Originally published in Acupuncture Today, October, 2011 (Vol.12, Issue 10)
The Herbalist’s Corner
Jake Paul Fratkin, OMD, L.Ac.
Good, I caught your attention. Too many students and graduates of TCM herbal programs in the US are married to the classical formulas, and are completely ignoring clinical applications and developments that have been going on in China since the founding of the People’s Republic in 1949.
Case in point. An acupuncture student in my city, not a patient, recently told me that she had been battling a cold for the last 5 days. I asked her what formula she was on, and she told me Xiao Chai Hu Tang[i], given to her by an herbal teacher at her college. I was mortified. This approach may have offered a great amount of comfort 1800 years ago, but herbal medicine has developed by leaps and bounds since then, especially in the last 50 years. I recently had the opportunity to read a private document produced in China that detailed the top 50 best-selling Chinese patent medicines in China. The number one best-seller was Gan Mao Ling. If our acupuncture student is typical of TCM students in the United States, this would mean 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.[ii]
Historical Developments Since 1949. Chinese medicine has been evolving tremendously since the founding of the People’s Republic of China, and many TCM students and practitioners have not kept up with the developments. Let’s look at the history. Chinese herbal medicine was in a complete institutional limbo between 1911 and 1949, when the country vacillated between periods of stagnation and instability, and outright war and chaos. During the rule of the guomindang (Kuomintang), the Chinese Nationalist Party under Chiang Kai-shek (Jiang Jie-shi) completely suppressed TCM in 1927 in favor of Western medicine.
With the founding of the People’s Republic, equality was given to TCM alongside of biomedicine, with the creation of separate (but equal) hospitals and medical schools. Some say this was due to the influence of Deng Ying-chao, the wife of the first Premier, Zhou En-lai. Deng’s mother was a TCM doctor, and she aspired to be a doctor herself, but was unable to do so due to the civil war. With the support and influence of Zhou En-lai, she was able to promote the development of TCM hospitals and universities throughout the country, starting in 1955. Of course, many of the revolutionary leaders were steeped in Chinese medicine, relying on herbs and acupuncture for medical treatment during the Long March, for example.
In the 1950s, mass campaigns were organized that involved people into large social movements. These were manufactured in part to expand and consolidate the rule of the Communist Party of China (CPC) on the local level, but significant health campaigns were enacted. Health campaigns included eradication of the four pests (rats, flies, mosquitoes and sparrows), sanitation of the water supplies including the building of dams and reservoirs (and eradication of snails that carried schistosomiasis), and the creation of medical clinics and hospitals throughout the country.
One part of the mass-movement health campaign was to go into smaller communities and ask questions like, “What unusual herbs do you have in your region that are unknown around the country?” or “Do you have any effective herbal formulas that might benefit people in distant parts of the country?” In the spirit of the founding of the new country, many people contributed this information voluntarily. Doctors who had previously been reticent to share their secrets were now encouraged by being valued for their seniority and expertise, and by being placed in positions of authority, such as head of departments at the regional TCM hospitals and medical universities.
The CPC made all of this information available in free or inexpensive publications, which were circulated thought the country. Now doctors in Lanzhou might hear of an unusual herb being used in Guangxi, and they would make their own efforts to obtain it. Similarly, herbal formulas were published that used these newer herbs, or used herbs in unusual combinations based on an respected local doctor’s experience. Quickly, the information spread throughout China and started a trend that greatly increased the amount of knowledge of herbs and herbal formulas.
To put this in context, when we look at the education of TCM students in this country, we find 300 formulas that are commonly taught. These represent the classical formulas, whose origins date back to Zhong Zhong-jing (circa 220 CE) and conclude around 1911. Since 1955, however, hundreds of new formulas came to be known, and have become famous in their own right. I would include here er xian tang (“Two Immortals”), developed in a Shanghai hospital in 1975 to address menopausal fatigue and heating up in a completely new way; gan mao ling, a Taiwan formula that made its way to the mainland in 1988, which is unrivaled for control and treatment of the common cold; geng nian wan, for menopausal sweating; ping chuan wan for asthma; tong jing wan for menstrual cramps; li dan pai shi wan for gallstones; bu nao wan for insomnia and anxiety; pai shi wan for kidney stone; ming mu shang qing wan for red eye and eye infection; or zhong zi wan for infertility.[iii]
Applying Formulas to Medical Conditions versus Pattern Differentiation.
I have been accused of applying Chinese herbal formulas, especially the newer ones, in a Western medical fashion, instead of relying on traditional pattern differentiation. This is not exactly the case. Certainly, a number of new formula/products are meant to address a focused diagnosis, such as hemorrhoid, sinus congestion, menstrual cramps, uterine fibroid, goitre, prostate swelling etc. This satisfies the need of consumers in an over-the-counter purchase at a herbal pharmacy, and in most of these cases, pattern differentiation is not particularly diverse. When qualified herbalists prescribe a prepared formula, however, it is incumbent that they analyze the ingredients and dosages carefully.
