Yong gang Han

Abstract: According to the section on “Herbalists and Alchemists” in the “Treatise on Literature” in the Han Shu ［Book of Han］, preQin dynasty traditional Chinese medicine was divided into 4 major schools. Among the 11 texts it mentions from the school of classical remedies, only the Tangye Jingfa ［Canonical Methods for Brews and Decoctions］was passed on through Shanghan Zabing Lun ［On Cold Damage and Miscellaneous Diseases］and Fu Xing Jue ［Extraneous Secrets］. The term “classical remedy” or “Jing Fang” has 4 layers of connotation: classic, selected, simplified, and precise. These 4 connotations are the 4 criteria for distinguishing “classical remedies” from “nonclassical remedies”. The 2 guidelines for creating classical remedies are “sovereign, minister, assistant, and envoy ［i.e. the medicinal roles］” and “the harmony of the 7 affects”. Classical remedies strive to be concise and precise. The author recommends 13 ingredients as the upper limit for a prescription.

Keywords: Classical remediesTangye Jingfa ［Canonical Methods for Brews and Decoctions］ Shanghan Zabing Lun ［On Cold Damage and Miscellaneous Diseases］ Fu Xing Jue ［Extraneous Secrets］ medicinal ingredients in a prescription

The origins of classical remedies

The section on the “Domain of Herbalists and Alchemists” in the “Treatise on Literature” in the Han Shu ［Book of Han］states: “［There are］ 18 volumes in Huangdi Neijing ［Yellow Emperor’s Inner Canon］, 39 volumes in Waijing ［Yellow Emperor’s Outer Canon］, 9 volumes in Bianque Neijing ［Bian Que’s Inner Canon］, 12 volumes in Waijing ［Bian Que’s Outer Canon］, 38 volumes in Baishi Neijing ［Bai’s Inner Canon］,and 36 volumes in Waijing ［Bai’s Outer Canon］. ［There are］ 25 volumes in the Pangpian ［Side Treatise］. These 7 medical classic texts ［contain a total of］ 216 volumes. The medical classics examine the blood vessels, channels and network vessels, bones and marrow, yin and yang, and exterior and interior of the human body to reveal the root of the hundred diseases, and distinguish between life and death. They use needles, stones, decoctions, and fire as treatment methods, and adjust the hundred medicinal preparations appropriately. The best preparation is like a magnet attracting iron, bringing about a powerful response. Unskilled practitioners who fail to grasp these theories make ［those who are in］ recovery worse and bring death to the living.

［There are］ 46 volumes in Wuzang Liufu Shan Shiliu Bingfang ［Prescriptions for 16 Mounting Diseases of the 5 Viscera and 6 Bowels］, 40 volumes in Wuzang Liufu Dan Shier Bingfang ［Prescriptions for 12 Jaundice Diseases of the 5 Viscera and 6 Bowels］,23 volumes in Qinshi Huangdi Bianque Yufu Fang ［Remedies of Qin Shi, Yellow Emperor, Bian Que, and Yufu］, 31 volumes in Wuzang Shangzhong Shiyi Bingfang ［Prescriptions for 11 Diseases of Damage to the 5 Viscera］, 17 volumes in Keji Wuzang Kuangdian Bingfang ［Prescriptions for Visiting Diseases of the 5 Viscera, Mania, and Withdrawal］, 30 volumes in Jinchuang Zongchi ［Incised Wounds, Slackening, and Tugging］, 19 volumes in Furen Yinger Fang Prescriptions for Women and Infants］, 32 volumes in Tangye Jingfa ［Canonical Methods for Brews and Decoctions］, and 7 volumes in Shennong Huangdi Shijin ［Dietary Contraindications of the Divine Husbandman and Yellow Emperor］. These 11 classical remedy texts ［contain a total of］ 274 volumes. Classical remedies ［use］ the cold and warm ［properties of］ roots, herbs, and stones. They measure the depth of disease ［and］ use the nourishment of medicinal ingredients in a way that is appropriate for the season and climate. They identify the 5 bitter and 6 acrid properties ［i.e. the medicinal properties required by the viscera and bowels］ to create formulas of fire and water ［i.e. hot and cold] that open what is blocked and resolve what is bound, returning ［the patient］ to normal.”

