Interview

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AN INTERVIEW WITH PROFESSOR SHEN PI'AN

Nick Lampert

The interview with Professor Shen Pi’an wasconducted in London on 7 October, two days afterhis excellent seminar on Managing RheumatoidArthritis with Chinese Medicine, jointly sponsoredby Donica Publishing and the RCHM. A report on hisseminar follows on pp.9-10. Editor

To start with, Professor Shen, could you say alittle about your early years and your family?

I was born in Wujiang in Zhejiang province in 1937.Later, at the age of 11, my family moved toSuzhou. I am one of four, with an older sister andolder brother and a younger brother. My oldersister and younger brother are now in Hangzhou,and my older brother is in Suzhou.

I understand that the practice of Chinesemedicine was a family tradition. Was this animportant influence?

Yes. My father didn’t practice medicine, he was auniversity teacher of literature, but there was astrong current of Chinese medicine within thefamily. My great grandfather was a Chinesemedicine doctor, and also an uncle and a greatuncle. My mother very much wanted me to godown this road. My older brother studied historyand my older sister did a degree in literature, somy mother strongly encouraged me to go intoChinese medicine in order to maintain the familytradition. Hence in 1956 I moved to Shanghai tostudy at the Shanghai TCM College (now aUniversity) and graduated in 1962 after six years oftraining.

During your studies, were there particularteachers who had an important influence onyou?

Not so much during my university years, but laterin the hospital there were a number of very gooddoctors who strongly influenced me. Aftergraduation I began working in the Shanghai TCMhospital, and have been there ever since.

Which department did you start with?

I began in the acupuncture department, where Istayed for two years. At that time I already startedto treat some patients with rheumatoid arthritis. Myboss noticed my work in that area and thoughtthat I might specialise in this field. However at thattime I didn’t understand anything about the generalidea of autoimmunity, I was just treating arthritisor rheumatoid arthritis. That understandingdeveloped later on.

I have read that during the CulturalRevolution period (1966-1976) many of yoursenior colleagues were compelled to leaveShanghai, but that you stayed and workedenormously hard during those years? Whatimpact did this time have on yourdevelopment as a doctor?

During that time I was asked to work in theoncology department to look after in-patients, mostof whom were in the late stages. Cancers were notthen differentiated into specialised departments,they were all brought together including lung, heartand liver, every type of cancer, patients withbleeding complications, patients in a coma and soon. At first I didn’t know what to do, so I had to askfor a lot of advice, including advice from westernmedicine doctors, in order to decide how to treatthese patients. I had to learn about a very widerange of conditions. This was a very difficult andintense time, but I learned a great deal. I didn’t getinvolved in any political matters, I justconcentrated on treating patients.

Also during that period, at the request of thehospital, I spent one year in the countryside, inNanhui. Nanhui is now merged into the big new cityof Pudong near Shanghai, but it was then a village.While I was there I started to collect local herbsand developed a stronger interest in herbalmedicine. At first I did not know anything aboutthese herbs, but I learnt a lot from local doctorsand was able to compare that knowledge with the

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textbooks, and then brought this knowledge backto Shanghai.

Also my wife (who didn’t come with me to thevillage) had studied pharmacology in Nanjing andalthough she had specialised in western medicine,she had also studied some of the pharmacology ofChinese medicines and had a lot of books on thatsubject. All this helped me to understand the herbsmuch more deeply.

Were your parents affected greatly by theCultural Revolution?

Yes, they were both from the educated classes,both from so-called ‘landlord’ families. They werekicked out of their home by the Red Guards—actually my father left in advance of that, becausehe was so terrified by what was happening. Indeedhe didn’t survive long after this traumaticexperience and died in 1967. My mother thenmoved to Suzhou with my brother.

After the Cultural Revolution you remained,then, in the Shanghai TCM hospital andcontinued to develop your interest inrheumatology and autoimmune disease?

Yes but there was no rheumatology departmentthen—rheumatology was included within theinternal medicine department. At that time,because I had worked so hard during the precedingperiod and had been noticed, I was offeredpromotion to an administrative position. But I didn’twant to be a manager, I wanted to continue withclinical work. And that is what happened, and laterI became a director of internal medicine, a clinicalposition, with a special focus on SLE.

Your excellent book on the Management ofAutoimmune Disorders with Chinese Medicinecovers a wide range of autoimmuneconditions.* Which of these disorders have

you been especially concerned with in recentyears?

I have been mainly treating six conditions: RA, SLE,Sjögrens syndrome, systemic sclerosis,polymyositis/dermatomyositis, and Hashimoto'sthyroiditis.

