Minor Bupleurum: My Favorite Formula

by Bob Flaws, Dipl. Ac. & C.H., FNAAOM

(This article was originally published in the RCHM Newsletter. The RCHM is the Register of Chinese Herbal
Medicine in the U.K. Since then, I have slightly expanded it and reworded a few sentences.)

There is supposedly a Chinese saying that goes something to the effect that, "New practitioners use many formulas; old practitioners use only a few." This saying may or may not be apocryphal. However, in my case it is certainly true. After 20 years of practicing Chinese medicine and based on the theories and methodology of Li Dong yuan, I find that I use various combinations and modifications of four basic formulas for  90% of my patients with chronic conditions. These four formulas are Bu Zhong Yi Qi Tang (Supplement the Center & Boost the Qi Decoction), Xiao Chai Hu Tang (Minor Bupleurum Decoction), Xiao Yao San (Rambling Powder), and Ban Xia Xie Xin Tang (Pinellia Drain the Heart Decoction). Although I do not have a favorite from among these four, I would like to discuss Xiao Chai Hu Tang, the most commonly prescribed Chinese medicinal formula in the world.

Xiao Chai Hu Tang (Minor Bupleurum Decoction)

Radix Bupleuri (Chai Hu), 9g
Radix Scutellariae Baicalensis (Huang Qin), 9-12g
Radix Panacis Ginseng (Ren Shen), 6-9g
Rhizoma Pinelliae Ternatae (Ban Xia), 9g
mix-fried Radix Glycyrrhizae (Gan Cao), 3-6g
Fructus Zizyphi Jujubae (Da Zao), 3-5 pieces
uncooked Rhizoma Zingiberis (Sheng Jiang), 2-3 slices

This formula is recorded in Zhang Zhong-jing’s late Han dynasty Shan Han Lun (Treatise on Cold Damage) and is the prototypical formula for harmonizing the defensive and constructive in a shao yangpattern of cold damage. However, this formula has a much broader scope of application than that classical description implies. As a harmonizing formula, it not only harmonizes the defensive and constructive but also the liver and spleen, liver and stomach, spleen and stomach, and stomach and intestines. Since exterior-resolvers and qi-rectifiying medicinals are often interchangable, both up-bearing and tending to effuse clear yang, this formula can be used to treat liver depression qi stagnation with concomitant spleen vacuity and dampness. In addition, since out-thrusting is another way of clearing internal heat (especially depressive heat), this formula may be used to clear heat in the liver, gallbladder, stomach, and/or lungs.

Li Dong-yuan, author of the Pi Wei Lun (Treatise on the Spleen & Stomach) and arguably the most famous of the Four Great Masters of Medicine of the Jin-Yuan Dynasties, was an expert at treating complex, multi-pattern conditions where there was spleen qi vacuity, depression of the qi mechanism, and some sort of heat. In such cases, the evil heat involved is engendered from the middle or lower burners and only secondarily wafts up to collect in and disturb the upper burner or body. Li called this type of evil heat "yin fire." He called it yin is because A) it develops from the lower or yin part of the body, B) it is often damp or yin in nature, and C) it is pathological.

Li’s five principles for treating yin fire conditions, i.e., complicated conditions where there is spleen vacuity, an inhibited qi mechanism, upward counterflow, and evil heat (damp heat, depressive heat, vacuity heat, or upward stirring of ministerial fire), are to:

1. Fortify the spleen and boost the qi while harmonizing the stomach and intestines. 2. Rectify the qi mechanism, upbear the clear and downbear the turbid. 3. Clear heat of whatever kind from wherever necessary. 4. Do whatever elese needs doing depending upon the presenting condition (e.g., quicken the blood, transform phlegm, eliminate dampness, moisten dryness, etc.) . 5. Prioritize the above four necessities and apply in appropriate order of precedence and proportion.

Within Xiao Chai Hu Tang, Bupleurum courses the liver and rectifies the qi, upbears the clear and disinhibits the qi mechanism. Ginseng, mix-fried Licorice, and Red Dates fortify the spleen and supplement the qi (as well as nourish the heart spirit). Pinellia and uncooked Ginger harmonize the stomach, downbear turbidity, eliminate dampness and transform phlegm. And Scutellaria clears heat from the liver, gallbladder, stomach, large intestine, and lungs. Likewise, because Bupleurum is bitter, acrid, and cool, it also has some ability to clear both damp and depressive heat from the liver/gallbladder. Therefore, this formula embodies Li Dong-yuan’s five principles of treating yin fire conditions — in this case, eliminating dampness and transforming phlegm in terms of principle number four, and relatively equally supplementing the spleen, rectifying the liver, and clearing heat in terms of principle number five.

As the great mid-century architect of modern Chinese medicine, Qin Bo-wei said,

"When I say to use Liu Wei Di Huang Wan (Six Flavors Rehmannia Pills), I do not mean

to use the ingredients of Liu Wei Di Huang Wan but rather the idea of Liu Wei Di Huang Wan."

