Determining the Appropriateness of a Formula

Originally published February 2012

The Mayway Herbal Consultants are available every day by phone and email to answer your questions and address your concerns about our herbs and products. In the Consultants’ Corner we will share in-depth information about the most frequently asked questions.

TCM Syndrome - Pattern

Many practitioners have contacted the Mayway consultants over the years with questions regarding how to determine whether a given formula is appropriate for their patient. There is not one simple or universal answer to this question. This is particularly true when complex cases present with several different aspects, only part of which matches the formula in question.

Pulse diagnosis Though there is not always a clear-cut answer to this, in general, the Chinese syndrome-pattern diagnosis is the most important match to look for. Even when the TCM diagnosis is accurate, patients may have more or fewer symptoms than what are classically indicated for a given formula and do not need to present every symptom in the indications for a formula to work.

For example, if a patient had Liver Qi stagnation, they could have a wide variety of complaints in a variety of systems ranging from emotional to reproductive to neurological. There are clinical reasons to choose Shu Gan Wan or Si Ni San over Xiao Yao Wan, but any of these three formulas would be helpful to move the Liver Qi to benefit this patient.

Looking more closely at the other functions of the formula can help guide your selection. For example, Shu Gan Wan harmonizes the Liver and Stomach, invigorates the Blood, and eliminates Food Stagnation. Si Ni San regulates Liver and Spleen and clears heat from the interior. Xiao Yao Wan softens the Liver, nourishes Blood, and strengthens the Spleen. So, if the patient also had signs of Liver attacking the Stomach and Food Stagnation, then Shu Gan Wan would be the best fit. If instead they had signs of Qi stagnation creating constrained heat in the interior impeding the flow of Qi to the extremities presenting with cold fingers and toes with the limbs and body warm, then Si Ni San would be the best match. Finally, if they had signs of Spleen Qi deficiency and/or Blood deficiency, then Xiao Yao Wan would be the best choice. Even if all of the signs and symptoms that a given patient has are not described in the classical indications, if the syndrome pattern diagnosis closely matches a formula’s functions, then that formula can be used successfully.

Tongue and Pulse

Practitioners have often wanted to know whether the tongue and pulse always need to match what is described in classic text-books in order for a formula to be suitable. In many instances, we have noticed that the tongue and pulse can vary slightly from what is included in classic texts.

For example, Sheng Mai San is indicated for Lung Qi and Yin deficiency. The tongue is pale-red with a dry, thin coat, and may have many surface cracks. The pale-red color is due to the combination of a Qi-deficient tongue, which could be pale, and a Yin-deficient tongue, which could be red. The tongue may have many surface cracks due to the Yin and fluids being deficient. However, a patient could present with many of the signs and symptoms that match Sheng Mai San, yet be predominantly Qi-deficient, and present with a pale-dry tongue with a scanty coat, or be predominantly Yin-deficient, and present with a red tongue, and the formula would still be appropriate. The pulse for Sheng Mai San is deficient, rapid, thin, and irregular. This does not mean that the pulse must have all of the qualities mentioned, but rather that those are the various combinations that would be likely, depending on what the predominant presentation is.

Combining Formulas

In cases of complex and multi-pattern presentations where one formula just doesn’t seem to fit, practitioners may prescribe two (or more) formulas in order to more completely address the case. Moderating the doses of formulas taken concurrently offers a way to target the chief complaint and secondary complaints in tandem. A practitioner may decide that a patient needs to have a small dose of one formula with a large dose of another, or may even decide the patient needs to take the standard dose of two or more formulas. The proportions are dictated by the constitutional patterns, symptom presentation, and treatment goals. This can be done using pills and tablets as well as extract powders.

Assessing Results

Chinese medicine can have both immediate and lasting results but when compared with Western medicine, it is often experienced overall as a gentler and thus more gradual system. Of the avenues of administration for Chinese herbs, decoctions tend to be faster acting while patent medicines tend to work more slowly.

One of the challenges practitioners face is to know how long to administer a remedy before assessing its effects. Over the years we have found that there is a tendency with practitioners and patients alike to expect results too quickly. Because many of the conditions and patterns we treat in Chinese medicine practices are chronic and often multidimensional, it usually takes some time for results to be clearly felt. Of course each individual and each presentation is unique so there is not one standard for assessing results, but if the diagnosis is correct and there are no adverse effects occurring, it is best to give an herbal formula 4-6 weeks before determining if it is working or not. Many chronic imbalances can take many months to rectify so it is important to have some patience and perseverance with this system.

That being said, your patient should be experiencing some signs along the way that things are heading in the right direction. General health markers and signs of improved Qi should begin to appear. Areas that this can be seen are in energy, mood, sleep, digestion, and Shen. When these aspects of your patient’s health are improving it is likely you are on the right path. Conversely, when these indicators are adversely impacted, it is wise to reassess the clinical picture right away including, patient compliance, concurrent illness or infection, concurrent use of drugs or pharmaceuticals, diet, lifestyle, and life cycle events.

Author Bios: Laura Stropes, L.Ac., is a licensed acupuncturist and herbalist specializing in Chinese medicine gynecology and fertility, who has been practicing in Berkeley CA since 1998. She has been an herbal consultant for Mayway for over 10 years. In her consulting capacity she assists other acupuncturists, chiropractors, veterinarians and medical doctors in choosing suitable TCM herbal treatments for their patients.

Alisa Wrinkle, L.Ac., is a TCM practitioner practicing in Oakland CA since 1997. She has been an herbal consultant with Mayway for 14 years. In the course of her tenure at Mayway she has contributed to a wide range of projects including development of new products, consulting, teaching and writing. She assists practitioners from around the country with herbal concerns and advises on product selection.

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