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. 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
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's gan 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 of gan 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:
"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 ling teach 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 (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:
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