52 Huang Qi through the Tradition of Zhang Zhong-Jing Journal of Chinese Medicine • Number 83 • February 2007

Huang Qi through the Tradition of Zhang Zhong-Jing

By: Jason Abstract Balack This article looks at source texts and commentary to dissect how Zhang Ji (Zhang Zhong-Jing) used one medicinal, Huang Qi (Astragali Radix),1 to not only introduce a style of studying classical texts, but also render fresh clinical Keywords: choices and perspectives that lie outside mainstream TCM. Huang qi, Zhang Zhong- Introduction through which to view Huang Qi, complementing Jing, shang hang Ji (Zhang Zhong-Jing) has had a our zangfu training. han lun, jin gui profound influence on the development of Laying the foundation for linking a patient’s yao lue, Zhang Chinese herbal medicine. His books, Shang constitution and lifestyle with what many call “Huang Ji, Chinese Zhan lun (Discussion of Cold Damage) and Jin gui yao Qi symptoms (patterns)” is Zhang Ji himself. When medicine. lue (Essentials from the Golden Cabinet) form the Zhang Ji was asked, “What is the cause of painful foundation of modern Chinese medical herbology, obstruction of the blood (血痺, xue bi) disease?”, he supplying around twenty percent of prescriptions responded, “People who live a life of luxury have found in modern formularies. By analysing such weak bones and exuberant flesh. This is an important classical texts, coupled with later commentaries, we reason why they are fatigued and sweat, and when can gain insights that provide sometimes less obvious they lay down they frequently toss and turn (Chapter clinical options. For example, where traditionally Ma 6)”. Exuberant flesh here refers to someone who is Huang Tang might be thought of for an external wind- obese (Dǒng, 2001). Zhang Ji uses the prescription cold attack, through the examination of commentaries Huang Qi Gui Zhi Wu Wu Tang (Astragalus and and deeper understanding we can use it to treat Cinnamon Five-Substance decoction) for painful dysmenorrhoea (Chen, 2000). obstruction of the blood, the principal herb of which It is worth noting that when Zhang Ji wrote his is Huang Qi. material there was no zangfu diagnosis, and hence From this, commentators have created the label, “a no such phrases as ‘tonifies the Spleen’ or zangfu person of luxury” to describe those for whom Huang descriptions such as ‘Spleen qi deficiency’. Although Qi is indicated. A person of luxury has weak bones, TCM has integrated many of Zhang Ji’s ideas, many lives too comfortably and lacks proper exercise which have been left out. Therefore studying Zhang Ji’s usage leads to muscles that are soft and weak (Huang, 1998). of, for example, the herb Huang Qi (Astragali Radix) Therefore Huang Qi is indicated for people that have can provide us with a different perspective on how to a tendency towards plumpness with muscles that are view diseases and herb uses, enriching our practice soft. Huang (1998) thinks that constitutional Huang and liberating us from the confines of the somewhat Qi patterns often appear in the clinic and labels such simplified approach many of us are used to. people as having a “Huang Qi constitution.” More specifically, by analysing how Zhang Ji A person with a Huang Qi constitution has a facial prescribed Huang Qi to treat swelling, sweating and complexion that lacks lustre and is yellow-white, dull joint pain we can gain insights into the overall nature yellow-red, or dark yellow. They have soft muscles, of this herb. Of equal importance is recognising the a puffy, swollen appearance, dull eyes, a weak and specific herbal combinations that allow Huang Qi to feeble abdominal wall, and a pale, fat tongue body treat such complaints, as many actions attributed to with a moist coat. Normally they sweat easily, individual herbs such as Huang Qi occur only when are afraid of wind and often have allergies, nasal paired with other herbs. congestion and cough/wheezing and catch colds and flu. Bowel movements tend to be watery and The Huang Qi person without form or the first part is dry then sloppy. They A fairly unique way of approaching Chinese herbs is complain of a poor appetite, thirst with no desire to to consider the type of person best suited to the use of drink, frequent abdominal distension and fullness, a particular herb. This approach has spawned terms and a tendency towards puffy swelling, especially like ‘Huang Qi constitution’ and ‘Huang Qi abdomen.’ of the legs, as well as tingling and numbness of the Such perspectives provides us with a fresh lens extremities. Adults with a Huang Qi constitution Journal of Chinese Medicine • Number 83 • February 2007 Huang Qi through the Tradition of Zhang Zhong-Jing 53

