Writings on TCM Traditional Chinese Medicine and Herbs

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TREATMENT OF ALOPECIA WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Alopecia may arise from numerous causes, including stress reactions, hypothyroidism, exposure of the hair follicles to topicallyapplied chemicals, therapies used for cancer, and genetic male-pattern balding. The disorder is often classified by its specific manifestation, such as patchy balding (alopecia areata), total loss of head hair (alopecia totalis), or total loss of body hair (alopecia universalis). Alopecia areata and alopecia totalis frequently affect women, and the disorder may persist for several months to about a year, sometimes longer. Generally, alopecia is interpreted by Chinese doctors as the result of a deficiency syndrome, specifically involving blood deficiency, with generation of internal wind or invasion of external wind that affects the head; the situation is sometimes complicated by blood stasis and/or blood heat. The belief that there is an influence of wind in the etiology of the hair loss is reflected in the Chinese name for the disease, which is youfeng, literally oil-wind. The reference to oil, which can also mean glossy, is an expression characterizing the smooth, shiny scalp appearance where the hair has been lost. The Chinese name has led to some humorous translations; in the package insert for Alopecia Areata Pills, the primary indication is for "grease hair dropping." The underlying pathological processes cause the hair follicles to be undernourished. Blood deficiency can arise from poor diet, excessive use of drugs, the aging process, stress reaction (worry, anxiety, depression, which impairs spleen function and thereby reduces nurturing of blood), and debilitating diseases. Sudden hair loss, like other sudden health changes, is interpreted as a consequence of "wind;" in this case it is invading the channels that traverse the scalp. A typical description of the cause of alopecia is presented in Practical Traditional Chinese Dermatology (1): The hairs are the extension of blood, and the normal growth and development of long, pliable, and tough hairs depends on the sufficient supply of nourishment from ying and blood. If the supply of nutrients is reduced, the wind may be produced in the body to cause loss of hairs. Nervousness, depression, and mental instability may cause production of internal heat, and the excessive heat in the blood may produce wind and cause loss of hairs due to reduced nutrition supply, and such patients may show clinical manifestation of wind syndrome due to blood heat. In patients with chronic diseases and exhaustion of essence and blood, the deficiency of blood may also produce wind to cause loss of hairs, and such patients may show the clinical manifestation of wind syndrome due to deficiency of blood. In patients with their diseases wrongly treated or refractory to any treatment, the fresh blood can not be produced to nourish the hairs because of the stagnation of blood and obstruction of meridians, and such patients may show clinical manifestations of wind syndrome owing to blood stagnation. According to the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (2), Alopecia is mostly caused by deficiency of liver and kidney with subsequent failure of [blood to go up and nourish] the hair. The hair pores are open when the hair is poorly nourished, and wind invades the pores on the occasion. Therefore, deficient blood with wind [invasion] leads to hair loss. However, stagnation of liver qi and impaired qi mechanism will also result in hair loss because of the malnutrition of hair due to stagnation of qi and stasis of blood. The same encyclopedia has an elaboration of the etiology of alopecia in the volume of dermatology (16): This disease is often caused by deficiency of blood, which fails to cooperate with qi in nourishing the skin. The striae of skin and muscles in turn become loose, and the opening of the sweat glands is loose, hence, pathogenic wind intrudes from outside, causing blood-dryness and malnutrition of the hair. Besides, the mood of depression, stagnation of liver qi, and overwork may impair the heart qi and cause stagnation of qi and blood stasis so that qi and blood cannot nourish the hair, hence the occurrence of the disease; deficiency of the liver qi and kidney qi may also cause this disease, because the liver stores the blood whose state can be manifested by the hair, while the kidneys produce bone marrow which is also responsible for the growth of hair.

