Writing a Formula
This paper has a specific purpose and that is to give advanced students and beginning practitioners a practical introduction to writing Chinese herbal formulas. I am writing to help nudge these people towards that goal.
For over 15 years, I have been a clinic supervisor at two acupuncture schools in Southern California and unfortunately the writing of formulas is often the biggest frustration for students. My job is to go in treatment room the for a few minutes and talk to my student’s patient and then come out with an acupuncture point description and possibly ideas for an herb prescription. When you have 4 patients an hour I became very aware of my thought process during those times.
I should define what this paper is not. This is not the definitive guide nor is it the only way to write formulas. It is not an “easy guide”. It won’t take the place of learning formulas and herbs. It is only to give suggestions to the pathways the study that is necessary to be a formula writer.
What I am going to do is take a few “strategies” and see how an herbalist may apply them. In doing so I am going to use many book sources. These are used only as reference and I apologize to the authors if I overly simplify or mis-represent them. It should be stressed that I only giving the barest of introductions and heavily stress that readers explore each of these authors and books in depth. I am also not going to go into depth about basic theory nor history. I have to assume that if this book is of interest to you you will know or should know basic theory already. (For those who want a refresher in diagnostic techniques then I suggest Bob Flaws and Honora Wolfe’s The Successful Herbalist from Blue Poppy.)
I am going to make some assumptions about students, schools and the educational system. If these don’t apply to you or your institutions then please don’t be offended. My point is to show that there are educational deficiencies in presenting how to write formulas and this problem is not of students, faculty or the institution.
As I mentioned above, I am going to take separate strategies and try to differentiate them. This is not to imply that one is better than another. Once they are understood we can increasingly see how they overlap. We only looking at the same problem from different angles. And with more study we see that different strategies often come from the same source.
The basic premise of this paper is that in confronting a case the doctor has at his/her disposal a number of methodologies that may be appropriate for that case. One can only choose between what one knows. So obviously the limitation is that those with limited knowledge will have limited choices. For example, patents may be prescribed with only a cursory knowledge of Chinese medicine so with only a disease diagnosis the results may be less than satisfactory.
Why it’s not your fault:
Diagnosis is, of course ,what makes Chinese Medicine so valuable and unique.Yet there seems to be some problems with how this has been transmitted to modern students. This is at the heart of the issue and takes a bit of explaining. This is simple stuff, you know it but may have forgotten it in all the different segmented classes you have had.
For the most part modern herbalism has emphasized the zang-fu diagnosis. In school this is re-enforced by teaching styles and board exams. Many tests in a formula class will have multiple questions that go as follows: Case with multiple symptoms and perhaps the disease 1) (zang-fu) diagnosis 2) treatment principle 3) formula. The treatment principle will be a reversal of the diagnosis and the appropriate formula may or not be listed. If not, the diagnosis is uncertain. For many questions the smart student will read the case and jump to the formula and correlate the formula to the symptoms taking in account the tongue and pulse and matching other components that fit a diagnosis. Problem solved.
This gives is the impression is that the (zang-fu) diagnosis governs the final selection of the formula. What I am going to emphasize is that the “treatment principle” is that which governs the final selection of formula and modifications. Pattern diagnosis is only an abstraction while treatment principle are the concrete actions taken to rectify the disease.
What are Disease and Pattern/syndrome and Treatment Principles?
These three terms should be very familiar but I am going to review with particular notice to the art of formula selection and writing. One issue is that the lines between “disease/bing” and “pattern/zheng” has often historically and presently blurred. There is a compelling argument that “disease” has taken more importance in modern times.
A disease is a category that a number of symptoms fall under. Now as sophisticated Chinese medicine students, we have learned to be suspicious of both diseases and symptoms. We see diseases as too Western and symptoms as too simplistic in the face of a pattern diagnosis. This thinking leads to the mistaken belief that only the zang-fu diagnosis is necessary for the proper treatment.
This simplification ignores the place of diseases and fails to see pattern diagnosis as a movable and flexible term. If we go back to the Shang Han Lun we see that disease is the first thing mentioned. For example: Line 153- “Tai Yang disease (disease), the physician has promoted, sweat, it is followed by fever and aversion to cold (symptoms): because purgation was repeated (history), there is glomum below the heart. “. Note that this a level analysis but it is not a zang-fu diagnosis per se.
You will see I am deliberately pulling the reader away from the zang-fu diagnosis. This is not to say that it is never appropriate nor not useful, only that it is not the only diagnostic method. For example, we look at most Chinese internal medicine books and see that they are most always arranged by diseases. We tend to dismiss this arrangement because it mirror western diseases. Yet, many of these diseases exist in exact or approximate comparison to Chinese diseases.
