By Eric Brand

The modern educational style used in Chinese medicine allows students to have access to a wide range of experts across different disciplines.  While this is generally a huge advantage, students are often confused by the fact that different teachers send different messages, and students lack enough personal experience to know which approach fits best for any given situation.  Many topics in Chinese medicine lack consensus and many questions lack a single, harmonized answer that is supported by all practitioners.  We all agree on basic concepts from the Neijing such as the “liver governs the sinews,” or basic diagnostic criteria such as the relationship between tongue fur and dampness, but we often disagree on therapeutics and style.

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In herbal medicine, there are many questions that lack a harmonized, single answer.  As students, one of the things that we notice early on is variation on formula size and dosage.  We have some teachers that routinely prescribe 12-18 herbs for a given patient, while others often use only 4-8 herbs.  Many classical prescriptions from authors such as Zhang Zhong-Jing were very small and concise, while prescriptions by other famous doctors (such as Li Dong-Yuan) can be quite huge.  Is there one approach that is “better” than another in regard to formula size?

In ancient times, the terms “large” and “small” formulas were used, but the ancient definitions were somewhat confusing and have largely been left behind in favor of later theoretical developments.  In modern times, we often look at formulas such as Si Ni San (Counterflow Cold Powder) and describe them as small, while we look at large formulas like Li Dong-Yuan’s version of Qing Shu Yi Qi Tang (Summerheat-Clearing Qi-Boosting Decoction) and describe them as large. 

The size of the formula is not inherently related to its complexity- a large formula with many ingredients may nonetheless have a very straightforward focus while a small formula may encapsulate a variety of different principles and therapeutic directions.  For example, the yang-supplementing formula Zan Yu Dan (Procreation Elixir) has many ingredients but most of its ingredients reinforce the same principle of supplementing kidney yang and essence.  In such a case, the large formula is not difficult to understand and it doesn’t contain multiple different principles in the same way that a large formula customized for a patient with a multi-pattern complex does. 

Formula size varies based on a wide range of factors, including the delivery form.  For example, it is common for supplementing wines to be very large in terms of their number of ingredients, but the overall daily dose of each medicinal is low and the therapeutic principle is often fairly straightforward.  Typically one large pack (about five times the size of a standard daily pack) of 20-30 herbs is used for three liters of alcohol, so the actual daily dose is low even though the ingredients are numerous.  In a normal decoction approach, the daily dose of each medicinal tends to be higher but the ingredients tend to be slightly fewer in number. 

Generally speaking, the main rule of treatment is that the therapy must match the presentation of the case.  When I treat patients myself, I tend to enjoy the aesthetic appeal of having a tight, concise formula with a very clear direction and no unnecessary ingredients, yet at the same time I try to focus the formula around the needs of the patient and try not to let my own sense of aesthetics trump my feelings about the case.  I really appreciate the concise nature of classical formulas and the profound changes that result from subtle modifications, and many foundational formulas from texts like the Shang Han Lun tend to accomplish more with less by using few ingredients but a very eloquent composition.  At the same time, however, I am also cognizant of the fact that Zhang Zhong-Jing’s style was likely influenced by the fact that a more narrow range of medicinals were available in his time, and as much as I appreciate a number of famous historical doctors, I don’t feel particularly locked in to any one philosophical approach.  It is not uncommon to see patients that present with a complex mix of multiple patterns that require exemplary dui yao combinations from a much wider range of formulas than the early classics provide, and I can’t honestly say that I notice uniformly better results with small formulas vs. large formulas or vice versa.  Some cases just seem suitable for small formulas while others seem suitable for larger formulas.

While there are not any firm rules about formula size, there are a number of different approaches that tend to influence our style.  Some patients present with a complex mix of patterns that should be addressed simultaneously, while other patients have a relatively clear-cut presentation with only one or two patterns jumping out.  Sometimes the patient’s problems fit perfectly into a given Chinese medical explanation, while other cases are more elusive and mixed.  Some patients are delicate and sensitive and require very simple formulas while others need higher doses and greater complexity. 

If we look at the products in the Blue Poppy lines, we see that both large, complex formulas and succinct, classic formulas are present.  Many of Bob Flaws’ Originals formulas were designed based on the concept that most patients present with a complex mixture of patterns, and they tend to target the patterns that are the most commonly seen in relation to a given condition.  Often these formulas are influenced by the style of Li Dong-Yuan and include aspects of Li’s theory such as raising yang and treating yin fire, while others include concepts from later generations such as the involvement of blood stasis in complex, enduring, knotty diseases.  To a practitioner well-versed in Li Dong-Yuan’s approach or Bob’s work, some of these formulas seem quite straightforward, but the same formulas can often appear quite complex to someone that hasn’t been exposed to their underlying theory.  By contrast, the Classics line is primarily centered on exemplary classical formulas that often contain straightforward, simple principles, and can be mixed together as building blocks to treat more complex presentations. 

As with many aspects of Chinese medicine, it is easy to find practitioners that have a strong bias and preference in terms of formula style.  Yet different approaches clearly work for different individuals, and there is no one right answer that fits all scenarios.  Just as with herbal dosage or acupuncture style and intensity, the approach that is best for a given patient should always be determined based on case-by-case consideration, and a flexible approach that is adapted to the patient often feels better than an approach that is designed to match the practitioner’s bias rather than the patient’s actual presentation.  We all have the tendency to see things through our own personal bias, so striving to see our patients as they really are is a constant challenge for all practitioners.