1. January 10, live webinar. Interviewed by Charles Chace. Eastern Currents.
2. Saturday, January 21 & 22, 2012 San Diego, PCOM.
3. 7-week Advanced Herb Course, Boulder, Colorado. Jan. 29, Feb. 5, Feb. 26, March 4, March 18, April 1, April 8 or 15.
4. Sunday May 27th, CSTCM, Denver, Colorado.

Another Perspective: Studying the Classics For A Firm Foundation

By Jason Blalack, LAc and Z’ev Rosenberg, LAc

In Jake Paul Fratkin’s Acupuncture Today article entitled “Going Beyond the Classics,” it was suggested that Western practitioners of Chinese medicine are ignoring modern research only to be “married to the classic formulas.” Fratkin makes the case that China has been making advancement after advancement in medicine over the last 60 years that Westerners would be foolish to ignore.

Thus, Chinese medicine has evolved far beyond classic texts such as the Discussion of Cold Damage (Shang Han Lun), rendering formulas such as Minor Bupleurum Decoction (xiao chai hu tang) somewhat obsolete and instead now favors modern innovative formulas such as gan mao ling (感冒灵). There are a few key points that we would like to discuss surrounding this issue and specifically the obvious problems with gan mao ling.

Gan Mao Ling Explored

gan mao ling

It was suggested in Fratkin’s piece that gan mao ling, with its integration of Western and Eastern methodology, represents a pinnacle of development in Chinese medicine. The evidence given for this is that gan mao ling is the “number one best-seller” patent medicine in China, based on its supposed effectiveness for treatment of the common cold. A consequent conclusion was that “hundreds of millions of average Chinese people have a much better grasp on how to treat the common cold than herbal teachers in this country.” We assume this has something to do with Western practitioners not using this “valuable” formula as much as we should.

Observing students and other practitioners we have seen that gan mao ling is one of the more commonly prescribed formulas given to patients, so there would appear to be no shortage of use of this formula. However, for several reasons, gan mao ling is rarely the ideal prescription for most patients.

It should first be understood that patent medicines in China are heavily marketed to the average consumer, not unlike the over-the-counter medicines such as Theraflu at Walmart. Even consider the name, gan mao ling, which literally means miraculous [medicine for] the common cold and flu. Furthermore, patents such as gan mao ling can be found at corner stores, whereas many professional Chinese pharmacies do not even carry it. However, can we equate sales to efficacy? We don’t think so, nor do the doctors’ in Chinese hospitals and clinics. Long-term residents studying in China have actually never seen a doctor prescribe gan mao ling to a patient. In Japanese clinics, this formula is relatively unknown, and physicians actually rely on Discussion of Cold Damage (Shang Han Lun) formulas such as Cinnamon Twig Decoction (gui zhi tang) to treat these conditions. An overwhelming majority of physicians still rely on Chinese medicine’s established principles to treat colds and flu. Shouldn’t we emulate the best and brightest doctors and not the average consumer? One might ask, why don’t Chinese medicine physicians prescribe it?

Gan mao ling contains an interesting blend of five medicinals with a few ingredients that many western sources neglect to mention; caffeine, chlortrimeton (an antihistamine), and acetaminophen (Tylenol). No wonder people feel “better” after taking it! We do find versions in the West that do not contain these drugs, but the versions in China, that everyone is using do. In addition many of these Chinese spiked versions are easily obtained online from such websites as Amazon. There is little question that China’sgan mao ling is problematic. We have had patients who experienced jitters and inability to sleep after taking such “doctored” formulas. In fact, there have been reports of toxicity from such preparations ofgan mao ling from clinics in the United States. Consequently, medical websites discourage consumers from taking gan mao ling especially brands such as Yang Cheng, and rightfully so. In addition, we find numerous case studies in Chinese medical journals describing iatrogenic effects ranging from severe rashes to liver and kidney damage. Here is just one such example:

患者男,61歲,因5天前發熱、頭痛、全身不適,服用999感冒靈沖劑,10g,tid.當天服藥后,熱稍退,次日全身皮膚出現紅色丘疹,有癢感,顏面浮腫且逐漸加重,精神差,疲乏無力,小便量少,大便秘結.

“A 61-year-old male had a fever, headache, general malaise for five days, which led him to take 999 (a brand) gan mao ling chong ji, 10g, tid. That day after taking the medicine, his fever slightly reduced. The next day his whole body was covered in red papules, was itchy, and there was floating edema of the face. His condition gradually worsened, his essence-spirit started deteriorating, he became fatigued with lack of strength, had scanty urine, and constipation…”³

Medical Theory

Gan mao ling’s formulation contains over 75 percent antiviral medicinals, at least this is how many conceptualize it. It is based on a western biomedical theory, that a virus causes the common cold and therefore the virus must be eradicated. Thus, gan mao ling is often recommended regardless of a Chinese medicine pattern differentiation. However, gao mao ling’s antiviral approach is at direct odds with Chinese medicine’s fundamental theory.

From a Chinese medical perspective, gan mao ling is a bitter cold formula. Bitter flavors descend and cold-natured herbs are best for heat conditions. Chinese medicine theory states that for an external invasion one should use light acrid medicinals to release the exterior; giving cool acrid medicinals for a hot condition, and warm acrid medicinals for a cool condition. In the early stages of getting sick, most conditions do not have a hot presentation, and a cold formula is contraindicated. It is also contradicted in these cases to give a formula that primary has a descending action. If we recommend gan mao ling at the first sign of getting sick or when already sick, without pattern differentiation, we are applying a strategy that for the majority of people ignores Chinese medicine’s core theory for the treatment of external attacks. Some may wonder what relationship gan mao ling has with Chinese medicine, except for the use of some Chinese medicinals. Nonetheless, is it possible that we have a new more effective approach?

We are certainly not against modern developments, but in this case we find little evidence that this new approach outperforms classical principles and knowledge. Thus gan mao ling’s popularity and “efficacy” as a poster child for the great developments in Chinese medicine is hard to rationalize.

Clinical Observations

China’s observations of gan mao ling are not that helpful for us, since Western practitioners are hopefully using a product without added pharmaceutical drugs. What then have we noticed clinically in the West? Some claim that it is the cure all for common cold, others seem to find little to mixed results. However, those of us that look for subtler consequences notice that it acts similar to other antiviral formulas that contain bitter cold medicinals such as Isatidis/Baphicacanthis Radix (ban lan gen). Quite simply, these medicinals (and gan mao ling) can drive an exterior pathogen deeper in the body causing lurking pathogens.¹ Consulting the Warm Disease (wen bing) literature itself, we find further evidence that our ancestors already have been through this. Great physicians such as Ye Tian-shi and Wu Ju-tong(the physician who designed yin qiao san, an even more famous formula) warned against the excessive use of bitter, cold descending medicinals for exterior patterns. It should be pointed out that such formulas usually have an immediate symptomatic effect, because of the cold medicinals, but many times this is at the expense of causing longer-term problems. 1 If one does not track patients closely one can easily be deceived into believing there has been a positive effect. One possible and observed long-term effect has been damage to Spleen qi, leading to reduced appetite, bloating, loose stool, and a feeling of cold in the body. This of course weakens overall resistance to colds and flus in the long term, a tradeoff that is hardly worth the short-term gains.