So what is it we are looking for when we are accessing a patient? Hao and Lin write in the Journal of Chinese Medicine of five methodologies that one could see as a variation of the root and branch treatment. Although they tie these to the Shang Han Lun it could also apply to most other schools of prescribing. The first methodology is to be so lucky as to understand both the disease and pattern and then prescribe the correct formula that corresponds directly with them. The second is to only prescribe according to the symptoms. The third is to identify the pathogen and prescribe according to that. For example, its not uncommon to see one patient with phlegm and a number of disperate symptoms (and diseases). Treating the pathogen (phlegm and damp) can go a long way to unwinding the patients issues. Methodology four is a combination of methodologies two and three and is to treat symptoms (methodology two) while searching for the cause.
As Volker Scheid writes about in length (2014) the term zheng has transformed over the centuries. The way that we use in TCM has gone through its current transformation over the last century. His is a long and brilliant discussion but for us we can see that the zang-fu diagnosis/zheng in particular, has evolved to both integrate with and more importantly, in the last century, distinguish traditional medicine from western. In addition, the character has been translated as disease or syndrome. He writes about what should be a clearly understood concept: “Chinese medicine administers treatment based on zheng rather than biomedical diseases. Zheng are well-defined groups of symptoms and signs—hence the English translation of the term as pattern or syndrome.. The same bio- medical disease can manifest with a number of different Chinese medical zheng, while the same zheng may be present in a number of different biomedical disorders. ” Scheid
We are going to look at several strategies and I am going to associate them with English language references. Again, the reader is encouraged to delve into the original texts and not take my word for it.
Disease- Patent: Jake Fratkin
Constitutional: Huang Huang
Treatment Principles: Bensky and Qin Bo-wei (Blalack)
Shang Han Lun
When seeing a patient I’ll often scan my memory for a suitable patent that just “fits” the case as I see it. Hopefully, it is one I have or the school where I’m teaching has it in stock. For example, most cases of prostatitis can be helped with Kai Kit Wan or simple liver qi stagnation with blood deficiency presenting as irritability with Jia Wei Xiao Yao Wan. Sue me if its not sophisticated but many cases can be easily addressed with simple formulas. I like Jake Fratkin’s books to see what the common patents are from different manufacturers.
If we want to view established formulas based on organ systems I often look at the 3 Maclean/Lyttleton Clinical Manual books. The first two books focus on organ systems while the 3rd is more “disease” oriented and arranged by fluids, blood etc.
However, this is not “writing” formulas so we need to look at how formula writing is “arranged” by symptomology, disease and treatment principles.
If we look at most Chinese Internal and Formula books we see that they are usually arranged by disease category and treatment principles respectively. This creates the first problem when finding a formula based on zang-fu syndromes. Say, for example, that the patient has a “cold/ganmao” disease. We diagnose the syndrome as a wind-heat attack. We’re fine so far by opening the first section of Bensky (p. 3-58) or most formula books because our disease and syndrome are so closely aligned.
In an early stage this works because the treatment principle is to release the exterior. But what if the patient comes in with a “cold” they have had for a week? The pulse is deeper, slippery, the tongue is slightly coated with yellow and the person is hacking up yellow phlegm. Now we still have the disease of a cold/ganmao but the syndrome has changed. Now we have phlegm-heat in the upper jiao.
Turning to Bensky we now have to skip 700 pages back to chapter 17 (page 771) which has the broad treatment principle of Dispelling Phlegm. Here we see seven sections with has more detailed treatment principles. Under Formulas the Clear Heat and Transform Phlegm treatment principle we have a likely formula: Qing Qi Hua Tan Wan (Clear the Qi and Transform Phlegm Pill). Now if we only look at zang-fu this seems pretty inconvenient to have to skip around. However, by treatment principle then this makes perfect sense. Also if we had first consulted an Internal Medicine book we would have had a section on colds/ganmao and seen this likely scenario listed under one section. The Maclean-Lyttleton internal medicine series, for example, blends the diseases under different chapters and volumes by Organs. These in turn are further deliniated by pattern/syndrome.
Formula books that are arranged by zang-fu patterns, although well meaning, often become redundant because of this- basically all diseases can fall under a zang-fu diagnosis. Therefore most formula books will be arranged by Treatment Principles.