RECOMMENDED PRESCRIPTIONS In Practical Traditional Chinese Dermatology, three basic formulas are recommended:



Wind Due to Blood Heat Rehmannia, raw Moutan Scrophularia Biota leaf Morus leaf Anemarrhena Vitex Tang-kuei Morus fruit

Wind Due to Blood Deficiency Rehmannia, cooked Tang-kuei Peony Cnidium Lycium Ligustrum Cuscuta Eclipta Ho-shou-wu

Wind Due to Blood Stagnation Tang-kuei, tails Red peony Cnidium Persica Carthamus Biota leaf Angelica Green onion Ginger, fresh

Dictamnus

Astragalus Citrus

Jujube

A slightly different presentation of patterns and formulas is offered in the book Manual of Dermatology in Chinese Medicine (3) Blood Heat Giving Rise to Wind Rehmannia, raw Ligustrum Morus fruit Moutan Red peony Cornus Scrophularia Sesame, black Cuscuta Hematite Fu-shen Tang-kuei

Deficiency of Yin and Blood (Decoction) Tang-kuei Red peony Peony Cnidium Rehmannia Salvia Ho-shou-wu Morinda Cistanche Ligustrum Morus fruit Chiang-huo Schizonepeta

Deficiency of Yin and Blood (Pill) Ho-shou-wu Hoelen Achyranthes Tang-kuei Lycium Cuscuta Psoralea

Deficiency of Qi and Blood (Decoction) Tang-kuei Rehmannia Peony Codonopsis Atractylodes Astragalus Hoelen Ligustrum Ho-shou-wu Soja Cnidium Typhonium Licorice, baked

Deficiency of Qi and Blood (Powder) Tang-kuei Peony Citrus Astragalus Cinnamon bark Ginseng Atractylodes Licorice, baked Rehmannia Schizandra Hoelen Polygala

Blood Stasis

Red peony Cnidium Persica Carthamus Bakeri Jujube Ginger, fresh Musk

Again, the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine offers yet another group of formulas, the first three for "blood-deficiency and wind-dryness" and the latter two for "activating blood flow to remove blood stasis:" Shenying Yangzheng Dan, Modified Tang-kuei Peony Cnidium Rehmannia Ho-shou-wu Carthamus Ligustrum Cuscuta Chiang-huo Gastrodia

Yangxue Shengfa Wan Tang-kuei Peony Cnidium Rehmannia, raw Ho-shou-wu Carthamus Ligustrum Cuscuta Eclipta Salvia Soja

Qibao Meiran Dan Ho-shou-wu Hoelen Achyranthes Tang-kuei Lycium Cuscuta Psoralea

Tongqiao Huoxue Tang, Modified Tang-kuei Red peony Cnidium Persica Carthamus Sparganium Zedoaria Bupleurum Curcuma Turmeric Ginger, fresh Green onion

Huoxue Quyu Pian Tang-kuei Red peony Persica Carthamus Pangolin Artemisia (liujinu) Gleditsia Pyrolusite (zhiwu) Saussurea Clove Rhubarb Eupolyphaga