Fang Ji Huang Qi Tang pattern Fang Ji Fu Ling Tang pattern

Pathomechanism Wind-water, insecurity of exterior qi Skin-water, water qi exuberance with yang evil

Floating and moderate pulse, heavy Puffy swelling and twitching of the four limbs, Signs and Symptoms body stagnation, sweat with aversion inhibited urination, abdominal fullness to wind

Promote urination, dispel wind, restore Free the yang and promote qi transformation and Treatment Method defensive qi and secure the exterior separate and disperse the exterior and interior

Herb Traditional dose Modern dose Herb Traditional dose Modern dose

Fang Ji 1 liang 3g Fang Ji 3 liang 9g Huang Qi 1 liang,1 fen 3.75g Huang Qi 3 liang 9g Formula Content Gan Cao .5 liang 1.5g Gan Cao 2 liang 6g Bai Zhu 3 fen 2.25g Fu Ling 6 liang 18g Sheng Jiang 4 slices Gui Zhi 3 liang 9g Da Zao 1 piece present with an abdomen that is soft and spongy and fewest ingredients out of Zhang Ji’s prescriptions. It is Table 1: a navel which is deep and falling. With pressure there therefore very reliable for understanding Huang Qi’s is a feeling of no resistance as well as no real sensation essence. It treats the “disease of yellow sweat, with of pain and distension. This can be called a ‘Huang Qi body swelling (heaviness in movement), heat effusion, abdomen’ presentation (Huang, 1998). sweating and thirst. Also present are symptoms similar to those of wind-water5 and sweat that soaks Huang Qi’s nature the clothes and is the colour of Huang Bai [Cortex Zhang Ji’s use of Huang Qi in Huang Qi Gui Zhi Wu Phellodendri] juice. The pulse is deep.” (Zhang Ji, Wu Tang to treat painful obstruction of the blood Chapter 14). From this passage, we can see that one of presenting with “external symptoms, including body the primary symptoms is body swelling. The nature numbness or insensitivity, and other manifestations of the swelling is of the whole body because of the similar to painful obstruction of wind” (风痹, feng bi)2 phrase “symptoms like those of wind-water.6” The (Zhang Ji, Chapter 6) highlights Huang Qi’s sometimes other primary symptom is copious, yellow sweating. overlooked, moving or opening nature. When used in Huang Qi Shao Yao Gui Zhi Ku Jiu Tang is a good this formula Huang Qi has the function of activating example of the difference between modern TCM style the yang qi, easing blood circulation and dispersing and Zhang Ji’s style of prescribing. From modern numbness (Luo, 1987; Fan, 2000). It also has an indirect sources it treats “Exterior deficiency, damp obstruction, function of supplementing blood by moving it. Its evil in the exterior, and construction level heat (Dǒng, moving nature is also alluded to in Bensky’s (2004) 2001).” If one removes oneself from this discussion Materia Medica, which refers to Huang Qi as ‘quick’ and clinically diagnoses the above presentation with and by Fan when he refers to Huang Qi as ‘carrying construction level heat, from the yellow sweat and strength to the moving [sic]’ (Fan, 2000). heat effusion, one would be correct. Although it may be necessary to combine Huang Qi Consequently it would be easy to instead include with other moving herbs such as Gui Zhi (Cinnamomi deep heat clearers and miss this potential use. This Ramulus), Wu Tou (Aconiti Radix preparata) or Xi Xin formula addresses the pathomechanism, thereby (Asari Herba) in order to really engage this function, dealing with the heat. Therefore there is no need to it is clear that Huang Qi is effective for promoting include any heat clearers except for the mild Shao urination and reducing swelling on its own (Bensky, Yao. 2004). This moving and opening nature is clearly Another Zhang Ji formula, Fang Ji Fu Ling Tang used by Zhang Ji in his formulae for the treatment of Stephania and Poria Decoction), treats “skin water,7 swelling, sweating and joint pain.3 a disease where there is swelling of the four limbs, water-qi in the skin, and trembling/twitching of the Huang Qi for sweating and swelling four limbs (Zhang Ji, chapter 14).” Huang Qi Shao Yao Gui Zhi Ku Jiu Tang (Astragalus, A third formula, Fang Ji Huang Qi Tang (Stephania Peony, Cinnamon and Vinegar Decoction) contains and Astragalus Decoction), treats “wind-water, the largest dose of Huang Qi (5 liang, 15g4) and the floating pulse, heavy body8, sweat,9 and aversion 54 Huang Qi through the Tradition of Zhang Zhong-Jing Journal of Chinese Medicine • Number 83 • February 2007

