The "Ask Dr. Jiang" column is designed to explore corners of Chinese medicine that may not be easily understood by American practitioners or are underrepresented in American clinical health literature.
Dear Dr. Jiang:
I am concerned about the future of ma huang and my ability to use it in my practice. Even if it is not taken off the market, many of my patients are afraid to take it after all the negative publicity it has received. Are there any effective substitutes for ma huang?
Concerned About Losing Ma Huang
Los Angeles, California
Dear CALM:
Chinese doctors have been using ma huang for over 2,000 years. Let's face it: if there were other herbs that worked as well, they would already be using them. Ma huang continues to be used because it possesses powerful and unique qualities, and if a patient really needs these qualities, any substitute will produce less than satisfactory clinical results. We all have to live in the real world, however, and ma huang won't work if a patient is unwilling to take it, or if the law prevents you from prescribing it.
Before we can discuss possible ma huang substitutes, I need to set the record straight on ma huang itself. There are a number of misunderstandings that have developed in recent years, even among practitioners of Chinese herbal medicine. Let's take a look at them.
Misunderstanding #1: Ma huang increases energy.
This idea has no theoretical or clinical basis in Chinese medicine, and it cannot be found anywhere in the classical or modern Chinese literature. Ma huang's warm acrid qualities powerfully move the qi, and the "energy" people claim to enjoy is a result of that movement. Ma huang can indirectly increase energy in a patient who suffers fatigue due to excess cold from cold damage, but in this case, the fatigue is the result of excess, not deficiency. The results come from dispersing evil qi and allowing the right qi to reassert itself. In this and all other cases, ma huang is a reducing herb. It does not tonify.
Misunderstanding #2: Because ma huang is a warm herb, it should not be used in case of fever.
In fact, most of the ma huang formulas in the Shang Han Lun are designed for use in febrile presentations. This misunderstanding is perhaps the result of confusing Eastern and Western medical perspectives. Since there is no such thing as a fever due to wind cold in Western medicine or even in Western herbalism, some Western practitioners have assumed that ma huang's warm properties make it contraindicated in all fevers. As long as the febrile patient's symptoms match the indications of the formula, ma huang can and should be used in treatment.
Misunderstanding #3: ma huang should not be taken for more than a few days.
Wrong again. The length of treatment will depend on the formula being used; the condition being treated; the dosage; and the patient's overall constitution. If a formula like xiao qing long tang is being used to treat acute asthma due to wind cold, it should of course be discontinued after the acute symptoms of wind cold have abated. However, in the case of gui zhi shao yao zhi mu tang and wu tou tang, both of which are used to treat chronic wind-cold-damp bi patterns, administration can continue for several weeks or even months, since dampness takes a long time to expel.
Misunderstanding #4: All formulas containing ma huang are contraindicated in heat patterns and deficiency patterns.
This misunderstanding is a result of confusing ma huang as an isolated herb and ma huang as a constituent in a formula that contains other herbs. As an isolated herb, ma huang is warm, acrid and bitter. It is used to dispel cold excess, especially wind cold, and is therefore contraindicated for heat or deficiency, but Chinese medicine never prescribes ma huang as an individual herb; it is always used in a formula. In addition, many formulas containing ma huang are used to treat precisely the patterns for which ma huang by itself would be contraindicated. Ma xing shi gan tang, for example, is used to treat heat obstructing the lungs. Yue bi jia ban xia tang (yue bi tang with the addition of ban xia) is used for phlegm heat obstructing the lung. While both of these formulas take advantage of ma huang's ability to move lung qi and calm wheezing, they contain enough shi gao to counterbalance ma huang's warm quality.
Likewise, ma huang xi xin fu zi tang is used to treat wind-cold occurring in patients with underlying yang deficiency. In modern China, a pill made from this formula is sometimes taken as a long-term treatment for congestive heart failure in patients with heart yang deficiency. Yang he tang is used for yin sores due to phlegm blocking the channels and blood deficiency. Both of these formulas, while treating an underlying deficiency pattern, require ma huang to facilitate the movement of qi.
In summary, ma huang is a safe and effective herb as long as it is used according to the rules of Chinese medicine, which have been founded on direct clinical experience in the treatment of thousands of patients over many generations. When these rules are abandoned, as they have been in the United States, it is not difficult to see why so many adverse reactions have occurred. Not only is ma huang taken to "increase energy," something it cannot possibly do; and not only is it being taken without regard to pattern diagnosis or underlying constitutional needs, it is being taken as an isolated herb, rather than as part of a balanced formula. Most astonishing of all, it is being taken in raw powdered form, without any cooking or processing. According to the instructions in the Shang Han Lun, ma huang is supposed to be decocted first, and the foam removed, before adding other ingredients. This additional cooking, and perhaps also the removing of the foam, changes the chemistry of the decoction and removes any harsh or toxic qualities.
Now, to answer your question about ma huang substitutes. The only traditional substitution for ma huang that I'm aware of is the combination of fang feng and jing jie, but this substitution is only prescribed in the treatment of very weak patients; it wouldn't be used to treat patients who match the normal confirmation for ma huang use. I need to warn you, therefore, that the suggestions I'm about to offer are based primarily on theory, since there is no Chinese clinical experience in arbitrarily substituting other herbs when the patient really needs ma huang. Although the following substitutions are safe, no one can honestly say how effective they will be.
When considering substitutes, you will need to determine which qualities of ma huang you are seeking to replace. If you are trying to treat wind-cold-damp bi patterns, for example, try substituting qiang huo and du huo, both of which expel wind cold and wind dampness. These herbs might be substituted for ma huang in formulas such as ma xing yi gan tang, ma huang jia zhu tang or ge gen tang. In the case of wu tu tang, you can try substituting gui zhi, but in the case of gui zhi shao yao zhi mu tang, you might be able to remove the ma huang without replacing it at all, since that formula already contains gui zhi in addition to several other warm acrid herbs.
If you are using ma huang to treat external invasion with lung obstruction, you can try substituting zi su ye. This substitution might be made, for example, in ma huang tang. Since zi su ye is much weaker than ma huang, I would advise that you use it at a higher than usual dosage. If you are treating phlegm cold, as in the case of xiao qing long tang and she gan ma huang tang, in addition to zi su ye add xuan fu hua. If you are treating phlegm heat, as in the case of yue bi jia ban xia tang or ding chuan tang, substitute qian hu.
If you are using yang he tang to treat yin sores, you can try substituting bai zhi, since this herb releases exterior cold and expels pus. If you are using yang he tang to treat crane's knee wind (water swelling in the knees), use qiang huo or du huo as substitutes for ma huang.
If you are treating external cold with internal deficiency, as in the case of ma huang xi xin fu zi tang or ma huang fu zi gan cao tang, you might try using several other warm acrid herbs as substitutes, such as qiang huo, jing jie and fang feng.
This is the best I can do with a very difficult subject, CALM. Let us hope that we can educate the public, as well as government regulators, on the importance of keeping ma huang available for legitimate medical use.
Edited with the assistance of John Pirog, MSOM.
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