The “Treatise on Literature” in the Book of Han is the earliest extant bibliographical treatise; it is a comprehensive list of the Han dynasty national library. The author, Bangu, based it on Bielu ［Separate Records］and Qilüe ［7 Domains］,written by Liu Xiang and his son Liu Xin. Bangu divided the text into 6 domains: Confucians, philosophers, poets, militarists, astrologers and diviners, and herbalists and alchemists. At the time, TCM was considered part of the school of herbalists and alchemists, so related works are listed in the corresponding section. According to the“Domain of Herbalists and Alchemists”, preQin dynasty TCM was divided into 4 major schools, namely the medical classics school (7 texts), the classical remedies school (11 texts), the bedchamber school (8 texts), and the spirit immortal school (10 texts).

Modern scholars have proposed the concept of “broad” and “narrow” definitions of classical remedies. The “broad” definition of classical remedies includes the 11 texts listed in the “Domain of Herbalists and Alchemists”, while the “narrow” definition specifically refers to Zhang Zhongjing’s Shanghan Zabing Lun ［On Cold Damage and Miscellaneous Diseases］. Of the 11 texts on classical remedies, all have been lost to history except for Yi Yin’s Tangye Jingfa, which was preserved in Shanghan Zabing Lun and Fu Xing Jue.

I believe that both Tao Hongjing’s Fu Xing Jue and Zhang Zhongjing’s Shanghan Zabing Lun originate from Yi Yin’s Tangye Jingfa, and they are the existing representatives of the classical remedies school. Metaphorically speaking, Fu Xing Jue is the eldest son and Shanghan Zabing Lun is the second son of Tangye Jingfa. In ancient Chinese society, the primary responsibility of the eldest son was to serve as the successor of the nation or family, while the second son was free to innovate. Therefore, as the eldest son, Fu Xing Jue faithfully preserved Tangye Jingfa, while the second son, Shanghan Zabing Lun, drew from many sources to innovate on the foundation of Tangye Jingfa. For example, Tangye Jing only discusses “exterior and interior”, while Shanghan Lun adds the concept of “halfexterior, halfinterior”.

The connotations of classical remedies

I believe that the term “classical remedy” has 4 layers of connotation: classic, selected, simplified, and precise. These 4 connotations are the 4 criteria for distinguishing “classical remedies” from “nonclassical remedies”.

First, classical remedies are classic prescriptions. Tangye Jingfa is the only remaining classic text of the “11 texts on classical remedies”; Shanghan Zabing Lun and Fu Xing Jue have preserved this authentic classical remedy lineage.

Second, classical remedies are selected prescriptions. The original text of Fu Xing Jue recorded 60 formulas; the 52 that currently remain all originate from Tangye Jingfa and are true “classical remedies”. Because they were carefully chosen by Tao Hongjing from the 365 classical remedies in Tangye Jingfa, they are selected classical remedies.

Third, classical remedies are simplified prescriptions. Compared to the large formulas written by many modern TCM practitioners containing as many as 20 or 30 ingredients, the traditional medicinal formulations in Fu Xing Jue are concise with few ingredients. For instance, among the 24 major and minor formulas for supplementing and draining the viscera and bowels, minor drainage formulas have 3 ingredients, minor supplementation formulas have 4 ingredients, major drainage formulas have 6 ingredients, and major supplementation formulas have 7 ingredients. Xici ［Commentary on Appended Phases］in Zhou Yi ［Classic of Changes］says, “That which is simple is easy to understand; that which is concise is easy to follow. Ease of understanding yields familiarity; ease of following yields results.” The ancient saying that “the great way is the simplest” is not just empty words; simple methods and techniques are easy to master and apply.

Fourth, classical remedies are precise prescriptions. Still using the aforementioned 24 formulas from Fu Xing Jue as an example, all of them are precisely targeted at the core pathology. The minor formulas focus on the affected viscera. The major formulas also handle the mother or child viscera with “a formula within a formula” to treat the mother and child at the same time, supplementing vacuity and draining repletion in a precise treatment. The “precision medicine” sensationalized by modern western medicine and TCM is actually the same as what ancient Chinese practitioners promoted thousands of years ago.

