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
The six conformations: an exploratory post
The topic of the Six Conformations is huge. So huge, it’s been a bit intimidating to write about. But, it’s something that we hear a lot about in our Classical Chinese Medicine studies here at NCNM in Portland. So, as most times, see this as the beginning of a long exploration. If you’re here without much knowledge of the Six Conformations I hope that this, and related posts, will help broaden your understanding. If you’re here with lots of knowledge of the Six Conformations, I hope you will share your wisdom with us in the comments.
The Six Conformation system is another on par with the Five Elemental Phases. It is a way to sort the macrocosm and microcosm into manageable chunks that have meaningful relationships with one another. It’s worth mentioning that the Shang Han Lun is based on Six Conformation differentiation. In heaven, they refer to weather patterns - or atmospheric Qi. In the human being, they refer to systems in the body. This is important. When people hear about the Six Conformations, they often think about the channels only - so when I say Taiyin, folks automatically think, “Spleen and Lung channels.” This is erroneous thinking, even though many influential books translate Liu Jing as “Six Channels.” Just as the Five Elemental Phases don’t refer only to organs or layers of the body, but include those; the Six Conformations don’t refer only to channels or even their paired organs, but include those.
Let’s get the nitty gritty details out of the way. What are the Six Conformations?
- Taiyang - 太陽 - Great Yang - associated with the Bladder and Small Intestine organ systems
- Yangming - 陽明 - Yang Brightness - associated with Large Intestine and Stomach organ systems
- Shaoyang - 少陽 - Lesser Yang - associated with the Gallbladder and Triple Burner organ systems
- Taiyin - 太陰 - Great Yin - associated with the Lung and Spleen organ systems
- Shaoyin - 少陰 - Lesser Yin - associated with the Heart and Kidney organ systems
- Jueyin - 厥陰 - Reverting Yin - associated with the Pericardium and Liver organ systems
There’s a lot of layers of information associated with each of these categories. I couldn’t hope to look at all of it in one blog post. Let’s look at the most basic layers.
Climactic factors (for better or for worse)
The Six Conformations are related to Six climactic factors/Qi (Liu Qi). These should be in balance in nature, but when they are out of balance we know them as the Six Evils.
- Taiyang - Cold : associated with water, contracting quality
- Yangming - Dryness : associated with metal, dessicating quality
- Shaoyang - Fire : associated with fire, flaring/ministerial in quality
- Taiyin - Damp : associated with earth, sticky and heavy in quality
- Shaoyin - Heat : associated with fire,
- Jueyin - Wind : associated with wood, wandering in quality
As I said above, people often think Six Conformations = Six Channels. Me, I have the opposite problem — I have it so embedded in my head that the Six Conformations = Six Channels = Six Qi (atmospheric and evil) that sometimes I become a bit confused by it. My understanding so far is simple — when we talk about the Six Conformations out of context (as we are now) the concept includes shades of all these meanings (Qi/climactic factors, Jing/channels, layers of the body, etc) and much more. When we are looking at a Conformation more specifically as in a disease, we can tease out what piece of information is most relevant for us at the time. I hope this is clear. It’s a hard thing to explain.
The order of the conformations and the layers of the body
The specific order I keep using as I list the conformations is not without reason. While there is some discussion about the placement of Yangming, most of my teachers seem to agree on this order.
Taiyang is the most outward of the conformations. It governs the most superficial layers of the body and is associated with the Weiqi or defensive force of the human being. Think of the premiere formulas associated with Taiyang - Gui Zhi Tang and Ma Huang Tang. Both strongly resolve the surface. Yangming is the next layer deep - both in some sense physically and also in terms of how external pathogens must progress in their quest to do harm. It is in the Yangming stage that we get great fevers, this is a storehouse of immense Qi and Blood force in the average person. Think how well this resonates with the Stomach and Large Intestine organ systems, both deep dealers in the most basic, primal functions of life. The last Yang conformation, and thus the last protector against a disease becoming deeply internalized, is Shaoyang. Shaoyang is said to “pivot” (a long discussion) between internal and external, and thus has a kind of oscillating quality.
