A Manual of Classic Formulas for Primary Care
A review of a newly translated Chinese medical book
While the book reviewed below is very much a practitioner’s manual, I’ve done my best to write a review that’s accessible and informative for the general reader or the Chinese Medicine-curious. I hope it’ll serve to open some eyes to the clinical power of this ancient medicine, as well as calling attention to a great new book. -JE
Whether you call it TCM (Traditional Chinese Medicine), CCM (Classical Chinese Medicine) or TEAM (Traditional East Asian Medicine), most people here in the States think of it under the umbrella of yet another acronym: CAM (complementary and alternative medicine).
One can’t help but wonder whether this branding wasn’t a canny move on the part of pharmaceutical companies and other healthcare profiteers to keep potential “alternative” competitors out of the mainstream, by definition.
In any case, Chinese Medicine (as I’ll call it here for simplicity) is fully capable of functioning in a primary care capacity1, and it’s heartening to see a new translation of the work of Dr. Huang Huang (黃 煌) underscoring this capacity.
Expertly translated by Daniel Eng, Eran Even and Craig Mitchell and published by Eastland Press, A Manual of Classic Formulas for Primary Care continues Huang’s longstanding work with jing fang (classical formulas), a term that is “shorthand for formulas from the classics [i.e. ancient medical texts], or for experiential formulas that have been passed down from generation to generation.”2 In a field with a written record extending back more than two millennia, a classical focus can also simply be taken to mean an emphasis on the oldest extant texts and their approach, in particular Zhang Zhongjing’s seminal herbal manual, the Shanghan Zabing Lun (Discussion of Cold Damage and Miscellaneous Diseases).3
Huang Huang’s work has long focused on these Shang Han Lun formulas by Zhang Zhongjing, but with a twist. Drawing in part on the classically-based Japanese Kampo herbal tradition, Huang has developed ideas about constitutional type (tǐ zhì 體質) and elucidated the relationships between families of herbal formulas and the types of patients for whom these formula families are appropriate.
For instance, to start with a canonical example, formulas based on the herb guizhi (cinnamon twig) are mainly suitable for those Huang has helped delineate as the guizhi constitution, otherwise known as the delicate bookworm. In other words, these people—thin, chilly, prone to anxiety and weak digestion—are a good match for formulas like guizhi tang and its many variants (wen jing tang, xiao jian zhong tang, zhi gancao tang, etc).
Contrastingly, formulas featuring the bitter purgative dahuang (rhubarb root) are usually only suitable for big, robust patients prone to internal heat and constipation. These patients typically have dry, tough, yellow-coated tongues and big, hard bellies. They would do as poorly on guizhi tang as the bookworms described above would do on a dahuang purgative formula.
Needless to say, prescribing in the style of Dr Huang is about much more than recognizing the constitution of the patient. But recognizing the constitution allows one to get into the right ballpark before concerning oneself, as it were, with the pitch.
In terms of Huang’s corpus, his best-known earlier book, Ten Key Formula Families, probably remains the place to start for the Chinese medicine student looking to familiarize themself with Huang Huang’s thinking, as that book discusses the constitutional types in depth and gives more of the theory.
However the new book, A Manual of Classic Formulas for Primary Care, is perfect for the practitioner looking for further support in applying Huang’s principles and techniques in clinical practice. This is because A Manual preserves the hallmarks of Huang’s style while presenting a more disease-centric approach to the material.
Taking the book’s second half first, this section is organized by disease and presents several potential formulas for each of these disease categories: cancer (several types covered), diabetes, menstrual disorders, skin diseases, renal diseases, hypertension, GI diseases, common cold and influenza, bone and joint diseases, coughing and wheezing, and diseases of the oral mucosa.
While not pretending to be comprehensive, Huang good covers a good deal of clinical ground here and clearly demonstrates how to apply constitutional, formula-families type thinking to various diseases. As always, one key is to treat the presentation or pattern4 as opposed to the disease. Each formula discussion in these disease chapters includes at least one brief case study. Huang also takes the opportunity both in this section and in the first half (discussed below) to discuss such practical tactics as the “five-two method” (five days on a formula, two days off). These kinds of practice notes can be invaluable for the younger practitioner still refining his methodology.
As for the book’s first half, this section goes through forty plus herbal formulas in some depth, including a number of formula not discussed in Ten Key Formula Families. (In most cases because they were omitted because belong to a family other than the ten discussed there.) New additions include baitouweng tang, da xu ming tang and zhuling tang. For each formula, Huang gives the following: a brief introduction, textual references, recommended dosage and preparation, summary of clinical presentation, patient characteristics (constitution), suitable disease patterns, modifications, important issues, and commentary.
The commentary is quite extensive in some instances and includes valuable clinical pearls from Huang’s extensive prescribing experience. For instance, regarding the (not strictly classical) Kampo dermatology formula jingjie lianqiao tang, Huang notes in the commentary that “this formula is very effective in treating acne, especially when the pimples are red, protrude, have pustulated, and contain thick, sticky, and yellow fluids.”
For another example of Huang’s commentary, this time on da xu ming tang, a formula that will be unfamiliar to many practitioners, see this footnote.5
Regarding the translation, Eng, Even and Mitchell have done an admirable job. The book is readable and well-formatted, the terminology well-chosen and the phrasing clear and direct. The formatting and cover art are in accord with that of Ten Key Formula Families, providing a pleasing continuity to the canon of this important modern Chinese Medicine physician.
May more and more patients and practitioners alike be encouraged to lean on the richness and depth of Chinese Medicine for primary care.
A Manual of Classical Formulas for Primary Care can be ordered directly from the publisher, Eastland Press.
This isn’t to say that Chinese Medicine and biomedicine are always equally effective; biomedicine is stronger in most emergencies and surgical interventions, while Chinese Medicine is better suited overall to chronic conditions, preventative and restorative care, as well as many complex syndromes that don’t neatly fit a biomedical disease category.
One might quibble with the second part of this definition, which would seem to extend to almost any Chinese formulas and include much that’s not usually considered classical per se. Though Huang does work with plenty of post Han-dynasty formulas, including some empirical ones of his own devising, his approach is largely rooted in the work of Zhang Zhongjing.
This emphasis on and respect for the oldest available materials stands in stark contrast to modern medicine’s emphasis on the latest and newest research, drugs, etc. This is one indication of the distance between the worldviews underlying these medical systems, medicine being, after all, applied cosmology.
Though Huang does not put it this way, the concept of disease presentation can be thought of as midway between constitution and disease: a presentation is how a certain patient (or certain type of patient) will manifest a given disease. For instance, dysmenorrhea presents differently for a guizhi vs a dahuang person, as per the discussion above of those two contrasting constitutional types. One cannot treat the constitution only and ignore the disease most of the time, but one also cannot treat the disease only and ignore the constitution. Disease presentation is where the two meet.
On da xu ming tang: “this formula is useful for aphasia, as well as impaired swallowing, especially with a sudden onset. This is usually observed in cases of strokes or brain tumors with sudden deviation of the mouth and eyes, and hemiplegia. There may be mental confusion, difficulty in speaking or comprehension, diminished vision in one or both eyes, difficulty walking, dizziness and vertigo, loss of equilibrium, etc. All of these match the presentation for this formula. However, clinically, the opportunity to use this formula arises mostly in ischemic strokes and it should be used with caution, if at all, for hemorrhagic strokes or anyone with hypertension or a large and firm pulse” (32).