The number of ingredients in classical remedies

According to Zhang Dachang Yilun Yian Ji ［Collected Medical Treatises and Cases of Zhang Dachang］, “While there is a big difference between the academic achievements of post antique formulas and classical remedies, at least the latter follow rules and do not lead to excess. Overall, they are much better than the prescriptions of some mainland Chinese practitioners today. A prescription may use dozens of ingredients in large doses, with no distinction between their primary and secondary functions, and most of the preparation techniques are absurd. The notion that one should use many ingredients for severe diseases, specially selected ingredients for unusual diseases, and adjust doses as one sees fit actually does not work in practice. This is like wasting a whole roll of silk just to make a sheath for a pocket knife or filling a giant cauldron of water just to drink a cupful. For beginners, such practices would not be surprising; if experienced practitioners continued to do this, would it not be a joke? The ancients said it best: nothing can be accomplished without following norms and standards. This is an old cliché, but should not be forgotten.”

In my paper “Medicinal Pairs and Trios in Fu Xing Jue”, I discussed 2 major rules for formulating classical remedies, which are also the 2 major principles for combinations in classical remedies: “sovereign, minister, assistant, and envoy ［i.e. the medicinal roles］” and “the harmony of the 7 affects”. This paper primarily explores the number of ingredients in classical remedies.

Yifang Jijie ［Medical Formulas Gathered and Explained］, written by Qing dynasty practitioner Wang Ang, states: “When the ancients created formulas, they used few ingredients in large doses. This is like how a skilled soldier taking a single route is sufficient to breach barricades and capture the king. Later generations lacked the awareness of their predecessors; they decreased the doses and gradually increased the number of ingredients. This is like setting up a wide perimeter in hopes of possibly encountering the enemy. With so many components, attacking and taking control is sure to be complicated. Can one avoid benefiting the opponent if one does not succeed in this?”

In his text Sushen Liangfang［Good Prescriptions of Su and Shen］, Song dynasty scientist Shen Kuo wrote: “It is easy to understand the use of individual medicinal ingredients and hard to understand their use in compounds.” The chemical components of Chinese herbal medicine are very complicated. A single medicinal ingredient contains multiple organic and inorganic components, so even on its own, it has more than a single effect. The addition of more unknown factors and the combination of multiple ingredients create an extremely complex multi component system. Reactions such as acid base neutralization, oxidation, reduction, substitution, hydrolysis, polymerization, and condensation may occur, all of which could change the original nature of the medicinal ingredients.

According to the 5 flavor supplementation and drainage theory in Fu Xing Jue, any of the 5 flavors could be the “functional flavor” for a given viscus and the “substantial flavor” for the viscus that it restrains, so taking a single medicinal ingredient will act on at least 2 viscera at once, namely the affected viscus and the viscus it restrains (the grandchild), which means that supplementing a given viscus necessitates draining another. Specifically, the acrid flavor supplements liver wood while draining spleen earth, the salty flavor supplements heart fire while draining lung metal, the sweet flavor supplements spleen earth while draining kidney water, the sour flavor supplements lung metal while draining liver wood, and the bitter flavor supplements kidney water while draining heart fire. The greater the number of medicinal ingredients, the harder it is to grasp and control the effects they cause. For this reason, Fu Xing Jue, drawing upon Tangye Jingfa, strives for simplicity in its use of medicinal ingredients. If a minor formula can be used to solve a problem, it does not use a major formula, and even the major formulas contain no more than 7 ingredients.