Thinking of the Formulas
So we have established that Treatment Principles can have a prominent place in finding a formula how else might we the right formula? Sometimes when you see a patient sometimes their signs and symptoms match exactly to a specific formula. The sum of the signs and symptoms is called the “presentation”. This presentation is often evoked is important to our discussion here. The earliest and most famous examples come from the Shang Han Lun.
Signs and symptoms which add up to suggest a formula become a presentation. In a sense that presentation itself becomes the disease name or at least the syndrome itself. In the above we see all those signs and symptoms leading to Da Qing Long presentation.
In Huang Huang’s 10 Formula Families book presentations are associated with the major herb in a group of formulas. One can substitute your own major herbs. For example, a thick tongue coat, slippery pulse suggest to me a Ban Xia formula. A further refinement of signs and symptoms will follow more to food stagnation (Bao He Wan) or fuzzy thinking and depression (Wen Dan Tang). Or it may simply remain at Er Chen Wan (Ban Xia and Chen Pi).
But before we go into Huang Huang more in depth lets look at Kampo, a Japanese form of herbal prescribing. Kampo was created four centuries ago in order to circumvent much of the specialized knowledge and therefore the subjectivity and judgement of the prescribing doctor needed for diagnosis. Its premise is to match a number of signs and symptoms directly to formulas. Earlier I offered a description of formulas being filtered through the (zang-fu) pattern diagnosis. In Kampo, signs and symptoms point directly to the formula. These signs and symptoms also include the constitution- here noted as having a robust body type or a frail one.
We start with a disease category and we’ll pick headaches as our example. The two major presentations (often called conformations) of headaches are interior or exterior. The surface or exterior conformation is differentiated by sweating. If the sweating is scanty then the formula is Ge Gen Tang. If the sweating is spontaneous then the formula is Gui Zhi Tang. If there is doubt about the sweating or if the above doesn’t work then one book suggests Chuan Xiong Cha Tiao.
The conformation/presentation for interior has more possibilities. If there is fever with the headache and the disorder is half interior- half exterior (shao yang) then the possibilities are between Chai Hu Gui Zhi Tang for a robust constitution and Chai Hu Gui Zhi Sheng Jiang Tang for a frail constitution. If there is fever and there are miscellaneous other complaints (mainly women) then the formula will be Jia Wei Xiao Yao Wan (why are we not surprised!) but if there is extreme thirst it will be Wu Ling San. If there are chills and not fever then a general formula will be Gui Zhi Tang while damp conformations such as dizziness will be Tian Ma Gou Teng Yin or nausea and vomiting will be Wu Zhu Yu Tang.
This is a very tidy system and is often illustrated through charts. One still has to inquire as to interior and exterior, chills or fever and the other basic questioning that follow yin and yang dichotomies yet there is no point at which a “diagnosis” is made. The strength is in this because only what the patient shows is considered while judgement about the underlying cause doesn’t cloud up the final formula. This, of course, is the big weakness for those who are uncomfortable with not having a “root cause”. Yet Kampo are all Shang Han Lun formulas and the reasoning follows that text even when it is often applied to western diseases.
Huang Huang has a few English language books that are on the Shang Han Lun (and Kampo) way of prescribing using single herbs as the starting point. In Ten Key Formula Families in Chinese Medicine Huang analyses ten herbs correlated with ten conditions. The ten herbs are Ma Huang, Gui Zhi, Da Huang, Huang Lian, Ban Xia, Shi Gao, Chai Hu, Gan Jiang, Fu Zi and Huang Qi.
Huang Huang ideas are very useful tools in the clinic. By identifying the chief issues of the disease the practitioner can quickly find a focus and then refining the actual prescription. For example, an overall deficient patient who sweats easily and often has heart palpitations falls into the Gui Zhi Tang presentation. Further inquiry will tell you if this indeed the correct prescription. For example, used indiscriminately or for too long on robust (excess) persons Gui Zhi Tang is inappropriate. Again, these are basic also Kampo methodologies. Huang explains that these are not the only herbs one can use in this way and indeed his other book, 50 Herbs, looks at these herbs and others of the Shang Han Lun. It is the same concept but looked at from the herb level.
So when I see a patient with toxic heat I can immediately think of the Huan Lian formula “family”, those with damp phlegm issues one can think of Ban Xia and those with cloudy thinking I like Yuan Zhi (although this one is not in his book). Further, Huang often associates a second herb to most of these to form a two herb combination. This system works because of Huang Lian’s treatment action, bitter and cold, it descends fire and dries damp. If the fire is more at the skin level and has no damp component I may do the same process with Da Qing Ye and/or Jin Yin Hua. Looking at these individual herbs in the Bensky formula book I see a number of corresponding herbs and perhaps formulas that may correspond to the patient’s condition. Again, any of these methods are only tools to get you closer to making a final selection of herbs.
