understand the wisdom of the ancients. How many of us really understand the five odors and colors used in diagnosis? How many of us really understand the five flavors of herbs? This understanding is important to have on an intellectual level, of course, and textual analysis is important for that. But equally important is our lived experience of these things. Now, while we would be hard pressed to offer scents and flavors on the Internet, we can certainly talk about scents and flavors. But, what will really set this project, and ultimately this blog, apart is the inclusion of audio and visual content to help illustrate concepts.
I have been experimenting with audio and have been very impressed with the medium. I recently purchased some new equipment that will help me deliver higher quality audio to Deepest Health readers/listeners. I would love to continue to offer record of conversations, as well as music and soundscapes that illustrate particular points. Imagine the impact of not only reading an article about Shaoyang fire, but hearing audio that is evocative of this primal force and seeing photographs and drawings that seek to explore the concept further! We will offer audio as well as pictures, artwork and video. Some of it will be strictly in service of elucidating particular concepts, but also just to continue to enrich the site’s content - as with interviews, video of my talking head, and so on.
Some of what we put forward may be pure folly! You may watch a particular video, hear an audio, or read an article and think : By jove, they’ve gone off the deep end! And that’s when audience participation comes in. We want lively conversation! We want response! Further, as we explore the project you may find that you hear, see, smell and feel things that go along with (or contradict) what we are putting forward. We’ll post it! Put it forward! Let us create a living database of information that goes beyond the simple recounting of TCM textbooks. The future of Chinese medicine on the Internet, no less! :) But, it is important to note that for me, the Classical texts are the ground from which all I think about springs and ultimately it is what I want to keep connected to at all times. I believe this will help us from going too far afield, proposing theories and ideas that are radically disconnected from the thousands of years of clinical experience that we are fortunate to have access to as students and practitioners.
I hope this helps explain what we’re after. More to come.
Tags: Blogging, content, internet, multimedia, nature, patterns, study, symbolism, The Project, Theory, video, Year of Sagely LivingRelated posts
Entering the Flow
Whither Sagely Living?
Across a divide of space spanning a continent, a partnership in exploration has opened whose wellsprings lie removed further still across a span of centuries and oceans. I am speaking, of course, of this latest project that Eric and I have conceived in the course of our conversations over the last few months and weeks. If this is the new development of the Year of Sagely Living, then I count that undertaking a success. I perceive a greater alignment with the operating principles of that concept becoming active in our new pursuit. Or, rather, we have awakened to its possibilities, and take seriously the precepts of the Classical view we hold dear. Above all we are entering a flow. Let me explain.
A Story
I’ve been inspired almost as much by the College of Mythic Cartography as I have been entranced by Deepest Health. Willem Larsen, who is the genius behind CoMC, and is another resident of Cascadia, articulates what he terms “invisible technologies” that underlie his practice of rewilding: that is, decolonizing the mind from the non-indigenous. Another way to put this, is that he recognizes that some of the most important aspects of indigenous cultures, critical components of any definition of sustainability, lie in the cultivation of relationships based on mutual trust and support, and in story as an expression of those relationships to one’s land-base and greater family. He writes eloquently, and if I may borrow a phrase, appears to “live deliberately,” or as I am wont to say, with rigor. His explication of associative reasoning, and t
he role of riddles and story in enlivening knowledge struck me as deeply resonant with the conversations that Eric and I have shared, and with my entire orientation to practicing Chinese medicine.
Further back it correlates with what I’ve learned through many years of association with Leon Hammer. I read his first book, Dragon Rises, Red Bird Flies
The next insight, a thrill, to be honest, a thrumming indication of things to come, came at an interesting time. After years of practice I had decided to pursue further training in medical school, with the intention of seeking a psychiatric residency. The Baker Act places an acupuncturist in a unique bind. I’ve had patients whom I knew required 24-hour evaluation and supervision -in crisis- but was faced with the certainty that appropriate herbal medicine and acupuncture could resolve the condition more rapidly and with less trauma to the patient. So I conceived of enrollment in medical school as a means of surmounting institutional barriers. I enrolled in courses to prepare for the MCAT, and contemplated at length the options, when suddenly, in an intensely liberating flash of realization, I abandoned the plan resolutely. I felt renewed. I felt like I had been handed $200, 000 in cash and been given a reprieve that granted me 15 years of my life back. I went from being amongst the oldest of potential med students to being again among the youngest teachers in the Chinese Medicine field. Above all, I realized that the plan amounted to a digression that was perhaps the world’s greatest attempt at procrastination. In other words, my work had already begun and there was more to do.
