Constitutional Types within the Ten Key Formula Families
The idea of prescribing herbs based on presenting symptoms and patterns is not a new idea. Indeed there are books that can be found in Asia whose table of contents is arranged simply by formula presentation. Dr. Huang has taken this idea a step further by demonstrating that the primary function of certain herbs can be mapped to constitutional dispositions, and that there are specific signs that point clearly toward the safe and effective use of certain herbs and formulations.
The reality of constitutional types is obvious. Western physiology recognizes endomorphic, ectomorphic, and mesomorphic body types. In Chinese medicine we are all familiar with the five-phase peculiarities that sift us into one of five tribes. Even the parameters of the eight-principles can be applied to clinical work as we filter our patients into familial groups according to their tendencies toward yin deficiency, dampness, excessive heat, etc. I suspect we all have clinical experience with seeing how some people share certain differences and similarities, and found value in how this has assisted in sharpening our clinical gaze.
Through first reading, and then later translating Dr. Huang’s Ten Key Formula Families in Chinese Medicine, I have come to appreciate the clinical benefit of seeing how patients present with patterns that fit the therapeutic effect of certain herbal families. In the writing of an herbal prescription, it is useful to have a grasp of how patients fit the presentation for certain herbs. As Dr. Huang says in the introduction to his book:
“In reality, using an herb or formula name to stand for a presentation is more objective, concrete and reproducible than terms like yin deficiency, Spleen deficiency, or blood deficiency…Thus, herbal and formula presentations are the basic building blocks of treatment based on the differentiation of patterns.”
One of the easiest ways to begin to screen which formula family is suitable for a patient is to assess how they experience temperature and climatic changes. Guì zhï (Cinnamomi Ramulus) types almost uniformly will have a dislike of cold, but it is a pronounced sensitivity to wind and drafts that sets them apart. Má huáng (Ephedrae Herba) types are more likely to simply report an absolute dislike of cold, while the chái hú (Bupleuri Radix) type people seem to be less fussy about temperature and more so about changes in temperature. On the other ends of the spectrum there are the huáng lián (Coptidis Rhizoma) types who tend toward being hot and vexed, and the shí gäo (Gypsum fibrosum) people who tend to be thirsty, both of these types tend to prefer colder environments. Patients with a gän jiäng (Zingiberis Rhizoma) or fù zî (Aconiti Radix lateralis preparata) presentation do not just dislike cold, they chronically feel cold and generally present with the various complications associated with cold and yang deficiency.
Dryness or moisture of the skin and muscle tone provides another handy way of assessing constitutional types. Guì zhï (Cinnamomi Ramulus) types as you might well suspect, sweat easily; as a result their skin is moist. Generally speaking, they have fine, smooth skin that tends toward being pale, and while they don’t usually have well-developed muscles, they do have good muscle tone. The huáng qí (Astragali Radix) types, while they tend to sweat easily as well, have some significant differences from their guì zhï (Cinnamomi Ramulus) cousins; namely that they tend to have loose musculature, and are prone to edema. Unlike the guì zhï (Cinnamomi Ramulus) types, who have flat bellies, huáng qí (Astragali Radix) presentation patients have large soft bellies that can be deeply palpated without causing pain. Má huáng (Ephedrae Herba) types tend to have dry, scaly skin; running your fingernail across the skin will leave a white mark. They are also prone to a bit of oedema, especially in the face and around the eyes. Chái hú (Bupleuri Radix) types fall somewhere in the middle, the moisture or lack of in their skin is not remarkable. However, as they are prone to stagnation, they tend to have a dull complexion. They often have reasonably well developed musculature, as they tend to enjoy physical exercise and activity, which they use to move the stagnation out of their bodies.
Another useful area to pay attention to is the lower legs. Dr. Huang checks the condition of the skin here; if it is dry and flaky he takes it as a sign of blood deficiency. In my clinical practice I have found this to hold true, and especially see this in patients who are suffering from chronic conditions leading to a depletion of the Blood.