Education

To suggest that classic study including formulas such as Minor Bupleurum Decoction (xiao chai hu tang), should be replaced in the clinic and schools by newer modern discoveries such as gan mao ling is a stance that is hard to understand. Formulas such as Minor Bupleurum Decoction (xiao chai hu tang) are certainly still effective if one knows how to use them. Giving it for a common cold, ignoring Chinese theory, surely will give poor results. Thus, one practitioner’s failure to gain success with this formula for a cold simply means a misdiagnosis of the disease pattern and choosing a wrong formula. Actually Minor Bupleurum Decoction (xiao chai hu tang) is rarely indicated for external attacks, and is most suitable for external invasions that have penetrated into the shao yang, with bitter taste, wiry pulse, alternating fever and chills. Without a proper theoretical foundation, we can easily misuse even classical formulas and get suboptimal results.

Our schools are here to teach Chinese medicine in a manner emulating core curriculums of Chinese medical colleges in Mainland China and Taiwan. The programs include approximately 300 formulas, ranging from classical to pre-modern formulas. They instruct us in the fundamental principles that we need to treat the majority of diseases. One might ask, what principles do the study of gan mao lingteach us? Chinese medicine is not about learning a formula for the common cold, then learning a formula for menstrual cramps. Why should we encourage the lowest level of herbal prescribing, essentially on par with the Chinese consumer walking into a corner store? Why do we not encourage our students to treat like doctors in China e.g. creating individualized prescriptions? To portray modern China’s physicians as merely doling out patent medicines (especially gan mao ling) is simply incorrect. It is also misleading to suggest that this signifies a progression from the classical style of practice.

Modern styles of practice

Chinese medicine has experienced many changes throughout its history, especially in the last 60 years in response to political shifts and the introduction of biomedicine. In addition, modern physicians practice in very diverse manners, ranging from strict classical application to Western influenced approaches. There is however, much debate as to what aspects represent actual advancements or innovations. It would be naive to believe that everything new (and Western) is best. For example, there are a large number of doctors (both young and old) that adamantly disagree with the path Chinese medicine has taken. They believe, as we do, that the haphazard integration with Western medicine has resulted in over-simplification of the medicine and as a whole is far less effective than more traditional models of practice.

Just because China has a current Western medicine and scientific bias, does not make this perspective the most efficacious. Many that have spent time in China and have observed these Western integrative doctors practice are severely disappointed. Such doctors often ignore Chinese diagnostic tools (such as pulse and tongue), rely on Western tests for diagnosis, and consequently get questionable results. Some see this is as a simple past, present and future of the medicine. But really, the future of medicine is still up to us. We must evaluate these changes critically, and not just blindly except, “this is the way it is in China.”

We conclude that the use of ready-made, corner store “patent” medicines is a de-evolution, not an evolution of Chinese medical practice. To truly move forward, we need to strengthen our roots in the source materials, and then apply these to the new, challenging conditions that face us every day in our clinics. Thus getting our heads into the classics is an important part of the process, which has been emphasized throughout the ages.

Fei Bo-Xiong (費伯雄) (1800 – 1879), one of the most famous physicians of the late Qing-dynasty, had this to say:

“Anyone desiring to study medicine without first studying the classics of acupuncture – the Essential Questions and the Spiritual Pivot – will never gain a clear understanding of the channels and collaterals. Therefore, they will never understand how disorders evolve. If they do not also study the classics of herbal medicine – the Discussions on Cold Damage and the Essential Prescriptions from the Golden Cabinet- they will not know how to compose a prescription and to treat appropriately. Those who do not read the four great masters of the Jin-Yuan dynasties, finally, will never understand how to employ the methods of supplementing, draining, warming or cooling and how to vary the different treatment principles in an appropriate manner.”

References:

1. Blalack, Jason. “Issues in Using Antiviral Medicinals in the Treatment and Prevention of the Common Cold and Flu (Gan Mao)” Chinese Medicine Times, Summer 2011 (Vol. 6, Issue 2)
2. Fratkin, Jake. “Going Beyond The Classics” Acupuncture Today, October, 2011 (Vol. 12, Issue 10).
3. Liu Renquan 刘仁全, and Zhang Huie 张慧娥. “999 ganmaolingchongji zhi yaowu xing piyan he gan shen sunhai 感冒灵冲剂致药物性皮炎和肝肾损害.” Adverse Drug Reactions Journal 4.2 (2002).

Jason Blalack is the translator, compiler and editor of Qin Bo-Wei’s 56 Treatment Methods: Writing Precise Prescriptions with clinical commentary by Wu Bo-Ping, published in October 2011 by Eastland Press. He is a graduate of the Pacific College of Oriental Medicine in San Diego and maintains a full-time practice in Boulder, Colorado. He runs a website devoted to Chinese medicine case studies and discussion at www.chinesemedicinedoc.com/practitioners. Comments can be sent to:jblalack@chinesemedicinedoc.com .

Z’ev Rosenberg has lectured widely both to the public and to students of both Chinese medicine and macrobiotics over the last thirty years. He is the former president of the Acupuncture Association of Colorado (AAC), where he spearheaded a successful drive to register acupuncture practitioners in that state. He also has written several articles for professional Chinese medical journals, including Oriental Medicine, Protocol Journal of Botanical Medicine, Journal of Oriental Medicine in America, Journal of Chinese Medicine, and most recently The Lantern Journal. He presently continues to teach and chair the Herbal Medicine department at Pacific College of Oriental Medicine, San Diego, and has had a private practice in Chinese medicine since 1983.

Originally published in Acupuncture Today (Jan. 2012)

Slow Pulse (迟脉)

Ding Ganren (丁甘仁) (1865－1926)

(Rough translation by Jason Blalack)

The slow pulse is a yin pulse, it arrives three (or two) times with one breath, [or it]  departs and arrives extremely slow (man 慢). {Mai Jing} It is yang that does not prevail over yin. Therefore the pulse arrives insufficiently.{bin hu mai xue}

Slow pulse arrives only three times with one breath. Yang does not prevail over yin cold [pathogenic qi], [or there is] qi and blood cold. Nevertheless, distinguishing if floating and deep [will determine if that pathology] is in the exterior or interior. To disperse yin one must augment the source of fire.

Similarities of a slow pulse [with other pulses]

One breath three arrivals is slow. If it is a little quicker than slow it is regarded as moderate [pulse]. Slow, thin, and difficult is choppy. A slow pulse that [periodically] stops is a bound [pulse]. If it stops with a fixed number [of beats in-between] then this is an intermittent [pulse]. {Li Shizhen}

Moderate arrives four [times in each breath] and is slightly faster than a slow [pulse]…

Mr. Li (黎) said, “Slow [pulse] is overabundance of yin and debilitation of yang. Moderate [pulse] is overabundance of protective and weakness in the nutritive.”

Diseases of the slow pulse.

Slow pulse is yin and corresponds to a state of desolation of yang qi, which is cold and deficienct. You should warm and tonify. The slow pulse is in charge of yin organ disease or profuse phlegm, serious and protracted illness, immobile and mobile abdominal masses. One must pay careful attention [to such conditions].