In this last group, Qibao Meiran Dan is the same as the Pill for Deficiency of Yin and Blood mentioned above. This Chinese name of this formula is translated in Formulas and Strategies (17) as "Seven-Treasure Special Pill for Beautiful Whiskers." The prescription is attributed to a master herbalist of the Ming Dynasty, Shao Yingjie, but it was recorded by Wang An, in his book Yifang Jijie during the early Qing Dynasty (1682 A.D.). By that time, the formula had become quite popular. One can see that in virtually all formulations (the exception being the last two presented above), tonification therapy is important, but there are distinctly different groups of ingredients that are relied upon for different syndromes and by different authorities. Ginseng Nutritive Combination (Renshen Yang Rong Tang ), similar to the decoction for qi and blood deficiency related above, is a well-known traditional prescription given for general weakness and nutritional deficiency; that formula has been recommended by Japanese doctors for treating alopecia (4). While there are no individual herbs that stand out as being essential to the treatment of alopecia, there is obvious reliance on the ingredients of Siwu Tang (Tang-kuei Four Combination, comprised of tang-kuei, peony, cnidium, and rehmannia), as well as herbs that are characteristically recommended for preventing graying of hair (a condition also thought to be due to blood deficiency syndrome), notably ho-shou-wu, ligustrum, morus fruit, and biota leaf. Although mentioned only once among the ingredients for the above formulas, eclipta is also used for preventing greying of hair and is included in some of the formulas used in clinical trials, as described below. For blood stasis, red peony, cnidium, persica, and carthamus are the most frequently used. Wind-dispelling herbs are broadly selected from the range of available items, with dictamnus, chiang-huo, morus leaf, schizonepeta, vitex, typhonium, and green onion (congbai; Chinese chive) mentioned in the above formulas. Some herbs that have black color (the color of Chinese hair) are used: black sesame seeds, black soy beans (soja), and psoralea are examples. Cuscuta is mainly used for tonifying the kidney, a principle of therapy not much relied upon other than through inclusion of cooked rehmannia as part of the blood nourishing strategy. An examination of the herb formulas reveals very few ingredients in each formula for dispelling wind (sometimes none) and no ingredients specific to calming internal wind other than the single mention each of gastrodia and hematite (this may have been included mainly as a blood nourishing agent). The emphasis on wind in the etiology of alopecia as described in modern texts appears to be more of an academic nod to the ancient name of the disease than to a persisting belief that wind is an important factor in the disease. As with the formulas recommended above, those prescriptions subjected to clinical trials rarely include wind-dispelling or wind-settling ingredients.

CLINICAL EVALUATIONS OF INTERNAL THERAPIES Alopecia areata, the condition that is the subject of the clinical evaluations, can spontaneously resolve. Therefore, it is difficult to know the effectiveness of treatment in the absence of a carefully controlled study. The reports in the medical literature generally involve uncontrolled studies, which means that one can not separate out cases of improvements due to herb therapy from spontaneous remission. According to the reported results (summarized briefly below), with a treatment time of 1-3 months duration (though sometimes longer), the majority of cases treated are resolved or, at least, improved. An examination of formula ingredients reveals that tonic therapies, especially herbs that nourish the blood, are relied upon. Shengfa Wan (literally, pill to generate hair), is a modification of Qibao Meiran Dan, made by adding Erzhi Wan (a formula comprised of just ligustrum plus eclipta). According to Formulas and Strategies: This formula [Erzhi Wan] is widely used in China, both by itself and as an additive to other formulas when the liver and kidney yin need to be tonified. It is considered safe and relatively mild. It is often compared to Liuwei Dihuang Wan [Rehmannia Six Formula]....Erzhi Wan is considered by some to be superior in treating premature graying or loss of hair. The complete formula, containing ho-shou-wu, ligustrum, eclipta, lycium, cuscuta, tang-kuei, achyranthes, psoralea, and hoelen, was made as large honey pills, 10 grams each, and administered three times daily (5). The pills, which provided about 20 grams of herbs in powder form and 10 grams of honey as binder, were administered before meals, unless digestive disturbance occurred, in which case the pill was given after meals instead. Treatment time was 1-3 months. It was stated that of 21 cases treated, 2 cases were cured, 8 markedly improved, and 3 significantly improved (with 8 cases not improved). A similar formula, Shengfa Yin, a decoction comprised of ho-shou-wu, rehmannia, tang-kuei, schizandra, morus fruit, biota seed, ligustrum, and eclipta, was reported to cure 30 of 36 persons affected by alopecia areata, with 4 others improved (6). The obviously better results, compared to the report on Shengfa Wan, may have been due to use of a higher dosage form of administration and longer therapy (duration not specified in the report). According to another report, all of 50 cases of alopecia areata treated could be cured within 9 weeks with daily ingestion of a decoction of ho-shou-wu, black sesame, soja, astragalus, gelatin, atractylodes, longan, and jujube, taken along with cystine (100 mg, three times daily), and topically applying concentrated decoction of morus bark (7). Specifically, 6 cases were resolved after three weeks, another 32 cases after 6 weeks, and the remaining 12 by 9 weeks. Cystine is important to protein structure and was given to promote good hair formation; it is an oxidized form of the common amino acid cysteine. The high rate of success might have been due to the combination of using a decoction plus applying a topical preparation; the role of cystine is questionable, and it is not included in the other trials. In a large-scale study (8), the internal treatment for alopecia, Tuofa Zaisheng San, included ligustrum, ho-shou-wu, rehmannia, biota twig, salvia, schizandra, peony, tang-kuei, carthamus, cnidium, and chiang-huo, was given along with topical application of the drug minoxidil. According to the report, treatment time was 2-12 months, with 117 of 146 cases cured, and 11 cases improved. A follow-up after one year showed that there was relapse in only 10 cases. This formula is very similar to the patent remedy called Alopecia Areata Pills (Trichogen), which was developed during the 1970's and has been marketed worldwide since the 1980's. According to the package labeling, the formula is: Ho-shou-wu Rehmannia (raw and cooked) Tang-kuei Salvia Peony Schizandra Codonopsis Chaenomeles Chiang-huo

