by Bob Flaws

Change is an integral part of Chinese medicine on every level. It is inherent in yin-yang theory, five phase theory, and the movement of qi, blood, and fluids. Perhaps this is why so many famous Chinese doctors, such as Sun Si-miao, believed that an intimate knowledge of the Yi Jing (The Classic of Change) was a necessary part of one's Chinese medical education. This emphasis on change can also be seen in Chinese medical formula writing and usage since at least Zhang Zhong-jing's late Han dynasty Shang Han Lun/Jin Gui Yao Lue (Treatise on Damage [Due to] Cold/Essentials from the Golden Cabinet).

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The Shang Han Lun/Jin Gui Yao Lue is the locus classicus of Chinese medicinal formulas in Chinese medicine. Many of the formulas found in this classic are still some of the most important and commonly used formulas in clinical practice today. As Arnaud Versluys describes in his excellent on-line video about formula modification, Zhang Zhong-jing explicitly and implicitly practiced formula modification on a routine basis. In the Shang Han Lun/Jin Gui Yao Lue, there are a number of different families of formulas, such as the Chai Hu formulas, Gui Zhi formulas, Ma Huang formulas, Ren Shen formulas, and Gan Cao formulas. In each family, there is typically a base formula of which other members of that family are modifications. According to Arnaud, Zhang modified his formulas in three basic ways: changes in dosages of individual ingredients, the addition and/or subtraction of ingredients, and the combining of one whole formula with another whole formula to create a third, new formula. Thus we can see that formula modification was an integral part of the earliest surviving tradition for prescription within Chinese medicine.

That being said, by the beginning of the Yuan dynasty (circa 1300 CE), many Chinese doctors had fallen into the practice of the rote prescription of Zhang's formulas. This was due, at least in part, to an extreme reverence for Zhang Zhong-jing and his classics. However, due to the general intellectual ferment started in the Song dynasty (960-1280 CE), a revolution in Chinese medical thought and practice took place in the Jin-Yuan dynasties beginning with the work of Zhang Yuan-su. Zhang Yuan-su, a.k.a. Zhang Jie-gu, lived from approximately 1151 to 1234 CE and was the founder of the Yi-shui School named after his native district in Hebei province. One of Zhang's most famous sayings comes from his Yi Xue Qi Yuan (Explanation of Medicine) published in 1186: "The formulas of the past are not appropriate for the diseases of today." In other words, so much change had occurred in Chinese society since the late Han dynasty that new diseases had arisen due to new disease causes or at least a change in the importance of certain disease causes. Due to these changes, Zhang felt that the old, classical formulas of Zhang Zhong-jing were no longer exactly right for contemporary patients. This statement freed up the thinking of Zhang Yuan-su's students, such as Li Dong-yuan, who went on to write many new formulas, some of which have since become as well-known and commonly used as those of Zhang Zhong-jing. However, in creating their new formulas, the masters of the Jin-Yuan were firmly rooted in the classics. they did not throw the baby out with the bathwater. For instance, Zhang Yuan-su based his own practices and beliefs based on the teachings of such classics such as the Huang Di Nei Jing (The Yellow Emperor's Inner Classic), the Shang Han Lun, and Hua Tou's Zong Zang Jing (The Classic of the Central Viscera). This dynamic tension between conservatism and innovation is fundamental part of the history and practice of Chinese medicine.

Further, if we look at Li Dong-yuan's masterpiece, the Pi Wei Lun (Treatise on the Spleen & Stomach), we can see that Li built modification of his formulas into the very fabric of his methodology. For example, in Chapter 6, "Composing Formulas [Based on] The Division of Channels & Following the Diseases," Li presents two sample formulas, Tong Qi Fang Feng Tang (Free the Flow of the Qi Ledebouriella Decoction) and Qiang Huo Sheng Shi Tang (Notopterygium Overcome Dampness Decoction). After discussing each base formula, Li then presents a number of modifications. In other words, if there is this complicating situation, add these medicinals, but, if there is that complicating situation, add those medicinals. Today, this method of prescribing is referred to as either jia wei (adding ingredients) or jia jian (adding and subtracting). Essentially, this is the same methodology used by Zhang Zhong-jing in the late Han dynasty.

