Using Classic Formulas as Modules
In Chinese, the words gu fang [古方] mean “ancient formulas,” while the words jing fang [经方] mean “classic formulas.” Both these terms refer to herbal formulas created in China prior to the Jin-Yuan dynasties (1280-1368 CE). These are the formulas which form the core repertoire of Chinese medicine’s formulas and prescriptions. Many of these formulas come from Zhang Zhong-jing’s late Han dynasty Shang Han Lun (Treatise on Damage [Due to] Cold)/Jin Gui Yao Lue (Essentials from the Golden Cabinet/Coffer). They are the formulas that all of us memorize in school as undergraduates, such as Ma Huang Tang, Ge Gen Tang, Xiao and Da Chai Hu Tang, Si Wu Tang, Si and Liu Jun Zi Tang, Er Chen Tang, etc. Many of these formulas are sold by Blue Poppy Herbs as part of our “Classics” line. Recently, I happened to ask our General Manager for sales statistics on several of these formulas, and I was disheartened to learn that several of these formulas sell very, very poorly. That tells me that many of our customers do not really understand how Chinese herbal medicine is practiced in clinic as opposed to how it is learned in the classroom and presented in entry-level textbooks.
What I mean by this is that many of these formulas are rarely, if ever, prescribed by themselves in clinic in contemporary China. Instead, they are thought of and used as modules for the creation of individualized treatment plans or larger, more complex formulas. From reading the modern Chinese journal literature as well as clinical practice under seasoned doctors in China, it is clear that most patients with chronic diseases present multiple patterns simultaneously. This means that most such patients present a combination of vacuity (often the root) and repletion (commonly the tips or branches) as well as a combination of hot and cold. That also means that formulas for such complex, multi-pattern presentations need to supplement and drain at the same and often contain both warm/hot and cool/cold ingredients. However, most of the classic formulas we learn in school address a single pattern. Take Si Wu Tang (Four Materials Decoction) for instance. It nourishes the blood when there is blood vacuity and also secondarily and to a lesser extent quickens the blood. Or take Si Jun Zi Tang (Four Gentlemen Decoction). It fortifies the spleen and supplements the qi when there is a spleen qi vacuity. Or take Er Chen Tang (Two Aged [Ingredients] Decoction). It dispels dampness and transforms phlegm when there is phlegm dampness. However, in real life, no one (or at least no chronically ill patient) presents with simple blood vacuity, simple spleen qi vacuity, or simple phlegm dampness. Instead, chronically ill patients present with a combination of 3-8 patterns at the same time. For instance, because of the spleen’s role in both the engenderment of blood and the movement and transformation of water fluids, if the spleen qi is vacuous and weak, there also may be blood vacuity and phlegm dampness. Then, because of the blood’s importance in nourishing the liver and the mal-effects of phlegm and damp depressions on the qi, there will commonly be liver depression qi stagnation. Further, because of qi, phlegm, and damp depressions along with blood vacuity, over time, blood stasis will typically also be engendered.
In this case, one might combine Si Jun Zi Tang with both Si Wu Tang and Er Chen Tang. If there is also indeed liver depression qi stagnation, one might start with Xiao Yao San (Rambling Powder) which courses the liver and rectifies the qi, fortifies the spleen and supplements the qi, eliminates dampness, and nourishes the blood. However, in this latter case, if there is phlegm and dampness or dampness is more severe, one might want to combine Xiao Yao San with Er Chen Tang. If, blood vacuity is more severe, one might want to combine Xiao Yao San with Si Wu Tang. If spleen qi vacuity is more severe, one might want to combine Xiao Yao San with Si Jun Zi Tang. In other words, one should regard these classic or ancient formulas more as modules or building blocks than as stand-alone formulas for real-life patients. When one can write a prescription from scratch and fill it with bulk-dispensed, water-based decoctions, custom-mixed powdered extracts, or custom-ground whole-herb powders, one can add and subtract ingredients to exactly match the patients presenting patterns and complaints. However, from my experience, only 10 percent or less of North American practitioners of Chinese medicine have this ability and practice this way. The other 90 percent of North American and even more European practitioners of Chinese medicine prescribe ready-made formulas in one form or another, and this is exactly why Blue Poppy Herbs introduced our “Classics” line. We wanted these practitioners to have the building blocks for adding formulas together to more accurately and effectively treat the multi-pattern presentations that are our norm, not our exception.
