Western medicine has little to offer in the treatment of colds and flu and antibiotics, as controversial as they are, are often the primary treatment available. In contrast, Chinese medicine is very effective at treating colds and flu, thereby avoiding the many complications that can accompany antibiotic treatment such as abdominal cramps, diarrhea, superinfections, antibiotic resistance, etc.

Below I present a brief summary of a medical case from my clinical practice in Boulder, Colorado highlighting the value of Chinese medicine’s treatment for common cold and flu where Western medicine failed. This case not only demonstrates the perils that can occur from unnecessary antibiotic use, but also illustrates a larger problem in modern health care. In addition, I hope that it helps educate people in some basic concepts of Chinese medicine as well as spark a much needed dialogue between Western and Chinese medicine practitioners. I have retained some of the basic Chinese medicine terminology and ideas, to inform those interested in this ancient and effective perspective.

The Case: A mid-30s male on June 6, 2011, visited my office complaining of fevers that had persisted for six weeks. They were more severe in the afternoons and he was taking Advil (ibuprofen), a non-steroidal anti-inflammatory drug, to control them. He also had developed severe fatigue and eventually was unable to work and effectively perform activities of daily living.

At our first visit he reported that his symptoms began approximately six weeks ago, after he had been given an antibiotic, Augmentin, at urgent care for his cold / flu symptoms of 102° fever, chills, headache, sore throat, and sinus congestion. Unfortunately, he appeared to have severe side effects from the Augmentin, and after four days of vomiting and feeling generally worse, he was switched to a second antibiotic, a Z-Pak (Azithromycin). Two days later his condition worsened yet again, and his fevers climbed to 104°F.

Two weeks prior to seeing me he was finally hospitalized due to his persistent fevers and feeling very unwell. He was given multiple courses of antibiotics, lost 25 lbs. (he was not overweight), and accumulated $72,000 in hospital bills after all the conventional tests and treatments had been performed. After eight days he was discharged with a diagnosis of fevers of unknown origin. Within days his fevers once again started to spike and he started feeling very weak. This is when he decided to come see me for a Chinese medicine consult.

The Chinese Medicine Treatment & Results: After speaking at length with this patient, my treatment involved giving him one week of the modified raw herb version of a common formula called “Honeysuckle and Forsythia Powder (yin qiao san)”. This formula has been around for hundreds of years and has a proven track record for treating colds and flu. It has also been extensively researched with modern Western methods confirming its effectiveness.

After starting the herbs he immediately felt better. After one and a half days the patient was back at work and although his muscles were achy, they felt stronger. He continued taking the herbs and worked five full continuous days. When I saw him one week later, he was having no fevers and no longer needed the Advil; he felt almost 100%. He had no recurrence of the fevers when I followed-up with him eight weeks later.

About ten weeks later, he again developed a cold with a sore throat and went to urgent care. They surprisingly gave him the same antibiotic (Augmentin) that made him sick, similar to the first time. Within two days he was once again experiencing high fevers. After no effect from the antibiotics, he came back to me for a Chinese herbal consultation. I gave him a modified version of the previously given formula, which immediately cleared up the fevers.

From a Chinese medicine perspective my patient’s case history and the condition treated was not overly complex. In fact, two times I was able to quickly diagnose the person, and prescribe Chinese medicinals to effectively treat him (and might I add, for a very affordable price compared to the $72,000 he spent during his hospitalization).

In addition, Chinese medicine truly uses individualized and holistic treatments, even for a common cold. For example, a person that feels chilled will require a different treatment than one who feels warm. Thus 10 patients with a common cold may require 10 different herbal formulas.

Let me share with you the Chinese medicine perspective of this gentleman’s condition.

Antibiotics vs. Chinese Medicine’s approach

Nowadays, although many are leery of using antibiotics for colds and flu, their widespread use still persists. Chinese medicine though offers a valuable perspective on why they often cause complications.

According to Chinese medicine, when a disease is located in the superficial (exterior) regions of the body, as is common with colds and flu, the fundamental strategy should be to push the pathogen outward using light lifting medicines. Antibiotics though, are descending and heavy in nature and can actually drive a pathogen deeper into the body and lock in the pathogen (making it difficult to be expelled). The pathogen then brews, and can eventually transform into a more serious condition, and even cause a superinfection. In the above case, the antibiotics led to an increased fever and a worsening of his illness, leading to hospitalization.

