In this type of combination, two herbs with similar functions are used together to increase the therapeutic effect, achieving a safer and more effective therapeutic result than the use of a larger dosage of a single herb. For instance, Jing Jie ( Schizonepetae herba) and Fang Feng ( Saposhnikoviae radix) can expel wind and release the exterior much more strongly when they are used together. Jin Yin Hua ( Lonicerae flos) and Lian Qiao ( Forsythiae fructus) can more effectively reduce heat-toxin if they are used together. Da Huang ( Rhei rhizoma) and Mang Xiao ( Natrii sulfas) can promote bowel movement to treat severe constipation more effectively and safely than the use of Da Huang ( Rhei rhizoma) alone.

This type of combination involves two herbs that have different functions. The first directly targets the pathological condition and the second increases the therapeutic effect of the first. For instance, Zhi Mu ( Anemarrhenae rhizoma) nourishes the Yin of the Kidney and clears heat in the Lower-Jiao, while Huang Bai ( Phellodendri cortex) reduces empty-heat in the Lower-Jiao and is therefore able to enhance Zhi Mu’s function of nourishing the Yin.

In addition, this type of combination is widely used to correct the side effects of a particular herb, to prolong the action of a herb in a steady way, to moderate the movement of Qi and to harmonize the internal organs. In this type of combination, the first herb treats the main disorder and its dosage and function are larger and stronger than those of the second herb. The second herb serves to reduce the side effects and to moderate the speed and the temperature of the first. For example, sweet Zhi Gan Cao ( Glycyrrhizae radix preparata) can moderate the speed of hot Fu Zi ( Aconiti radix lateralis preparata)* and can also reduce the harsh purging effect of Da Huang ( Rhei rhizoma).

Moreover, some special strategies have been developed from this type of combination to achieve efficient therapeutic effects. For example, upward-moving and downward-moving herbs, and dispersing and restraining herbs may be used at the same time. The first herb treats the disorder and the second herb, which has different or opposite properties, directional tendency and functions, serves as its assistant. In this way, it keeps the action of the first herb steady and moderate. For instance, when the aim of treatment is to strengthen the exterior, the sweet and warm Huang Qi ( Astragali radix) is used to tonify and stabilize the Defensive-Qi. It is combined with a small amount of Fang Feng ( Saposhnikoviae radix), which is pungent and warm, and which is used to disperse wind from the exterior, thereby ensuring that Huang Qi does not trap the wind in the superficial region of the body. Fang Feng thus enables Huang Qi to achieve the desired therapeutic outcome without any side effects.

Another example is when one wants to strengthen the Heart-Qi and treat restlessness and palpitations. Here Ren Shen ( Ginseng radix) is often selected as it directly tonifies Heart-Qi. Ren Shen is combined with a small amount of Wu Wei Zi ( Schisandrae fructus) which is very sour and has a stabilizing and binding ability. It can stabilize the Heart-Qi which Ren Shen generates. Moreover, when the Heart-Qi is weak, it may find it hard to accept strong tonifying action and Ren Shen used on its own may lead to restlessness and palpitations at the start of treatment and may further consume Heart-Qi. In this condition, Wu Wei Zi can reduce the harsh effects of Ren Shen and make its action more moderate and longer lasting.

There are many examples that illustrate the benefits of this type of herbal combination. Huang Lian ( Coptidis rhizoma) descends and clears fire from the Stomach, but it may also suppress Stomach-Qi and cause discomfort in the Stomach. If Sheng Ma ( Cimicifugae rhizoma) is prescribed at the same time, it can ascend and disperse the Stomach-Qi constraint and Stomach-fire, thereby reducing the side effects of Huang Lian.

In this combination, the characteristic side effects or toxicity of a single herb can be minimized or neutralized by another. This combination strategy is often used when processing harsh and toxic herbs. For example, the toxic effects of Ban Xia ( Pinelliae rhizoma) can be reduced by Sheng Jiang ( Zingiberis rhizoma recens).

In this type of combination, the first herb suppresses or minimizes the toxicity of the second herb. For instance, Lü Dou ( Phaseoli radiati semen) can reduce the toxicity of Ba Dou ( Crotonis fructus)*, while Ge Hua ( Puerariae flos) can reduce the toxic effects of alcohol.

