While researching my next book, I discovered an intriguing case study by Dr. Gao Jianzhong 高建忠, who works at a hospital affiliated to the Shanxi University of Chinese Medicine. The case was published by one of his students, Dr. Feng Wenquan 馮文全, who included some of his own comments. I found these comments to be as captivating as the case itself, revealing much about both historical and contemporary Chinese medicine.
Admittedly, this reflects my personal biases and research perspectives. Nevertheless, I believe they could capture the interest of a broader audience. Therefore, instead of merely translating the original article, I have chosen to re-organize it to highlight these various aspects more distinctly, incorporating my own commentaries alongside those of Feng Wenquan. This method of multi-layered writing has a longstanding tradition in China, which supports my approach.
The case
Ms. Lu, female, 54 years old. Initial consultation on July 5, 2010. Her main complaint was coughing, wheezing, and restricted breathing for over six months, with no improvement from various treatments. Her current symptoms included aversion to wind and cold, coughing upon exposure to wind, and expectoration of white foamy phlegm. Coughing and wheezing worsened between 4:30 and roughly 5.00 am. She refrained from speaking loudly, because she feared this would trigger the cough. She had a dry mouth with desire to drink, she liked cold food, but dared not eat it as this worsened the restricted breathing. She sweated profusely, had a good appetite, and regular bowel movements. Her tongue was dark red with a thin white coating, and her pulse was thin and wiry.
Dr. Gao’s diagnosis was lung cold with phlegm stagnation and retention of wind evil. The treatment method he employed was to warm the lungs, transform phlegm, disperse wind, and stop coughing. To this end, he chose to use Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng) with modifications. The prescription read:
Cinnamomi Ramulus (guì zhī) 9g, Paeoniae Radix alba (bái sháo) 12g, Zingiberis Rhizoma (gān jiāng) 3g, Asari Radix et Rhizoma (xì xīn) 3g, Schisandrae Fructus (wǔ wèi zǐ) 9g, ginger-fried Pinelliae Rhizoma praeparatum (jiāng bàn xià) 9g, Evodiae Fructus (wú zhū yú) 3g, Gypsum fibrosum (shí gāo) 30g, dry-fried Armeniacae Semen (chǎo xìng rén) 12g, Glycyrrhizae Radix (gān cǎo) 3g.
The patient took three prescriptions prepared as a decoction.
After taking the medicine, all of the patient's symptoms disappeared. There was no more coughing or wheezing in the early morning, or any of the restricted breathing. Her sweating was significantly reduced. She reported that in the previous six months, during which she had taken many different types of medication, she had never experienced this kind of relief. She took three more doses of the prescription and then discontinued the treatment.
Dr. Feng’s explanation of Dr. Gao’s reasoning
In his commentary, Dr. Feng highlights three key points crucial to understanding Dr. Gao’s modification of Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng) in this case.
1. Why did Dr. Gao substitute Ephedrae Herba (má huáng) in the original formulas with Armeniacae Semen (xìng rén)?
This is based on the original text of the Treatise on Cold Damage, which states “For wheezing, take out Ephedrae Herba (má huáng) and add Armeniacae Semen (xìng rén) …”. He also quotes a commentary from A Collection of Reflections of Differentiating Materia Medica (Bencao sibian lu 本草思辨錄) of 1904, which states with respect to this substitution: “Ephedrae Herba (má huáng) discharges heart yin fluids above and unblocks kidney qi below. In a Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng) pattern, water below the heart already attracts the water of the kidney organ. If one would allow Ephedrae Herba (má huáng) to further stimulate the kidney qi, it might aggravate the wheezing to a point where it would not stop. Armeniacae Semen (xìng rén) is a lung and not a kidney herb. Hence the substitution. This is what is meant when we say to use Armeniacae Semen (xìng rén) to expand horizontally, while also directly directing downward.”
In Dr. Gao’s opinion, while Ephedrae Herba (má huáng) has indeed the function of relieving wheezing, in the formula Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng) Zingiberis Rhizoma (gān jiāng), Asari Radix et Rhizoma (xì xīn) and Schisandrae Fructus (wǔ wèi zǐ) already stimulate the true qi in the kidneys, so as to warm and transform the cold fluids in the lungs. If one would stimulate kidney qi even further with Ephedrae Herba (má huáng), Dr. Gao would be afraid that the asthma might become uncontrollable.
Furthermore, in this specific case, the patient sweated a lot, rather than presenting with an absence of sweating. In taiyang disorders with sweating one uses Cinnamomi Ramulus (guì zhī) instead of Ephedrae Herba (má huáng). This is another reason for the substitution.