Huang Huang associates these herbs with these symptoms:
Gui Zhi; Thin, fair, pale red lips, Sweats easy, Palpitations, deficiency
Ma Huang; Body aches, no sweating, Slightly fat, loose, light yellow skin, robust
Chai Hu; Chest and hypochondriac, Alternating symptoms, Alternating fever and chills, Medium slight thin, Dry skin, Easily affected, Qi stagnation
Da Huang; Excess – heat, damp, Descend, Bloating, Fever, irritable, Red tongue
Huang Qi; Spontaneous sweating, Edema, Non- healing, Yellowish pale complexion, pale, flabby tongue, Poor appetite
Shi Gao; 4 bigs -thirst, heat, sweat, pulse, Heat (but no constipation), Heat, irritatible, uneasy, thirsty
Huang Lian; Redness, heat, Irritability, restless, stomach, Red tongue- maybe dry, Insomnia, Heat in blood
Gan Jiang; Abdomen fullness, distension, Aversion to cold, Pale, thick coat
Fu Zi, Coldness, Yang Xu
Ban Xia; Nausea, vomiting, Ren 12- ren 14, To descend, Thick white, greasy coat
A Side Note about “Apps”.
If you are at the stage of choosing herbs for a formula I would strongly suggest that you look at a book for your choices and Not Use an App. Apps are fine for reminding yourself of the spelling or getting the general properties of an herb but every app I have seen (and I haven’t seen the Bensky ones) so far have been grossly inadaquate for the details needed to write a formula.
This is really the heart of writing a formula and not just prescribing as above in Kampo. For example, in Warm Theory (Wen Bing) there are 11 commonly used treatment principles: Release Exterior, Clear and dispel heat from the qi level, Harmonize, Dispel Dampness, Purge, Clear heat from ying level,Cool the blood, Open the orifices, Extinguish Wind, Enrich the Yin and Secure abandonment disorders.
Jason Blalack’s book on Qin Bo-Wei is entitled the 56 Treatment Principles which Qin divides into 13 major broader categories much like the above for warm diseases. Bob Flaws and Honora Wolfe have about a hundred treatment principles attached to more detailed zheng/diagnostic patterns such as “Upward flaming of liver fire: Clear the liver and drain fire ” (p. 171).
What a treatment principle comes down to What You Want to Do to a Patient. It is not an abstraction of the diagnosis. In an oft used example, you may see great Qi Deficiency in a patient with mettoragia but what you really want to do is stop the bleeding. The diagnosis may be broader but the treatment principle will be what you actually use in that formula.
Again, looking at the Bensky formula books, we see the chapters as Treatment Principles and the same is true for the Materia Medica. Each treatment principle may have a number of more specialized uses so one can’t just choose the first one that shows up. Qin Bo-Wei used standard formulas or created unique base ones for each of his 63 principles and then supplemented more options with modifications. His appeal is that one can use very concise (and small) formulas where each herb is very focused on one or more actions. This is in contrast to other forms of writing where 2 or 3 herbs will be used for one principle.
I cannot say enough about how useful the concepts of Qin Bo-wei are. Even if you only use “standard formulas”, by using the treatment principles one can have much more focused formulas. And again this only works if you know the herbs well in terms of taste, temperature, properties and actions. One cannot rely on a group of herbs to do the work.
Finally we get to Bensky or more accurately Scheid, Bensky, Clavey et al 2nd edition of Formula’s and Strategies. I can’t emphasize enough that if you want to delve further into Chinese Medicine, theory and practice, this is the book to read.
Formula books became widespread in 1075 (Scheid) when the Chinese government decided that ordinary patients should have the right to buy herbs at the local herbal pharmacy without having to get a prescription. The Formula books (“formularies”) were an effort to standardize and give consumers easy access to low-cost medicine especially during times of epidemics. “Between 1078 and 1252, the pharmacy service also compiled and distributed a series of official formularies. These formularies listed around three hundred prescriptions that had been collected from skilled physicians and after evaluation by members of the pharmacy service judged to be effective. ” (Scheid 2014)
In many ways Formulas and Strategies is direct descendant of these books. Once again, the majority of these books are arranged by treatment principle and not diseases or zang-fu. In treating a patient it is therefore important to establish (by diagnosis) the treatment principle. Going to that section will give you a number of options. If you are lucky the proper formula will unfold in front of you. If not then there a number of options. You can look at the description and decide to use the principles of the formula but leaving some herbs out, modifying or otherwise substituting different herbs. Sometimes, two or three formulas can be blended together. If encountering a symptom, I may look in the index for any clues to formulas I might have forgotten or not be familiar with.