This is also the same methodology taught as standard at all Chinese medical schools in the Peoples Republic of China today. Based on this methodology, in clinic, one rarely ever sees a standard formula prescribed in its textbook standard form. For instance, Liu Wei Di Huang Wan (Six Flavors Rehmannia Pill) is a very commonly prescribed base formula in China. However, often only the three supplementing medicinals are retained (Shu Di Huang, Shan Yao, and Shan Zhu Yu) and another 6-12 ingredients may be added. Nevertheless, the name of the formula typically written on the patient's chart is Liu Wei Di Huang Wan Jia Jian (Six Flavors Rehmannia Pill with Additions & Subtractions). Similarly, one may say they are prescribing Er Xian Tang (Two Immortals Decoction) when the only ingredients from that standard formula kept are Xian Mao and Xian Ling Pi.

In China, where the standard of professional Chinese medical care is still the bulk-dispensed, water-based decoction, it is easy to write such modified prescriptions. In the West, where there is wide-spread reliance on ready-made medicines (either pills, capsules, tablets, or extract powders), it is not quite as easy to modify these ready-made medicines. However, because the hallmark of professional Chinese medicine is treatment based on the patient's personally presenting patterns and the combination of these patterns may be constantly changing, we still should try to address the totality of the patient's condition even with ready-made medicines. In fact, this is not that hard to do. There are two ways of going about this.

On the one hand, we can use ready-made medicines which are themselves already modifications of standard formulas. For instance, Chinese doctors with lots of clinical experience often create formulas based on that experience to specifically address commonly seen multi-pattern presentations of a particular disease or group of diseases. This is exactly what Blue Poppy Originals attempt to do. Each formula within this line is based on some promodern precedent(s), and each formula seeks to address three or more patterns commonly seen in patients with a particular disorder. In addition, Blue Poppy Originals have been selected or formulated to specifically address the constellation of patterns most commonly seen in Western patients with a given condition.

On the other hand, one can combine two or more standard, ready-made versions of famous premodern formulas in order to address multi-pattern presentations. In this case, each formula becomes a module or building block of the larger, total formula. This is exactly what Wei Yi-lin did in creating Chai Ling Tang (Bupleurum & Poria Decoction) in the Yuan dynasty. Wei combined Xiao Chai Hu Tang (Minor Bupleurum Decoction) with Wu Ling San (Five [Ingredients] Poria Powder) to create a new formula which treats all the symptoms associated with Xiao Chai Hu Tang along with all the symptoms associated with Wu Ling San. This is the methodology which is standard in Taiwan where powdered extract formulas rule the day. Using this method, one can combine two, three, or even four formulas together, depending on the size of each formula, to create a new, much more complex and comprehensive formula. This is the method we recommend practitioners use when prescribing Blue Poppy Classics or the Great Nature line.

In addition, both these two above methodologies can be further modified by also prescribing the patient one or more single ingredients (a.k.a. singles) in the form of powdered extracts. These singles can either be encapsulated or dissolved in hot water. In the latter case, the resulting tea can be used to help swallow or "wash down" the other pills, capsules, or tablets. If the patient is already making a hot water infusion out of one or more ready-made powdered extract formulas, then adding a specified amount of one or more powdered singles is easy to do. In fact, these can be premixed by the dispensary so that the patient does not even have to think about this process.

Thus, historically and in contemporary clinical practice, modification is the name of the game when it comes to practicing Chinese internal medicine. In my experience, rarely will a textbook standard formula fit all the exigencies of a chronically ill patient presenting three or more patterns simultaneously (unless, of course, the textbook formula is already a complex one). Frequently, Chinese medical beginners will ask me whether this or that simple formula is appropriate for their patient. In almost 100% of these cases, the patient described is presenting a combination of patterns, not a single pattern, and, therefore, he or she requires a combination of formulas, not a single formula which addresses only a single pattern. In sum, modification of formulas is at the very heart of the professional practice of Chinese medicine.

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