In this type of combination, some herbs can reduce the therapeutic effect of others. For instance, Lai Fu Zi ( Raphani semen) can reduce the ability of Ren Shen ( Ginseng radix) to tonify the Qi. This type of herbal combination and effect should be avoided in treatment. The Chinese medical tradition has identified 18 antagonistic substances:

In this type of relationship, as soon as the two herbs are used together, a dangerous effect can arise so the use of this type of combination is absolutely forbidden. Traditionally there are 19 substances involved:

This is a special pattern in herbal relationships. Some herbs can be used alone to treat a simple syndrome or to achieve special effects based on their characteristics. Some herbs can be used alone because they have reasonably balanced properties and functions. For instance, in critical conditions, Ren Shen ( Ginseng radix) can be used on its own in a large dosage to rescue the Yang and Qi from collapse. Dan Shen ( Salviae miltiorrhizae radix), which can cool the blood, clear heat and promote blood circulation, is often used alone in conditions where heat is consuming the Yin and blood, leading to blood stagnation. Dang Gui ( Angelicae sinensis radix) can also be used alone as it has a moderate action in promoting blood circulation and tonifying the blood.

Of the above seven types of relationship, those of mutual accentuation and mutual enhancement are commonly used in treatment; mutual counteraction and mutual suppression can also be used, especially to reduce herbs’ side effects or toxicity. The single herb effect is only used in a limited number of disorders; relations of mutual antagonism and mutual incompatibility should be avoided in treatment.

In addition to these relationships, there is another kind of relationship between herbs in treatment. In this type of combination, two herbs work as one unit although they have different properties and functions, and in this case they are equally important. Together they treat a condition with which a single herb would not be able to deal. For example, to treat warm and cold coexisting in one syndrome, where Yang and Qi deficiency generate cold while stagnation of Qi generates heat, the patient may, on the one hand, have a cold, weak and sensitive Stomach and prefer warm drinks and compresses; on the other hand, the patient may have a dry mouth with a bitter taste and heartburn. In this situation, the pungent and warm Ban Xia ( Pinelliae rhizoma) which can disperse cold is used with the bitter and cold Huang Qin ( Scutellariae radix) which can reduce the accumulated heat. Without this combination, it is almost impossible to treat this syndrome effectively. Another example is when one needs to regulate the Lung-Qi, clear heat and relieve shortness of breath. The pungent and hot Ma Huang ( Ephedrae herba)* is used to stimulate the Yang and disperse the Lung Qi; the sweet and cold Shi Gao ( Gypsum) is used to descend the Lung-Qi and clear the heat of the Lung. This combination can regulate the Qi and smooth the breath.

(See Figure I.1 on page 34.)

Clear and correct syndrome differentiation is very important for selecting a suitable treatment method and creating an effective formula. Detailed differentiation of a syndrome should include the following parts.

The treatment principle takes the main syndrome in a complex condition as the target for treatment. In the process of treatment, the syndrome will change and the treatment principle will thus change too. For instance, in a syndrome of Liver-Yang ascending and generating Liver-wind, the treatment principle should be to intensively and quickly descend Liver-Yang and extinguish Liver-wind. Once the Liver-Yang has returned to its original place and the Liver-wind has disappeared, a syndrome of deficiency of Spleen-Qi and stagnation of Liver-Qi may then become the main syndrome. The treatment principle should change to that of spreading the Liver-Qi and strengthening the Spleen.

Following the treatment principle, which is established in accordance with the syndrome differentiation, a formula can be composed. A formula is neither a group of herbs that treat all symptoms nor a combination that only treats the main syndrome. It has a structure where herbs are organized in order to meet the needs of the treatment. The structure of a formula contains four parts, namely: the chief, the deputy, the assistant(s) and the envoy. Each of these has specific functions in the formula.

In order to compose effective formulas, the principles, methods and strategies of selecting herbs are very important. They enable a practitioner to compose formulas to treat a variety of syndromes. The principles, methods and strategies introduced in each chapter of this book are abstracted from a large number of formulas, integrating the knowledge of single herbs, herbal combinations, syndrome differentiation, treatment methods and treatment sequence. They are the essential part of this book.

Before composing a formula, the relevant syndrome is first identified. The syndrome is analyzed and divided into the principal syndrome and the secondary syndrome, which are manifested in the main symptoms and the secondary symptoms, with specific signs on the tongue and the pulse. These are the first steps in selecting the appropriate herbs to fulfill different roles in the formula. Moreover, the syndrome analysis evaluates the development of the disorder of the internal organs with regard to the pathological change. This provides another clue to assist the selection of the herbs in the formula. For instance, if Liver-Qi stagnation is diagnosed, it follows that the Liver can easily attack the Spleen, so in the formula some herbs that strengthen the Spleen should be prescribed. Similarly, if the patient has a Yang constitution, the stagnation of Liver-Qi can quickly generate Liver-fire, so some herbs that prevent the generation of fire or prevent the heat becoming strong should be added as well. In a condition of excess heat in the Lung, one should be aware that strong fire can easily consume both the Yin and the Qi, so one should not only prescribe herbs to reduce fire, but also herbs that nourish the Yin and tonify the Qi.

