My Favourite Formulas
It is commonly said that new practitioners use many formulas, but old practitioners only use a few. In my experience, this is very true. The explanation for this is that old practitioners with many years of clinical experience have realized that most patients (at least those with chronic conditions) present only a small group of patterns. In fact, the most commonly presenting pattern in such patients is a wood-earth disharmony. What this means is either a liver-spleen, liver-stomach disharmony, or liver-spleen-stomach disharmony. It is rare to find a middle-aged adult without one of these patterns at the root of their disease mechanisms. This is why it is said that, “In adults, blame the liver,” “The liver is the thief of the five viscera and six bowels,” and “Depression makes for hundreds of diseases.”
Further, according to the Ling Shu (Spiritual Pivot), “[When] disease first occurs in the liver, in three days, it will also be in the spleen.” Along the same line, Zhang Zhong-jing, in the Jin Gui Yao Lue (Essentials of the Golden Cabinet), “[When] liver disease appears, know that the liver transmits to the spleen. [Therefore,] one must first replete the Spleen.” Thus it is also said, “Liver disease is spleen disease.” Because of the close relationship between the liver, Spleen, and Stomach vis á vis the Qi mechanism, it is rare to have an enduring disease in either of these viscera without disease in the other. The Liver governs coursing and discharge which keeps the Qi mechanism freely flowing and uninhibited, the Spleen governs upbearing, the Stomach governs downbearing, and the Qi mechanism is nothing other than the upbearing, downbearing, entering, and exiting of the Qi. This is why Zhang Xi-chun said,
“[If] one desires to treat the Liver, one must first upbear the Spleen and downbear the Stomach, bank and nourish the central palace. When the central palace’s Qi transformation becomes generous, Liver Wood is automatically rectified”.
When there is a Liver-Spleen or Liver-Stomach disharmony, the treatment principle is to either harmonise the Liver and Spleen or harmonise the Liver and Stomach. In terms of clinical practice, that means picking the guiding formula from the harmonizing category of formulas. There are five main types of harmonizing formulas:
1. Defensive & constructive harmonizing formulas
2. Liver & Spleen harmonizing formulas
3. Liver & Stomach harmonizing formulas
4. Spleen & Stomach harmonizing formulas
5. Stomach & Intestines harmonizing formulas
In general, it is from among these harmonizing formulas that older practitioners typically choose as a starting place for many of their patients. When we know how to modify the main formulas in the harmonizing category with various additions and removing, we can treat 80-85% of our patients successfully. There is a reason why Xiao Chai Hu Tang (Minor Bupleurum Decoction), perhaps the most famous harmonizing formula, is the single most commonly prescribed formula in Chinese medicine as evidenced by Japanese insurance reimbursement records. That being said, what are my favourite formulas? Answer: Xiao Chai Hu Tang, Xiao Yao San, Ban Xia Xie Xin Tang, Bu Zhong Yi Qi Tang, Ge Gen Tang, and Gui Zhi Tang.
Xiao Chai Hu Tang (Minor Bupleurum)
Although this formula was first introduced in the Shang Han Lun (Treatise on Damage [Due to] Cold) as the prototypical Shao Yang aspect harmonizing formula, in day to day clinical practice, it is more commonly used to treat a Liver-Spleen or Liver-Stomach disharmony complicated with heat in the Liver/Gallbladder, Stomach, Lungs, and/or Heart. That Heat may be either depressive or Damp Heat. In addition, there may also be the complication of Phlegm, Dampness, and turbidity. Within this formula: *Chai Hu (Radix Bupleuri) courses the Liver and rectifies the Qi by upbearing Yang and out-thrusting depression.
*Dang Shen (Radix Codonopsitis Pilosulae) fortifies the spleen and supplements the Qi.
*Huang Qin (Radix Scutellariae Baicalensis) clears externally contracted or retained Heat evils and depressive or Damp Heat from the Liver/Gallbladder, Stomach and Intestines, Lung, and/or Heart.
*Ban Xia (Rhizoma Pinelliae Ternatae) harmonizes the Stomach and downbears counterflow, transforms Phlegm and dispels Dampness.
*Sheng Jiang (uncooked Rhizoma Zingiberis Officinalis) aids Ban Xia in all these activities.
*Mix-fried Gan Cao (Radix Glycyrrhizae Uralensis) and Da Zao (Fructus Zizyphi Jujubae) aid Dang Shen in fortifying the Spleen and supplementing the Qi. They also supplement the Heart and quiet the Spirit. Since the Heart gets its Qi and Blood from the clear upborne by the Spleen, Spleen vacuity is commonly complicated by some element of Heart Qi vacuity.
Common modifications of Xiao Chai Hu Tang
Xiao Chai Hu Tang may be modified in numerous ways. The following are only some of the best known, most common modifications:
1. If Phlegm and/or Dampness are pronounced, add Fu Ling (Sclerotium Poriae Cocos) and Chen Pi (Pericarpium Citri Reticulatae).