Thus, in clinical practice, I rarely use this formula in its standard, textbook form. If I need to regulate the blood in addition to coursing the liver and rectifying the qi, fortifying the spleen and supplementing the qi, transforming phlegm and eliminating dampness, and clearing heat from the lungs, stomach, liver/gallbladder, or large intestine, I typically will add Radix Angelicae Sinensis (Dang Gui) and/or Radix Albus Paeoniae Lactiflorae (Bai Shao) or maybe even all of Si Wu Tang (Four Materials Decoction).

For instance, when women catch a cold or manifest fluey symptoms before or with each menstruation, this usually indicates a constructive and defensive disharmony complicated by blood vacuity. In that case, the blood, which is the mother of the qi, is insufficient to nourish and root the defensive qi. The defensive qi thus does not do its duty of securing and astringing the exterior, leaving the body easily invaded by external wind evils. Prior to the menses, the blood is downborne viathechong mai/bao mai from heart to uterus. If there is a blood vacuity, there may not be sufficient blood left over to nourish the liver during the premenstruum. In that case, there will be the engenderment or worsening of liver depression qi stagnation. Since exterior-resolving is associated with upbearing and out-thrusting, if the qi mechanism is depressed due to lack of blood to nourish the liver premenstrually, then any external evils invading the body may also not be efficiently out-thrust. Instead, they may linger in the body as hidden or retained evils waiting for the right set of circumstances to become pathologically active once again. In addition, since the spleen is the root of phlegm engenderment, if the liver becomes depressed, the spleen becomes vacuous and weak, and the lungs are fettered by external evils, then accumulation of phlegm dampness is all the more likely. To top this all off, liver depression complicated by phlegm and damp depression is all the more likely to transform into depressive heat and heat, which is yang, tends to float upwards to accumulate in the lungs, the florid canopy. The combination of Minor Bupleurum and Four Materials treats this complicated but commonly seen gynecological scenario.

If I need to moisten dryness (due to persistent heat), I typically add Tuber Ophiopogonis Japonici (Mai Dong) and/or Radix Trichosanthis Kirlowii (Tian Hua Fen) and may change Ginseng to Radix Pseudostellariae (Tai Zi Shen). If I need to rectify the qi more, I might add Rhizoma Cyperi Rotundi (Xiuang Fu), Radix Linderae Strychnifoliae (Wu Yao), and/or Radis Auklandiae Lappae (Mu Xiang) depending on where the qi stagnation is manifesting and how serious it is. If there is more phlegm, I might add Sclerotium Poriae Cocos (Fu Ling), Pericarpium Citri Reticulatae (Chen Pi), and/or Bulbus Fritillariae (Bei Mu). If the phlegm is in the chest annd/or throat, I will probably add Radix Playtcodi Grandiflori (Jie Geng). If there is phlegm nodulation, I will probably add some or all of Radix Scrophulariae Ningpoensis (Xuan Shen), Spica Prunellae Vulgaris (Xia Ku Cao), Concha Ostreae (Mu Li), Herba Sargassii (Hai Zao), Thallus Algae (Kun Bu), and Semen Citri Reticulatae (Ju He). If there is more dampness due to spleen vacuity, I might add Sclerotium Poriae Cocos (Fu Ling) and Rhizoma Atractylodis Macrocephalae (Bai Zhu). If the spirit is not quiet, I might add Os Draconis (Long Gu) and Concha Ostreae (Mu Li). If there is more qi vacuity, I will usually add Radix Astragali Membranacei (Huang Qi). If there is more heat, which medicinals I add will depend on the nature of the heat and where it is located. For instance for either damp heat or heat in the heart, stomach, and/or intestines, I will typically add Rhizoma Coptidis Chinensis (Huang Lian). If there is depressive heat causing vexation, I might choose Fructus Gardeniae Jasminoidis (Shan Zhi Zi). While if there is damp heat affecting the skin with itching, then Radix Sophorae Flavescentis (Ku Shen) and Cortex Radicis Dictamni Dasycarpi (Bai Xian Pi) might be good choices. And for wind heat evils affecting the throat, Fructus Arctii Lappae (Niu Bang Zi) and Radix Isatidis Seu Baphicacanthi (Ban Lan Gen) are often good choices.

In other words, this formula can be modified in numerous ways to fit large numbers of presenting situations. Since most patients with chronic diseases suffer from liver depression (The Heart Transmission of Medicine says, "In general, depression is part of any disease. If depression endures, it will generate disease. If a disease has endured, depression will be generated."), spleen vacuity ("Enduring disease damages the spleen."), and some kind of evil heat (viz. the theories of Liu Wan-su, Li Dong-yuan, and Zhu Dan-xi), this formula is an extremely useful one beyond just harmonizing the shao yang division.

Caveat: Although Minor Bupleurum is the most commonly prescribed Chinese medicinal formula in the world today and is extremely safe for a wide range of patients and conditions, it should not be used in tandem with Interferon therapy, as in certain types of cancer and chronic active hepatitis. Recently, several patients in Japan died from this combination due to liver failure. Until the exact mechanisms of this complication and all its co-factors are ascertained, I believe this caveat should be considered absolute.
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