This presents a stark contrast to modern TCM. According to Fangyao Liangxiaoxue ［Formula and Medicinal Dosimetry］, edited by Tong Xiaolin, an academician of the Chinese Academy of Sciences: “Modern prescriptions contain an average of 19 ingredients; among these, the total dose of all ingredients in the majority of formulas is between 200 and 250 grams. Compared to classical remedies, the number of ingredients used by modern clinical prescriptions has noticeably increased, while there is no major difference in the total dose of all ingredients. Calculations show that the average dose of individual ingredients (total dose of all ingredients / number of ingredients) in modern formulas is less than that of classical remedies. ［…］ In proven cases of classical remedies used by expert TCM practitioners, a single formula contained an average of 10.83±4.09 ingredients, with 11 ingredients being the most common for a total of 134 formulas (13%). The average total dose of all ingredients was 127.43±70.24 grams, with a minimum of 15 grams and a maximum of 678 grams.” Overall, it is clear that the prescriptions written by the majority of modern TCM practitioners tend to contain a relatively large number of ingredients, while the 11 ingredient formulas typically written by expert practitioners fit the requirements of TCM classics.

Clinical application methods of classical remedies from Fu Xing Jue

I recommend the following methods for clinical application of the 24 major and minor formulas for supplementing and draining the viscera and bowels from Fu Xing Jue: (1) Use a single minor or major formula. (2) Supplement a minor or major formula. (3) Combine 2 minor formulas. (4) Combine a minor formula with a major formula.

I do not recommend combining 2 major formulas for a simple reason: the greater the number of ingredients, the more complicated the interactions between ingredients and the more difficult it is to maintain control. Not only does this fail to conform to the ancient concept that “the great way is the simplest”, it also deviates from the modern concept of “precision medicine”.

In terms of the number of ingredients in a prescription, I advocate for an upper limit of 13 ingredients in TCM prescriptions. My teacher, modern TCM master Fang Yaozhong, always emphasized that “words must be based in fact; believe nothing without evidence”; is there evidence for my proposal in the TCM classics?

Chapter 74 of Huangdi Neijing Suwen ［The Yellow Emperor’s Inner Canon, Elementary Questions］, entitled “Comprehensive Discourse on the Essentials of Utmost Truth”, states: “1 sovereign and 2 ministers is a small composition; 1 sovereign, 3 ministers, and 5 assistants is a midsized composition; 1 sovereign, 3 ministers, and 9 assistants is a large composition.” In Neijing, which belongs to the medical classics school, there is a 3level system of medicinal roles consisting of sovereigns, ministers, and assistants. Small formulas have 3 ingredients, midsized formulas have 9 ingredients, and large formulas have 13 ingredients.

The preface to Shennong Bencao Jing ［The Divine Husbandman’s Herbal Foundation Canon］ states: “Medicines consist of sovereigns, ministers, assistants, and envoys, which serve to mutually diffuse, contain, unify, and harmonize each other. It is best to use 1 sovereign, 2 ministers, and 5 assistants, or one can use 1 sovereign, 3 ministers, and 9 assistants and envoys.” In this text, which belongs to the classical remedies school, small formulas have 8 ingredients, while large formulas have 13 ingredients.

Fu Xing Jue, which belongs to the classical remedies school, contains 24 major and minor formulas for supplementing and draining the viscera and bowels. Minor drainage formulas have 3 ingredients and minor supplementation formulas have 4 ingredients; minor formulas focus on the affected viscera. Major drainage formulas have 6 ingredients, focusing on the affected viscera and the mother viscera. Major supplementation formulas have 7 ingredients, focusing on the affected viscera and the child viscera.

In my first few years of systematically using Fu Xing Jue in clinical practice, most of my prescriptions contained 11 ingredients. At present, I generally tend to use 9 ingredients in each prescription. Tian Heming (1883-1980), a famous TCM practitioner from Chengdu, Sichuan province, who lived to the age of 97, carefully followed Zhang Zhongjing’s methods by using a small number of selected medicinal ingredients. He preferred to use formulas containing 8 ingredients, so people called him“Tian 8 Ingredients”.