Next, an appropriate treatment principle to treat the presenting syndrome is established. For example, to treat an excess heat syndrome in the Lung, the treatment principle is to reduce the heat, nourish the Yin, regulate the Lung-Qi and, at a later stage, strengthen the Lung-Qi.

As soon as a treatment principle is established, the composition plan and treatment strategies can be arranged. For instance, to treat the syndrome of excess heat in the Lung and Stomach, one would first prescribe herbs that have sweet-cold, bitter-cold or salty-cold properties, and which have the functions of clearing heat and reducing fire in the Lung and Stomach. Second, herbs that are sweet and cold and that can nourish body fluids and protect the Yin, which has been severely consumed by the excess heat, should be selected. Herbs that can tonify the Qi should be selected if the Qi is weakened severely by the heat. Herbs that moderate the actions of the harsh herbs in the formula, and reduce their side effects, should also be added.

The composition plan and the treatment strategies are effected by appropriate herbs, which are selected carefully according to their properties, functions and characteristics. Take again the treatment of excess heat in the Lung and Stomach as an example. Shi Gao ( Gypsum) is selected as the chief in the formula because it has cold, sweet and pungent properties, enters the Lung and Stomach meridians and can directly and intensively reduce excess heat in the Lung and Stomach. Zhi Mu ( Anemarrhenae rhizoma) is selected as deputy because it is moistening and cold. On the one hand it can accentuate the function of Shi Gao to reduce the excess heat; on the other hand it can nourish the Yin, which has been badly damaged by the heat, thereby directly treating the secondary syndrome. Gan Cao ( Glycyrrhizae radix) and Jing Mi (non-glutinous rice) are selected as assistants to tonify the Qi of the Spleen and to protect the Stomach from injury by the pathogenic heat and the bitter, cold and heavy herbs.

Generally speaking, the most common dosage for most crude herbs in Chinese texts is about 3–9 g orally per day. Modern concentrated herbal powder is six times stronger than crude herb, thus the common dosage for most single herbs is 0.5–1.5 g per day. According to my own experience, this dosage can be reduced to 0.2–0.5 g. A list specifying the dosages for individual herbs can be found in Appendix I.

Bland herbs, which promote urination and leach out dampness, can be used in relatively large doses; these include Fu Ling ( Poria), Yi Yi Ren ( Coicis semen) and Che Qian Zi ( Plantaginis semen).

Tonifying herbs can also be used in relatively large doses; these include Huang Qi ( Astragali radix), Shu Di Huang ( Rehmanniae radix praeparata), Mai Men Dong ( Ophiopogonis radix) and Bai He ( Lilii bulbus).

Aromatic herbs that open the orifices, expel wind-heat or wind-cold and promote Qi movement should be used in relatively small doses; these include Bing Pian ( Borneol), Su He Xiang ( Styrax), Bo He ( Menthae herba), Chai Hu ( Bupleuri radix), Xin Yi ( Magnoliae flos), Bai Zhi ( Angelicae dahuricae radix), Mu Xiang ( Aucklandiae radix)** and Sha Ren ( Amomi xanthioidis fructus).

Herbs that are used alone should be prescribed in relatively large doses; when they are prescribed as part of a formula, the dosage should be smaller.

The dosages of herbs in a formula should follow the standard dosages of the individual herbs. However, dosages may be varied within the normal dosage range according to the position each herb occupies in the formula. Generally speaking, a relatively large dose of the chief herb(s) should be prescribed, whereas envoy herbs should be given at small dosages. The dosages of the deputies and the assistants depend on their number and the strength of the functions required of them. In a small formula (i.e. one that contains less than five herbs), the dosages should be relatively large. In a medium-sized formula (containing 9–12 herbs), medium-sized dosages should be used. In a large formula (containing more than 20 herbs), the dosages should be low.

The dosages of the individual herbs in a formula should be varied according to the presenting syndrome. For instance, the usual dosage for Chai Hu ( Bupleuri radix) is 6–9 g per day. It is pungent and neutral, and can effectively ascend and spread the Liver-Qi. It is very often used as the chief herb in formulas to treat Liver-Qi stagnation. However, in situations where Liver-Qi stagnation is accompanied by blood deficiency, a smaller dosage of Chai Hu (e.g. 6 g), should be prescribed to ensure that its Qi dispersing effect does not consume or weaken the blood. If the presenting condition features Liver-Qi stagnation with Spleen-Qi deficiency and an accumulation of dampness in the Upper- and Middle-Jiao, Chai Hu should be prescribed at a relatively large dosage, such as 9 g, because it needs more strength to disperse in order to overcome the dampness. In a case with Liver-Qi stagnation, Liver-Yin deficiency and Liver-Yang rising, Chai Hu should be prescribed at a very low dose, such as 3 g, or even removed from the formula altogether to prevent its ascending property from exacerbating the tendency of Liver-Yang to rise.