If has strength and slow this is cold pain. If slow and lacks strength then definitely deficiency cold. A distal slow pulse certainly corresponds to upper burner cold. The middle position masters cold in the middle causing unbearable pain. The proximal position is kidney deficiency with heaviness in the lower back and legs, fecal and urinary incontinence, and hernia stretching to the testicles.

Slow pulse governs the yin organs. If has strength then there is cold pain. If lacks strength then deficient cold. If floating and slow then this is exterior cold. If deep and slow then this is interior cold.

Left distal position: Heart fire and qi debilitation and essence spirit exhaustion. (The Heart masters fire season (火令??)), fulminant pain in the heart [region] and abdomen (cold pathogen),  or vomiting of clear oral mucus (In general the slow pulse is suitable for the Heart-sovereign).

Left middle position: Liver and Gallbladder qi is cold, ???, cold hands and feet, pain under the ribs, tense and cold sinews, aversion to eating and not eating. For this type of disease, it is also suitable to tonify and nourish the Heart blood.

Left proximal position: Kidney deficiency lower back pain, unable to bend forward and backward (qi that is cold).  Reversal cold of the extremities. Black facial complexion, abdominal pain, tinniutus, bowed head (头倾) (within water (坎) there is true yang, if slow [pulse] then yang qi is debilitated, solitary yin is unable to survive) (This yin maybe be a typo, and be yang). Kidney deficiency with turbid urine and no menses.

Right distal position: aversion to cold, shivering (yang qi not ascending). Lack of strength when speaking, wheezing and cough that wears them out, and clear nasal mucus.

Right middle position: Non-transformation of food and drink (fire is unable to generate earth), vomiting at the sight of food, or vomiting and diarrhea that contains food, or inability to lift the limbs (This pattern is suitable to warm and tonify)

Right proximal position: Ministerial fire debilitation, slow and lacks strength (maybe a typo: should be “has strength”), lower abdomen pain reaching to the genitals (cold qi pathogen). If slow and lacks strength this is counterflow cold from lower [burner] deficiency (yang fire debilitation)

When I arrived, I saw that the patient was experiencing hasty wheezing and shoulder breathing and spontaneous sweating from his head. This was heat in both the exterior and interior. His tongue coat was dark grey and his tongue was so contracted that he was unable to speak. I immediately took his pulse and found it floating, rapid, and strong, yet extremely empty upon stronger pressure. Because of this I thought that this was a pattern of extreme yang ming heat where the yin aspect was about to be exhausted. It actually was a worsening pattern from incorrect administration of  (gui zhi tang) and Minor Bupleurum Decoction (xiao chai hu tang).

I immediately gave her White Tiger and Ginseng Decoction (bai hu jia ren shen tang), substituting Dioscorea Radix (shan yao) for the nonglutinous rice (jing mi) [1]. In addition, I substituted Scrophulariae Radix (xuan shen) for Anemarrhenae Rhizoma (zhi mu). She took two packets of the formula in succession and her thirst was relieved, and her wheezing stopped. Her pulse was no longer floating and rapid although it was still strong. Her tongue stretched out and she was able to speak. Her phlegmatic cough was no longer intense and appeared to be milder. He then continued with a modification of Follow the Dragon Decoction (cong long tang), omitting the Perillae Fructus (su zi) and adding 4 qian of Ginseng Radix (ren shen) and 8 qian of Ophiopogonis Radix (mai men dong).

After taking 7 packets she was completely cured.

赵××，患温病。医者投以桂枝汤，觉热渴气促。又与柴胡汤，热尤甚，且增喘嗽，频吐痰涎，不得卧者六七日。医者谓病甚重，不能为矣。举家闻之，惶恐无措。伊芳弟××延为延医。急投以白虎加人参以山药代粳米汤，更以玄参代知母。连服两剂，渴愈喘止，脉不浮数，仍然有力，舌伸能言，而痰嗽不甚见轻。继投以从龙汤，去苏子，加人参四钱，天冬八钱，服七剂全愈

—

Follow the Dragon Decoction (cong long tang) contains:

Fossilia Ossis Mastodi (long gu) (not calcined, crushed) 30 grams
Ostreae Concha (mu li) (not calcined, crushed) 30 grams
Paeoniae Radix alba (bai shao) 15 grams
purified Pinelliae Rhizoma (qing ban xia) 12 grams
Dry-fried Perillae Fructus (chao su zi) (crushed) 12 grams
Dry-fried Arctii Fructus (chao niu bang zi) 9 grams

Charles Chace and I provided  commentary to the case in the article Tracing The Dragon, published in the RCHM Journal Autumn 2011, Vol. 8, No. 2.

Please feel free to leave any comments, questions, or criticisms here.

Writing Precise Prescriptions

• Read the introduction and excerpt (PDF).
• Read Qin Bowei’s 56 Methods: A Clinical Perspective. An article describing the boo’s history, usefulness of viewing things through the lens of treatment methods (principles), and clinical examples.

This book can be purchased from Eastland Press.

What people have to say:

“This book is a major step in the dissemination of Qin Bo-Wei’s ideas. Perhaps more importantly, it represents a highly refined vision of how Chinese medicine can be understood in the West. Here we are presented with much more than a list of signs and symptoms linked to a pattern, which in turn is linked to a fixed formula. Instead, this book illustrates the nuances inherent in every step of the diagnostic and treatment process.”

—Charles Chace, author of A Qin Bowei Anthology

I want to offer a very sincere thanks for your dedicated work on the new book. The introduction alone made me feel like I (and so many others) had been heard, that treatment methods offered during coursework can sometimes feel needlessly frustrating to navigate – for a host of both good and “bad” reasons. The book has so many of the things I wish I’d had before now. The Q&A sections are a particular favorite. I can’t count the number of hazy responses I received to some of these very questions in my own training. Otherwise: it’s concise without holes and never feels pithy; it’s visually easy to absorb (so vital); and it has a beautifully considered index to boot (why books on all manner of subjects ignore this art, I’ll never know). I won’t spill over here, but truly, a gift.

—Michael Castle, Great Wave Herbal Pharmacy

This wonderful book presents in an easy to understand fashion the ideas of Qin Bo-Wei, one of the most important practitioners of Chinese medicine in the 20th century. As a teacher of Chinese herbs for over ten years I highly recommend this book to anyone wishing to deepen their knowledge of herbal medicine and apply the principles presented in this book in their clinical practice. It’s a must read for students and experienced practicing herbalists alike.

-Warren Sheir, Chinese herbal medicine instructor

Original Case by:

[Patient] Gu (age 44) had already greying whiskers and hair on the temples. His facial complexion though was bright. He was emotionally worried and irritable. [There was] yang ascending and agitating [the spirit] with phlegm and thin mucus also ascending and overflowing.  The divine pivot says, when yang qi descends, joins and enter the yin, then the yang qiao vessel is full and one is able to sleep. [At this moment though] qi was disseminating and discharging outward and yang was not entering yin. He would drink alcohol in hopes of muddling his consciousness enough so he could sleep. This was not a good method for managing this disease. In middle age and afterwards, men’s lower base is the first to become depleted. [The treatment] was to use Eight-Ingredient Pill (ba wei wan) in the morning and Pinellia and Millet Decoction (ban xia shu mi tang) in the evening. (yang qiao vessel deficiency).

