Hybrid treatment strategies.

I have been thinking lately about situations that have forced me to break out of some of my prescription practices and look at creative ways to approach formulation. One of these is mixing of various forms of herb preparations to achieve the exact combination of effects that I seek for a given patient. I will cite some examples. These examples fall into two main categories as follows:

1.       Combining different forms of herb preparations such as combining honey pills with granules or a bulk-herb decoction with granules.

2.       Combining external applications with internal formulas.

An example of the first category:

Most honey pill formulas are intended to address the constitutional imbalance of the patient (root). Granules, being a form of herb decoction, are faster-acting and thus ideal for treatment of branch conditions. Thus, when a case requires simultaneous treatment of root and branch, we can combine honey pills with a granule formula that addresses the branch symptoms.

Example 1 - Treatment of root and branch by combining honey pills with granules (or bulk-herb decoction).

For example, herbal treatment of a menopausal woman with recurrent urinary difficulties (yin-vacuity with lower-burner damp-heat) might call for the combination of Liu Wei Di Huang Wan to nourish yin with additions of Huang Bai (Philodendron bark), Zhi Mu (Anemarrhena rhizome), Bai Jiang Cao (Patrinia herb - note that I have also found the substitute herb (Thlaspi herb- aka Xī Mì) to be effective in this context) and Mu Tong (Akebia root). We could construct a granule formula for this, but if we feel that honey pills would more potently address the root yin-vacuity disharmony we may want to combine honey pills with granules. The proper way to take honey pills is with a liquid. Why not have the liquid be something that addresses the branch symptom?

Thus, in this instance we might employ a formula as follows:

Honey Pills of Liu Wei Di Huang Wan 3 pills each dose. The pills should be chewed and then washed down with a glass of hot water into which is dissolved 2 grams of the granule formula below (take this pill-granule mixture 3 times per day):

Granule Formula

Huang Bai 20%

 Zhi Mu 20%

Bai Jiang Cao 40%

 Mu Tong 20%

This is a way of addressing the main limitation of pills – their inability to be modified. The combination’s use of honey pills combines the longer-lasting supplementation that slower-acting honey pills provide along with the faster acting decoction aimed at the branch symptoms.

One nice aspect of this root-branch/pill-granule treatment is that as the branch symptoms decrease one can increase the root formula (honey pills) and decrease and adjust the branch formula (granules) according to presenting symptoms.

As an aside, I have lately modified this method by duplicating the honey-pill formula in the granule formula. In the above example this would manifest as me using the following granule formula for the wash-down liquid for the honey pills:

Zhi Bai Di Huang Wan 40%

Bai Jiang Cao 40%

Mu Tong 20%

My thinking behind this way of prescribing is that for the herbs in Liu Wei Di Huang Wan, I am giving the patient both the water-soluble decocted components (from the granules of Zhi Bai Di Huang Wan) and the non-water-soluble bulk-herb components (from the honey pills) for a well-rounded supplementing approach.

Naturally, one can use a bulk-herb decoction as the wash-down liquid as well. This would give an even stronger supplementing function to the combination.

Example 2 – When it is useful to wash down granules with a bulk-herb decoction.

In most cases we use granules (or tablets or capsules) because they are easier for the patient to prepare, they taste better than the decocted herb, and patients can easily carry a granule formula with them. All of this contributes to better compliance. For some situations, however, it is best to take granule extracts as a mixture of granules mixed into an herb decoction or to use a single-herb decoction to wash the granules down. I will cite some examples.

1.       For herbs that don’t well withstand the heat inherent in the extraction, concentration and granulation process used to make granules the function of the herb may not be well-expressed in the granule extract form. Examples include Yu Xing Cao (Houttuynia) and Gou Teng (Uncaria).

For most purposes Yu Xing Cao should be cooked for just a few minutes and Gou Teng should cook under 20 minutes. Thus, when using Yu Xing Cao as a bulk herb it is best to cook it (20-30 grams per day) by soaking in room temperature water for 30 minutes (use enough water to cover the herbs), bringing this mixture to a boil, and lowering the heat to a simmer for 3-5 minutes. Once strained out, this makes a pleasant tasting tea that can be used to wash down a granule extract formula. This tea can be mixed with or used to wash down granule formulas such as Yin Qiao San to treat the end stage of a wind-heat external contraction where phlegm-heat fetters the lung (this pattern is characterized with chest tightness and phlegm that is difficult to expectorate). This Yu Xing Cao decoction also can be combined with granule-extract formulas such as Ba Zheng San to address damp-heat urinary issues.

 As an aside, Yu Xing Cao tea, made in the manner described above, can also be used as a wash to soothe diaper rash. Follow this with a nice herbal baby powder or some Spring Wind Ointment (see further discussion regarding external applications).

As another aside, Yu Xing Cao, briefly cooked, is often the base herb used with herbs such as Bo He, Pu Gong Ying and Feng Wei Cao to make Qing Cao Cha (青草茶). Qing Cao Cha (literally, Green Herb Tea) is a drink sold at street stands in Taiwan (often iced and slightly sweetened). It is a popular drink used to clear heat, resolve toxins, engender fluids and cool down the body during the hot summer months.

Let’s now turn to Gou Teng. Gou Teng single-herb decoction can be used to invoke the herb’s ability to clear heat, calm the liver and extinguish wind. It should be cooked 15-18 minutes ( typical dose is 10-15 grams per day) and then taken with a granule formula such as Tian Ma Gou Teng Yin (or some other formula that calms the liver and extinguishes wind). In this case, the goal is to boost the function of the Gou Teng already in the granule-extract formula because the extended cooking time required to make a granule-extract can reduce some of the functions of Gou Teng.