to wind (Zhang Ji, chapter 2). Commentary from Arcane will have puffy swelling and in the afternoon there will Essentials from the Imperial Library says that Fang Ji Huang be puffy swelling of the lower limbs. In some people the Qi Tang treats “wind-water that has a floating pulse, puffy swelling is not obvious but the muscles are soft and [indicating] that the [pathogen] is in the exterior. The spongy just like the appearance of puffy swelling. Because patient possibly has sweating on the head with no other of the puffy swelling, the patient is often aware of body exterior disease. They also have lower body heaviness,10 heaviness, non-flexibility with exercise, and heavy joint where above the waist is harmonised, and below the waist pain (Huáng, 1998). Huang Qi’s mechanisms of action here is swollen [extending] to the genitals, with difficulty in are to promote urination, as well as activate the yang and bending.” qi (in the organs and channels.) The common thread in these three formulae is Huang Qi and together they illustrate how Zhang Ji used Huang Huang Qi for joint pain Qi to disperse swelling and eliminate dampness.11 The use of Huang Qi for joint pain is an example of its The last two formulae have the common ingredients of: ‘opening and moving’ qualities. This is illustrated in the Huang Qi, Fang Ji (Stephania tetrandae Radix) and Gan formulae: Wu Tou Tang (Aconite Decoction), which treats Cao (Glycyrrhizae Radix). Both formulae treat water qi “panarthralgia (历节病, li jie bing)12 where the joints are disease with water qi spilling into the exterior muscles very painful and are unable to bend and stretch” (Zhang Ji, and puffy swelling of the body. These herbs work together chapter 5), and San Huang Tang (Three Yellows Decoction)13, to travel the exterior (走表, zǒu biǎo), promote urination, which treats “wind stroke with hypertonicity of the hands and reduce swelling. and feet, pain of the hundred joints, heat vexation, confused One further formula that is instructive is Gui Zhi Jia Huang mind, aversion to cold and no desire to eat lasting all day Qi Tang (Cinnamon plus Astragalus Decoction) which adds (Zhang Ji, chapter 5).” Because Huang Qi and Ma Huang Huang Qi to Gui Zhi Tang (Cinnamon Twig Decoction) are the common ingredients in these formulas, we can see to treat “A person with a heavy body that after sweating that together they can treat joint pain. feels lighter. If the condition progresses for a long time there will be body twitching accompanied by chest pain. Summary There will be sweat above the waist and none below. The We can see that exploring Huang Qi through Zhang Ji’s waist and hips will be slack and painful, as if something approach can lead us to a broader understanding than was stuck under the skin. If severe the patient is unable to we gain from most modern materia medicas. Although eat, and