Literally the first thing I did was sign up for the Associates program at Heiner Fruehauf’s site. And then it happened. The article and videos related to Wang Fengyi, the late nineteenth and early twentieth-century founder of a unique lineage of storytelling healers curing with their stories, chants and humble, ethical behavior gave me back the feeling that had enlivened me in Leon’s book, and in every subsequent, often wordless, intimation of the realities laid out before me. It also unleashed a period of intense creativity that led to new insights into everything from the underlying structures of Dr. John Shen’s herbal formulas, to aspects of Dr. Hammer’s methodology and model, and even provided the impetus for the Year of Sagely Living. I discovered Rewilding not long after that.
Rewilding is ultimately predicated on awareness, just like the others practices that inform my life. As a Muslim, I cannot endorse the animist beliefs, and according to some this would indicate that I do not understand the movement. Where awareness is the focus I am fully in accord. I would even argue that awareness is the crux of the critique of modern civilization.
Through a Dark Wood
So this is where our project unfolds: from these disparate elements, we intend to construct an experiment in awareness. Not in terms of normative practices, but in terms of opening ourselves to the symbolic fields articulated by Chinese medicine, and with a commitment to document our findings and chart our exploration. We are saying, “Yes! And…” to the implications a symbolism rooted in antiquity, as a method for creating new symbolic content that is appropriate to the times and places where we are. It is not enough to rehearse old mythologies. That is not to disparage the Classics in any way. Rather, it follows Basho’s admonition to seek what the master’s sought. Where else are these patterns to be articulated if not in our lives?
Another very significant element is our engagement with the concept together. We hypothesize that by allowing the conversation to publicly unfold, much as it has in private, and also to avoid setting arbitrary limits upon it, we will create a free-wheeling and unfettered mode of expression about Chinese medicine. I am the control group in this particular experiment; because like all-too-many clinicians I am not as steeped in the Han Dynasty symbolism that informs the pristine logic of NCNM’s program. And this with having studied Classical Chinese at UC Berkeley! And my estimation is that the conversation will enrich us. After all, dialogue is the form that the Classics assume, both in structure, and in the rich legacy of commentaries that exist. In fact, I’ve dubbed it: Han Dynasty 2.0.
Improvisational Classical Scholarship
This is also not to suggest a mere modernization or even urbanization of an alien cosmology. Every patient encounter is an opportunity to approach the unknown. What mysteries are in each of us? What stories? Riddles? In the meeting of microcosm and macrocosm, there is a grain of sand. If there’s a universe in a grain of sand, then what of the pearl produced by its slow gestation?
As Eric quoted earlier: “it’s a way of effortlessly being with awareness and allowing Chinese philosophical and medical concepts to shape the perspective.”
Sapere Aude
How can this become a practice that is effortless and yet produces insights that will carry over into our clinical work? It is quite simple. In my estimation, the most integral question is a simple one: why? But that does not obviate the need for us to likewise attend to the what’s of our experience. In other words, our answers will be as good as our questions. Everything has its voice, and it may speak to us in a way that we can understand. One way that I describe pulse diagnosis is as a way of listening to the ever-communicating body. So, we will take the rich world of symbolism and metaphor that we’ve inherited from Chinese medicine, and simply frame our questions according to what we want to investigate. In the process we will learn to apply this method to anything that strikes us, and also begin to see the webs of meaning that inhere in the very messages that are being communicated in multivalent means by the body. And we can use all of our senses to seek our answers, and in so doing we will begin to inhabit our bodies and experience our lives in wholly new ways.