Much of the time you have to treat withChinese medicine alongside western medicine.I imagine that one of the big challenges ishow to bring together the insights of theChinese medicine tradition and the modernunderstanding of autoimmune disease?

Yes, I have never refused modern technology andmodern developments. I rely a great deal on theresults of modern diagnostic techniques includingblood tests, X-rays, CT scans, ultrasound, and Ialso take into account modern pharmacologicalresearch. In treating autoimmune conditions I haveinherited many formulas from the classic works, butI have combined these with modern researchresults, modern technique and modern theory. As aresult I have developed a new way to approachthese conditions. Over the years I have developed50 new formulas, including formulas for the sixconditions that I mentioned. One of these is theformula I spoke about in my recent seminar onrheumatoid arthritis, Qiang Huo Di Huang Tang.

Is it realistic to remove western medicine, oris it always a matter of reducing reliance onit?

This depends on the condition and the situation. Iprefer to combine them at the beginning, sincewestern medicine can provide temporary relief andsuppress the symptoms. But it does not treat theunderlying condition and in the long-run thecondition remains unchanged or the patient willsuffer from a lot of side-effects. By bringingChinese and western medicine together the patientwill in the long-term get a better result. Theimmune suppressant medication can definitely beremoved over time. Prednisolone is harder towithdraw from, but in the case of RA and Sjögrenssyndrome that can be done. It is harder in the caseof SLE.

You can think of it this way. From my point of viewautoimmune conditions are caused mainly bypathogenic factors, whether internal or external,and you have two ways to get rid of them. One isto attack, the other is to transform. You couldcompare this with a situation where a wild dog hasentered your house. One method of dealing withthe dog is to kill it, but the dog will put up a fightand this will leave a mess which will leave its markand cause trouble. The other way is to open thedoor and encourage it to leave! This approach isslower than the western medicine approach, butcauses less trouble in the long run, and my dream

Prof. Shen examining lupus patients in wardrounds

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is to establish the approach that I have developedin the treatment of autoimmune conditions as abranch of medicine internationally.

I understand from your recent seminar thatyou are not attached to any particular schoolof thought in the Chinese medicine tradition(eg Warm diseases, Shang Han Lun, Spleenand Stomach school etc), but draw on avariety of currents.

Yes I draw on a variety of approaches. I would saythat there were two big peaks in the history ofChinese medicine. One was during the late Handynasty, represented by Shang Han Lun and ZhangZhongjing, and the second in the early Qingdynasty, represented by Ye Tian Shi who developedWarm Diseases thinking. I would add that animportant general feature of the work of Ye TianShi was that he emphasised the need to addresspresent-day conditions. He was a thinker and sawthat the classic formulas were not enough in thetreatment of new types of disease. There are twotypes of physician. There are the big majority wholearn the classic formulas and apply them and theycan be good physicians. And then there are thosefew, great physicians like Ye Tian Shi, who rethinktheir work, they go back and develop their owntheoretical understanding based on the results oftheir practice.

One of the big strengths of Chinese medicineseems to be in the broad area of immunedysfunction, which may be understood toinclude also inflammatory skin disease suchas eczema?

Yes, but from my point of view the treatment ofinflammatory skin conditions is too simple! Theseconditions can be successfully treated by manypractitioners, but I prefer to take on the difficultcases, I like to take on a greater challenge!

I’m aware that you have written many books,but you have also been a very activepractitioner. You must have immense energy!How have you managed to combine theseactivities?

Well, through most of my career, every day when Icame back from the hospital, I would work hardwriting, often till the middle of the night. When Iwas young I didn’t know how to type, it was all inlong-hand, and one of my books was entirelywritten by hand. Later I learned how to use acomputer which made life a little easier. Also I havea very good quality of sleep, and I work efficiently.I always take a break at lunchtime, at least half anhour. I should also say that I don’t attend as manymeetings and conferences as I used to, and afterreaching the age of 70, I stopped writing in theevenings.

I think we can forgive you for that! But youhave travelled abroad quite a lot over recentyears?

Yes, I have been in America, Austria, Germany,Singapore, Cambodia, Thailand. I have beentravelling to Singapore every year for the past fewyears because I have a friend from Cambridge whois now living in Singapore, and he likes me to comeand check his diagnoses and treatments. AlsoShanghai is cold in winter and Singapore is warm!

