JCM Review
Formulas & Strategies is a well known text to most practitioners of Chinese herbal medicine. It is one of the first books that I ever acquired and is probably the book that I refer to most often in my clinical practice. The first edition was a landmark book and is still possibly the only formulas book that explores the tradition in depth, offering historical origins of formulas, original and current posology, explanations, and most importantly commentary, critical analysis and comparative data. It is the book that most people use to study Chinese herbal formulas in English.
The arrival of the second edition is therefore a landmark event. It is a significant progression from the first, greatly expanding the number of formulas, going into greater detail concerning their history and application, comparing, contrasting and analysing selected formulas and further exploring influences from other Asian countries.
The introduction and ‘how to use this book’ sections, as with the first edition, are essential reading. These first pages guide the reader towards an understanding of the essence of Chinese medicine and Chinese medicinal concepts but then progress further on a journey to places such as Korea, Japan and Taiwan, all of which have made their own impact on Chinese medicine. Building on the information contained in the first edition, the authors discuss how each of these countries has helped promote, influence and develop Chinese medicine, historically and currently.
For practitioners who are interested in herb powders and granules, there is an excellent section on how they are produced and how they should be prescribed. The authors attempt to de-mystify the art of concentrated granule and powder prescribing and educate the reader in their correct use. The discussion covers dry herb equivalents, concentration ratios, processing, Good Manufacturing Practice and Quality Assurance. The authors explain in detail how to prescribe and dose concentrates effectively and in accordance with best practice in order to maximise their effectiveness in clinical use.
The discussion of formulas begins - as in the first edition and in keeping with the tradition - with formulas that release the exterior. There is excellent discussion of the aetiological and physio-pathological processes involved, appropriate treatment strategies and the classical source texts from which the formulas have been derived. Theories from contemporary doctors of the time are discussed and compared with modern applications. There is emphasis on the need for careful and accurate diagnosis with practical information on the successful use of the formulas. Detailed information is given on preparation and decoction methods, on the correct time to take formula, and how to adjust the dosage according to the patient’s constitution and even geographical location.
Taking Cinnamon twig decoction (gui zhi tang) as an example, there are of course similarities with the first edition with sections on indications, analysis of the formula, commentary, cautions and contra-indications, modifications, variations and associated formulas, but with several new additions. Key new sections outline the method of preparation and key symptoms, and offer a commentary on exterior deficiency, a discussion of ingredients, correct usage, controversies, biomedical indications and comparisons with other formulas.
Subsequent chapters offer all of the above, focussing on the same careful analysis of signs and symptoms and pathogenesis, followed by suggested treatment strategies and formulas, written using language that engages and enthuses the reader. There is an excellent commentary in the chapter on Formulas that Regulate Blood on ‘Appropriate Type of Pain’ and the use of the Tangkuei and Paeony Powder (dang gui shao yao san). This firstly outlines the classical use of this formula for the treatment of sustained pain (xiu tong) - with presenting pain that is relatively mild but continuous - as described by Ming dynasty physician Xu Bin in Discussion and Annotations of the Essentials from The Golden Cabinet. However, the authors then point out that the Chinese characters (included in the text) can also be read as jiao tong, meaning hypertonic or tense pain, whereas another translation of the characters indicates ‘slight pain’. In the light of this, the conclusion of the authors is that it is helpful to follow the analysis of the contemporary physician Huang Huang in One Hundred Classical Formulas, who states that, ‘this formula treats all kinds of pain provided that it fits into the overall manifestation of the pattern for which the formula is being indicated.’ This type of commentary is typical of this second edition and forces us to question and critically analyse formulas, rather than to accept the writing of one particular physician, and encourages us as practitioners to grow and develop through constant learning.
Throughout the book there are references to classical and contemporary texts, and in Chapter 15 (formulas that treat dryness) in the section on the actions and synergies between chief and deputy ingredients, we find the recommendation by some contemporary sources that mai men dong should be used at dosages of between 45g and 70g in the formula Ophiopogonis decoction (mai men dong tang) and that lesser amounts will diminish the formula’s efficacy. We are guided to the New Compilation of Materia Medica where an extended discussion argues,
“Ophiopogonis Radix (mai men dong) drains lurking heat from the Lungs and clears heat pathogens from the Stomach. It tonifies consumptive damage of the Heart qi, stops vomiting of blood, augments the essence, strengthens the yin, relieves irritability, stops thirst, beautifies the complexion, is pleasing to the skin, reduces fever from deficiency, resolves Lung dryness and stops coughing. It truly should be prescribed as a chief herb, but can also be used as a deputy or assistant. Unfortunately the common people do not know about the marvellous uses of mai men dong (anymore). Gradually they have used less and less (of it) and it no longer achieves results. This is too bad. They do not know that one must use mai men dong in large amounts in order to open up its power. (In cases of) lurking heat in the Lungs scorching dry the yin fluids in the interior, only a large dose of mai men dong can control the fire. (In cases of) fire blazing within the Stomach and depleting its yin, only a large dosage of mai men dong can extinguish this fire.”
The text goes on to analyse the use of zhi ban xia in the formula and how it assists the chief herb mai men dong by regulating the qi and directing it downwards. From Discussion of Blood Patterns, we are given a discourse on the actions and synergies between all of the ingredients of the formula, amongst which is found, “When the fire and the qi are directed downward, the body fluids are generated. When the body fluids are generated, fire and qi are naturally directed downward. They flow as they should and not in a perverse manner.”
It is a strength of this second edition that it not only gives us information on how to use herbs, but provides a well constructed and logical argument for why the herbs in a formula are selected and how they interact with each other, and consequently how these properties have resulted in them being used for the bio-medical diseases that they have become associated with.
There is little or no mention in the book of the pharmacokinetics or pharmacodynamics of particular formulas, adverse reactions are not mentioned, nor is nephro, hepato or feto toxicity. I think that this is acceptable in a book of this kind as it allows the authors to retain their focus on the history, traditional usage and application of herbal formulas. I would, however, have liked to have seen a discussion on the controversy surrounding the usage of xi xin - possibly one of the biggest current controversies affecting Chinese medicine and one that seems to have been overlooked in this text. Conservation issues seemed to be covered only sporadically. There is a mention of rhinoceros horn and its endangered status but nothing when it comes to the use of mu xiang, Saussurea lappa, (root) and its schedule 1 CITES classification. I would also have preferred the use of botanical names for the individual herbs rather than their pharmaceutical name but understand some of the difficulties in providing this information and perhaps this is something that can be worked on for the third edition.
This book, in my opinion, is an essential text for all students and practitioners of Chinese herbal medicine. It accomplishes the difficult task of providing the reader with accurate, well-researched and comprehensive information, using engaging language and a beautiful presentation. It is a book that can be read through methodically, page by page or it can be dipped in an out of as clinical practice dictates.
There is a substantial amount of new, revised and updated information in this second edition, including many more useful new formulas, and I have no hesitation in recommending it whole heartedly to all students and practitioners.
Tony Booker
