During my years of tutoring and teaching traditional Chinese medical students, one issue comes up repeatedly. Students always express frustration over their lack of knowledge of Western herbs and their inability to discern whether the Western herb a patient is taking will help or hinder their TCM treatment protocol. This is an interesting dilemma in a TCM clinic. Initially, my response to such issues was to encourage students to solely focus on Chinese medicinals in lieu of Western herbs. However, with the growing number of patients self-medicating themselves with Western herbs, I felt that there was a need for TCM students and practitioners to at least possess a basic familiarity with the most commonly used Western herbs. This is similar to TCM students and practitioners having a basic working knowledge of Western pharmaceuticals.
One important concept to keep in mind is that traditional Chinese medicine essentially is an independent modality. By this I mean it is not necessary or essential for students or practitioners to integrate Chinese medicinals with Western herbs. Using Western herbs in lieu of Chinese medicinals due to a lack of knowledge of the Chinese materia medica or poor TCM diagnostic skills in not only bad medicine; it is unethical. TCM practitioners should practice and administer what they are trained in: Chinese medicine. The integration of Eastern and Western herbs is a work in progress and does not have the clinical foundation of a 5,000-year old tradition to base decisions upon. This being said, I do feel it can be helpful for students and clinicians to be able to dialogue with their patients and offer honest, intelligent answers to patients questions concerning Western herbs. Over the next year, my column will explore the idea of integrating Eastern and Western herbs, and hopefully is a lucid and welcome addition to this "work in progress." With the approach of the cold and flu season, I felt a discussion on the pros and cons of the Western herb echinacea would be a timely and germane topic.
One of the most commonly misdiagnosed and therefore mistreated clinical scenarios is gan mao or the common cold. It is very common to see students and practitioners alike prescribe yin qiao san or gan mao ling without feeling a pulse, examining the tongue, or even pursuing a minimum amount of questioning. While sometimes a patient's pattern is simply wind heat or wind cold, in today's fast-paced, overworked environment, patients rarely present without some type of vacuity. If this vacuity is not addressed, the presenting pattern will not resolve and might potentially be exacerbated due to improper treatment.
This is not a modern dilemma. Texts such as the Shang Han Lun discuss the results of improper treatments and the iatrogenic effects of incorrectly prescribed medicinals. The sine qua non and inherent strength of traditional Chinese medicine is treatment based on pattern discrimination. It is odd to witness students and clinicians disregard this axiom when presented with an acute cough, fever, or sore throat in the cold and flu season. Worse yet is to witness the recommendation of a single Western herb such as echinacea in place of a TCM formula based on the presenting pattern.
Echinacea is one of the few Western herbs that possesses a highly refined clinical history and energetic classification. Echinacea, most notably echinacea augustifolia, was widely used during the 19th century by the Eclectics, a group of physicians who integrated herbs along with Western medicine. This movement declined and eventually disappeared by 1939. However, the Eclectics left behind a large body of writings and scientific journals revealing the use of a differential diagnostic system very similar in many ways to traditional Chinese medicine. King's American Dispensatory, a two-volume tome of Eclectic herbal classification compiled by Felter and Lloyd, focuses echinacea augustifolia's action to the lungs, stomach, blood, and liver, and gives it a bitter, pungent and cool nature. According to this text, echinacea appears to strongly clear heat from the lungs, stomach and blood and helps to purify "bad blood." With this in mind, it becomes apparent how the sole use of echinacea has limitations in complex pattern presentations. Would we administer shi gao or lu gen by itself? Not likely. Therefore, we should not resort to recommending just echinacea without combining it with appropriate Chinese medicinals. If there is an underlying qi, blood, or yin vacuity, echinacea will not work and may allow a condition to worsen. This is where traditional Chinese medicine can be used to strengthen the clinical efficacy of a single Western herb.
It is very common to encounter acute wind cold or wind heat patterns with an underlying qi vacuity. In this scenario, the body's qi is too weak to expel the invading pathogen even if strong heat-clearing or wind-dispelling medicinals are prescribed. I often see patients who have self-medicated with echinacea to keep symptoms at bay because they "don't have time to get sick." By the time they present in the clinic, the initial acute invasion has often progressed further to the interior, and qi vacuity symptoms are obvious. In these scenarios, it is important to remember that simple formulas will not work. Formulas such as shen su yin, ren shen bai du san or huo xiang zheng qiwan can be used in wind cold/qi vacuity patterns. In situations where wind heat patterns present with an underlying qi vacuity, modifications of xiao chai hu tang can be used with better clinical results than yin qiao san or gan mao ling. Xiao chai hu tang also can be combined with the aforementioned formulas depending upon the complexity of the presentation.
Xiao chai hu tang is one of my favorite formulas to modify for patients who have used echinacea and have failed to improve in wind heat/qi vacuity patterns. If more lung symptoms are worsening with the typical cold and flu symptoms, one can add bei mu, jie geng and gua lou to xiao chai hu tang to use concurrently with Echinacea, with excellent results. With this modification we are able to clear wind heat and lung heat, dissolve phlegm, and supplement the qi to assist the body in expelling the pathogen. If a sore throat is worsening, one can add ban lan gen and niu bang zi to xiao chai hu tang along with echinacea. Are you beginning to see the potential clinical applications?
It is important to remember that echinacea is only as strong as a person's immune system and vitality. Echinacea can stimulate an immune response and can potentially clear heat. However, if a patient's wei qi is vacuous, no amount of immune system-prompting or heat-clearing action will adequately work. In these scenarios, we need to remember the elegantly complex TCM formulas at our disposal. Or, if a patient asks us if echinacea can be used to treat their cold or flu symptoms, we can explain confidently that in TCM, we treat the patient, not the disease. Echinacea may or may not be effective depending upon the patient's pattern and underlying constitutional vitality.
Another relevant clinical issue to contend with when discussing echinacea and TCM formulas is correct dosing strategies. To insure effective therapeutic outcomes, the clinician must explain correct dosing to the patient. Frequent dosing is critical in acute colds and flu. Taking eight pills of a patent medicine or two capsules of echinacea TID will most likely not resolve any symptoms. Many studies of echinacea with negative outcomes reflect this. In most cases, doses need to be taken every 2-3 hours for the first 24 hours. Thereafter, one can switch to dosing every 4-6 hours until symptoms begin to subside. This must be combined with adequate hydration and bed rest. The most effective way to combine echinacea with Chinese medicinals in an acute wind heat pattern is to use a liquid extract and combine this with a warm Chinese medicinal tea or liquid extract to insure rapid absorption.
As mentioned earlier, the Eclectic tradition mainly used echinacea augustifolia root, while most modern German studies have used the aerial portions of echinacea purpurea or pallida. An entire article could be written discussing controversies over which type and/or part of echinacea is most clinically effective. I would suggest using echinacea preparations that use the entire plant, with several species/types. This should ensure adequate clinical outcomes.
I hope you enjoyed our first discussion on the integration of Eastern and Western herbal traditions. It is my intention to stimulate discussion and creative thinking with this series of articles. As herbalists and clinicians, it is vital for us to remember that our practice, whether Eastern or Western, is not static, but constantly evolving. In the next article, we will discuss two ayurvedic herbs and the potential cross-pollination with TCM formulas in lower back pain.
Happy Holidays!
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