Translated by: Jason Blalack

Original Chinese: 顾（四四） 须鬓已苍。面色光亮。操心烦劳。阳上升动。痰饮亦得上溢。灵枢云。阳气下交入阴。阳跷脉满。令人得寐。今气越外泄。阳不入阴。勉饮酒醴。欲其神昏假寐。非调病之法程。凡中年已后。男子下元先损。早上宜用八味丸。晚时用半夏秫米汤。（阳跷脉虚）

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (临证指南医案 lin zheng zhi nan yi an).

Commentary: This case shows one approach to dealing with complex patterns of excess and deficiency, giving separate formulas at different times of day.  Ye uses his typical style of focusing on the pathodynamics and uses little in the way symptomatic “sleep” herbs. Brilliant! Eight-Ingredient Pill (ba wei wan) is another name for Kidney Qi Pill (shen qi wan). Pinellia and Millet Decoction (ban xia shu mi tang) is from the Divine Pivot and contains Pinelliae Rhizoma preparatum (zhi ban xia) and  Setariae Fructus (shu mi).

Comments? Questions? Mistakes?

by Jason Blalack
Originally published in the Chinese Medicine Times (Summer, 2011)

Introduction

There is a current trend for Chinese herbalists to prescribe medicinals based on their Western function. For example, modern research demonstrates that da qing ye (Isatidis Folium) and ban lan gen (Isatidis/Baphicacanthis Radix) are antiviral. Consequently, there are those in both Asia and the West that recommend their use for the treatment and prevention of the common cold and flu (gan mao), regardless of the pattern. For example, ban lan gen chong ji (板蓝根冲剂), a popular antiviral prepared medicine advertises, “Drinking [sic] a cup of this tea when exposed to others that are sick with a cold or when you think you are coming down with a cold to avoid getting sick yourself.” [i]

Although such an approach is exciting, integrative, innovative, and research based, this article will examine why the use of such medicinals in the treatment and prevention of externally contracted diseases is usually not warranted.Thus, including such medicinals into a formula because of its Western medical function, without understanding the intricacies of how it affects the overall Chinese medicine treatment principles, other medicinals’ actions, and the formula as a whole, can not only lead to an ineffective treatment, but can make the patient’s condition worse and actually injure the patient.

Ban lan gen (Isatidis/Baphicacanthis Radix) is probably the most popular antiviral used in gan mao prescriptions. It therefore serves as a good example for analysis, and the issues and concerns around its use can be extrapolated to other similar-natured antiviral medicinals.

The Birth of a New Approach
In the 1950’s Mao Zedong (毛泽东) announced his plan for the unification of Western and Chinese medicine. This dramatically changed how Chinese medicine developed, was perceived, and practiced. Although there were already some who where integrating Western medicine ideas prior to this, Mao’s “vision” forced many prominent physicians to research and practice in a Westernized manner.[ii] Consequently, medicinals were increasingly described by their Western attributes and subsequent treatment strategies immerged, influencing a whole new generation of doctors and consumers.

Ban lan gen (Isatidis/Baphicacanthis Radix), being one of the most promising discoveries, has since become a key ingredient in popular herbal beverages such as Isatis root herbal drink (板蓝根凉茶 ban lan gen liang cha) and prepared herbal formulas such as ban lan gen chong ji and gan mao ling (感冒零). Ban lan gen (Isatidis/Baphicacanthis Radix) has become very famous and even U.S. research facilities, such as the NIH, have begun exploring its antiviral properties. [iii]

Not surprisingly, a great deal of marketing has followed this herb’s growing fame. For example, promotional material for Isatis root herbal drink quotes the Inner Classic, “The sage does not treat an illness that has already [developed], [but instead] prevents disease.” It goes on to say,

“It can prevent disease when there is none. When there is disease it can treat it… It eliminates toxins from the body, boosts the immune system, fights bacterial and viral infections, and balances yin and yang… It clears heat, but does not damage the Spleen and Stomach” [iv]

Legitimizing an herbal product as one that keeps you healthy as well as treats disease is obviously profitable. Ban lan gen chong ji (an herbal formula) is even touted as “one of the most popular herbal beverages in China, and a staple in every household.” [v] My Chinese teacher says that it is a common belief among Chinese that “it can be used for (treat) almost anything, when there is heat.” Thus at the first sign of a sore throat or common cold (among other conditions) many drink (self-prescribe) this.

It is unclear if this popularity is related to true efficacy or marketing. Either way, the above products demonstrate how prevalent ban lan gen (Isatidis/Baphicacanthis Radix) is in mainstream Chinese culture and how it and other antiviral medicinals are viewed as seemingly safe and effective for external attacks as well as preventative medicine.

Recently though, there have been many disagreements with this perspective. Consequently, there are numerous articles, essays, and case studies illustrating the pitfalls of this antiviral approach. Therefore, we should look more closely at how this method relates to Chinese medical theory and what doctors notice when people prescribe ban lan gen (Isatidis/Baphicacanthis Radix) and other antiviral medicinals.

Medical Theory

New theory says the common cold is a virus. If we kill the virus we eliminate the disease. This is in contrast with Chinese medicine’s approach, which is to regulate and adjust the body’s internal terrain so that the pathogen is expelled. Although the virus may be eliminated and Chinese medicine’s terminology of “eliminating a pathogen” may even sound similar, the treatment approach of these two systems is dramatically different. Nonetheless, labeling a medicinal as “antiviral” is not the problem. The issue is that antiviral medicinals are often used in a way that is at direct odds with fundamental Chinese medicine theory.

Chinese medicine’s core principle for treating externally contracted diseases is to expel the pathogen. For example, for a common cold or flu due to a wind pathogen, the proper treatment method is to diffuse the Lungs and disperse wind. Thus, one should simply use acrid, balanced medicinals to disperse the wind and resolve the exterior. For a mild illness, one needs only a light treatment. Therefore, one should use medicinals that are balanced, smooth, light, and quick to guide the wind pathogen from the protective aspect to the outside of the body.

For example, Wu Jutong (1758-1836) stated,

“One treats the upper burner like a feather. Unless one’s touch is light, one cannot grasp it.”

It was also said in the Qing dynasty, “If the disease is in the upper burner, [the treatment should] be light and lifting.” [vi] Ban lan gen’s (Isatidis/Baphicacanthis Radix) nature though, is bitter, cold, heavy and primarily directs downward. Traditionally, Ban lan gen (Isatidis/Baphicacanthis Radix) was used for more serious presentations that usually involve internal heat. China’s Materia Medica (中华本草 zhong hua ben cao) describes ban lan gen (Isatidis/Baphicacanthis Radix) this way:

“It enters the Liver and Stomach channels, clears heat, resolves toxicity, cools the blood and unhinders the throat. It is indicated for warm toxin macular eruption, high fever with headache, massive head scourge epidemic, dark purple-red tongue, putrefying throat cinnabar sand, cinnabar toxin, mumps, painful obstruction of the throat, swelling of sores, chicken pox, measles, hepatitis, influenza, epidemic cerebrospinal meningitis, pneumonia, unconsciousness, swollen throat, and fire eye.”