Prof Shen beside a scroll sent by a patientpraising his treatment skills

Prof Shenreading his

book onarthritis

Prof Shenlecturing inShanghai

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On another matter, there has been a strongtrend towards the use of extracts and awayfrom the use of raw herbs in Chinesemedicine. What do you think about that?

I’m not against use of extracts (granules andpowders). Modern technology has done very welland the quality these days is high. To give acomparison: there is a Shanghai dish called rou sichao mao dou, beans and shredded pork, you stirthese together. If you cook them separately andthen later put them together some people think thisis not the dish, but I think it’s OK, it’s still delicious.Also with granules, if you bring them together theeffect is going to be the same.

But if you cook a stew you get a particularquality because you have cooked theingredients together, which is not the qualityyou get when you cook them separately andthen put them together?

Yes, the taste may be different, but from the pointof view of nutrition it’s the same, the ingredientsare the same.

Do you think that Chinese medicine has agood future in China, or are there somethreats?

I think the future is promising and that Chinesemedicine is flourishing, because there is a big spacefor it, and the Chinese people continue to believe init. Each type of medicine has its own advantages.Western medicine has advantages in the treatmentof acute, emergency conditions, bacterialinfections, surgery, transplantation. But don’tforget that the people who need this type oftreatment may be only 5% of the population. Thenthere may be 10% who need nothing, but thisleaves a big majority who suffer with chronicproblems, for example autoimmune and metabolicconditions, and Chinese medicine can treat thesebetter than western medicine. Such conditions arelifelong, and you can’t expect people to takewestern medicine throughout their lives, this willlead to damaging complications, and will shortentheir lives. Chinese medicine also has an advantagein relation to an ageing population. With cancerswestern medicine has made a certain amount ofprogress, but this remains basically an unsolvedproblem.

I read that recently you have been appearinga lot in the media in China. Could you saysomething about that?

Yes. I was invited to broadcast a series of dailytalks for the Shandong TV station. These haveincluded back problems, stomach problems, allsorts of conditions, focusing only on herbalmedicine. I have done 48 broadcasts so far and weare still doing it, there will be 100 in all. They arealso being broadcast on the Yellow River Channel in

America and some professors have already beentelling me how wonderful the series is. The serieswill also now be shown on a Shanghai station. Manypeople who have seen the programme come to seeme in the hospital as a result, and there are longqueues! I was told that the Shandong stationtelephone line was exploding!

Well that is a very good sign, and thank youso much for your thoughts.

Acknowledgments

My huge thanks to Yanping Li from DonicaPublishing for arranging this interview, fortranslating Professor Shen's answers and forproviding additional explanations. My sincerethanks also to Dr Yao Chonghua for help during theinterview and with photographs, and to RodgerWatts of Donica Publishing for doing so much tomake the seminar and the interview possible. NL

*RA, SLE, discoid lupus, Sjögrens syndrome,systemic sclerosis, polymyositis/dermatomyositis,mixed connective tissue disease, Raynaud’s,ulcerative colitis, Crohn’s, thrombocytopenicpurpura, auto-immune-haemolytic anaemia, auto-immune hepatitis, Graves disease, Hashimoto’sthyroiditis and MS.

Prof Shen and Nick Lampert during theinterview, London October 2013

Prof Shen broadcasting in Shandong

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Prof Shen on Rheumatoid Arthritis

Managing rheumatoid arthritis withChinese medicine

A one-day seminar with Professor Shen Pi’an,Director, Rheumatology and Immunology

Department, Shanghai TCM Hospital. Saturday5 October 2013, Regent’s College, London

Prof. Shen’s seminar was wide-ranging and rich inobservations based on a lifetime of clinicalexperience in treating rheumatic and otherautoimmune conditions. It reflected a rare comingtogether of reflective thought and practicalexperience, all delivered in an informal, animatedand engaging manner--a high octane performance,not bad for a man in his late 70s! He was ablyassisted by Yanping Li of Donica Publishing, whointerpreted, and by Dr Yao Chonghua, who coveredsome of the material in the early afternoon. It isimpossible to do justice to the day in a brief report,but a fuller picture can be gained from thesubstantial (60 page) booklet that accompanied thepresentation, which has also informed the notesbelow. The booklet includes a detailed generalrationale for Prof Shen’s approach to the treatmentof rheumatoid arthritis (RA), followed by athorough analysis of 20 case histories from hispractice. The booklet may be obtained from DonicaPublishing; enquiries as to availability and price todonica@donica.co.uk).

