True and False Classical Formulas

The master and disciple were talking.

A middle-aged woman appeared at the door.

"Hello! Are you Doctor Su?" the woman asked as she came in.

Su Ziyang nodded. "Yes, I am."

"Oh, I'm Xiaoli's friend. She came to you for a cough a couple of days ago!" Afraid Su Ziyang had been too busy to remember, the middle-aged woman added, "The one with the round face! Do you remember her?"

The woman was afraid Su Ziyang had been too busy to remember her friend, but how could he forget?

He had only treated that one patient in the past few days.

"Yes, yes! I remember!" Su Ziyang nodded. "What can I help you with?"

The woman continued, "Oh, your medicine worked wonderfully for Xiaoli. She stopped coughing completely after just two doses. She said you were a skilled doctor and told me to come see you!"

Hearing that the patient who had taken the Minor Blue Dragon Decoction had recovered made Su Ziyang happy.

"Let me take your pulse first!"

Su Ziyang motioned for the woman to rest her hand on the pulse cushion.

Su Ziyang's fingertips were highly sensitive now. Once he placed them on her wrist, he began carefully feeling her pulse.

As mentioned before, the pulse had three positions.

They were divided at the prominent bone just behind the wrist.

The three positions were cun, guan, and chi.

Cun was the position closest to the palm. It corresponded to heaven and the upper burner of the body; the left hand indicated the heart, and the right hand indicated the lungs.

Guan was the position below cun. It corresponded to man and the middle burner of the body; the left hand indicated the liver and gallbladder, and the right hand indicated the spleen and stomach.

Chi corresponded to earth and the lower burner of the body; the left hand indicated the kidneys, and the right hand indicated the gate of life.

As Su Ziyang took the woman's pulse, he found that the guan pulse on her left hand was very large, while the pulses at both ends were thin, like a person with a tiny head and skinny legs but an enormous belly.

After taking her pulse, Su Ziyang asked tentatively, "Is your digestion poor? Does your stomach always feel bloated and full?"

He asked tentatively because he wasn't sure. He only felt that she should have a problem with her spleen and stomach, since the guan pulse was so pronounced.

After asking, Su Ziyang failed to notice his master, who was sitting behind him, nodding in approval.

The woman grew very excited at Su Ziyang's words. "Oh my! Xiaoli really wasn't lying to me. You look so young, Doctor, but you found my problem just by taking my pulse!"

Her reaction startled Su Ziyang. He could only pretend to be calm and maintain his hard-won image as an expert.

Having made his diagnosis, Su Ziyang began writing up the case.

The woman's name was Li Hui.

Li Hui said she had suffered from the condition for over a year.

Her main symptoms were a feeling that something was in her stomach, an inability to eat, severe bloating and fullness, and a constant feeling of discomfort.

When she first noticed it, Li Hui had been terrified, thinking she had esophageal cancer.

She had hurried to the hospital for an examination. A gastroscopy found nothing wrong, except for two polyps in her stomach. Her attending physician at the time said her symptoms were mainly caused by the polyps and recommended removing them.

Li Hui thought the doctor was right and agreed. She underwent a gastroscopic polypectomy.

By rights, once the polyps were removed, her symptoms should have disappeared too. But not only did they fail to improve, they got worse.

The attending physician prescribed Li Hui some more stomach medicine, but after taking it for about two months, her symptoms had not improved at all. Li Hui went to a more authoritative hospital for another examination, and the results were all normal.

The doctor then suggested that Li Hui visit the traditional Chinese medicine department.

Li Hui went and booked an appointment with a specialist. The old man had the air of an immortal sage; he took her pulse and prescribed some Chinese medicine.

Li Hui went home.

She took home fourteen doses of Chinese medicine, but they had no effect. She sought treatment again, and this time the old specialist changed the formula.

All told, she had taken his prescriptions for just under three months. It couldn't be said they had done a bit of good; it could be said they had been utterly ineffective.

After listening to Li Hui's account, Su Ziyang examined her tongue.

Li Hui's tongue had an unusual appearance: the front half was red, and the back half was white.

White represented cold.

Red represented heat.

Combining Li Hui's symptoms and tongue coating with her pulse, Su Ziyang recalled a condition: focal distention syndrome.

Focal distention syndrome was mainly caused by a mingling of cold and heat, which also matched Li Hui's tongue, half red and half white.

Focal distention meant obstruction, a sign of blockage preventing passage.

There was a particularly typical prescription for this condition, called the Pinellia Decoction to Drain the Heart.

At that thought, Su Ziyang did not rush to a decision. Instead, he asked Li Hui about the prescriptions her previous doctor had given her.

Li Hui took several slips out of her bag.

Su Ziyang looked at them, and there on the first slip was the Pinellia Decoction to Drain the Heart. But the old Chinese medicine doctor had added some digestive aids to the formula.

The first slip included an ingredient called hematite. Judging by the direction of the formula, Su Ziyang thought it should be the Inula and Hematite Decoction. The Inula and Hematite Decoction was also a formula for directing stomach qi downward.

The third slip was a haphazard combination of formulas, including the Four Gentlemen Decoction and a medicine to help the spleen and stomach with transportation and transformation.

Su Ziyang began to wonder. It was clearly focal distention syndrome, and the old doctor had used the Pinellia Decoction to Drain the Heart, so why hadn't it worked?

Could it be that it isn't focal distention syndrome?

But it clearly is. If it isn't focal distention syndrome, what else could it be?

Su Ziyang pondered it. Could the dosage be the problem? Or the quality of the medicine?