Quite simply, according to Chinese medicine theory ban lan gen (Isatidis/Baphicacanthis Radix) is contraindicated for wind attacks (the most common externally contracted pattern), wind cold attacks, and some types of wind heat attacks. It should be noted that when people first feel like they are starting to “catch something” they usually have a wind attack, not full-blown wind heat or wind cold. If ban lan gen (Isatidis/Baphicacanthis Radix) is used in these situations it can cause many problems, such as lurking pathogens, as discussed below.

Its downward nature can drive the pathogen deeper and its cold nature not only can congeal a cold pathogen, but can also turn a heat pathogen into a cold pathogen, essentially freezing it. This is very similar to what happens when antibiotics are given incorrectly.

Clinical Practice
According to doctors’ case records and writings, pre-modern physicians did not consider ban lan gen (Isatidis/Baphicacanthis Radix), and similar medicinals, appropriate for early stage common colds and flu.[vii] We do know that they were aware of these medicinals because we see them used for other conditions, as mentioned above. In the Qing dynasty, epidemics were devastating families and dealing with external pathogens became a focal point for many physicians. Quite simply, if they could eliminate a pathogen or keep it from entering, they could save a life. These innovative physicians were looking for the most effective treatments, yet they still favored a light, scattering, and diffusing method utilizing mild and light herbs when treating externally contracted diseases. A great deal of theory came out of these doctors’ clinical practice.

Much of these ideas have now been time-tested and validated to be effective. In addition, my colleagues and I have used these core Chinese medicine principles in treating gan mao for years with a high success rate. Therefore, there is no reason to believe that the traditional theories and methods are ineffective. The obvious question is, if ban lan gen (Isatidis/Baphicacanthis Radix) is so effective why did these doctors not use it for such conditions? Although I cannot find any pre-modern or classical discussions of this question, modern doctors do articulate concerns, as discussed below.

Although we find advocates for this Western science perspective there is unfortunately a scarcity of actual case studies where formulas with ban lan gen (Isatidis/Baphicacanthis Radix) were successfully used to treat common colds and flu that manifested solely in the exterior. Actually most cases that one can find revolve around its unfavorable outcomes. We are now seeing many mainstream articles in Chinese openly criticizing this approach, such as, Is ban lan gen (Isatidis/Baphicacanthis Radix) able to treat gan mao?[viii], To use ban lan gen (Isatidis/Baphicacanthis Radix) one must differentiate disease[ix] and ban lan gen (Isatidis/Baphicacanthis Radix) is unable to guard against the common cold and flu.[x]

Another article that does advocate ban lan gen’s (Isatidis/Baphicacanthis Radix) use for wind heat conditions says this:

“If [ban lan gen (Isatidis/Baphicacanthis Radix)] is used to treat wind cold gan mao, not only will it be ineffective, but it also worsen the gan mao and damage the body. If one just stereotypically uses ban lan gen (Isatidis/Baphicacanthis Radix) for the incubation periods of gan mao [preventative treatment], it may have an effect, may not, or may even cause more problems.”[xi]

Although some do advocate it for wind heat patterns, in my opinion its inclusion should revolve around the pattern’s severity, location of the pathogen (deeper levels), patient’s constitution, and if there is concurrent internal heat. Therefore, the vast majority of externally contracted conditions, according to Chinese medicine theory, would not warrant ban lan gen’s (Isatidis/Baphicacanthis Radix) use. It has other concerns as well:

“ban lan gen’s (Isatidis/Baphicacanthis Radix) nature is cold and bitter and can easily can damage the Spleen and Stomach. Therefore it is unsuitable to use ban lan gen (Isatidis/Baphicacanthis Radix) in patients with Spleen and Stomach deficiency cold patterns (e.g. low appetite or an uncomfortable feeling after eating something cold). Its use can bring about a serious illness, due to the draining of ‘correct qi’. This is especially true in children where their digestive system is not yet fully developed.” [xii]

Case studies illustrate the potential consequences of bitter cold medicinals the best. For example, Zhao Shaoqin has a case study entitled Lurking Ice [xiii] where the etiology is described as, “This was a [pattern of] summerheat-damp brewing heat, in which excessive cold medicinals were taken. This covered the pathogen [creating] lurking ice in the middle burner.”

There was also a 45-year-old [patient] Li that presented with a typical gan mao with fever and chills and body aches. He self-prescribed antiviral patent medicines, ban lan gen chong ji and gan mao qing[xiv]. Although this relieved his fever and chills, it drove the pathogen deeper into the body, into the shao yang, resulting in a serious presentation with essence spirit deterioration, dizziness, etc. Xiao chai hu tang (Minor Bupleurum Decoction) was given and cured him.[xv]

Zhao Shaoqin had an interesting case where a “summerheat condition turned to congealed cold by merely eating cold food and drinks.” [i] Thus, if something as simple as cold natured foods can transform a heat pathogen into congealed cold, one must ponder the potential effects of giving strong cold medicinals.

Another example is the case where a lurking pathogen was created by adding antiviral medicinals, da qing ye (Isatidis Folium) and ban lan gen (Isatidis/Baphicacanthis Radix) to a typical gan mao formula. This was discussed in the article written by Charles Chace, Jack Shaefer, and myself (2007) entitled Lurking pathogens- three modern case studies.[xvi] Hence, even if a formula contains venting medicinals, this class of cold and bitter medicinals can weigh down the formula and in many instances prevent proper eviction of the pathogen from the body. There is no shortage of cases where cold and bitter medicinals create problems in externally contracted diseases.

In our clinic we have also seen quite a few side effects and complications from patients who have taken formulas that contain these antivirals such as gan mao ling and other Western gan mao patent formulas, especially when taken at the first signs of a cold. One problem in evaluating these occurrences is that initial symptoms can quickly resolve due to the cold and bitter medicinals. Since many practitioners do not follow patients closely they can easily overlook the etiology and development of problems, such as lurking pathogens. Thus, symptoms that initially resolve can return after a few days or even weeks or the pathogen can transmute into another problem (such as a urinary tract infection). Even worse, a deeper lurking pathogen may be created that will cause problems in the future.

Western research
A complete evaluation of the issues related to Western style research on medicinals, especially in China, is beyond the scope of this paper. However I would like to bring up one clinical point. Sometimes merely defining a medicinal as antiviral is too simplistic. If we want to play the Western medicine game we are destined to run into similar problems as they do. For example, there are many pathogens that give rise to upper respiratory tract infections such as mycoplasmal pneumonia, pneumococcus, chlamydia pneumoniae, and legionella pneumonia. Although ban lan gen (Isatidis/Baphicacanthis Radix) has a definite antiviral function, it actually has a pretty poor effect against pathogens such as mycoplasmal pneumonia and chlamydia pneumoniae type infections. Therefore, if one is unable to determine the specific pathogen of the flu and indiscriminately uses this medicinal, one may not obtain the desired effect.[xvii] Hence, we must ask, what does it mean to be antiviral? Even herbs commonly used as food, such as chen pi (Citri reticulatae Pericarpium), when tested in a laboratory are said to be antiviral!

Summary
There are many that advocate using antiviral medicinals at the first sign of gan mao / an external attack, regardless of the pattern, pathogen, or patient’s constitution. Some go as far as suggesting that one should use such medicinals as a preventative medicine. I have found no clinical evidence to support this approach.