suffers from body pain, vexation and agitation, and simplified interpretations of these functions do appear in inhibited urination. There is yellow sweat (Zhang Ji, chapter modern texts, it is clear that much useful information has 14).” The sweat, body pain and heaviness, and vexation been lost in the distillation process which has given rise to and agitation are symptoms of a Gui Zhi Tang pattern. The modern TCM. Returning directly to the source literature addition of Huang Qi helps treat the heaviness, sweat, and and early commentaries allows us to fill some of these gaps inhibited urination (Huáng, 1998). and arrive at a more full and balanced understanding of the clinical possibilities of herbs such as Huang Qi. Sweating summarised Huang Qi can treat either spontaneous or night sweating. Jason Blalack, who is primarily a clinician, has written and The sweating is usually severe enough that the bed covers published many articles that integrate material he has translated and clothes will be completely damp. Many will have with his own clinical and theoretical understanding. He graduated yellow sweat stains and will sweat copiously when they from PCOM in San Diego, and has since pursued advanced training in Asia. He has held teaching and clinical supervisor eat, most notably on the upper part of the body. Some will positions at SWAC (Boulder Campus) and CSTCM (Denver). He not only have spontaneous sweat in the day, but also have currently maintains a private practice in Boulder, Colorado and sweat at night, where their whole body will be soaked teaches advanced classes to graduates and students. upon waking. In the clinic, the patient’s chief complaint may not be sweating, but upon examination one may Bibliography discover sweat that is of large amounts, elicited easily, and Bensky, Dan (2004). Chinese Herbal Luo Xiwen (1987). Synopsis of occurs with slight exertion (Huáng, 1998). One of Huang Medicine, Materia Medica. Prescription of the Golden Seattle, WA: Eastland Press. Chamber. Beijing: New World Qi’s mechanisms of action to deal with sweating is its Chen et al (2000). Dǒng zhèng Press. ability to ‘secure the exterior.’ huá – 董正华杨轶主编. (2001). 王焘 Wáng Tāo (752). Essentials 金匮要略通解. 中国西安: 三 from the Imperial Library (外 秦出版社 台秘要 Swelling summarised . ) Fan, Min (2000). Class Notes on Zhāng Jī (Zhāng Zhòng-Jìng, 张仲 It is important that the puffy swelling in Huang Qi the Essentials from the Golden 景) (circa 150-219 c.e.), (金匮要 patterns is of the whole body type, but the swelling of Cabinet. San Diego, CA. 略 [jīn guì yào lüè]) (Essentials from the Golden Cabinet) the lower limbs should be somewhat obvious. Because of Huang Huang -黄煌编著. (1998). 张仲景五十味药证. the change of the body’s position, in the morning the face Journal of Chinese Medicine • Number 83 • February 2007 Huang Qi through the Tradition of Zhang Zhong-Jing 55