"Young Doctor Su?" Li Hui interrupted his thoughts. "His prescriptions were wrong anyway. Why are you looking at those? I took them and they didn't do a thing!"

Li Hui's words were full of dissatisfaction with her previous doctor.

But Li Hui couldn't be blamed. Anyone who took medicine for three months without a damn bit of effect would be angry.

Still, Su Ziyang admired Li Hui. Even though it clearly wasn't working, she had managed to keep taking it for three months.

"Then how about I prescribe a formula for you to try?" Su Ziyang asked.

"Go ahead. I trust you!" Li Hui quickly nodded.

Su Ziyang began writing the Pinellia Decoction to Drain the Heart in his notebook.

"Pinellia drains the heart, with coptis and scutellaria; licorice, dried ginger, and ginseng join them there. Jujubes harmonize the mix to treat deficiency and distention; the method lowers yang and brings yin into harmony!"

That was the mnemonic verse for the Pinellia Decoction to Drain the Heart.

The Pinellia Decoction to Drain the Heart came from the Treatise on Cold Damage and Miscellaneous Diseases.

Ancient dosages:

Pinellia (half a sheng, washed); scutellaria (three liang); dried ginger (three liang); ginseng (three liang); coptis (one liang); jujubes (twelve); licorice (three liang, honey-fried).

According to the conversion, one sheng of pinellia was 130 g.

Half a sheng was 65 g.

But classical formulas had a characteristic: one dose was drunk in three portions. That was equivalent to decocting three doses together.

So, when prescribing it now, the original amounts had to be divided by three.

According to the Han dynasty units of measurement unearthed at Mawangdui,

one liang in the Han dynasty was equivalent to 15.625 g today.

Approximately 15 g.

Su Ziyang remembered what Mr. Mengfei had said about the weights used in classical formulas.

So Su Ziyang wrote the amounts on the prescription.

Pinellia (21 g)

Scutellaria (15 g)

Dried ginger (15 g)

Ginseng (15 g)

Coptis (5 g)

Jujubes (4)

Licorice (15 g, honey-fried)

Seven doses.

After finishing the prescription, Su Ziyang entered it into the system.

"All right, you can go downstairs and have the prescription filled," Su Ziyang instructed her. "When you decoct it yourself, don't forget to add four jujubes. We don't include them in the medicine you take home."

"All right. Thank you, Doctor Su! Thank you, thank you! Doctor Su, may I add you on WeChat?"

Su Ziyang nodded. "Of course. Contact me if you need anything!"

After adding Su Ziyang on WeChat, Li Hui thanked him again and left.

Su Ziyang turned to look at Mr. Mengfei. His master was giving him a thumbs-up. "A teachable young man!"

"Master, I didn't get the diagnosis wrong, did I?"

Now that the patient was gone, Su Ziyang felt unsure again.

Mr. Mengfei shook his head. "No, no! Hers is a typical case of focal distention syndrome. It's exactly a Pinellia Decoction to Drain the Heart pattern!"

"But?!" Su Ziyang's question went unspoken.

Mr. Mengfei said, "You want to ask why the other doctor prescribed the ingredients in the Pinellia Decoction to Drain the Heart, but they had no effect, right?"

Su Ziyang nodded.

"Very simple. What he prescribed wasn't the Pinellia Decoction to Drain the Heart."

"It wasn't? But!"

Su Ziyang was even more puzzled.

"Let me ask you," Mr. Mengfei said. "You know the Cinnamon Twig Decoction, right?"

Su Ziyang nodded. Of course he knew the Cinnamon Twig Decoction.

"How much cinnamon twig does the Cinnamon Twig Decoction use?"

"Three liang!" Su Ziyang was puzzled. He didn't know why his master had brought up the Cinnamon Twig Decoction.

"And what is it called if you add another two liang?" Mr. Mengfei asked.

"The Cinnamon Twig Decoction with Added Cinnamon Twig!"

"By rights, only the amount of cinnamon twig has been increased. Why isn't it still called the Cinnamon Twig Decoction? Why emphasize the added cinnamon twig instead?"

"Ah!" The question stumped Su Ziyang again.

That's right.

He had never thought about such questions.

Why did the Cinnamon Twig Decoction use three liang of cinnamon twig?

Why did the Decoction to Drain the Heart use half a sheng of pinellia?

Those were all questions.

Su Ziyang only remembered his teacher saying in class that medicines were used in specific proportions for treatment.

The amount of each ingredient in a formula, which was used in greater quantity and which in less, could not be altered.

But no one had ever stipulated that a Cinnamon Twig Decoction had to contain three liang.

And during Su Ziyang's clinical internship, he had felt that his teachers prescribed dosages by feel.

Ten grams, twenty grams.

No one seemed to have said why an ingredient was used in a quantity of ten grams.

Because it felt like ten grams.

This ingredient was used in a greater quantity because I wanted to use more of it.

That ingredient was used in a smaller quantity because I felt I should use less.

Seeing Su Ziyang fall into confusion, Mr. Mengfei said, "Let me put it this way. You can't add or remove a single ingredient from a classical formula. That's a rule. Add or remove one ingredient, and it's no longer that formula. The same goes for dosages."

"Then, Master, if that's what you're saying, classical formulas can't rule over every disease. If you can't add or remove anything?"

"What I just said was a bit too absolute. I should put it this way: it's not that you can't add or remove ingredients; you have to do so within the rules of classical formulas, rather than adding or removing them at random!"

"Then what are the rules of classical formulas?"

Su Ziyang was even more puzzled.

"That's a long story!"