Let look at a few cases and see how we can apply the above.
A 35 year old man makes an appointment. Over the phone he tells me he needs help with “heartburn” that he has had for several years. When he comes in he tells has an uncomfortable feeling in his stomach and a slight burning there that is worse when he hasn’t eaten. He says he has tried antacids and other pharmaceuticals that might help for an hour or so. He tells me it has gotten so bad that he goes into a panic attack before it happens. Sometimes he can’t tell which comes first, the heartburn or the panic, or if there is a trigger to them. His stomach is intermittently painful and feels tight. He denies being angry person and indeed seems rather shy and uncomfortable.
My initial thoughts over the phone because I heard “heart burn” several times was that this would be an excess case of heat and/or food stagnation. However, when he comes in for the appointment I see a slight man with a palish white complexion. This doesn’t look like an excess case. The pulse turns out to be thready/thin. His tongue is reddish and has no coat in the middle stomach area.
Obviously, my jump to an excess condition is now re-evaluated to a diagnosis of stomach yin deficiency. My treatment principle is now to nourish stomach yin.
From treatment principles I want to “nourish the water to quell the fire”. My lead herb (in my mind) is Sheng Di Huang. Because its in the stomach I probably will supplement that with Gou Qi Zi and Mai Men Dong. For the stomach pain I prescribe Chuan Lian Zi. Although the pain is in the “chai hu area” below ribs Chai Hu would be too drying and harsh. I now have a simple 4 herb formula.
The astute reader that what I have created is darn close to the formula Yi Guan Jian. Now that I have often seen this type of case (after many mistakes of prescribing the wrong thing) I could label the condition itself as a “Yi Guan Jian” presentation. If we were to identify the dominant treatment principle as “nourish Yin” then it would be easy enough to look in Formulas and Strategies in that section. After going through the ones for lung yin deficiency then soon we would get to Yi Guan Jian for the stomach. Also as a yin tonic and heat clearer, we could put Sheng Di as being the main herb in a Sheng Di “family”.
This case then has several ways that leads to Yi Guan Jian: 1. Treatment Principles 2. Yi Guan Jian “presentation” 3. Kampo 4. Bensky 5. Formula Family (lead herb)
Lets take another case:
A woman comes in complaining of migraines, shoulder and neck pain. She has migraines almost every day to which she takes Imitrex daily. She says she has firbromyalgia and has stopped exercising because that will trigger a migraine. Because of the lack of exercise she has gained 40 pounds over the years.
The tongue is puffy, with teethmarks and pale and the pulse is deep and week.
The diagnosis is spleen qi deficiency causing damp and blood deficiency with qi and blood stagnation.
The treatment principle will be to tonify spleen, drain damp, move qi and blood and tonify blood.
The formula will be Bai Zhu 15, Chuan Xiong 6, Ge Gen 9, Mu Gua 9, Yan Hu Suo 12, Yi Yi Ren 12.
So in this case, actually Yi Yi Ren is the main herb to both drain damp and tonify the spleen. Bai Zhu will also tonify the spleen. Chuan Xiong, Mu Gua and Yan Hu Suo. Ge Gen “raises the clear yang of the yangming” and acts as a guide to the neck and back.
Looking back it is possible that Bai Shao would have been good. Dang Gui for example would help the blood deficiency but I would rather first tonify the spleen than give the relatively cloying Dang Gui at this time.
The Book of Modules – Cormac Ferguson
This book is an ingenious guidebook that is extremely helpful especially when putting the final touches on an already agreed upon formula. In the book Ferguson stresses having accurate treatment principles (what he calls “treatment plans”). For example, in the Large Intestine section he lists a dozen symptoms and diagnosis according to heat, cold, damp, toxic heat etc… What follows each diagnosis are established small combinations of herbs. This is useful in having a number of two and three herb “modules” for numerous symptoms and diagnosis.
What I have done here is try to give a sense of ways to think when prescribing a formula to a patient. If you are lucky the right formula will pop right up in your brain (and you will have it in your herb room). This article is not meant to be the only way of prescribing- in fact, I want to stress that unless you have a true mastery of one all inclusive method you might be choosing from a number of different methodologies depending on the patient or the case. Learning treatment principles will serve you well no matter what method you want to utilize. The knowledge of formula writing and prescriptions is a life long endeavor and adventure.