It’s no secret that Travis C. and I are both generally bulk herb people. That is, if my patients are at all willing and able, I want them to take bulk herbs. Especially since we can decoct those herbs for patients in the shop, it takes that final hurdle off the field. But the more deeply we get into practice, the more we see that there are many situations and conditions in which patients can benefit from the ease of a granule administration. Whether its traveling or hiking, busy work schedules or kids with delicate palates, our patients have had need of a simpler way of taking their medicine. Enter the granule.
Think of whole formula granules as a single item with the same sort of collective mechanism of action as a single herb
Naturally since we are bulk prescribers and have learned most of what we know about herbs from mainland China-trained herbalists, we went immediately to prescribing granules in the same way we would for bulk. That is, we would build a formula from single ingredients, taking into account the general 5:1 concentration rule that is applied to most granules and adjusting the dose to reach a similar kind of formula as we would have had in bulk. And this method generally served us well except when we came up against a single herb that we didn’t carry, either because it is difficult to find in granule or because we just hadn’t had a need for it yet. We’d bring in that herb on the next shipment and continue on with patients getting pretty solid clinical results. Yet there was a little nagging voice in my head saying “But what about the alchemy?!”
As individual bulk herbs cook together in a decoction pot, their constituent parts interact with one another and change the way that other components are extracted. Biochemically we think of this as creating variable pH situations, mineral concentrations, and the effect that these variables have on the extraction of other water soluble components. Chinese Medicine-wise we know that the qi of our ingredients is shaped and adjusted by its neighbors in the cooking pot. Without doubt, the interaction of ingredients when making a decoction is part of the overall effect of a formula, classic or otherwise.
So what about our single granule combos? Patient’s were getting better and that is the metric we primarily use when determining the effectiveness of any sort of herbal administration. And yet, what if we could give them herbs that were whole formulas cooked together and then transformed into granules? As it turns out, we could. We just needed to bring in whole formulas from our granule vendor Evergreen Herbs.
“But wait!” your saying. “What if a patient needs xiao chai hu tang but I want to take out the most of the Huang Qin? I wouldn’t be able to do that if I had to use a whole formula granule!”
You’re right, you wouldn’t be able to make that sort of change. But I have something for you to think about it. Instead of looking at the individual parts of Xiao Chai Hu Tang like huang qin and thinking that you would like to reduce the upper burner heat clearing component because your patient doesn’t have signs for that herb, I challenge you to think about it like this:
Xiao Chai Hu Tang harmonizes the shao yang, soothes the liver, and mildly clears heat from stagnation. Think of those qualities as the primary method of action for XCHT. So you can use the whole formula AS IF it were a single component and not worry too much about any individual ingredient in that formula (exempting obvious concerns like allergies of course)
Let me give you an example:
I have a patient with a sense of pressure in their ears that comes and goes, dry and red eyes, difficulty staying asleep, a slight olive cast to their skin, a pale and swollen tongue with toothmarks, very mild lower leg edema, and hypochondriac tenderness. (You’ll notice I don’t include a pulse here because I don’t use pulse much in my diagnostic process preferring tongues and abdomens. But for those of you that use pulse, the following info works even better I think…)
I diagnosed the patient with shaoyang disharmony (xiao chai hu tang) causing stagnation of phlegm fluids in the upper jiao (ban xia hou po tang), fluid accumulation (wu ling san), and heat from stagnation. Using whole formula granules, I was able to write a formula made of 55% XCHT, 30% BXHPT, and 15% WLS that gave me access to all the treatment principles I was looking for with a much simpler method of writing the formula. And sure, I could have taken XCHT and added some ban xia and hou po, chen pi and zhu ru, and a little zhu ling to activate the bladder qi transformation stagnating the fluids and I might have even gotten the same results. But it was intellectually fun to work from a different angle and to flex my diagnostic and herbal muscles to see how it felt to try something new. It is not to say that one form of prescribing is superior to the other, just that thinking of whole formula granules almost as singles gives us a new way to prescribe granules to patients.
This method of whole formula prescribing is more common in Taiwan than on the mainland but has a very robust clinical record of getting solid results. You can listen to more details about granule creation, concentration, and dosing strategies by listing to this great podcast from Qiological where herbal knows-alot, Legendary Herb Company founder and friend of Root & Branch, Eric Brand talks about the ins and outs of granule herbs.
Think about using whole formula granules for their mechanisms of action collectively.
Combine different formulas almost as if they were singles to achieve certain actions and worry less about their constituent ingredients
No one method has all the answers but trying new ways of prescribing can keep your diagnostics fresh and effective.