When treating acute diseases, or the active stage of chronic diseases, the dosages of herbs in a formula should be large. When the disorder is under control, the dosages should be reduced. Formulas that open the orifices, induce sweating, vigorously purge accumulation by promoting bowel movement and induce vomiting are used only once. Afterwards, the dosage must be adjusted according to the patient’s condition. For instance, to treat severe constipation due to severe obstruction of food, Qi, blood and fire-toxin in the abdomen, a vigorously purging formula should be given to eliminate accumulation. But only a single dose should be given. If the condition of the patient does not improve and the syndrome remains the same, this formula should be given again. As soon as the patient has a bowel movement, use of the formula should cease, and a gentle formula to regulate the Qi, moisten the intestines and protect the Spleen should be prescribed.

Formulas that contain strong herbs to treat acute and excess syndromes should not be used at high dosages for more than 4 weeks. These include formulas that:

In treating chronic diseases, or after intensive treatment for acute disorders lasting 1–4 weeks, the herbs in a formula should be prescribed at lower dosages. Herbs that tonify or harmonize the functions of the internal organs should be added.

Intensive treatment can be repeated, according to the disease and the patient’s condition.

Gentle tonifying herbs can be used for months or even years at low doses to keep the patient’s condition stable, to strengthen the body’s resistance and to maintain a good health.

It is good to have breaks in long-term treatment of chronic disorders. The best time to do this is in the summer because summer-heat or damp-heat may weaken the function of the Spleen at this time, and the herbs may overburden the Spleen and cause digestive disorders.

Relatively large dosages can be prescribed for young people, people with good constitutions and people in good physical condition when they suffer from acute excess syndromes. Small dosages are prescribed for elderly people, people with weak constitutions and people who suffer from chronic diseases.

Foodstuffs and drinks possess warm or cold properties which may influence the action of herbs. Generally speaking, coffee, spices, mutton, liver, fat, oil and nuts can easily generate heat. Most fruit, vegetables and cold beverages have a cold nature and can bring cold into the body. Milk products and fat may generate phlegm. This should be taken into consideration when prescribing the herbs in a formula.

In addition to the nature of the presenting disorder and the patient’s constitution, seasonal and climatic factors should also be considered.

In summer or in places with a warm dry climate, pungent, warm and bitter herbs should not be used at high doses because the pores of the body are not tightly closed and so the body fluid can easily be consumed by heat. This precaution relates to herbs that induce sweating, expel wind and cold, disperse the Lung-Qi, dry dampness and increase urination.

In winter or in cold places, cold, bitter, sour and astringent herbs should be prescribed in a relatively low dose. This precaution relates to herbs that clear heat, cool blood and drain downward. In humid places, herbs that transform dampness, activate the Qi movement and promote digestion should be used in relatively large doses because the herbs need extra strength to overcome the dampness.

At times of great stress and high emotion, or of severe physical exertion and tiredness, the body becomes more sensitive, and herbs should be prescribed at lower dosages than normal. For instance, to treat severe tiredness due to Spleen-Qi and Heart-blood deficiency, herbs that tonify the Qi and blood should be used in the formula but their doses should be very low because any strong stimulation and tonification may cause further disorder in the body. If the patient suffers from insomnia and anxiety, formulas that calm the mind and sedate the Heart-spirit should be used first. At the time of menstruation, or if the patient has a bleeding wound, or immediately after surgery, herbs that promote Qi and blood should be prescribed at low dosages. If the patient is breast-feeding, herbs that are very warm or cold or that have harsh properties should not be used or only prescribed in low doses.

The dosages prescribed should take proper account of the patient’s medical history.

When patients suffer from chronic liver or kidney disease, the selection of the herbs and their dosages should be determined carefully to avoid placing an unnecessary workload on these weakened organs. At the same time, herbs that protect these organs and promote their function should also be included. For instance, acute or chronic liver diseases are mainly differentiated into a syndrome consisting of Spleen-Qi deficiency, damp-heat and heat-toxin accumulation, and herbs that treat this syndrome can be used. Chronic kidney diseases are mainly differentiated as Kidney-Yang and Spleen-Yang deficiency, dampness accumulation and heat-toxin in the blood. Herbs that treat this syndrome should be used in appropriate doses to help restore kidney function.

If a patient has recently undergone surgery, the Qi and blood need time to get strong again, so pungent, very warm or very cold herbs should only be used in low doses.

In situations where western drugs are used together with herbs and have similar functions, such as inducing sweating, stimulating blood circulation, removing congealed blood, purging the intestines and sedating the mind, the dosage of the drug or the herbs should be reduced.