2. If there is pronounced thirst due to Heat and no Phlegm Dampness, remove Ban Xia and add Tian Hua Fen (Radix Trichosanthis Kirlowii). If there is thirst and Phlegm or Dampness, keep Ban Xia and add Mai Men Dong (Tuber Ophiopogonis Japonici) and/or Tian Hua Fen (Radix Trichosanthis Kirlowii).
3. If there is Qi stagnation abdominal cramping pain, add Bai Shao (Radix Albus Paeoniae Lactiflorae).
4. Also for abdominal pain associated with Qi stagnation and Dampness, add Sha Ren (Fructus Amomi) and Mu Xiang (Radix Auklandiae Lappae).
5. For abdominal distention and pain due to Qi stagnation, add Yan Hu Suo (Rhizoma Corydalis Yanhusuo), Xiang Fu (Rhizoma Cyperi Rotundi, and Zhi Shi (Fructus Immaturus Citri Aurantii).
6. For scanty, reddish yellow, astringent, and painful urination, add Jin Qian Cao (Herba Lysimachiae Seu Desmodii) and Bai Hua She She Cao (Herba Oldenlandiae Diffusae Cum Radice).
7. For constipation with yellow tongue fur, add either Da Huang (Radix et Rhizoma Rhei) or Huo Ma Ren (Semen Cannabis Sativae) and Zhi Shi (Fructus Immaturus Citri Aurantii).
8. For fever, cough with yellow Phlegm, and pain in the chest, add Jie Geng (Radix Platycodi Grandiflori), Gua Lou (Fructus Trichosanthis Kirlowii), and Zhe Bei Mu (Bulbus Fritillariae Thunbergii).
9. For malaria-like diseases, add Qing Hao (Herba Artemisiae Annuae Seu Apiaceae) and Chang Shan (Radix Dichroae Febrifugae).
10. Also for malaria-like diseases, add Chang Shan (Radix Dichroae Febrifugae) and Cao Guo (Fructus Amomi Tsaokuo).
11. For malaria-like diseases with a heavy sensation in the limbs, loss of appetite, and a soggy pulse, remove Sheng Jiang and Da Zao and add Cang Zhu (Rhizoma Atractylodis) and Hou Po (Cortex Magnoliae Officinalis). This results in Chai Ping Tang (Bupleurum Leveling Decoction).
12. For dizziness and vertigo, add Ju Hua (Flos Chrysanthemi Morifolii), Gou Teng (Ramulus Uncariae Seu Uncis), and Jue Ming Zi (Semen Cassiae Torae).
13. For concomitant Yin vacuity, add Bie Jia (Carapax Amydae Sinensis) and Qing Hao (Herba Artemisiae Annuae Seu Apiaceae).
14. For chest oppression and Stomach duct fullness, add Xiang Fu (Rhizoma Cyperi Rotundi) and Zhi Shi (Fructus Immaturus Citri Aurantii).
15. For concomitant Kidney yang vacuity with cockcrow diarrhoea, lower abdominal bloating, and thirst, add Fu Ling (Sclerotium Poriae Cocos), Ze Xie (Rhizoma Alismatis Orientalis), Shan Yao (Radix Dioscoreae Oppositae), and Tu Si Zi (Semen Cuscutae Chinensis).
16. For Lung Qi and defensive Exterior vacuity, add Wu Wei Zi (Fructus Schisandrae Chinensis) and Huang Qi (Radix Astragali Membranacei).
17. For severe fatigue, add Huang Qi (Radix Astragali Membranacei).
18. For recurrent Lung Heat diseases, add Huang Lian (Rhizoma Coptidis Chinensis) and Gua Lou Ren (Semen Trichosanthis Kirlowii). This results in Chai Xian Tang (Bupleurum Fall Decoction).
19. For cough with sticky, hard-to-expectorate Phlegm, add Gua Lou Ren (Semen Trichosanthis Kirlowii), Jie Geng (Radix Platycodi Grandiflori), and Zhi Shi (Fructus Immaturus Citri Aurantii).
20. For dry cough, add Mai Men Dong (Tuber Ophiopogonis Japonici) and Zhu Ru (Caulis Bambusae In Taeniis).
21. For sinusitis with a yellow nasal discharge due to Gallbladder Heat invading the brain, add Cang Er Zi (Fructus Xanthii Sibirici) and Bo He (Herba Menthae Haplocalycis).
22. For muscle tension and chronic intestinal disorders with chilled extremities, add Gui Zhi (Ramulus Cinnamomi Cassiae) and Bai Shao (Radix Albus Paeoniae Lactiflorae). This results in Chai Hu Gui Zhi Tang (Bupleurum & Cinnamon Decoction).
23. For pleurisy and wilting diseases involving the Lung, add Qin Jiao (Radix Gentianae Qinjiao), Di Gu Pi (Cortex Radicis Lycii Chinensis), Zi Wan (Radix Asteris Tartarici), Bie Jia (Carapax Amydae Sinensis), Dang Gui (Radix Angelicae Sinensis), and Wu Mei (Fructus Pruni Mume). This results in Qin Jiao Fu Lei Tang (Gentiana Macrophylla Support Marked Emaciation Decoction).