2.       Herbs unavailable in granule form.
Another time when it may be suitable to use a single (or multiple) herb decoction to mix with a granule-extract is when an herb required in a formula is not available as a concentrated granule. Many herbs are not available as extract granules because they are too expensive or because the market for them is not big enough to support the batch-size required to efficiently produce a granule. Seldom-used, but important herbs are missing from most granule collections. A few examples: Shu Yang Quan, Zao Xiu, Ba Yue Zha, Ling Xiao Hua, Nan Sha Shen and Liu Ji Nü.
If one or more of these herbs are needed for a formula, having the patient cook up a single herb decoction to wash down his or her granule formula can be the solution (pun intended).

3.       When large doses are needed.
If a large dose of a single herb is needed in a formula it often is hard to include it in a granule formula because it will require the patient to take far to many grams of a granule. For example, if one wanted to use a daily dose equivalent of 60 grams of a bulk herb such as Bai Hua She She Cao, Ban Zhi Lian or Xia Ku Cao in a granule formula, that would require at least 15 grams of the single-herb granule. Since we usually have patients take about 10-12 grams of granules per day it is plain to see that adding 15 grams herb concentrate of one herb would make for a granule formula that is too large for most patients. Giving such a large granule formula would obviate the convenience associated with granules. In these cases having the patient cook up the bulk herb decoction for the large-quantity herb and using that decoction to wash down the granule extract formula is a practical way to include the large dose.

In some cases cooking the single-herb decoction down and making it into a syrup can be a helpful option. This syrup can then be mixed with hot water and used to wash down a patient’s granule extract formula. This is especially useful for herbs that have a strong taste or for patients that will be taking that particular herb for a long period of time. See this article on the Spring Wind Web Site for a discussion on how to make herb syrups.

Examples of when it is advantageous to combine external applications with an internal formula.

1.       When treatment of the branch impedes the treatment of the root.
I recall an article in a book by a Chinese-medicine gynecology doctor in China where she discussed treatment of vaginal discharge. She mentioned that most of the cases she saw were owing to spleen vacuity that led to the spleen’s inability to process fluids. This led to downpour of damp-heat that gave rise to yellow, thick, odiferous discharge. She pointed out the difficulty of simultaneously addressing the damp-heat branch and the spleen-vacuity root of the situation because the cold, damp-drying herbs needed to address damp-heat downpour would harm the spleen and impede efforts to supplement the center. Her solution was to use an herbal douche to address the branch (damp-heat downpour) while addressing the root (spleen vacuity damp encumbrance) with internal herbs.

2.       When quick results are needed.
Internal herbs sometimes do not bring the fast results that are needed to ease a patient’s discomfort. This is certainly true for many skin disorders, but also for sports injuries and even for some internal disorders. Prescribing a wash, lotion, ointment, liniment or some other form of external treatment to relieve symptoms can convince the patient to give acupuncture and internal herbs a chance to bring the more permanent relief provided by treatment of the underlying root imbalance.

While most practitioners are familiar with products such as Spring Wind’s line of external products for skin issues, sports injuries etc., many are not familiar with external applications that help relieve symptoms of internal disorders. One such treatment commonly employed in China is the use of bulk-herb Wu Zhu Yu (Evodia) to treat heat disorders of the upper body by grinding the herb to a powder, mixing it with rice vinegar and applying it to KI-1 (Yong Quan-湧泉). Note that the mixture should be moist but not runny. This paste  should be covered with cloth tape and changed once every 12 or 24 hours. Application is contralateral for one-sided symptoms and bilateral for bilateral symptoms.

Additionally, external applications can be preventative, as in the use of an ointment such as Spring Wind Ointment to supply a soothing barrier to the skin and help prevent something like diaper rash.

Combining external applications with acupuncture, massage or cupping.

It is common to follow acupuncture or massage treatments of musculoskeletal disorders with a plaster, liniment or soak compress. Spring Wind’s article on Treatment of Sinew Damage discusses this in detail. Jason Robertson the co-author, with the late Wang Ju Yi of Applied Channel Theory in Chinese Medicine has a novel approach to this process. In a recent telephone conversation Jason explained to me that he uses Spring Wind soft plasters in a unique way. Essentially, he uses the plaster to help him locate the tender spots for acupuncture or massage treatment and to help elucidate the channel most affected. For example, in a patient with upper back pain where palpation does not immediately reveal the most sensitive spots because the entire area is tense or painful, Jason has found that applying a plaster in a thin layer to the affected area and shining a heat lamp on that for a short period of time helps to relax the area and after wiping clean the plaster, palpation of the area will then more clearly reveal the troubled spots and affected channels. Those troubled areas can then be treated with acupuncture, moxa (or moxa on needle), and massage. Jason has promised to share the details of this process in a future email so that others can benefit from his experience and knowledge.

Conclusion:

Most of us are familiar with muti-media approaches to healing. We combine food therapy, herb therapy, massage and acupuncture in our treatment plans. I hope that the discussion above stimulates practitioners to try new approaches by combining herb preparations in various forms.

If you have questions or comments, or want to share your unique uses of hybrid treatments please email me at andy@springwind.com or email Spring Wind at customerservice@springwind.com.