Signs and symptoms, aetiology and pathology

The talk covered the common symptoms and signsof RA, including joint manifestations, differentialdiagnosis of joint swelling in SLE, osteoarthritis,ankylosing spondylitis, gout; non-articularsymptoms; the progression of RA; RA classificationcriteria. This was followed by a discussion ofaetiology and pathology. Based on his own clinicalexperience and reading of the classics, Prof Shenhad developed the concept of a 7+1 pathogenicmechanism, emphasising seven pathogenic factors(PFs) (Wind, Cold, Dampness, Heat, Blood Stasis,Phlegm, Toxins) plus root Kidney Deficiency, whichin the long term depletes the Essence and damagesBlood, resulting in damage to sinews and bones.

In the majority of cases of RA at the early orintermediate stages, the internal organs are notinvolved, rather there is a close relationship withthe Eight Extraordinary Vessels, and this hadinformed Prof Shen’s approach to patternidentification. Treatment does not generally need totake internal organ Deficiency into account. Byeliminating the seven PFs, the disease will graduallybe brought under control and as a result Vital Qiwill gradually recover. Subsequently, the focus canturn to benefiting the Kidneys and strengtheningthe bones. This is not treatment that supplementsthe Zang organs, still less one that greatlysupplements Qi and Blood.

Having said that, it is true that in a small minorityof patients, at the later stages of RA, swollen andpainful joints and joint deformity maybe

accompanied by symptoms of internal organdamage: Lung, Heart, Liver or Spleen deficiency, inaddition to Kidney deficiency may be involved.Treatment will then support Vital Qi and dispel PFssimultaneously.

Key to successful herbal treatment of RA

Discussion of the general basis of treatmentincluded analysis of a core formula which he hasdeveloped based on the 7+1 pattern identification:Qiang Huo Di Huang Tang (grounded in predecessorformulas San Gen Tang and Qiang Huo San GenTang). The formula consists of:

Qiang Huo (Rhizoma et Radix Notopterygii)—releases exterior Cold and dispels Wind-Damp tobenefit the joints.

Sheng Di Huang (Radix Rehmanniae Glutinosae)—benefits Kidneys and enriches Yin, clears Heat andgenerates Body Fluids.

Huang Qin (Radix Scutellariae Baicalensis)—clearsHeat and dries Dampness, relieves Toxicity.

Zhi Chuan Wu (Radix Aconitii CarmichaeliPraeparata)—dispels Wind and eliminatesDampness, warms the channels to alleviate pain(use with care).

Bai Fu Zi (Rhizoma Typhonii Gigantei)—driesDampness and transforms Phlegm, dispels Windand relieves spasms, relieves Toxicity, dissipateslumps and alleviates pain (use with care).

Ku Shen (Radix Sophorae Flavescentis)—clearsHeat and dries Dampness.

Jin Que Gen (Radix Caraganae Sinicae)—moves Qiand invigorates Blood to alleviate pain.

Bai Jie Zi (Semen Sinapsis Albae)—warms theLungs and sweeps out Phlegm to benefit movementof Qi, dissipates lumps and frees the networkvessels to alleviate pain.

Jiang Huang (Rhizoma Curcumae Longae)—breaksup Blood stasis and moves Qi to free channels andalleviate pain.

In those countries where Zhi Chuan Wu and Bai FuZi could not be used, they could be replaced by WuJia Pi and Hai Feng Teng, but inevitably the effectwould not be as strong.

Numerous modifications and additions wererecommended depending on the presentation andthe relative predominance of the various PFs andKidney deficiency.

Biomedical characteristics

Apart from the use of material medica that disperseinflammation and relieve pain, it is also veryimportant to make use of those that controlantibodies and disperse swelling and effusion. Themain body of a formula should consist of materiamedica with anti-inflammatory, analgesic,immunosuppressive, anti-allergy, anti-vasculitic,anti-synovitis and bone substance-protecting

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properties. A number of laboratory studies hadsupported the use of Qiang Huo Di Huang Tang inbiomedical terms. It was emphasised that the mosteffective results are achieved through the use ofmateria medica with a strong pharmaceutical effectthat do not cause side-effects at relatively highdosages, and the core formula had been based onthese principles.

Supporting Vital Qi generally not required

Prof Shen emphasised that supporting Vital Qi isnot required for most RA patients. The fortifyingSpleen/supplementing Qi herbs can cause retentionand stagnation of Wind-Damp and premature useof such herbs will often result in aggravation of thecondition (‘closing the door with the robbers stillinside’). Some, in particular Huang Qi, canstimulate the production of antibodies and raise thetitre of erythrocyte sedimentation, rheumatoidfactor, c-reactive protein, and anti-citrullinatedprotein antibody. Clinical observation hadsuggested that long-term intake of Huang Qi, RenShen, Xi Yang Shen, Dang Shen, Ling Zhi led toaggravation of joint pain and swelling in RA. Hencethese ingredients could be recommended for short-term and subsidiary use only.