As an extension of this, when I hear that a formula like Sheng Mai San (Engender the Pulse Powder) or Er Chen Tang sells very poorly, then I know not enough of our customers understand this modular approach. Take Sheng Mai San as an example. This three-ingredient formula comes from Zhang Yuan-su’s Yuan dynasty Yi Xue Qi Yuan (Expounding the Origins of Medicine). It contains:
Ren Shen (Radix Ginseng)
Mai Men Dong (Tuber Ophiopogonis)
Wu Wei Zi (Fructus Schisandrae)
According to Scheid, Bensky, et al. in Chinese Herbal Medicine: Formulas & Strategies, 2nd edition, this formula treats a qi and yin vacuity resulting in a dry, unproductive cough. However, this formula is also commonly used in clinic to treat a variety of cardiovascular diseases presenting a combination of qi and yin vacuities. Since cardiovascular diseases most commonly occur in the elderly and the elderly commonly suffer from both a lack of qi and exhaustion of yin, this makes perfect sense. This formula can also be used to treat type 2 diabetes presenting with a spleen qi vacuity and a lung, stomach, and/or kidney yin vacuity. In fact, many, many chronic diseases, including many autoimmune diseases, contain core elements of qi and yin vacuities. Therefore, this small, three-medicinal formula can be added as a module or building block to any other formula when qi and yin vacuities complicate one or more other patterns. In other words, in my experience, this is a very useful little formula. Do I ever prescribe or have I ever even seen it prescribed all by itself? No, absolutely not! Do I routinely see patients with qi and yin vacuities as part of their overall pattern presentation? Yes, every single day! This means this should be a commonly purchased formula, not for use by itself but for use as an add-on to other formulas.
Or take Er Chen Tang. As stated above, this formula eliminates dampness and transforms phlegm. Now, please think about the North American and European diets and lifestyles: too much sugar and other sweets (think high fructose corn syrup), too many fatty meats, too many milk products (milk, cream, cheese, yogurt, sour cream, crême fraiche, etc.), too many refined flour products, too many chilled, uncooked foods and drinks, too much thinking and worry, and too little physical exercise. This is a perfect recipe for the internal engenderment of dampness and phlegm, and, consequently, we see a rapidly spreading epidemic of obesity in the developed work along with all the morbidity and mortality of being over weight. In Chinese medicine, it is a basic statement of fact that “fat people [have] lots of phlegm,” and phlegm is nothing other than congealed dampness. According to the U.S. Centers for Disease Control (CDC), in 2007, the rate of obesity in 27 states was 25-29 percent, while the rate in three other states was 30 percent or higher, and these rates are going continuously higher every day. That means we know that, in those 27 states, at least 25 percent of the population suffers from phlegm dampness. That also means that Er Chen Tang could be added to many other classical Chinese herbal formulas such patient might be prescribed for their other presenting patterns. So for Er Chen Tang to be a poor seller, I again have to think that many of our customers are just not themselves thinking from a modular point of view.
Bottom line, it is vitally important for all professional practitioners of Chinese medicine to understand that how we study and learn herbal formulas in school and how these same formulas are prescribed in clinical practice are two different things. That is why all our schools require that classroom study be supplemented by clinical observation and practice. It is only in clinic that one sees and learns the “real deal.” If someone’s school does not/did not have a good clinic taught by truly seasoned practitioners, then I urge readers to do one of two things (or, of course, both): 1) go to China for 1-3 months of clinical practice specifically in herbal/internal medicine, or 2) read the “discussions” sections of numerous of the Chinese journal articles available at the Blue Poppy TCMinfoline. Such discussions typically explain the most commonly seen multi-pattern presentation of a particular Western medical disease and then go on to explain why the various ingredients are in the protocol for that combination of patterns. By studying these discussions, one will gain a better understanding of how Chinese medicine is practiced in China today. I personally find these discussions invaluable.
Copyright © Blue Poppy Press, 2009. All rights reserved.