Abdallah
Tags: abdallah stickley, classical-chinese-medicine, commitment, content, creativity, Cultivation, heiner fruehauf, imagination, patterns, scholar, symbolism, The Project, visionRelated posts
Using the imagination in Classical Chinese medicine
The importance of the role of pattern differentiation in Chinese medicine cannot be overstated. Some go so far as to say that Classical Chinese Medicine is “pattern medicine.” What on Earth can that mean? I think about it in a few ways. First, Chinese medicine takes patterns very seriously. I don’t think most Chinese medicine physicians have theoretical discussions about what constitutes causality. Nor do they seem to be interested in carrying out complex calculations about the distribution of particular disease states across space or time. Despite this apparent failure, Chinese medicine practitioners through history have been interested in the correlation between disease states and other features of the human environment. They have taken a keen interest in the rise and fall of particular conditions in particular places at particular times. Second, a strong feature of our medicine is the perception of subtle patterns in a seemingly hopelessly complex tangle of symptoms and subjective feelings. Where other medical systems throw out the pieces that don’t fit, good Chinese medicine practitioners are always mindful of the “stray” symptoms. They always seem to come into play at some point. Finally, Chinese medicine relies on patterning to allow relatively quick training of practitioners. This can go too far, as it has in many iterations of contemporary Chinese medicine.
Taking all of this into consideration, I find the idea of patterns to be an interesting one. Recently in a class about pharmacology, we began to discuss the role of the imagination in medicine. All human beings have imagination - though some of us are more skilled in using ours than others seem to be. Our professor began to get us thinking about imagination as being especially useful in becoming aware of patterns. How does that make sense to me? Well, let’s look briefly into the meaning of “imagination”:
imagination |iˌmajəˈnā sh ən|
the faculty or action of forming new ideas, or images or concepts of external objects not present to the senses
ORIGIN Middle English : via Old French from Latin imaginatio(n-), from the verb imaginari ‘picture to oneself,’ from imago, imagin- ‘image.’
Taking this definition at face value, what my professor was saying makes lots of sense. The pattern is not present to the senses. Which is to say that I cannot point to anything that is, for instance, “Yang Ming disease.” I do take in a large amount of data (pulse, tongue, color, sound, odor, presenting emotion, symptoms, lab results, subtle information heretofore undefined) through my various senses, but this thing Yang Ming disease is never taken in. It is a concept, an organizing concept. In some real sense, Yang Ming disease is not there. It is an unbelievably useful structure that I can use to order the data I am taking in and craft a treatment that is a response to the disease state being presented by my patient. My ability to grasp this imaginative construct is crucial in my efficacy.
We can take this further, though I get a little weak in the knees as I depart from that relatively solid conceptual ground. We can use structures like Yang Ming disease in a way that is imaginative, or we can turn them into prisons from which no healing can escape. Let’s take Yang Ming disease as an example. The defining line of Yang Ming disease in the Shang Han Lun states:
In Yang Ming disease, the Stomach family is full.
Boy, talk about a range of possible interpretations. We can look deeply into the characters, we can look at all instances in the history of Chinese medical texts of those characters, we can look at all the Yang Ming formulas and see how they treat this “fullness” of the “Stomach family,” we can do many things in order to understand the statement. But, if we don’t let our imagination run free, our efforts may never bear fruit. Once we have obtained all of that data as I listed above, we must let our minds explore. What would the Stomach family being full do in terms of psycho-emotional disturbance? What images come to mind when we consider the Stomach family being full? What is our subjective experience of this disease state?
I believe this kind of activity, while perhaps not good material for scholarly publication, is crucial to my development as a Chinese medicine practitioner. It helps me to understand the formulas and point protocols more fully, not to mention nourishing me deeply as a human being. I also believe that the use of imaginative faculties is, at least in part, behind the brilliance of ancient Chinese medical theory.
I’m interested in hearing how others think about this issue. It’s a small thing, perhaps, but interesting to consider.
Eric
Tags: imagination, Learning, patternsRelated posts
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