Kidney deficiency

RA patients will however benefit from enrichment ofKidneys, to protect bone substance, enhanceadrenocortical function to assist in dispersinginflammation, and to regulate immune function(some Kidney-enriching herbs possessimmunosuppressive actions). Suitable Kidney-enriching medicinals include Sheng Di Huang, ShuDi Huang, Xu Duan, Du Zhong, Gu Sui Bu, Jie GuMu, Yin Yang Huo, Rou Cong Rong, Lu Jiao, Zhi GuiBan

Combining Western and Chinese medicine

The great majority of RA patients who come forChinese medicine treatment will also be takingwestern medicine. An integrated strategy allows theadvantages of each method to compensate for theother’s disadvantages and improves the overalleffectiveness of treatment. During acute episodesor a sudden deterioration in the condition, Westernmedicine can be used to bring the situation undercontrol, and where the main emphasis is placed onWM (which generally means a selection fromNSAIDs, immunosuppressants, corticosteroids andbiologics), CM can be used to control side-effects(eg gastric problems with use ofimmunosuppressants).

CM tends to work slowly (treatment over 3-5 yearsor even longer maybe required), but the benefitswill start to be noticed after 2-3 months. Patientstaking both WM and CM can slowly reduce intake ofWM and in some cases stop altogether. While long-term use of WM may cause serious side-effects andlong-run aggravation of the overall condition,observation over many years has shown that long-

term treatment based on Qiang Huo Du Huo Tangis very safe.

Case HistoriesProf Shen went through a number of case histories.The following two illustrate some modifications tothe core formula:

Wind-Cold-Damp-Heat complex (a female aged38 with recurrent swelling and pain in multiplejoints for 6 months)—ingredients added to the coreformula included Ren Dong Teng (to dispel Wind,eliminate Dampness and clear Heat), Ting Li Zi (totreat Dampness/Damp-Heat), E Zhu, Zhi Qiao, WuZhu Yu (to invigorate Blood and free the networkvessels to alleviate pain), and Chen Pi, Fo Shou, BaiDou Kou, Gan Cao (to mitigate the effects of thehasher herbs such as Chuan Wu and Ku Shen). Thepatient was also told to decoct the herbs once moreand to soak her hands and feet in the liquid. Mostjoints responded well, with much less swelling, painand stiffness.

Treatment of Exterior, Interior, Deficiency andExcess simultaneously (a female patient aged 78with recurrent swelling and pain in multiple jointsfor more than 30 years). The explanation of a largeand complex prescription was as follows: (1) QiangHuo, Zhi Chuan Wu, Du Huo to release exteriorCold/dispel Wind-Damp to benefit the joints (2)Ren Dong Teng, Hu Zhang, Huang Qin to clear Heatand relieve Toxicity, dry Dampness (3) Sheng DiHuang and Jin Que Gen to benefit Kidneys andenrich Yin, supplement Qi and invigorate Blood torelieve pain (4) Ting Li Zi to drain the Lungs, moveWater and disperse swelling (5) Bai Jie Zi to sweepout Phlegm and free the network vessels (6) Bai FuZi and Fa Ban Xia to dry Dampness and transformPhlegm (7) Jiang Huang to break up Blood stasisand move Qi (8) Chen Pi, Fo Shou and Bai Dou Kouto regulate Qi, fortify Spleen and dry Dampness (9)Zhi Qiao to break up stagnation and transformPhlegm (10) Shi Chang Pu and Huo Xiang totransform Dampness and increase appetite (11) YeJiao Teng to nourish the Heart and quiet the Spirit(12) Bai Ji Li to calm the Liver and relieveDepression and dispel Wind (13) Da Huang toattack and lead out stagnation to treat constipation(14) Gan Cao to regulate and harmonise. Inaddition an external soak and some exercises wererecommended. Progress was noticeable but slowduring the first two months, but after another 4months the joints had improved sufficiently to allowthe patient to walk with the aid of a stick.

These examples are cited to illustrate thedevelopment of the core formula, but for a betterinsight into the approach readers are once moredirected to the booklet that accompanied theseminar, and to Shen’s Textbook on theManagement of Autoimmune Diseases with ChineseMedicine (Donica Publishing).

NL