I do think there are times that ban lan gen (Isatidis/Baphicacanthis Radix), or other clear heat and toxin medicinals, should be used in cases of gan mao. Such decisions though should be made from a Chinese medicine perspective respecting the centuries of wisdom that we have to guide us.

Therefore, the vast majority of patients that I treat for the common cold and flu do not require this class of medicinals, nor do I need to think about herbs as being antiviral or antibacterial to get results. I find the best clinical results from adhering to core Chinese medicine principles.

Endnotes:

[i]http://drheathersherbs.com/index.php?main_page=product_info&cPath=1_4&products_id=34
[ii] Taylor, K. (2005). Chinese medicine in early communist China, 1945-63: a medicine of revolution. New York, NY: RoutledgeCurzon
[iii] http://baike.baidu.com/view/2762507.htm
[iv] ibid
[v] http://www.chinamedicinemall.com/tonic_liquid.htm
[vi]These are referring to the use of light medicinals with an outthrusting nature, such as sang ye (Mori Folium), ju hua (Chrysanthemi Flos), and jing jie (Schizonepetae Herba) for conditions ine the upper burner, which also refers to the exterior of the body.
[vii] This is based on my review of around 25 pre-modern case record books as well an internet search in Chinese. It certainly is possible that there were physicians that practiced in this manner. If anyone finds such evidence please contact me so that I can revise my position.
[viii]板蓝根不是万能药能不能治感冒(10-21-2009) http://www.cdtdyy.com/News_Show.asp?id=188,来源：中国中医药报
[ix]China’s Chinese Medicine Newspaper (中国中医药报2010年1月18日) http://www.zysj.com.cn/yianxinde/7/71161.html
[x] http://www.621m.cn/search/doc/83258
[xi]喝板蓝根预防感冒要对症－http://focus.mz16.cn/baodian/20081222/92620.html
[xii] ibid
[xiii] Zhao Shaoqin (赵绍琴) (1996). An Essential selection of Zhao Shaoqin’s Clinically Verified Case Records(赵绍琴验案精选Zhao Shaoqin yan an jing xuan). Beijing: Xue yuan chu ban she学苑出版社。
[xiv]shan zhi ma, ban lan gen, gui zhen cao, gang mei gen, da qing ye, and chuan xin lian
[xv]江西中医药 1988; <4>:25
[xvi] This can be viewed at: http://www.chinesemedicinedoc.com/practitioners/articles/. It was originally Published in The Lantern (2007).
[xvii](2008) Is Taking Ban Lan Gen effective for the Common cold and Flu? (感冒了喝板蓝根管用吗gan mao le he ban lan gen guan yong ma) http://www.sz60.com.cn/news_view.asp?newsid=36106（文章来源：家庭医师更新时间：2008/12/22)

** This is a work in progress and currently only intended for review by the CHA (Chinese Herb Academy) and The Traditional Chinese Medicine Yahoo Groups :

Working Introduction:

Below is a case record from my clinical practice in Boulder, Colorado that highlights the strength of Chinese medicine’s treatment for common colds and flu. It also illustrates a problem with the health-care system in the U.S. and hopefully will spark a deeper much needed dialogue between Western and Chinese medicine.

Case record (2011): [Patient] X, a male in his mid-30s, came in with a chief complaint of fevers of unknown origin that had persisted for six weeks. The fevers were severe in the afternoons and would also wake him around 3-4 am, when his Advil “wore-off”.

He recently was hospitalized for eight days, when his fevers started reaching 104°F. They were characterized by a strong sensation of shivering cold (rigors). After multiple courses of antibiotics, a loss of 25 lbs. (he was not overweight), and $72,000 in hospital bills, he was discharged. Although his fevers had finally decreased he had no diagnosis, and within days of being discharged his fevers started to return. After a couple days of worsening symptoms he came in to see me for a Chinese medicine consult.

History: Prior to the fevers he was overworked and was not sleeping much. For the last few years he had been taking Metformin for diabetes and Pepcid for acid reflux.

Six weeks prior, he went to urgent care complaining of elevated temperature (102°) and chills, severe headache at the temples and occiput that was worse lying down, sore throat, and a “sinus infection” with nasal congestion. He was given Augmentin, which caused him to vomit. After four days of vomiting and feeling generally worse he was told to stop the Augmentin and given a second antibiotic, Azithromycin. Two days later his condition worsened and his fevers climbed to 104°F. He ended up in the emergency room where he had elevated liver enzymes (possibly from the Augmentin), normal CBC (including WBC), and was suspected to have left lobe pneumonia. He was given IV antibiotics and fluids and remained in the hospital for 8 days while they ran a battery of tests. Nothing conclusive was found.

In my office: The patient reported severe fatigue (unable to work), fever and chills, no sensation of heaviness, no thirst, no dryness of the lips or mouth, and the stools had recently become drier. Previous to the last few days he generally felt cold with the fevers, but now he had started to feel hot with the fevers. He was taking eight Advil a day to control the fevers (4 every 12 hours). When the Advil would wear off the fever would spike and he would start to sweat. His pulse was slippery, floating, and rapid. His tongue had cracks, no coat, was slightly red with small purple spots on the underside of the tongue.

Diagnosis & pathodynamic: Wind-cold pathogen constrained in the muscle layer transforming to heat in the protective level.

Treatment Principles: Use acrid cool medicinals to clear and resolve (disperse and vent out heat in the exterior).

Formula: Two packets of Honeysuckle and Forsythia Powder (yin qiao san) were given (bulk herbs). Cook time was 15 minutes. One packet was consumed over two days, taken between meals three times a day.

Prescription:

jing jie (Schizonepetae Herba) 6g (add)
jin yin hua (Lonicerae Flos) 15g
lian qiao (Forsythiae Fructus) 15g
dan zhu ye (Lophatheri Herba) 6g
niu bang zi (Arctii Fructus) 9g
jie geng (Platycodi Radix) 6g
bo he (Menthae haplocalycis Herba) 3g (add)
dan dou chi (Sojae Semen preparatum) 12g (add)
lu gen (Phragmitis Rhizoma recens) 18g
gan cao (Glycyrrhizae Radix) 3g

Result: After one packet the patient was back at work and although his muscles were achy, they felt stronger. After finishing two packets, he requested a two-bag refill from the pharmacy. He worked five continuous full days and at the next appointment (one week later) he was having no fevers, taking no Advil, and felt almost 100%. At this point I gave him a constitutional formula based on ban xia xie xin tang (Pinellia Decoction to Drain the Epigastrium). He had no recurrence of the fevers.

Commentary:

Although this case had a fortunate outcome with a straightforward treatment, I think it highlights some important issues in regard to Chinese medicine theory as well as Western and Chinese medicine’s roles in treating disease.

Chinese medicine commentary

This case started with a fairly typical flu, most likely caused by a wind-cold pathogen. The prescribed antibiotics constrained the pathogen in the muscle layer. Antibiotics, usually considered cold and bitter, are not appropriate in such situations, which require an acrid warm approach to disperse and release the exterior cold.

The patient had a fairly robust constitution, which helped prevent the pathogen from sinking into the interior. Over time though, the pathogen transformed to heat. The fluids were only starting to become affected as evidenced by the dry stools, yet the lips and mouth were not dry. This was not a pathogen that had entered the Large Intestine or yang ming. The presentation was fairly straightforward from a Chinese medicine diagnostic perspective. We had a lingering pathogen in the superficial aspects of the body and a clear heat and resolving the exterior method was appropriate.

