Discussing Formula Patterns and Herb Indications in TCM Through Case Examples
The classical-formula school of TCM attaches particular importance to formula patterns (fangzheng) and herb indications (yaozheng). Of course, many in the classical-formula school have a regrettable habit: they revere only the limited ancient formulas recorded by Zhang Zhongjing and dismiss effective later formulas, which is a kind of sectarian bias. But the classical-formula school's emphasis on formula patterns and herb indications, and its rejection of interpreting TCM through the abstruse talk of yin-yang and the five phases, is well worth affirming.
Professor Hu Xishu spent his whole life striving to separate classical formulas from the "Huangdi Neijing." The works of Professor Hu Xishu and his disciples deny that the "Shanghan Lun" and "Jingui Yaolue" drew on the "Huangdi Neijing," and they have textualized from many angles that phrases in the preface to the "Shanghan Lun" such as "compiled using the Suwen" were later additions tampering with Zhang Zhongjing's original text in order to attach the yin-yang, five-phase and meridian theories of the "Huangdi Neijing."
Professor Chen Susheng's "Wu Xing Pingyi" and Professor Jiang Chunhua's textual research on the yin-yang five-phase theory (see Jiang Chunhua's "Zhong Yi Yu Ke Xue") both did solid philological work, proving that applying yin-yang and five-phase theory to TCM is rather far-fetched. Readers who are interested may look them up themselves. Japanese Kampo physicians such as Yoshimasu Todo and Tōyama Yoshihiro basically discarded the yin-yang five-phase theory.
If we seriously read the original ancient clinical works such as the "Shanghan Lun" and "Jingui Yaolue," it is not hard to see that what clinical physicians like Zhang Zhongjing truly valued were formula patterns and herb indications: "When there is such a pattern, use such a medicine"; "know what adversity has arisen, and treat according to the pattern"; "Guizhi Tang is originally for resolving the muscles; if the pulse is floating and tight, with fever and no sweating, it must not be given. Always bear this in mind and do not err." Every formula has very clear indications, and some also have contraindications; when the indication appears, use the corresponding formula, and the effect is immediate.
But we do not see Zhang Zhongjing using yin-yang five-phase theory to explain patients' diseases. It was not until Cheng Wuji in the Jin-Yuan period that later people began to interpret Zhang Zhongjing's works in their own language, more than a thousand years after Zhang Zhongjing's death. These interpretations made heavy use of yin-yang five-phase theory, passing error onto error with endless pernicious influence. They draped a veil of metaphysics over TCM clinical works that were originally clear and built on formula patterns and herb indications.
Professor Hu Xishu believed this arose because ancient TCM physicians, to make a living by treating wealthy families, inevitably had to invoke seemingly profound theories to impress people, hence the talk of "pattern differentiation and treatment." Old Hu held that TCM should do "pattern differentiation and treatment-by-pattern" rather than "pattern differentiation and treatment-theory"; such high-flown talk is unnecessary. Once it is clear which pattern a patient has, simply use the corresponding formula. This evidence-based approach to treatment is far more reliable than rambling about yin and yang. So when Old Hu treated patients, he generally only said this patient has a Guizhi Tang pattern, that patient has a Xiao Chaihu Tang pattern, and prescribed directly according to the pattern.
"Truth is half a sheet of paper; idle words fill ten thousand scrolls." This maxim could not be more apt for TCM. The "Shanghan Lun" is very thin, but the books that interpret it, ancient and modern, are countless; later readers have made the "Shanghan Lun" ever more complex. Hundreds of people have annotated the "Shanghan Lun," and one could spend a lifetime reading their annotations and still not finish.
I watched a lecture by Cui Yongyuan on the topic of "plain reading." Cui Yongyuan defined "plain reading" as: reading someone's book according to what they themselves originally meant, without over-interpreting the author's intent, without reading a thousand lines out of a single line—that is plain reading.
Cui Yongyuan told a true story that happened to him. Once on a program, they invited a calligrapher as a guest. Cui Yongyuan was very excited because he had read the guest's book. So Cui Yongyuan talked at length about calligraphy theory; the guest was also excited and asked where Cui Yongyuan had read these theories.
Cui Yongyuan said he had read them in the guest's so-and-so book. The guest told him, "My book has no such words." Cui Yongyuan took out the book and flipped through it; indeed, the guest had never said such a thing. Cui Yongyuan reflected feelingly that we modern people have grown accustomed to distorting others' meaning according to our own thinking, and cannot understand others with the attitude of "plain reading."
We modern people, reading ancient works, easily make the mistake Cui Yongyuan made. We take our own preconceptions to understand ancient works, refusing to believe that ancient works mean only what they say on the surface, insisting on reading a whole thick book out of a single ancient character. If Zhang Zhongjing were transported to the present day and saw how everyone interprets his "Shanghan Lun" and "Jingui Yaolue," he would surely be stunned, feeling utterly lost.
When I first began studying TCM, I too easily fell into such theoretical traps. But later, as I read more and saw many masters criticize yin-yang and five phases and raise doubts about them, I finally found the entrance to TCM. I then devoted myself wholeheartedly to studying and memorizing TCM formula patterns and herb indications. The life of TCM lies in clinical efficacy, and the foundation of TCM clinical efficacy lies in formula patterns and herb indications.