2. The second question is why Dr. Gao added a large dose of Gypsum fibrosum (shí gāo) to a prescription intended to treat cold phlegm in the lungs?
Dr. Feng explains that in his practice, Dr. Gao pays great attention to a patient’s likes and dislikes. often according more value to their own subjective perceptions, than to objective external parameters. In this case, the patient liked cold foods, but was afraid to eat them in case they might aggravate her symptoms.
Although Dr. Feng does not explain this any further, we can assume from the presentation and the resolution of the case, that it was an excess pattern. This implies that the patient’s own yang qi was strong, but hemmed in by the cold phlegm fluids. Hence, the physiological yang transformed into pathological fire in the stomach, manifesting with a good appetite and desire for cold foods.
3. The third question is why Dr. Gao added Evodiae Fructus (wú zhū yú) to the formula?
Dr. Feng explains that the worsening of the patient’s symptoms in the early morning indicated to Dr. Gao that the clear yang was not able to rise, which it should do at that time. As a consequence, turbid yin was not able to descend either, causing the aggravation. Again, he does not provide additional explanations. However, we know from the formula Four-Miracle Pill (sì shén wán), but also from its status as a jueyin medicinal, that Evodiae Fructus (wú zhū yú) can facilitate the clear yang to rise, while also directing the turbid yin downwards; and that it does so specifically with respect to the Liver, or jueyin, which governs the transformation of yin into yang.
Classical formula practice without jingfang rhetoric
One thing I personally like about this case, is that it is a brilliant application of a classical formula in clinical practice, without any of the jingfang rhetoric that is nowadays so often attached to this kind of practice, at least in the West.
In his own commentary, Dr. Feng does cite Cao Yingfu 曹穎甫 from his Record of Experience in the Use of Classical Formulas (Jingfang shiyan lu 經方實驗錄): “I want students of classical formulas to adapt them to clinical practice.” However, Dr. Feng refers to Cao as “one of the great exponents of cold damage therapeutics” (shanghan dajia 傷寒大家), and not as a jingfang practitioner.
Furthermore, Dr. Feng cites Cao Yingfu in order to emphasise the importance of the saying ”medicine turns on discernment” (yizhe yiye 醫者意也), with which he opens his entire case. Discernment (my translation of yi 意), is generally viewed as the capacity of experienced physicians like Dr. Gao, to read symptoms and signs in light of their own knowledge and experience so as to understand how everything hangs together, and then respond to it with a matching prescription or treatment.
The opening lines of the case history are therefore worth to be quoted in full, because, once more, Dr. Feng references one of the heroes of jingfang practice in an unexpected and surprising way.
“The saying medicine turns on discretion, means that a physician must embed his discretion into the herbs of a formula, thereby imbuing them with a distinctive vitality. In doing so, one allows non-sentient herbs to embody luminous human sentience and thereby effectively treat stubborn diseases. Xu Lingtai 徐靈胎 (Dachun 大春), a physician from the Qing Dynasty, said:
‘... the nature of herbs is distinct from that of the human body. How then, having been ingested, might they obtain a desired effect. To this end, the sages stipulated methods for compounding prescriptions …’
It follows that the effectiveness of treating diseases with medicines depends entirely on the doctor's skill in formulating prescriptions.”
Cao Yingfu and Xu Dachun are widely depicted not only by proponents of jingfang practice as representing a turning away from Song dynasty subjectivism, associated with the diagnosis and treatment of putative disease dynamics (bingji 病機), in both China and Japan in the course of the eighteenth century. The ensuing move towards a formula pattern approach of prescribing is associated by historians with the broader cultural evidential scholarship and Han learning movements. Dr. Feng shows that real life people, and real life Chinese medicine, have always been more complex than such historical caricatures. For even as this is a clear case of jingfang practice, it is shot through with Song learning, as well as traces of Neo-confucian, Buddhist, and, dare I say it, traditional Chinese medicine (TCM) terminology and thinking.
Enlightened realisation of vital methods
The prescription used by Dr. Gao in the above case, Modified Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng), stems from the Treatise on Cold Damage. It is therefore a classical formula. The reasoning by means of which Dr. Gao arrived at his modifications, however, stem from his understanding of the patient’s disordered qi dynamic, specifically impediments to the ascending and directing downward of yang qi and body fluids. Explicitly thinking about and working with the qi dynamic was an invention of post-Song medicine. Dr.. Gao’s understanding of the function of Ephedrae Herba (má huáng), meanwhile, is couched in terms of organ functions intelligible to any TCM practitioner.