Finally, and perhaps due to Dr. Huang’s time spend in Japan, he often palpates the abdomen as part of his diagnostic process. Tightness under the ribs is a sure sign of the chái hú (Bupleuri Radix) presentation, while a flat and tense abdomen with tight rectus abdominis muscles and easily felt pulsation of the aorta points towards a guì zhï (Cinnamomi Ramulus) presentation. A big belly with drum-like distension, when accompanied by a reddish and oily complexion is the sign for a dà huáng (Rhei Radix et Rhizoma) presentation, while a big soft belly that can be deeply palpated without discomfort to the patient is a key sign of a huáng qí (Astragali Radix) presentation.
I find that going to the abdomen to help clarify a diagnosis, or to correct one’s errors is helpful indeed. Here is a recent example of using abdominal diagnosis to get a handle on the constitutional disposition of one of my patients. A 37 year old women came to me for help with painful periods and digestive problems. She had been diagnosed with endometriosis, and had seen an acupuncturist, who had helped her gain some relief. Her periods were painful, she had a history of ovarian cysts and had surgery for them in 1999. This lead to adhesions, for which she underwent further surgery, and eventually was given the diagnosis of endometriosis. Recently she had suffered from alternating constipation and diarrhoea, along with anal fissures. She had trouble digesting oils and fats, her appetite came and went, and she tended to wake every two hours during the night. Her tongue was puffy with a thin yellow, greasy coat, right pulse deep and thready, left pulse slippery. The lower abdomen was lumpy and tender to the touch, and there was a pronounced feeling of epigastric focal distension, which we could both feel upon palpation. I saw her as having cold (and thus Blood) stagnation in the lower jiao along with a hot/cold complex in the middle burner leading to dampness. Given the intensity of the focal distension I gave her the bàn xià (Pinelliae Rhizoma preparatum) family prescription; bàn xià xiè xïn täng (Pinellia Decoction to Drain the Epigastrium). This helped with her bowels and she reported a reduction in pain with the period. Then in an attempt to clear stagnation out of her lower abdomen I switched her to an old standby for Blood stagnation in the lower jiao, the guì zhï (Cinnamomi Ramulus) family’s guì zhï fú líng wán (Cinnamon Twig and Poria Pill). This was a big mistake as her periods become more painful and she had severe abdominal bloating. Again, going back to the abdomen I found that the hypochondriac area was now extremely tight, and the tenderness in the lower abdomen was unchanged. Her pulses were wiry, and her tongue still puffy, pale with a thin yellow coat. Clearly the cinnamon twig formula had not helped her, and in retrospect she did not fit the presentation. As she currently had a bupleurum presentation, the formula was switched to one from the chái hú (Bupleuri Radix) family, in this case xuè fû zhú yü täng (Drive out Stasis from the Mansion of Blood Decoction) as it addresses stagnation of both the blood and qi. This helped her period pain and her sleep. Her digestion still fluctuates, at times being fine and at other times there are bouts of constipation and bleeding from anal fissures. Currently, she is on a modification of xuè fû zhú yü täng (Drive out Stasis from the Mansion of Blood Decoction) that includes dà huáng (Rhei Radix et Rhizoma) and chì sháo (Paeoniae Radix rubra). She is making good progress.
Paying attention to a patient’s constitution, as a way to understand for which herbal formula family they have an affinity, gives us a kind of shorthand for quickly and effectively making decisions about which prescriptions would be of benefit. As with any system, once you begin to understand the underlying dynamics and processes, you can begin to see a wider integrated picture of how illnesses come into being, are held in place, and how to effectively intervene. Additionally, I have found you can begin to use a surprisingly small number of formulas to treat a wide range of problems. Better yet, as you accumulate your own clinical experience, you will begin to notice certain signs and symptoms, which at one time seemed out of place, now fit neatly into your expanded understanding of formula presentation.
Michael Max spent 5+ years in Taiwan and Mainland China studying language and medicine. He currently maintains a busy practice in St. Louis, MO., and continues to work on translations of material not yet available in English. You can find more information about the classic formulas and Dr. Huang’s work at www.classicformulas.com.
Huang. (2009). Ten Key Formula Families in Chinese Medicine. Seattle: Eastland Press.