20% 20% 10% 10% 10% 10% 10% 5% 5%

The herbs are extracted, formed into small pills (250 mg each), and recommended to be taken 6 pills each time, three times daily (daily dose of the extract is 4.5 grams), for a course of treatment of 600 pills (if taken continuously, 6 bottles of the product, over a period of 33 days). Since the body weight of the Chinese, at the time this package insert was written, was quite a bit lower than most Westerners, the dosage should probably be increased by as much as 50%. The package insert proclaims "satisfactory results" were attained with over 1,000 trial cases and that: After treatment for a period of time, light color, newly grown, soft hair gradually becomes darker and black. But in a few occasions the patients have recurrence of baldness. In order to reduce the recurrence, one or two [additional] courses of treatment is necessary to ensure efficacy. Alopecia that occurs in the elderly is responsive to treatment, according to one report (9). A double-blind placebo-controlled study of an anti-aging mixture named Huolisu, including astragalus, salvia, and ho-shou-wu, was conducted with 507 subjects, 287 receiving the herbs. The power of the placebo and the rate of spontaneous remission was here demonstrated, with nearly 35% of the control group showing some improvements in both subjective and objective measures. However, the herb treatment group had nearly 77% of patients showing improvements, including a reduction in alopecia during a 3 month trial.

TOPICAL TREATMENTS Alopecia often occurs in individuals who are relatively healthy; they may suffer from substantial emotional stress and poor nutrition, but the most evident symptom-or the symptom of greatest immediate concern to them-is the alopecia. In such cases, topical treatments are