Now we enter the interior of the body, going ever deeper. Taiyin is the first of the Yin conformations and in some way exemplifies a kind of “doing without doing” — the most active of the passive organ systems. Going a layer deeper we find Shaoyin, the north and south poles of the body - Heart and Kidney, the basic axis of the functioning of the human body. When external pathogens reach this deeply, serious disease is the result. Finally, Jueyin - the deepest, but also the possibility of rebirth into the Taiyang conformations in the classic cyclic manner of Chinese philosophical systems. Jueyin is deeply involved with blood, as can be seen clearly in its encompassing of both Liver and Pericardium.
Pairing of the organ systems : insight into pathology
The more I write about this, the more I find to write. For now, I’ll just mention one quick thing. The conformations can be paired in the following way:
- Taiyang - Shaoyin : BL/SI with KD/HT
- Yangming - Taiyin : ST/LI with SP/LU
- Shaoyang - Jueyin : GB/TB with LR/PC
Anyone can see the wisdom of these pairings - reuniting the five elementally associated organ pairs. We have been taught that these are pairings of mutual support. Taiyang is supported by Shaoyin, and Shaoyin feeds Taiyang. Thus, when you have a disease in one, the other is somehow involved. There are particular ways that we have learned to understand this system of differentiation. But a simple thing to consider is this — take one manifestation of Yangming disease, serious constipation. What happens if one over purges in Yangming disease and why? It’s easy enough to say that overpurging (using cold and bitter materials) will cause damage to the Spleen that can manifest itself in a variety of ways, including as diarrhea. Why is that?
One way to explain it is to consider that Taiyin is the support of Yangming, so that when you overtax Yangming it will draw energy from Taiyin, ultimately depleting it. Of course, there are people who would explain this in a much more nuanced way but when I’ve mentioned it to others they seem to understand. Hopefully it will be helpful to you.
I’ll talk more about how I’m learning about the six conformations in the future. I’ll be interested to read any comments - add your thoughts to the discussion!
Eric
Tags: classical-chinese-medicine, shang-han-lun, six conformations, Theory, Zhang Zhong JingRelated posts
On entering into a philosophical morass: Chinese medicine and Western science
Let’s get something straight. I’m very confused about the role of Western scientific research as it is currently practiced in verifying the claims of practitioners of Chinese medicine. Various studies, including the famous “sham acupuncture” study seem to challenge the premise that the theoretical bases of Chinese medicine are an accurate description of reality and our interactions with it. For instance, concerning the study referenced above, if any old needle through the skin will cure migraines - what of channel theory? What of our highly developed ideas about acupuncture techniques? Similar doubt is cast on Chinese herbalism by placebo controlled double blind studies showing no significant improvement in patient outcomes with the administration of various herbal extracts or even, in some cases, whole herbal formulas. What gives? Why spend all this money to learn a highly nuanced medical system if that system can’t stand on its own two feet? (Yes, I know, there are plenty of studies that verify CM’s efficacy, but that’s beside my specific point here).
I’ve talked in various articles on this site about my basic opinion about the relationship between Western science and Chinese medicine. At my school, NCNM, we talk about these things quite a bit in classes, in the hallways, in subversive meetings around Portland, Oregon. But, to be totally frank, the conversations don’t often delve deeply. This isn’t because we don’t want to go beyond the surface. Sometimes it feels like these concepts are coated with Teflon - the mind so readily slips off. It’s such work just to get through the program, I think most of us just don’t have the mental energy to work through this kind of analysis. Further, most of us weren’t attracted to the medicine because of analytical research indicating that it is effective. To some extent, it’s a gut level reaction. Or you could say that it’s a spiritual attraction - whatever you like.
I find, though, with my dual background in Western philosophy and Western science, I simply can’t let the matter lie. Believe me, I’d rather it be any other way. So, I’m going to attempt to unpack this issue - it’s going to take some time. It’s going to take a lot of reading and a lot of thinking and I’m not even sure what kind of result I can expect. I want to make it abundantly clear that I fully believe that Classical Chinese Medicine *does* stand on its own two feet, that it is deeply rooted in a science that needs no independent verification. I simply want to understand, for myself, what that means. In a sense, for me, this (long) journey will be an intellectual exercise. Perhaps an important one. We’ll see.