As long as physicians earnestly study patients' symptoms and master formula patterns and herb indications, without falling into the trap of yin-yang and five phases, and without rambling about impractical nonsense like "upper heat and lower cold," "non-intercourse of heart and kidney," or "internal heat and external cold," their clinical skill will improve greatly.
Formula patterns and herb indications are the part of TCM closest to the spirit of evidence-based medicine. Only by having a basis can we maximally ensure definite efficacy. The mystical, incompletely logical "principles" easily make TCM empty and fanciful. The so-called "medicine is a matter of the physician's intent" overemphasizes the physician's subjective guesswork and neglects objective evidence, making TCM quite hard to learn. The ancients placed "principle, method, formula and herb" with principle at the top, so they talked at length about "medical principle"; but now we know that much of that principle is absurd and ridiculous. What is truly practical are "formula patterns" and "herb indications"—the formulas and herbs at the very bottom.
For example, artemisinin has an antiprotozoal effect against malaria, but the ancients did not know about Plasmodium; they thought artemisia "is bitter in taste, cold in qi, and non-toxic. It enters the stomach, liver, heart and kidney channels. It specifically resolves steaming bone fever, and especially drains summer-heat fire." There were all sorts of interpretations of artemisia treating malaria, but none of them hit the mark. Now we know that the artemisinin in artemisia acts against Plasmodium, so we understand how it treats malaria.
But the ancients, not knowing, relied on their own imagination and reasoning to give an explanation, based on yin-yang theory, of how artemisia treats malaria. This explanation obviously had great historical limitations and was wrong. If we only value its "formula pattern" and "herb indication," know that it can treat malaria, and follow the record in "Zhouhou Fang": "Take a handful of artemisia, soak in two sheng of water, wring out the juice, and take it all" to treat malaria, we can avoid the error of over-interpretation.
Many of the scientific principles by which Chinese herbs and TCM formulas treat disease were unknown not only in the past but even now; perhaps more people will need to research in the future before the true principles are understood. But this does not prevent us from using them to treat disease. Once we master formula patterns and herb indications, we can obtain clinical efficacy even without yet understanding the principles of Chinese medicine. Pretending to understand and wildly interpreting with yin-yang five-phase theory will instead lead us into a great trap: in future, when treating disease, we will first consider yin-yang five-phase theory rather than formula patterns and herb indications, and errors will naturally be endless.
Let me give one small example.
The author recently treated a TCM patient with "skin water" (pishui). The patient was a cancer patient but also had some other diseases. The patient had for years disliked sweating and felt cold; at present the four limbs were edematous, the face was also puffy, and there was no bodily pain. I judged that this matched the Fangji Fuling Tang formula pattern, and directly prescribed Fangji Fuling Tang. The chronic, years-old problem improved markedly after only a little over a week of medication.
This formula discussion on Baidu can be said to be a representative example of how modern people distort Zhang Zhongjing's words according to their own understanding. In fact, the original text in the "Jingui Yaolue" is very simple: "In skin water disease, the four limbs are swollen, water qi is in the skin, and there is a trembling, shaking movement"; treat it with Fangji Fuling Tang. There was no such rambling. Once a physician is familiar with the symptoms of skin water and knows the indication of Fuling Fangji Tang, following the principle "when there is such a pattern, use such a medicine" (meaning: when such symptoms are present, use the corresponding medicine), and directly using Fuling Fangji Tang, the disease is treated. Do not add feet to the snake by explaining with so much irrelevant theory; the more you explain, the more confused it becomes.
The formula discussion on Baidu is not Zhang Zhongjing's own words but later people's explanation of his formula. Would Zhang Zhongjing himself endorse this interpretation? The interpreter of course thinks he has understood Zhang Zhongjing's meaning, but I fear Zhang Zhongjing himself would not agree.
Many famous and proven formulas in history have outstanding clinical efficacy, but TCM learners, just like Cui Yongyuan interpreting the guest's book, refuse to "plain-read" the originals, preferring to understand them with their own "ideas"; the result is that they get more and more confused, and in the end cannot treat disease clinically.
So Professor Hu Xishu advocated that TCM learners carefully study each formula's "formula pattern"—the indications for using it—and each herb's "herb indication"—the indications for using it. Yoshimasu Todo specifically wrote a book called "Yaozheng" (Herb Indications), which values evidence, avoids empty talk, and discusses only the indications for using various herbs.
I know many TCM learners or enthusiasts find this hard to accept, because they have already accepted yin-yang five-phase theory as a given. Many people, having learned only the surface of TCM, plunge into these abstruse talks and talk big; their clinical results are mediocre, but they can speak eloquently in debate. This is also an important reason why TCM efficacy is gradually declining and TCM is steadily declining: on the one hand, clinically effective physicians are fewer and fewer; on the other, the boasts grow bigger as they interpret disease through yin-yang five-phase theory, which makes people shake their heads.
There is a saying in Chan Buddhism: "My own eyes were originally straight, but because of my teacher they have become blind." It means one's own understanding was originally correct, but because of being misled by those who taught us, one has become blind. TCM's yin-yang five-phase theory has this side effect on TCM clinical practice.
Confucius said: "To know what one knows and to acknowledge what one does not know—that is knowledge." I, your humble servant, am not clever, but I wish to act on these words. Now, when we know the principle by which TCM treats disease, let us say we know it; when we do not know the principle, let us say we do not yet know, and leave it to later people to research. Is this not a wisdom that respects facts?