Reductionist methods in the manufacturing and testing of single substance herbal medicines can illustrate chemical pathway clues and mechanisms of action. Practitioners may develop a clinical style of prescribing single herb and supplement therapies based upon this information.
In such instances, these single finished products have often not been sufficiently tested to work together. These prescriptions are not harmonized for a whole system approach, but rather as individual chemical compounds to directly address single, or groups of, symptoms. This approach is similar to treating symptoms with drugs and less like prescribing a classical Chinese herbal formula.
Single herbs can be effective in reducing significant health barriers, but not always. Traditional Chinese Medicine (TCM) practitioners have the advantage of prescribing from a longstanding tradition of clinical expertise with Dui Yao formula construction. Dui means "two" and Yao means "herbs." The concept is also named "pair medicine" where two herbs are used together to emphasize and harmonize one another for greater efficacy in the body.
Some patients are wary that TCHM is not rooted in evidence-based practice. Engage the patient by telling the story of how the Huang Di Nei Jing (Han 25-220 C.E.) was written in the spirit of classifying relationships within nature from a naturalistic observation as a scientific process! The Huang Di Nei Jing discussed herbal formulas, but it was Shen Nong's Classic of the Materia Medica (Han 100 C.E.) where a broader span and greater depth into herbal formulation begins. These two works set the stage for Zhang Zhong Jing's formula methodology presented in the Shang Han Lun. Herb formulas began associating with patterns, such as 'Gui Zhi Tang Pattern' during this time.
Many TCHM Dui Yao pairs and formulas have been clinically tested and evidence-based for hundreds, and in some cases thousands of years. The key to clinical efficacy is in a practitioner's application of the evidence that exists. A TCHM practitioner not only has the opportunity to write a personalized prescription, but also to adjust it to fit the patient's changing symptoms according to the Dui Yao.
Treating Ben (root) and Biao (manifestation)
Addressing patient patterns with herbal medicines begins with pattern diagnosis and differentiation. Gather patient symptomology in a hierarchy from most concerning to least. Ask: What needs clearing first? What needs nourishing the most? Next, choose herbal components to address these concerns in order of importance. One method is to begin first with addressing patterns of excess (repletion) while simultaneously managing deficiency (vacuity) to invite balance within a single formula.
Single extracts often cannot function in this way. The Taoist system of contrasting yin and yang is a foundation for TCHM. Chinese herb pairs can address two sides of a presentation at the same time. Philippe Sionneau in his book, "Dui Yao: The Art of Combining Chinese Medicinals" (considered the pre-eminent scholar in Dui Yao theory) writes about the expertise of the herbal masters from the past 2,000 years. He recognized the development of efficient and effective herb pairs through clinical trial and error over millennia. Relying on such clinical wisdom is not just a functional starting block for a new herbalist, but a foundational place to return to indefinitely for even the most experienced clinician.
Adjusting Doses and Pairs
Chinese herbal masters kept detailed patient records. They observed patients' symptoms closely and charted the effects of herbal combinations for decades before training apprentices that practiced in the same tradition. These effective combinations were the result of evidence-based medicine. Today's practitioner must follow this detailed observational approach. If the Dui Yao pair does not change the symptom presentation, a different pair must be selected. Keep detailed records and use 1-10 scales to measure symptoms.
If symptoms are changing slightly, perhaps increase the dose and monitor the patient closely for side-effects of any kind, expected, and unexpected. Be prepared to lower the dose when the time is right. If nothing changes, go back to the drawing board and select another Dui Yao pair. "Bensky's Formulas and Strategies" textbook can be used to locate the formula that comes closest to the patient's chief complaint. The text offers a section at the end of each formula for modifications that often carry useful Dui Yao pairs worth considering and alternatives for changes.
Dui Yao Examples
Xiao Yao San is an example of a formula that contains a harmonizing Dui Yao pair, that both reduces excess and nourishes deficiency. Xiao Yao's Chai Hu (cool and acrid) courses the liver, and Bai Shao (sour) nourishes the blood by constraint. Liver yang can benefit from the coolness of Chai Hu to keep it from overheating and creating Liver depression. There are other herbs in the formula but this pair play a significant role.
Er Miao San (Two Marvel Decoction), created by Zhu Danxi, is a successful formula comprised of just two herbs, Huang Bai and Cang Zhu. The Huang Bai clears heat and dries damp but is bitter and cold. The Cang Zhu harmonizes because it is spicy, warm, and able to dry dampness. These herbs used as a Dui Yao pair, clear heat with swelling and pain, in conditions such as rheumatic eczema, or with gout and arthritis in the lower part of the body.
Examples of Dui Yao Energetics
- Ban Xia + Ginger = Reduces the toxicity of Ban Xia and ends nausea
- Da Huang + Mang Xiao = Drain heat/fire while softening and purging
- Gui Zhi + Bai Shao = Relaxing and tonifing Yang Qi simultaneously
- Huang Lian + Wu Zhu Yu = Calms Liver fire while warming Stomach Qi
- Jing Jie + Fang Feng = Enhances the diaphoretic quality synergistically
- Shu Di Huang + Rou Gui = Calms Kidney yang while stimulating Kidney Jing
Dui Yao Combination Examples (if you are looking to use one consider a pair)
Notice the prevalent use of Gan Cao in the Shang Han Lun!
- Bai Zhu + Fu Ling
- Ban Xia + Da Zao
- Ban Xia + Gan Cao
- Ban Xia + Shen Jiang
- Da Huang + Gui Zhi
- Da Huang + Hou Po
- Da Huang + Mang Xiao
- Da Huang + Zhi Shi
- Fu Zi + Gan Cao
- Fu Zi + Gan Jiang
- Gan Cao + Da Zao
- Gan Cao + Gui Zhi
- Gan Cao + Sheng Jiang
- Gui Zhi + Shao Yao
- Huang Qin + Chai Hu
- Huang Qin + Chai Hu
- Huang Qin + Da Zao
- Huang Qin + Gan Cao
- Huang Qin + Huang Lian
- Huang Qin + Shao Yao
- Huang Qin + Sheng Jiang
- Ma Huang + Da Zao
- Ma Huang + Fu Zi
- Ma Huang + Gan Cao
- Ma Huang + Gui Zhi
- Ma Huang + Sheng Jiang
- Ma Huang + Shi Gao
- Ma Huang + Xing Ren
- Mu Li + Gui Zhi
- Mu Li + Long Gu
- Ren Shen + Da Zao
- Ren Shen + Gan Cao
- Ren Shen + Shen Jiang
- Sheng Jiang + Da Zao
- Sheng Jiang + Gui Zhi
- Shi Gao + Geng Mi
- Zhi Mu + Shi Gao
- Zhi Shi + Hou Po
- Zhi Zi + Dou Chi
- Zhi Zi + Zhi Shi
Examples of single herbs that work well with Dui Yao pairs
- Da Huang + (Zhi Shi + Hou Po)
- Gan Cao + (Bai Zhu + Fu Ling)
- Huang Qin + (Ren Shen + Ban Xia)
Click here for previous articles by Shellie Rosen, DOM, LAc.