deemed especially appropriate, because of the localization of the symptom. Also, since the hair follicles are just below the skin surface, topical treatment is deemed a means of rectifying the problem even if an internal therapy is also needed to improve the function of the internal organs, nourish the blood, and overcome disorders such as blood stasis. There are three major approaches to topical treatment with herbs: 1. Use strong circulatory stimulants, such as hot pepper or ginger, to try and restore the scalp circulation. 2. Use blood-vitalizing herbs, such as those used in internal therapies, to promote microcirculation. 3. Employ herbs with a reputation for benefiting the hair, such as ho-shou-wu, morus fruit, or ligustrum. The diversity of recommended topical treatments, which includes some that are not easy to explain by the usual interpretations of herb actions, makes it difficult to select one that would be workable, and most Westerners are not well disposed to making these unusual preparations and using them regularly, so only brief mention will be made here. In Practical Traditional Chinese Dermatology, three topical treatments are described: A mixture of dictamnus, biota leaf, ginger, crataegus, and angelica is made as a tincture and applied once or twice a day. Fresh slices of ginger are rubbed onto the bald area to produce a hot feeling, three times daily. Powder of chuanwu (a type of aconite) is mixed with vinegar or ginger juice and applied once a day to the bald area. In Manual of Dermatology in Chinese Medicine, these topicals are mentioned: A mixture of biota leaf, zanthoxylum, and pinellia is made as a decoction and mixed with fresh ginger root juice, and applied to the affected area twice daily. A mixture of artemisia, chrysanthemum, mentha, siler, kao-pen, vitex, schizonepeta, and musk; make a decoction (musk is added separately) and wash the head with it; let it set in the head for 5 minutes, and repeat; then rinse with warm water. Cordyceps tincture is applied to the affected area 3-5 times daily. Brassica is powdered, mixed with oil to form an ointment, and applied to the affected area once daily. In the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 16: Dermatology, these are suggested: Psoralea tincture (Bugu Zhiding), applied three times daily. Fresh ginger roots slice: rub the affected part rapidly. According to the book Oriental Materia Medica (10), the herb swertia is "80% effective in treating all cases of hair loss." Research in Japan has shown that an extract of swertia (a relative of gentiana that is used frequently in the treatment of hepatitis) dramatically enhances the circulation to the skin when applied topically. This herb has been extracted in an essential oil base (geraniol) in the hair tonic product Gentax that is produced and widely used in Japan and is now available in the U.S. (via Kenshin Trading Company, in Torrance, California). The crude herb swertia is rarely exported from the Orient, so is difficult to obtain other than in this prepared form. A popular Chinese "hair growth" tincture-Lily Brand Hair Tonic-is made with extract of capsicum (and other undisclosed ingredients); this is similar to the home remedy made by the Chinese with red chilies soaked in wine. The action of capsicum, like that of ginger and zanthoxylum, is to promote local circulation via "counterirritant" action (spicy components cause the vessels to dilate). The largest clinical evaluation of a topical treatment for alopecia involved over 8,300 patients (11). The liquid, known as "101 Hair Regenerating Alcohol" (which has been made available in Chinese shops in the U.S.) contains ginger, ginseng, astragalus, tang-kuei, cnidium, persica, carthamus, salvia, and some undisclosed ingredients. The liquid was applied 2-3 times per day, for 2-3 months. It was claimed in the report that the "cure" rates for alopecia areata, alopecia totalis, and alopecia universalis were 91.7%, 83.4%, and 62.1% respectively. Less than 6% of those treated in each category failed to respond to the treatment. In another large-scale clinical evaluation, 822 patients suffering from alopecia areata or alopecia totalis were treated with the topical formula, Suxiao Ketuling Shengfa Jing (12). The ingredients, extracted in alcohol, include capsicum, eclipta, ho-shou-wu, biota twig, drynaria, ginseng, carthamus, and cnidium. According to the report, 630 patients were cured and others had partial regrowth of hair; only 48 patients (less than 6%) showed no response. Yet another topical treatment that was evaluated is Jumei Renshen Shengfalu (13). The liquid extract of biota twig, drynaria, ginseng leaf, and melia was applied topically for 88 cases of alopecia areata resulting in improvement in 71 of those cases, and 74 cases of alopecia seborrheica, with improvement in 52 cases. A control group was treated with a "Western" style topical liquid containing salicylic acid, resorcinol, glycerin, and carbolic acid. The effective rate for that treatment was only 48%. Both the herb and drug liquids were applied twice daily for 2-3 months.

HAIR LOSS ASSOCIATED WITH CHEMOTHERAPY Chemotherapy for cancer and certain other drug treatments may cause alopecia, which is difficult to prevent while the drug is being used. In books about treating side effects of cancer therapy (e.g., Cancer Treatment with Fu Zheng Pei Ben Principle (14) and Treatment of Toxic Side Effects Resulting from Radiation and Chemotherapy (15)) there is no mention of alopecia. Nonetheless, ITM received reports of some cases of patients undergoing chemotherapy that did not result in hair loss or resulted in less hair loss than was expected (these cases were unexplained by Western doctors in the U.S.); the patients were using Chinese herb tonic formulas to help prevent leukopenia. One of the proposed mechanisms involved in overcoming leukopenia is promoting microcirculation in the bone marrow; the herbs that accomplish this, such as millettia, hu-chang, and salvia (see: Millettia (Jixueteng)) may also promote microcirculation in the skin and, thereby, help alleviate alopecia. So, there is some preliminary and circumstantial evidence, as well as theoretical basis, to expect that this type of alopecia might be prevented by early intervention with Chinese herbs. When the drug therapy or radiation is stopped, the combination of tonic herbs and topical application of circulation-promoting agents may help to more quickly