Some points to keep in mind:

1. High fever can still be an exterior problem
2. An ongoing fever for 6 weeks to 6 months can still be an exterior problem
3. The lack of dryness and internal organ symptoms gives evidence that the pathogen was still on the exterior.

It should be noted that the treatment, although fairly basic, was not a mechanical, reflexive action. In my practice I rarely give an unmodified formula, let alone Honeysuckle and Forsythia Powder (yin qiao san). I was a little embarrassed when writing this case up, having published material discussing how this specific formula (and formulas in general) are best thought of as ideas and should not be given as presented in our textbooks. Although formulas are best constructed for each individual presentation, in this case, the stock formula seemed to be spot on.

Furthermore I do not want to suggest that Honeysuckle and Forsythia Powder (yin qiao san) should be given indiscriminately in other cases of fever of unknown origin. One still should perform an appropriate differential diagnosis.

I think though that the nature of the condition, being an uncomplicated pattern, and the simplicity of the treatment really speaks to the strength of the Chinese medicine model compared to Western medicine’s approach to diagnosis and treatment.

The integration of Western and Chinese medicine

Although this is only a single case it does represent a common clinical occurrence and is also emblematic of a greater problem in health care. Cold and flu are treated very successfully with Chinese medicine, even ones that seem fairly urgent. Chinese medicine has quite an arsenal of options that have actively been developed over 2000+ years of clinical practice. There is case study after case study in Chinese and English that demonstrate the effectiveness of the Chinese medicine approach for these conditions.

Western medicine has little to offer since most colds and flu are viral. However, antibiotics are often given because the patient requests “something” or there is a suspected (usually secondary) bacterial infection. Although antibiotics can have their place, the majority of the time Chinese medicine can resolve the problem without their use, hence avoiding the multiple issues that come along with antibiotic treatment.

All health care providers are trying to come up with the best care possible for our patients. Hence it would be worthwhile if we could respect each other’s strengths while acknowledging our own weaknesses. Chinese medicine doctors all too often write off Western medicine because it is not “natural,” or supposedly just treats the “symptoms.” Western medicine writes off “alternative” medicine due to lack of rigorous research.

Is it unreasonable for practitioners to refer to other modalities that have a better handle on a given illness? Ultimately we should all be working together, creating a team that centers on the patient’s best interest.

I often have patients ask me to converse with their Western doctors about collaborative treatments. Some MDs that are open-minded enough to engage in such discussions. Quite simply though, most medical doctors make little effort to understand Chinese medicine. Hence one is unable to discuss Chinese medicine on its own terms (its theory and terminology) and is forced to artificially describe its actions and methods in pseudo-Western medicine lingo.

In contrast, Chinese medicine physicians not only are required to take Western medical courses in their curriculum, ranging from Western physical exam to pharmacology and pathophysiology, but often actively seek out ways to integrate the knowledge into Chinese medicine.

Chinese medicine in 2006 treated more than 3.1 million U.S. adults with acupuncture[1]. Major insurance companies, such as Kaiser, not only cover Chinese medicinal services but are starting to discuss Chinese medicine on its own terms.[2] Is it not reasonable for Western doctors to have at least one course in their training centered on Chinese medicine? Is it not reasonable for them to strive for at least a basic understanding of a medicine that has been around for over 3000+ years?

In conclusion, Chinese medicine is more appropriate than Western medicine for many conditions. However discovering what these may be is a bit difficult if the two cannot openly work together. Quite simply, Chinese medicine must first be understood on its own terms (within its own system). For example, WebMD states,

“Research in China and worldwide has shown Chinese medicine to be helpful for many types of illness. Because Chinese medicine differs from Western medical practice in diagnosis and treatment methods, it is difficult to apply Western scientific standards to it.[3]”

That is, Chinese medicine most often gives individualized treatments based on constitution and whole-body presentation, not a Western disease or a mere symptom. Hence typical research models do not accurately reflect Chinese medicine’s abilities.

However, we can learn from case studies and individual doctor’s experience and see how Chinese medicine thinks about disease as well as what can be successfully treated. What will it take for Western medicine to acknowledge Chinese medicine and start to work together?

Please feel free to post any comments.

[1] http://nccam.nih.gov/health/whatiscam/chinesemed.htm

[2] https://members.kaiserpermanente.org/kpweb/healthency.do?hwid=aa140227spec

[3] http://www.webmd.com/balance/tc/chinese-medicine-topic-overview

by: Jason Blalack

In Chinese medicine, our understanding of technical terms shapes our clinical picture and ultimately how we treat. One such term that recently peaked my interest was the term 烦 (fan), translated as vexation (Wiseman) or irritability (Eastland Press). These translations seem reasonable since modern dictionaries define it as:

1. vexed, irritated; annoyed, terribly upset, worried mood, or
2. to trouble

However sometimes our assumed meaning, based on a translation or modern understanding, is different than how it is used in various Chinese medicine contexts, especially historically.

Thus 烦 (fan), can have very different meanings depending on the context it is used. I would like to present a brief analysis of how it is used in the Discussion of Cold Damage (Shang Han Lun), in which it occurs around 90 times. It is found in numerous compounds, which help define it, such as Heart irritability (心烦 xin fan), internal irritability (内烦 nei fan), irritability and restlessness (烦躁 fan zao), irritability thirst (烦渴 fan ke), restlessness and irritability (躁烦 zao fan), vexing pain (疼烦teng fang), among many others.[i] Understanding how it was classically used helps us understand its meaning today.

Hence, the understanding of these terms, and the passages that they are contained in, have direct clinical relevance today because they make up our core understanding of key symptomatology for patterns such as shao yin with Kidney yang deficiency and formulas such as xiao chai hu tang (Minor Bupleurum Decoction).

Understanding these terms does not come without complication. As with many classical texts there is controversy. Some choose to understand the term more literally, some with a more modern slant, others strive to look at the time period’s understanding and pick apart the context. Let us look at a few perspectives from the Discussion of Cold Damage, which should be noted, is just one of many.

In general, Zhang used irritability (烦 fan) to mean:

1. Heart irritability (心烦 xin fan) or irritability and restlessness (烦躁 fan zao)
2. To show that a symptom was of a serious nature
3. Nausea

1. Heart irritability (心烦 xin fan) or irritability and restlessness (烦躁 fan zao) in the Heart is the most general type of usage for 烦 (fan) . According to mainstream view this relates to symptoms related to the essence-spirit, not unlike how we understand the terms in English. Consider the line 24:

When in Greater yang disease, the patient initially had taken gui zhi tang, but instead [becomes] fan (烦) and [the condition] is unresolved…”

Looking at how fan (烦) was used in Han dynasty gives an added perspective of the term. For example in the shuo wen jie zi (the first Chinese dictionary, complied by Xu Shen, 121 A.D.) it defines 烦 (fan) as a “heat headache.” Discussion of Cold Damage commentators such as Hao Wan-Shan’s[ii] emphasize the importance of this symptom. It is a “hot type headache, where there is heat and also pain.” Hence this 烦 (fan) here has the additional meaning of heat irritability (烦热 fan re) or even just feverishness (发热 fa re). Actually one may interpret this above passage (line 24) as just having an increased fever. Other lines with a similar usage include: 38, 46, 102, 107, 118, and 264.

