The following was originally the basis of a lecture to second year acupuncture students. It is based on my five years of close observation with several Chinese physicians. I was privileged to work with Li Wei, professor of herbal formulae at OCOM, on a daily basis for this five year period.
Dr. Li’s father was a traditional herbalist who made young Li begin to study the classics at the age of ten, particularly emphasizing the works of Li dong yuan and Zhu dan xi. By fourteen, she was seeing patients under her father’s supervision. At 18, during the height of the cultural revolution, Li Wei was sent to the countryside to be a barefoot doctor. After Mao died in 1976, Li Wei was allowed to return home where she entered medical school. An honors students, she soon was chief of renal pathology at her local provincial hospital. She supplemented her classical education in TCM with formal postgraduate studies. While working in a western medical clinic, she was distinguished by use of classical prescribing skills to enhance her patients health.
This is my analysis of the prescribing I witnessed during this five year period, with insights drawn from discussions with professors and reading of various texts. However, in the end, it is wholly mine and I deserve full credit or blame for any contained herein.
1. Make a complete diagnosis. Elucidate up to three clear treatment principles. Be sure to focus on branch, as well as root symptoms.
2. Make the treatment of excess symptoms or signs your primary thrust. It is often necessary to combine supplementation and reduction therapies simultaneously, but the emphasis is generally on the reduction. The exceptions are in very severe cases of deficiency.
3. If the condition is purely one of excess, there is often a good preexisting base formula to work with. Nevertheless, such formulas are generally modified to account for a specific patient’s presentation.
4. After choosing a base formula, modify it by deleting herbs that may be contraindicated and adding herbs to enhance the treatment of the most prominent or debilitating symptoms. When adding herbs to treat specific symptoms, always keep your TCM diagnosis in mind. Choose only those herbs that are appropriate for the underlying pattern. For instance, if a patient has a productive cough, one would not use herbs that increase the fluids in the lungs, even if they are known to treat cough. such herbs would be reserved for dry coughs.
5. DOSAGE is the key to success. It must be learned from an experienced clinician. In general, serious illnesses with strong symptoms are treated with large doses of carefully crafted formulae. This maximizes benefit and minimizes side-effects. If one is not doing precise bian zheng lun zhi, one should use smaller doses to avoid adverse effects.
6. Treating chronic complaints is different. They generally involve varying combinations of excess and deficiency. Many times there is a good base formula to treat the apparent root of the patient’s constitution. However, these formulas often do not address the complicated branches of most chronic disease.
7. Sometimes there is a good branch formula available that can be combined with a root formula to treat a particular patient. In such cases, it is still common to make deletions and additions.
8. Some formulas are designed to treat root and branch, excess and deficiency. The experienced prescriber learns to recognize the patients who conform to these formulas (such as xiao yao san, liu wei di huang wan , du huo ji sheng tang). In such cases, it is still common to make deletions and additions.
9. In the treatment of most chronic complaints, the process appears to be as follows:
A. Small branch formulas or herb pairs or triplets are chosen to address prominent branch symptomology. The selection of branch herbs always takes into consideration the underlying TCM patterns (of both excess and deficiency).
B. The root patterns of the patient are addressed with varying degrees of strength, depending on the prominence of deficiency vs. excess. If the patient is relatively strong and branch symptomology is severe, the focus is on the excess pattern. Despite one’s suspicions of underlying patterns of deficiency, it is still better to clear the excess first. If the patient feels better after this treatment, it should be continued until symptoms have been resolved as much as possible. The patient may exhibit signs of deficiency as the excess is cleared. It is then appropriate to add supplements to the therapy.
C. If there is evidence of deficiency or because a disease has been of long duration, supplementation therapy is often warranted. If there are no signs or symptoms of deficiency, but the disease has been of long duration, it is often still acceptable to gently supplement the patient. The exception is when the signs and symptoms of excess are very prominent. Always consider the nature of the branch symptomology when choosing supplements for chronically ill patients without prominent deficiency signs. Yin and blood tonics are to be avoided in phlegm damp. Qi tonics are problematic in dampheat stagnation. Yang tonics are generally contraindicated in excess heat conditions.
D. Supplementation in chronic patients with both excess and deficiency generally does not involve the use of entire classical formulas to treat root deficiencies. Typically, parts of formulas, or maybe only their emperors, may be added to a formula that is otherwise focused on branch symptomology and excess patterns. The more prominent or severe the deficiency is, the more focus that will be on treating that aspect of a patients condition.
E. In very severe deficiency, with minimal or no excess, the focus is on treating the root. There is often a preexisting classical formula. However, specific deletions and additions are still made, as necessary, to treat specific branch symptomology.