Also of note is that pulse, tongue or abdominal diagnosis are not key. Instead, Dr. Gao emphasises the importance of inquiring into what a patient does and does not “desire” (yu 欲). In terms explained in several of my recent blogs, I see this as a methodology for forming “one body with the ten-thousand things:” gaining an awareness of another person’s qi process that allows one to effectively intervene in it.
Dr. Feng refers to this awareness as “discernment” with reference to the adage that “medicine turns of discernment.” Although the adage itself is historically much older, its use as referring to a physician’s capacity to adjust classical formulas to presenting cases can be traced back to Zhu Danxi’s 朱丹溪 critique of the Song dynasty’s Imperial Formulary. Danxi is famous, of course, for aligning Chinese medicine with Song dynasty Neo-confucianism, and therefore the very antithesis of a jingfang physician.
Moreover, Dr. Feng clearly rejects the assumption that the effectiveness of Chinese medicine is grounded in the biochemical effects of medicines alone. Quoting Cao Yingfu and Xu Dachun, he is adamant that it is the skill of a physician in composing formulas that is key to how successful a clinical intervention is.
In the concluding sentence of this case history, Dr. Feng refers to his teacher Dr. Gao, as someone embodying the “enlightened realisation of vital methods” (yuanji huofa 圓機活法). This term, too, was popularised by Danxi, who used it to describe Zhang Zhongjing’s ability to translate the teachings of the Inner Canon into practically useful formulas. Both components of this phrase have Buddhist origins.
“Vital methods” (huofa 活法), is a term that entered Chinese medicine from Buddhism via poetry. In Song dynasty poetry, vital methods denoted the flexible use of established methods for composing poems, and in a wider sense the process of personal development that drives creativity, and that ultimately leads one to become a good poet. In medicine, vital methods have very much the same meaning. They refer to a physician’s ability to adjust ancient formulas to clinical cases in the here-and-now, or to create new formulas if necessary.
In Song Buddhism, the term I have translated as “enlightened realisation” 圓機 (yuanji), refers to a person’s capacity to fully realise the Buddha’s teachings, often in a sudden flash of enlightenment. Interestingly, Danxi described his own realisation that each patient requires their own individualised medicine as an enlightenment (wu 悟). The compound term yuanji itself is composed of two ideograms: yuan 圓, a circle, and ji 機, a mechanism or trigger
In a narrow sense, the circle embodies all of the Buddha’s teachings as outlined specifically in the Lotus sutra. In a wider sense, this circle encompasses all phenomena without distinction. It is all-encompassing. Becoming enlightened refers to the realisation that beyond the apparent difference of the myriad phenomena, in reality they exist without duality or distinction. Once one becomes aware of the nature of this circle (triggered in the course of a sudden enlightenment), one can then freely move around the circle, unhindered by the distinctions the human mind habitually creates.
The Buddhist roots of much of Chinese medicine have long been excised from its official histories. Hence, even though the phrase “enlightened realisation of vital methods” is still used in contemporary Chinese medical discourse, I am pretty certain most practitioners do not know much about its origins, nor are they practicing Buddhists. Neither will they be intimately familiar with the ties between Chinese medicine and Neo-confucianism. No more, at least, than any biomedical physician would be with the positivist philosophies that have shaped biomedical thinking. That does not mean, however, that these philosophies do not do their work beyond the surface; or that we might not recover them in order to imagine for ourselves what Chinese medicine is, or what it might be.
For me personally, enlightened realisation of vital methods in Chinese medical practice, embodied by Zhang Zhongjing, Zhu Danxi, and Dr. Gao, denotes the capacity to align what we know about the world with the tools we have to influence it. It requires knowledge (of herbs, formulas, and disease dynamics) and skill (in differential diagnosis, as well as in communicating with patients). It is ultimately grounded, however, in cultivation (xiu 修) and effort (gongfu 功夫) aimed at putting oneself in a position where one can do whatever is necessary for the patient, drawing on all that is contained within the circle/teachings of our tradition.
Note
The original paper was published in the China Newsletter of Chinese Medicine and Pharmacology (Zhongguo zhongyiyao bao 中国中医药报) under the title Enlightened Realisation of Vital methods in Using Classical Formulas (Yuanji huofa yong jingfang 圆机活法用经方) on 25 November 2010. It is available online at https://www.zysj.com.cn/yianxinde/76086.html
Many thanks also to Dan Bensky for comments on an earlier draft.
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