Chinese medicine also pays special attention to the thermal nature (temperature) of the illness. If a condition is cold natured (e.g. the patient feels chilled) then warming medicines are used. If the condition is hot, then cold medicines are used. Antibiotics are considered cold natured. In the beginning of this case, the patient’s condition was cold in nature and applying a cold strategy (antibiotics) was incorrect. Cold plus cold congeals the pathogen, trapping it in the body, inhibiting it from being expelled. In addition overly cold strategies inherently can damage the digestion, for example, cause diarrhea. Of note, consider classic signs of a bacterial infection (where antibiotics are most effective), redness, heat, swelling, pain, and green or yellow phlegm. In Chinese medicine, this corresponds to a heat condition. He did not have this type of presentation.

In addition, Chinese medicine’s strategy is not to directly kill bacteria or viruses. Such “killing” strategies (even herbal ones), may render short-term symptomatic relief, giving the impression of success, but can damage the body and often lead to latent pathogens[i]. In contrast, Chinese medicine uses strategies to regulate and adjust the body’s internal terrain to stimulate the body’s natural immune power to eliminate the pathogen. This strengthening process is helpful in preventing recurrences or lingering (or resistant) pathogens.

Thus, an inappropriate treatment not only leads to poor results, but also can have long-term consequences by creating “latent pathogens.” These are pathogens or conditions that linger in the body for weeks and sometimes months to years. A person is often unaware of this internal process, but would however feel different symptoms, which often then get diagnosed as new diseases. The misery layers upon itself.  This can cause catastrophic health problems and cost a patient enormously. Therefore, although antibiotics are sometimes of value, they often lead to lingering conditions or future reinfections because of their inability to push pathogens outward.

These philosophical differences in treatment are at the heart of why Chinese medicine can succeed so well in treating colds and flu (and many other diseases) when Western medicine fails. In addition, these unique clinical and ancient perspectives are something that, in my opinion, would be useful for Western medicine to consider. The art of effective medicine is in learning how to identify individual presentations, instead of merely treating “the disease”, and then matching appropriate treatment strategies to these presentations.

Jason Blalack practices Chinese and Functional medicine in Boulder, Colorado and is the author of the Chinese medicine herbal textbook, Qin Bo-Wei’s 56 Treatment Methods: Writing Precise Prescriptions.

When: Mondays, 11:30-2:00

Where: The Boulder Birth Community Classroom (in the Boulder Nurse Midwives office building, across from Foothills Hospital), 4800 Riverbend Road, Suite 100, Boulder, CO 80301

Who: Practitioners Kate Blalack, Ashley Crutchfield, and Tara Brockman are all nationally certified and licensed acupuncturists who specialize in family and women’s health, and have over 25 years combined professional experience.

Cost: Sliding scale from $20-40. Cash or check only. No proof of income required.

Contact: Kate Blalack, L.Ac. 303-545-5792 x 107, or kblalack at ChineseMedicineDoc.com with questions or to make an appointment.

Acupuncture during pregnancy is a safe, time-tested way to address many issues, such as:

• Morning sickness
• Constipation, heartburn
• Back pain, hip pain, carpal tunnel
• Fatigue, headaches, dizziness
• Rashes and sinus congestion
• Anxiety and depression
• Breech presentation
• Labor preparation

For more information on the Boulder Birth Community Classroom, including prenatal and partner yoga classes, birthing classes, nutrition talks, parenting classes and breastfeeding support, visit the Boulder Nurse Midwives site.

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

“There is nothing else available in the English language literature that I know of that comes even close and this information alone makes the book a ”must buy” for any serious practitioner. Add to this the clinical experience of two master physicians, the clarity with which Jason Blalack makes that experience accessible, and the immediate translatability of what is discussed to virtually any situation one might encounter in clinical practice and it becomes an absolute bargain.” For the full book review see RCHM  (Register of Chinese Herbal Medicine) (UK) (Spring 2012).

- Volker Scheid, co-author of Formulas and Strategies (2nd edition) (Eastland Press)

“… That Blalack places as much importance on the comfortable language of his presentation as he does the book’s concepts proves a genuine desire for the material to be used… My own copy of Qin Bo-Wei’s 56 Treatment Methods, now just a few months old, is already becoming tattered and has quickly risen above the flotsam of the usual “standards”, ones upon which so many of our current ideas about Chinese herbalism are based. I likewise hope that all those invested in this field give the 56 Methods a prominent place – not only on their bookshelves but in the application of their art.”

- Excerpt from The Fetch’s Book Review

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

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

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)