In clinical practice, I suggest that the first choice should be to use a single minor or major formula, which can be supplemented with other ingredients. The second choice is to combine 2 minor formulas for a total of 6 to 8 ingredients, or combine 1 major formula with 1 minor formula for a maximum of 11 ingredients. Whenever possible, one should avoid combining 2 major formulas. The first reason for this is that 2 major formulas contain a total of up to 14 ingredients, which exceeds the limit of 13 ingredients. The second reason is that 2 major formulas would target 4 viscera, resulting in a lack of focus and prioritization. Expert TCM practitioners are like expert martial artists; among the 5 viscera, they choose one to focus on as a priority for supplementation or drainage, just like an expert martial artist’s decisive final move! If the disease symptoms are so complex that it is hard to confirm which one of the 5 viscera is key to the pathology, then focus on the affected viscus, include its mother or child, or include the viscera that restrain or are restrained by it. Following the pattern of engendering, restraining, controlling, and transforming is still an acceptable choice. Using medicines that focus on 3 viscera at a time is likely to yield mediocre results.

In addition, I frequently combine 2 minor formulas in clinical practice by using 1 minor drainage formula and 1 minor supplementation formula. Why does the combination of 1 minor drainage formula and 1 minor supplementation formula yield good results?

According to chapter 66 of Huangdi Neijing Suwen, entitled “Comprehensive Discourse on the Arrangement of the Original ［Qi］ of Heaven”: “The emperor said, ‘Good. What is meant by “qi may be abundant or lacking; the ［physical］ form may be exuberant or debilitated”?’ Gui Yuqu said, ‘［This refers to］ the respective abundance or lack of the qi of yin and yang, so they are called the 3 yin and 3 yang. ‘The form may be exuberant or lacking’ refers to the treatment of the 5 phases, among which each may be excessive or insufficient. Hence, at the start, ［a phase］ may be in excess and insufficiency will follow it, or ［a phase］ may be insufficient and excess will follow it. If one knows that which has come up and that which follows, the qi can be predicted.”

It can be seen that the excess of a given viscus, bowel, channel, or network vessel inevitably accompanies the insufficiency of another viscus, bowel, channel, or network vessel that is associated with it, and the opposite is also true! What practitioners must do is use the 4 examinations to accurately locate the viscera, bowels, channels, and network vessels affected by the pathology. After the viscera, bowels, channels, and network vessels involved in the core pathology have been confirmed, one can supplement or drain them and those to which the pathology has shifted based on motherchild and overwhelmingrebellion relationships. Supplement vacuity and drain repletion; this is the actual application of the concept that “the great way is the simplest” in TCM!

About the Author:

Han Yonggang earned his doctoral degree from the Institute of Basic Research in Clinical Medicine at the China Academy of Chinese Medical Sciences. He studied under Wang Yongyan, a member of the Chinese Academy of Engineering, and Professor Gao Sihua, former president of Beijing University of Chinese Medicine. He has worked in the UK since 2009, where he is currently employed at Chelsea Natural Health Clinic and the London Academy of Chinese Acupuncture. He is a member of the World Classic Chinese Medicine Association Expert Committee, a standing member of the World Federation of Chinese Medical Societies Expert Committee on Prescription Dose Effects, and a council member of the World Federation of Chinese Medicine Yunqi Societies.

Email:[email protected] WeChat: yonggang01

References

1. Zhang Dachang. Zhang Dachang Yilun Yian Ji ［Collected Medical Treatises and Cases of Zhang Dachang］. Beijing: Xueyuan Chubanshe ［Academy Press］, 2008.

2. Han Yonggang. Medicinal pairs and trios in Fu Xing Jue. World Chinese Medicine Journal (Swiss version). 2002, 2(4): 226-236.

3. Han Yonggang. Overall principles for the formulation of supplementation and drainage formulas for the viscera and bowels in Fu Xing Jue. The Journal of Chinese Medicine and Acupuncture. 2022, 29(2): 45-48.

4. Tong Xiaolin. Fangyao Liangxiao Guanxi Mingyi Huijiang ［Collected Speeches by Famous Practitioners on Formula and Medicinal Dosing Relationships］. Beijing: Renmin Weisheng Chubanshe ［People’s Medical Publishing House］, 2014.

5. Tong Xiaolin. Fangyao Liangxiaoxue ［Formula and Medicinal Dosimetry］. Beijing: Kexue Chubanshe ［China Science Publishing & Media］, 2015.