Huang Qi and its combinations

Other Name Huang Qi dosage Indications ingredients

Guì Zhi painful obstruction of Huang Qi Gui Zhi 3 liang Shao Yao the blood, whole body Wu Wu Tang (modern 9g) Sheng Jiang insensitivity, numbness Da Zao

Guì Zhi Shao Yao deficiency taxation and Huang Qi Jian 1.5 liang Sheng Jiang abdominal urgency, various Zhong Tang (modern 4.5g) Zhi Gan Cao signs and symptoms from Da Zao insufficiency (chapter 6). Yi Tang

Huang Qi Shao Yao 5 liang Guì Zhi yellow sweat, body swelling Guì Zhi Kǔ Jiǔ Tang (modern 15g) Shao Yao

Guì Zhi Shao Yào Guì Zhi Jia Huang 2 liang whole body encumbered and Gan Cao Qi Tang (modern 6g) heavy with pain and sweat Sheng Jiang Da Zao

Huang Qi, Gui Zhi (Cinnamomi Ramulus) and Shao Yao (Paeoniae Radix). Treats: whole body insensitivity, numbness and pain, yellow sweat, puffy swelling and inhibited urination.

Other Formula Name Huang Qi dosage Other ingredients Formula Name Huang Qi dosage ingredients Ma Huang Fang Ji Huang Fang Ji 1 liang 1 fen Fang Ji Fang Ji Huang Qi 1 liang and 1 fen Qi Tang (with Bai Zhu (modern 3.75g) Bai Zhu Tang (modern 3.75g) modifications) Gan Cao Gan Cao Fang Ji Ma Huang Fang Ji Fu Ling 3 liang Guì Zhi 3 liang Shao Yao Tang (modern 9g) Fu Líng Wu Tou Tang (modern 9g) Gan Cao Gan Cao Chuan Wu

Huang Qi and Fang Ji (Stephania tetrandae Radix) Ma Huang Treats: swelling of the four limbs. 2 fen Du Huo San Huang Tang (modern 1.5g) Xi Xin Huang Qin

Huang Qi and Ma Huang (Ephedrae Herba) Treats: whole body heaviness, sweating and panting, or joint pain. 56 Huang Qi through the Tradition of Zhang Zhong-Jing Journal of Chinese Medicine • Number 83 • February 2007

Footnotes 6 Wind-water is further defined by Herbal Pinyin Glossary: ā ī Zh ng J in Chapter 14 as puffy （白术） 1 A full list of pinyin, Chinese swelling of the whole body. Bái Zhú (Rhizoma Atractylodis characters, and Latin names of Macrocephalae) herbs mentioned are at the end 7 Skin-water has a floating pulse, of the article. as well as whole body skin (and Chuān Wū （川乌） (Radix Aconiti flesh) swelling, that pits when 2 In painful obstruction of wind pressure is applied, no aversion Carmichaeli) the (wind) evil is relatively strong to wind, abdominal distension Dà Zǎo （大枣） (Fructus Jujubae) and there is migrating non-fixed ā ī like a drum, no thirst. (Zh ng J Dú Huó （独活） (Radix Angelicae pain, accompanied with limbs chapter 14, Dǒng 2001) and body tingling and numbness. Pubescentis) 8 身重 - Body heaviness and Therefore painful obstruction of Fáng Jǐ （防己） (Radix Stephaniae the blood can have pain with a stagnation (sensation of strong pathogen (Dǒng, 2001). heaviness with inhibited physical Tetrandrae) movement) with pain - wind ā ī （茯苓） 3 Zh ng J does also make use of damp causes stagnation in the Fú Líng (Poria) Huang Qi’s ability to secure / muscles, bones, and joints (Dǒng, Gān Cǎo （甘草） (Radix Glycyrrhizae) tonify (the exterior), namely for 2001). Guì Zhī （桂枝） (Ramulus Cinnamomi) sweating. ǒ 9 Spontaneous sweating (D ng, Huańg Bǎi （黄柏） (Cortex Phellodendri) 4 Dosage in a complicated issue 2001) in the shang han lun. Therefore I （黄芪） 10 下重 – This can also mean rectal Huáng Qí (Astragali Radix) have included both the original （黄芩） dose in liang (or fen), followed by heaviness. Huáng Qín (Radix Scutellariae) the most commonly used modern 11 For example, Huang Qi with Bái Jiāo Yí （胶饴） (Maltose) ā ǎ dosage in grams. One must be Zhú and G n C o reinforces yang Kǔ Jiǔ （苦酒） (Acetum) aware that a modern day liang is qi (Luo, 1987). Má Huang （麻黄） (Herba Ephedrae) around 31.25g and the translation 12 This can be an acute condition to grams is not a mistake. or an acute attack of a chronic Shēng Jiāng （生姜） (Rhizoma Zingiberis 5 Wind-water has a floating pulse, condition (Fan, 2000). Officinalis) external signs, joint pain, aversion （芍药） to wind (Zhāng Jī, chapter 14). Sháo Yào (Radix Paeoniae Alba) Water swelling (oedema) is Xì Xīn （细辛） (Herba Asari) caused by wind-evil with puffy swelling of the face spreading to the whole body (Dǒng 2001).