A formula may indicate menstrual hot flashing, but as the herbalist studies the formula, she/he can tell if it addresses various differentiations such as kidney yin deficiency, kidney yang deficiency, blood deficiency or liver stagnation. Conversely, when a practitioner diagnoses his/her patient, he/she should know what kind of formula they are looking for, and seek out the formula that best product that addresses the need. Of course, this is not necessary for the practitioner who custom-prescribes. But with manufactured products, one must apply the formula/product correctly, by analyzing its content and deciding if it is appropriate or not.[iv] The key for the practitioner is to know well the materia medica. Ony then can she/he know what rhe product is actually doing.
The Newer Textbooks from China.
Since 1987 or so, TCM textbooks began to appear that addressed illnesses by the Western names (endometriosis, lupus, duodenal ulcer, diabetes, etc.) References would be given to the traditional TCM diagnosis (Skin Bi Syndrome for scleroderma, for example), but organization of the chapters, at least, was around the medical diagnosis. More and more, a summation of the medical etiology of the disease would be included, along with modern laboratory diagnostic parameters. What remained truly TCM would be various pattern differentiations applied within the medical diagnosis, and of course, herbal formulas and adjustments based on pattern differentiation.
This reflects the direction of TCM in China today. Herbal practitioners are accepting medical parameters to a disease process based on anatomy, physiology, and diagnosis, and they have an understanding of the pharmaceutical therapies that are offered. This is important to them because many patients coming to TCM hospitals will have had medical evaluations and diagnosis, and the doctors need to be clear on prognosis and effects of pharmacological intervention. To them, knowledge of both orientations serves them and the patient best. But let’s be clear. When they come to a TCM doctor, the therapies change. Now it is herbal medicine, prescribed and monitored by TCM doctors, using traditional pattern differentiation.
There is a new generation of bilingual textbooks that are coming out of China. These publishers include People’s Medical Publishing House, Shanghai University of TCM, Higher Education Press, Academy Press, etc.[v] Most of these books address diseases by their medical names: pediatric books will have chapters of chicken pox and eczema; gynecology texts will talk about uterine fibroid and endometriosis.
Are they betraying the great classical tradition of TCM for a bastardized modern amalgam? Certainly not. They represent the past, present and future of Chinese medicine. The doctors and teachers who write these books are all thoroughly steeped in the classical literature relevant to their specialty, and in the original language! But they have also studied advancements in biomedicine as well, and understand how to communicate with their medical colleagues, as well as to know the limitations of, or complications due to, pharmaceutical treatment.
More importantly, these textbooks should be the guiding light for Chinese herbal practitioners outside of China, like us. We still need to know how the best and brightest minds in China are dealing with complicated illness. Here, I am addressing those who do individual herb prescribing (raw or powder), the benchmark of the higher-level herbalist. To ignore what has been coming out of China over the last 50 years, and by dwelling only in the world of classical formulas, is to limit your ability and effectiveness. And because 45% of Chinese people continue to rely on herbal medicine as their first choice in healing,[vi] China will remain the guiding beacon for the rest of your professional lives.
Author’s announcement: I have recently organized all of the herbal products available in America into a convenient 80-page PDF document. Take a look: www.drjakefratkin.com/products/whos-got-what
[i] Xiao chai hu tang. “Minor Bupleurum Decoction”; Shang han lun, “Injury (by) Cold Discussion”; Zhang Zhong-jing, 220.
[ii] I have previously written on the subject of modern treatment of viral illness in Acupuncture Today. See: “The Potential Avian Flu Epidemic”, Acupuncture Today, April, 2006 (Vol. 07, Issue 04), and “Modern Applications for Antiviral Therapy”, Acupuncture Today, March, 2005 (Vol. 06, Issue 03).
[iii] All of these can be found in Jake Fratkin, Chinese Herbal Patent Medicines, The Clinical Desk Reference, Shya Publications, 2001. This book lists 850 herbal formulas, which include most of the classical 300 formulas. The others are modern hospital-generated formulas that have made their way into the mainstream.
[iv] Custom prescribers actually benefit from studying the modern formulas. Many are unavailable as herbal products, and need to be made. Many of the formulas can be found in my book. See Endnote 3, above.
[v] Most are available from Redwing Books (www.redwingbooks.com).
[vi] 45% of Chinese use herbal medicine as either their first or second recourse in an illness. This number was mentioned in a lecture given by a senior member of the China Academy of Traditional Chinese Medicine in 2009.