restore hair growth in those who begin the herb treatment after hair loss has already occurred.

REFERENCES 1. Li Lin, Practical Traditional Chinese Dermatology, 1995 Hai Feng Publishing Company, Hong Kong. 2. Xu Xiangcai (Chief ed.), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 6: Therapeutics of Acupuncture and Moxibustion, 1990 Higher Education Press, Beijing. 3. Shen De-Hui, Wu Xiu-Fen, and Nissi Wang, Manual of Dermatology in Chinese Medicine, 1995 Eastland Press, Seattle, WA. 4. Otsuka K, et al., Natural Healing with Chinese Herbs, 1982 Oriental Healing Arts Institute, Long Beach, CA. 5. Jiang Haiyan, Treatment of 21 cases of alopecia with Shengfa Wan, Sichuan Journal of Traditional Chinese Medicine 1987; 5(4): 47-48. 6. Lan Ke and Chen Huiren, Treatment of 36 cases of alopecia areata with Shengfa Yin, Hubei Journal of Traditional Chinese Medicine 1988; 6: 19. 7. Tang Bingguang, Treatment of alopecia areata mainly with Chinese herbs , Hunan Journal of Traditional Chinese Medicine 1987; 3(3): 55, 61. 8. Lu Jingbin, Treatment of 146 cases of hair loss with Tuofa Zaisheng San and Shengfa Shui, Journal of Integrated Traditional and Western Medicine 1987; 7(7): 438-439. 9. Du Xin, et al., Antiaging effect of Huolisu-A controlled, double-blind study of 507 subjects of middle and old age, Chinese Journal of Integrated Traditional and Western Medicine 1986; 6(5): 271-274. 10. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 11. Zhao Zhangguang, Treatment of 8324 cases of alopecia with 101 Hair Regenerating Alcohol, Journal of Traditional Chinese Medicine 1988; 29(9): 693-694. 12. Zhang Zhongxing, Treatment of 822 patients with alopecia areata with Suxiao Ketuling Shengfajing, Hubei Journal of Traditional Chinese Medicine 1991; 13(6): 9-10. 13. Xiang Xirui and Xue Changhua, Treatment of alopecia with Jumei Renshen Shengfalu, Chinese Journal of Integrated Traditional and Western Medicine 1989; 9(1): 39. 14. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing House, Fujian. 15. Cheung CS, Kaw UA, and Harrison H (compilers), Treatment of Toxic Side Effects Resulting from Radiation and Chemotherapy by Traditional Chinese Medicine, 1980 Traditional Chinese Medical Publisher, San Francisco, CA. 16. Xu Xiangcai (Chief ed.), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 16: Dermatology, 1990 Higher Education Press, Beijing. 17. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. June 1999