Consequently, many believe that this aspect of heat is an important component of understanding the term irritability (烦 fan) in a medical context and if we do not see heat, then it is not irritability. In addition irritability in the heart (心烦 xin fan) will also need to have this heat sensation which is especially present in the chest. This may be an objective or subjective feeling.

2. 烦 (fan) used to express the seriousness of a symptom. For example, in line 156, it says “…give xie xin tang. If the focal distention is unresolved and the person is thirsty, has a severe dry mouth (口燥烦 kou zao fan)…”. Some textbooks tend to interpret this as “… and the person is thirsty, has a dry mouth, has vexation….”

Line 240 begins with “病人烦热 (bing ren fan ren) …” Although some textbooks understand this as “When the patient has heat vexation” others interpret this as “When the patient has severe heat…”

Other instances of this type of usage are lines 174, 175, and various passages in the Essentials from the Golden Cabinet (see endnote[iii]). Hence we get dramatically different interpretations depending on how one understands this 烦 (fan).

3. Nausea: Modern day Chinese medicine uses 恶心 (e xin) for nausea, however this technical term was not used in the Discussion of Cold Damage, or the Inner Classic. Zhang Zhong-Jing instead used phrases such as 欲吐不吐 (yu tu bu tu) line 282 or 温温欲吐 (wen wen yu tu) line 324 among others, to express nausea.

Commenters such as Li Xinji believe that 心烦 (xin fan) refers to nausea in some instances. His argument is that 烦 (fan) according to historical record has this meaning of  “entangled disturbance (搅扰纠结 jiao rao jiu jie)”, with commentary explaining this as being  a “frequent disturbance”. Heart (心 xin) in Chinese medicine often refers to the location below the heart or stomach duct.  Hence this is a “churning disturbance in the stomach duct region”, hence nausea.

For example, in Line 96, which is a key passage for xiao chai hu tang (Minor Bupleurum Decoction) says,

When in cold damage [that has lasted for] five or six days [or] wind strike, [there is] alternating chills and fever, and [the patient] has a sense of discomfort and fullness in the chest and ribs, being dejected with no desire to eat, 烦心喜呕 (fan xin xi ou) 胸中烦而不呕 (xiong zhong fan er bu ou).”

Here 心烦 (xin fan) is often interpreted as irritability and restless within the Heart. However Li Xinji points out that if we look at what comes before and after this term, “no desire to eat”, 心烦 (xin fan), “likes to vomit” it makes sense that this actually refers to nausea. He further says, this 心烦 (xin fan) has nothing to do with spirit-light symptoms of the Heart (神明之心 shen ming zhi xin).

Also notice line 326, “…pain and heat in the HEART (心中疼热 xin zhong teng re), hunger with no desire to eat…” – This “heart” here also refers to the stomach.

Hence looking back at line 96, the next series of characters are “irritability in the chest without vomiting (胸中烦而不呕 xiong zhong fan er bu ou).” This 胸中烦 (xiong zhong fan) has the meaning of irritability and restless within the heart (chest). So the whole passage is:

When in cold damage [that has lasted for] five or six days [or] wind strike, [there is] alternating chills and fever, and [the patient] has a sense of discomfort and fullness in the chest and ribs, being dejected with no desire to eat, nausea (心烦 xin fan) with a tendency to vomit, or [there is] irritability and restless within the heart without vomiting, or thirst…”

There are other instances where 烦 (fan) and 心烦 (xin fan) refer to nausea, such as in lines 282, 315, and 355. Notice how the surrounding symptoms are specifically gastrointestinal symptoms such as desire to vomit, dry retching etc.. Understanding things in this manner explains many contradictions in passages such as in line 282.

For example line 282 discusses a shao yin disease with Kidney yang deficiency. One of the symptoms mentioned is 心烦 (xin fan) which is often understood as irritability and restless in the heart. However if one looks at the surrounding symptoms, as we did above, we see;

In shao yin disease, [there is] a desire to vomit, but no vomiting ( or: with an inability to vomit), nausea (心烦 xin fan), and a desire to sleep…”

Does “irritability in the heart (心烦 xin fan)” a heat symptom, make sense when there is lower burner deficiency and cold? Some commentators justify this by explaining the irritability in the heart  as a “contradictory” symptom caused by the “lower burner struggling with exuberant yin cold which is pushed upward, where it harasses the Heart.” In my opinion, a more likely explanation is the same pathodynamic proposed for the “desire to vomit”, which is, turbid yin counterflowing upward, causing disharmony of the Stomach qi that disturbs the normal downbearing.

In summary, the ideas presented above are just one opinion, as there are many valid interpretations. They are presented to hopefully widen one’s clinical gaze. No one knows for sure of Zhang Zhong-Jing exact intentions but we can try these ideas out in the clinic and see what makes the most sense.

As a comparison it is interesting to look at a modern Chinese medicine Chinese language dictionary’s definitions for 烦 (fan):

1. Heat (热 re)
2. Irritability and restlessness (烦躁 fan zao)
3. Internal heat irritability in the Heart (内热心烦 nei re xin fan)

It further defines 心烦 (xin fan) as “irritability heat and oppression in the Heart (心中烦热郁闷 xin zhong fan re yu men).”

These entries in and of themselves are a bit circular in definition and hard to grasp, which is what led me on this quest to begin with. As we have seen above, these terms have a large variety of meanings that are not as straight forward as some may like.

Throughout history people use terms in different ways, figuring out the true meaning is never easy. Therefore this essay probably brings up more questions than gives answers, but that is the nature of Chinese medicine. Becoming comfortable with contradictions and varying interpretations and how to make use of them is a useful clinical skill.

For further reference, here are 11 translations for the term 心烦 (xin fan):

• Restless feelings and agitation in the chest
• Anxious feeling or restlessness in the chest
• Anxious restlessness
• Heat in the chest and suffocation (usually translated as ‘anxious agitation’)
• Mental restlessness
• A restless feeling in the chest
• Heart vexation
• Cardiac vexation
• Vexation
• Irritability of the heart
• A feeling of restlessness, heat, and oppression in the region of the heart

English translations have an even more difficult task, because readers often assume they understand the meaning of a technical term based on a seemingly transparent phrase, e.g. “mental restlessness.” Each translation evokes a bit of a different meaning.

However instead of being limited to a single author’s translation of a phrase we can begin to make use of the large breadth of possibilities and usages. Hence none the above are necessarily wrong, if matched to the correct context. However most likely they are going to fall short in certain instances or other people will simply have a different opinion on the meaning. However if we can keep in mind open I think it can help us find some truth in our own clinical experience.

Thank you for reading this essay. Feel free to leave any comments, corrections, or questions?

[i] I purposely chose to use very literal translations, because as we will see, the meaning of these terms can be very different based on the context of a given passage. Also for convenience I chose to mostly use irritability for 烦 (fan), but this, as well as vexation, is an incorrect portrayal in some instances.

[ii] 郝万山强伤寒论

[iii]《金匮要略·痉湿暍病脉证治》：“湿家身烦疼，可与麻黄加术汤发其汗为宜……”；《金匮要略·妇人杂病脉证并治》