24. If there is dry-stool constipation, add Mang Xiao (Mirabilitum). This results in Chai Hu Jia Mang Xiao Tang (Bupleurum & Mirabilitum Decoction).
25. If there is alternating fever and chills, headache in the lateral sides of the forehead, vertigo, fullness and pain in the chest and rib-side regions, white tongue fur, and a bowstring, slippery pulse on the right and a bowstring, floating, large pulse on the left, remove Ren Shen and Da Zao and add Zhi Ke (Fructus Citri Aurantii), Jie Geng (Radix Platycodi Grandiflori), and Chen Pi (Pericarpium Citri Reticulatae). This results in Chai Hu Zhi Jie Tang (Bupleurum, Citrus & Platycodon Decoction).
26. If a female patient catches a cold before or with each period accompanied by alternating fever and chills, lack of appetite, and a bowstring pulse, add the ingredients of Si Wu Tang (Four Materials Decoction), i.e., Dang Gui (Radix Angelicae Sinensis), Bai Shao (Radix Albus Paeoniae Lactiflorae), Shu Di (cooked Radix Rehmanniae Glutinosae), and Chuan Xiong (Radix Ligustici Wallichii).
27. For constipation or diarrhoea which burns the anus, abdominal glomus and fullness which feels hard to the touch, nausea, continuous vomiting, a bitter taste in the mouth, despondency and slight irritability, yellow tongue fur, and a bowstring, forceful pulse, remove Ren Shen and add Da Huang (Radix Et Rhizoma Rhei), Bai Shao (Radix Albus Paeoniae Lactiflorae), and Zhi Shi (Fructus Immaturus Citri Aurantii). This results in Da Chai Hu Tang (Major Bupleurum Decoction).
28. If there is severe vomiting and constipation, to Da Chai Hu Tang add Huang Lian (Rhizoma Coptidis Chinensis) and Wu Zhu Yu (Fructus Evodiae Rutecarpae).
29. If there is severe pain and constipation, to Da Chai Hu Tang add Dang Gui (Radix Angelicae Sinensis) and Yan Hu Suo (Rhizoma Corydalis Yanhusuo) or Chi Shao (Radix Rubrus Paeoniae Lactiflorae) and Tao Ren (Semen Pruni Persicae).
30. For menstrual irregularity and premenstrual tension, add Xiang Fu (Rhizoma Cyperi Rotundi) and Bai Shao (Radix Albus Paeoniae Lactiflorae) or Bai Shao and Dang Gui (Radix Angelicae Sinensis).
31. For premenstrual breast distention, add Chuan Lian Zi (Fructus Meliae Toosendan) and Xia Ku Cao (Spica Prunellae Vulgaris).
32. For vexatious Heat before menstruation, reduce the dosages of Ban Xia and Ren Shen and add Dan Pi (Cortex Radicis Moutan), Zhi Zi (Fructus Gardeniae Jasminoidis), and Sheng Di (uncooked Radix Rehmanniae Glutinosae).
33. For oedema, add Fu Ling (Sclerotium Poriae Cocos) and Ze Xie (Rhizoma Alismatis Orientalis).
34. For Heart palpitations and insomnia, add Yuan Zhi (Radix Polygalae Tenuifoliae), Suan Zao Ren (Semen Zizyphi Spinosae), and Dang Gui (Radix Angelicae Sinensis).
35. For premenstrual mental dullness and headache, add Ju Hua (Flos Chrysanthemi Morifolii) and Chuan Xiong (Radix Ligustici Wallichii).
36. For clots in the menstruate, add Dan Shen (Radix Salviae Miltiorrhizae) and Ji Xue Teng (Caulis Millettiae Seu Spatholobi) or Pu Huang (Pollen Typhae) and Wu Ling Zhi (Feces Trogopterori Seu Pteromi).
37. For infertility due to Liver-Spleen disharmony plus Kidney Yin and Yang vacuity, add Zi Shi Ying (Fluoritum) and Nu Zhen Zi (Fructus Ligustri Lucidi).
These modifications are only meant to give some idea of the modifiability of this formula and are not comprehensive.
(For details on the rest of Bob’s favourite formulas, you can find them in The Successful Chinese Herbalist: How to Prescribe Correctly, Gain Patient Compliance, and Operate a Profitable Dispensary by Bob Flaws and Honora Lee Wolfe).
While it is necessary and important to memorize between 80-100 formulas as an undergraduate, it is important to understand that school is different from real-life clinical practice. Once in practice, I encourage practitioners to look deeply into the few most commonly prescribed formulas and attempt to plumb the depth of their functions and indications. When you do this, I feel confident that you will come to see how important the harmonizing formulas are as a basis for the treatment of the majority of our patient population. Further, when we are able to do this, we no longer have to rat through this or that book of formulas, nor must we stock such a wide range of medicinals. To me, all the formulas in this chapter and their modifications form one common über-formula (note 1), any part of which can be combined with any other part. When we understand this, we can also understand why one early 19th century Chinese doctor said, “Medicine is really easy.”
Note 1. Über is a German word literally meaning “over”, “above”, “overarching”, or “greater”.