In a preliminary way, I can imagine that my exploration is going to have to go over some of the following terrain:
1. What is the nature of Western science as it is currently practiced? Essentially, what assumptions does Western science take for granted and how are they being challenged? My sense is that I’ll have to look pretty deep into the gaping maw of materialism in this part of my journey.
2. How do modern research standards grow out of the above assumptions? How are they independent from them? How have modern research standards evolved and how are they currently evolving?
3. How can the ideas of a non-material essence to the human being come back into acceptance by science? Is that desirable or necessary? What would that mean and what are the philosophical and practical implications?
4. Is there merit to the assertion that the scientific system that grows out of one world view cannot be adequately assessed or criticized by the scientific system that grows out of another? If so - what does this mean for an increasingly globalized world where many different worldviews are forced to interact?
5. What produces the most favorable patient outcomes and how would we measure those outcomes?
I’m going to have to look into a lot of disciplines in which I don’t have much expertise. That’s okay with me. I’ve come to accept that in any endeavor, there’s probably someone who knows more than me. That’s the benefit of this kind of public dialogue - lots of folks can contribute.
I’m interested to hear your thoughts in the comments.
Eric
Tags: Acupuncture, chinese-herb, classical-chinese-medicine, integrative-medicine, philosophy, philosophy of science, Theory, western research, western-scienceRelated posts
Tradition and innovation in Chinese medicine
As I was working on one of my upcoming reviews, MORE books came to review - one of these being the masterful volume on Pulse Diagnosis by Dr. Leon Hammer
In Dr. Hammer’s book, he discusses the Mai Jing
Last night I was in a meeting of a group I am privileged to be part of called the Presidential Ambassador Leadership Society or PALS. It is currently based at NCNM but has a larger vision of being replicated at other natural medicine schools. The purpose of PALS is manyfold, but last night it was most definitely focused on developing our own capacities in various areas of personal development including leadership, vision and most importantly - openness to new ideas. While listening to the talk, I wondered about Chinese medicine and the tension that seems to be there between the need to adhere to tradition and the inevitable human urge to innovate. My school and particularly certain professors in the school tend to privilege tradition over innovation, though several professors are extremely innovative and I consider them to be on the bleeding edge of Chinese medicine development. So this tension, so present at the AAAOM conference, so present in academic journals, so present in online interactions between practitioners is fully displayed in the hallowed halls of NCNM as well.
I am not, by nature, a conservative person. I thrive in an environment of near constant change, particularly internal change. I have always been the first in my peer group and my family to try new things, to reach towards new vistas and to adapt to new technology. In my undergraduate studies in both biology and philosophy and later in my graduate studies in ethics, I sought out new theories and methodologies and looked to the future as the answer to many of our most perplexing questions in the present. But my study of Chinese medicine has changed me a little. In some ways, I see moving back towards the Classics and the Classical way of perceiving the world as the most significant advance we can make today. I find myself EXCEEDINGLY reluctant to adopt new systems of diagnosis and treatment, even if they are purported to be clinically viable.
But these last few weeks have found me discovering a middle ground between the futurism and love of innovation of my past and the canonical conservatism of recent years. For every branch and leaf you see on a tree there is a long root and many rootlets to support it. The tree doesn’t ignore its roots, and there is no favoring of upward growth over deep nourishment from the Earth for a healthy specimen. My roots lie in the Classical texts and in the methods of reasoning and understanding that I can extract from them. But my leaves and branches rise to the sun. I think this is a healthy approach. But I would like to talk more about what it means.
What kind of balance are you striking between adherence to tradition and respect for innovation? Where do your tensions lie?
Eric
Tags: balance, changing-the-world, chinese-medicine, Classical Texts (general), Personal Development, philosophy, professional-development, Theory
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