ALZHEIMER'S DISEASE: TREATMENT WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Alzheimer's disease is currently thought to contribute to about 75% of all cases of senile dementia that occur in the U.S. The disorder is marked by reduced levels of acetylcholine, development of amyloid plaques, and degeneration of brain tissue. It produces cognitive and coordinative dysfunctions with notable loss of memory. From the modern medical viewpoint, the cause of Alzheimer's disease is not yet established. There is a genetic component, since the frequency of the disease is higher in an identical twin or a child of a person with Alzheimer's disease, and the disease occurs with higher frequency in persons with the genetic disorder producing Down's Syndrome. But other factors, as yet unidentified, seem to be at least as important as genetics, based on the distribution of the disease. No infectious agent that might cause the disease has been identified, and there is no current evidence suggesting that an infection is involved. Except for one of the rare genetic forms of the disease that causes early dementia, Alzheimer's usually does not occur in clinically obvious form before age 60. The incidence of the disorder increases with age, such that up to 30% of those over age 80 are believed to suffer from some degree of Alzheimer's disease. A recent study has suggested that early subtle signs-such as limited linguistic complexity-reveal the tendency to develop Alzheimer's disease. Such indicators may be detected before age 30. This would support the idea that the disorder has a genetic basis which yields an evident mental disease under the influence of the aging processes. It is possible, though not proven, that chemical pollutants, high fat diet, and sedentary life style may lead to the severe form of the disease. Current orthodox medical treatment involves use of hydergine, dexedrine, and a variety of antidepressant drugs, all of which can produce modest improvements, especially in early stages of the disease. There are several experimental drugs in various stages of clinical trials that may improve the outcomes. Because of the advanced age of most sufferers, it is unlikely that even the most effective treatments would be able to produce complete remission. In Europe, one of the main therapies for Alzheimer's disease is Ginkgo biloba leaf extract, which is a widely-used plant drug sold in pharmacies. This flavonoid-rich extract promotes blood circulation to the brain as well as to other parts of the body. Because a large investment in research dollars has been made in testing ginkgo extract, many people do not realize that the same or similar effects may be attained by using other herbs that are a source of circulation-promoting flavonoids.

THE CHINESE MEDICAL APPROACH Currently, there are two treatment approaches to Alzheimer's disease in China: use of complex herbal formulas based on the traditional methods of Chinese medicine, or administration of an alkaloid drug, called huperzine A, derived from the herb huperzia. This drug inhibits the breakdown of the neurotransmitter acetylcholine, allowing more of it available for brain functions, including memory. Huperzine A has passed Phase I trials in the U.S. and it may become available as a prescription drug at the end of this decade. It is not possible to get sufficient quantities of huperzine A by simply consuming the whole herb from which it is derived, nor its crude extract in reasonable dosage. There are, however, numerous Chinese herbal formulas that may significantly increase levels of acetylcholine. In analyzing the Chinese medical therapies for Alzheimer's, it is important to recognize the difficulty in distinguishing this condition from other cases of senile dementia, mainly atherosclerotic dementia. A firm diagnosis of Alzheimer's is made by extensive procedures that might include a CT scan, MRI, and EEG. In most cases, such procedures are not routinely done in China; therefore, the symptom pattern is used as the diagnostic criteria. Some reversible diseases produce dementia and even severe depression may produce dementia, so the treatments that are reported to be successful for dementia might not succeed in actual cases of Alzheimer's disease.