NOTE: There are two general themes that run through the process of individualized herb prescribing, as it is most typically practiced by modern Chinese practitioners of TCM. The first is what anthropologist Judith Farquhar calls the pivot of pattern differentiation. The second and closely related phenomena is based on the philosophy of using ancient formulas as building blocks to be freely manipulated for the treatment of modern diseases, rather than left essentially intact and untarnished. This approach is hotly contested by purists, who believe that the ancient scholars developed a perfect medicine, applicable to all situations, past, present and future. The mainstream of Chinese medical thought has varied in different eras, but the modern practitioners seem to generally favor the former method of formula selection. Even though modern practitioners will sometimes use barely modified ancient prescriptions (see #8, above), this is usually limited to a few favorite formulas.
What Judith Farquhar calls the pivot of pattern differentiation (Chinese: bian zheng) is a very illuminating concept. Ms. Farquhar is a medical anthropologist, who studied Chinese medicine at a TCM school in China (PRC). she is fluent at written and spoken Chinese. Her book Knowing Practice is a landmark study in the actual practice of Chinese medicine. Her focus in this book is to unravel the relationship between the theory, history and practice of modern TCM. A source of frustration to beginning students and practitioners is the apparent gap between textbook theory and the clinical practice of experienced herbal prescribers. It sometime may appear that theory has been dispensed with, in favor of pure empiricism. But as Farquhar points out, this is not truly the case. What the Chinese student comes to understand during their long period of training and internship is that practice and theory have a pivotal, rather than a linear causal, relationship.
Chinese medical theory allows one to discern discrete patterns of disharmony in a patient’s system, and to derive specific treatment principles from this diagnosis. In the textbook situation, the TCM diagnosis proceeds logically and linearly to a specific formula. In the hands of an experienced clinician, the diagnosis serves a pivot, a pivot into what Farquhar calls the Chinese medical archive. This archive includes the common written heritage of TCM, the results of modern research, and family or other personal oral transmissions. How one accesses this archive is influenced by one education and training. What one does with the archival information is always guided, if only unconsciously at times, by the theories of Chinese medicine. The archive is vast, thus to enter it at random would lead to overwhelming confusion. Bian zheng allows one to enter the archive in the general area circumscribed by your diagnosis. At first, this even this limited area is still somewhat overwhelming, but by closely observing the experienced clinician, one learns a path through the jungle.
There are many paths one could pursue in exploring the archive, but without a guide, it is easy to get lost. Too many guides pointing in too many different directions is also not helpful. Once one has developed competency in one style of practice, then it may be time to pursue others. However, deeply expanding one’s depth of knowledge in a highly focused area often produces results that far exceed those of practitioners who constantly pursue new paths, without ever following any to their destinations. The foundation of successful herbal prescribing is the observation and imitation of an experienced clinician. Textbook prescribing is doomed to fail. Purists who use minimally modified classical formulas are not doing textbook prescribing, despite using textbook formulas. Such practitioners do not match formulas to diagnoses, but match them precisely to patient presentations (somewhat like homeopathy or specific medicine).
What one does in the archive is a highly personal matter. As stated,the modern practitioner does not feel bound to classical formulae. Thus, when he or she accesses the archive, it is for formative ideas, rather than finished products. The questions that guide one’s exploration are varied, as well. How have I seen this treated successfully in the past? What combinations of herbs can I borrow from existing formulae to address the treatment principles and major symptoms?
ADDENDUM: Using a standard text to select your base formulae
When practicing pure TCM,unadulterated by modern pathological concepts, one always has the tools of bian zheng lun zhi to guide them in making a pattern differentiation and selecting a formula. If you have selected a minimum of three treatment principles that are the mutually engendering root of a chronic illness, you are in a position to use a book arranged such as Bensky’s Formulas and Strategies to locate a formula. This is true, even if you are beset with a case that you have never seen before or the patient has a modern disease name you have never heard of. Here’s how:
1) Bensky is arranged by category, which is fairly analogous to treatment principle in most cases. So one can begin by identifying the formula category that is closest to your primary treatment principle (i.e. tonify qi or transform phlegm, etc.)
2) Then, see if there is a subcategory that conforms to one of your other treatment principles (i.e. transform phlegm, calm wind)
3) Examine the formulae to see if they have typical modifications to meet your other treatment principle(s)
4) Always remember the harmonizing category, which contains formulae addressing several common mutually engendering disease mechanisms (i.e. phlegm, spleen qi xu, liver depression, failure of clear ascent and turbid descent, dampheat)