HISTORICAL DEVELOPMENT OF IDEAS ABOUT SENILE DEMENTIA According to the fundamental ideas of Chinese medicine, the brain is an outgrowth of and is nourished by the kidney. Therefore, brain defects and deterioration of the brain may be prevented, limited, or halted by the ingestion of kidney tonics. Rich nourishing agents such as placenta, rehmannia, and cistanche; kidney essence astringents, such as rose fruit and schizandra; and qi and blood tonics that ultimately help nourish the essence, such as astragalus, polygonatum, and tang-kuei, are frequently recommended to benefit the brain. The cognitive functions of the brain are said to be regulated by the heart: the kidney provides the substance, the heart the regulation of activity. Memory, cognition, and wisdom are believed to become disordered if the heart is agitated or if the influence of the orifices that connect the heart and brain are blocked by phlegm obstruction of the channels. The herbs zizyphus, biota, polygala, and acorus are considered important for treating heart disorders affecting memory and cognition. To benefit the function of the heart, qi tonic herbs are also used, as they enhance the energy or qi of the heart. Formulas based on the combination of heart-regulating herbs coupled with kidney and qi tonic herbs are sold in China as Bu Nao Wan (Brain Tonic Pills) or Jian Nao Wan (Healthy Brain Pills). In the book Jingyue Quanshu (Collected Works of Zhang Jingyue; 1637 A.D.), a chapter on dementia (chidai) describes the problem as a combination of collapse of original qi (yuanqi) and the presence of impure qi in the meridians and heart orifices. Tonification therapy is the proposed solution, as the restoration of normal qi will help to dispel the pathological qi. A formula developed by Zhang for dementia is Qi Fu Yin, comprised of ginseng, cooked rehmannia, tang-kuei, atractylodes, zizyphus, baked licorice, and polygala. The latter herb helps to clear the phlegm obstruction of the orifices. In the book Bianzheng Lu (Manual of Medical Differentiation; 1690), Chen Shiduo proposed that the first step in development of dementia is depression of liver qi, which is usually caused by emotional problems. This liver qi disorder might eventually lead to exhaustion of the stomach qi because the pathological qi from the liver is easily transmitted to the stomach, where it disrupts normal digestive functions. The resulting undigested food in the stomach can produce obstructive phlegm. He said that "treating phlegm is treating dementia." To accomplish the goal, he suggested that one would tonify the spleen and stomach, resolve phlegm, and clear the orifices of the heart. A formula that Chen developed is Su Xin Tang, comprised of ginseng, hoelen, pinellia, bupleurum, coptis, evodia, gardenia, aconite, tang-kuei, peony, and zizyphus. Bupleurum invigorates the flow of liver qi; coptis and gardenia purge the pathologic qi of the liver, while evodia disperses the liver qi that is damaging the stomach functions; pinellia and hoelen resolve phlegm. Chen devised

some alternative formulas for dementia, including ingredients such as shen-chu to enhance the stomach's digestive activity, arisaema to cleanse the accumulated phlegm, and acorus to open the clogged orifices. At the end of the 19th century, Wang Qingren, who is famous for developing the use of blood-vitalizing therapies, proposed that dementia was caused by an emptying of the material substance making up the marrow and brain, and by stagnant blood clogging the orifices. A formula he developed for this purpose is Tong Qiao Huo Xue Tang , comprised of red peony, cnidium, persica, carthamus, onion, musk, jujube; rice wine is added to the water when preparing the decoction. Onion and musk help to clear out the clogged orifices. The wine helps activate the blood-vitalizing properties of the formula. The modern (post-1950) Chinese approach to Alzheimer's follows closely the ideas of Wang Qingren. Degenerative changes in tissues are usually treated by herbs that promote blood circulation-often relying on salvia in place of persica and carthamus used in Wang's time-plus tonics to treat the deficient organ. The brain is nourished with kidney tonics and qi tonics, such as rehmannia and ginseng. Many physicians still pursue the method of differential diagnosis, and the treatments may vary rather than follow a set pattern based on the disease description. In China, a patent remedy, Nao Li Kang (Restore Brain Power Granules) has recently been developed. In the patent remedy application to the Sichuan Ministry of Health, it was reported that the formula was carefully tested in 31 patients with Alzheimer's disease and atherosclerotic dementia confirmed by CT scans. The formula ingredients include rehmannia, salvia, polygala, and polygonatum. Three months treatment with the formula resulted in improvements in 40% of the Alzheimer's patients and in 86% of the atherosclerotic patients. Although the improvement rate for Alzheimer's was relatively low, because this disease is so difficult to reverse, the result is still of interest. The treatment of Alzheimer's should begin at its earliest signs, since any brain cells that have been destroyed cannot be regenerated and the fibrous and mineralized plaques that form in the brain are unlikely to be removed as a result of the ingestion of herbs. Chinese herbs can still prove useful in later stages, by preventing further degeneration or optimizing the function of the intact brain cells, but attempts to more fully resolve the disease could only meet with success in the early phases. During this earlier period, a definitive diagnosis of Alzheimer's is not always possible, but one can safely administer the Chinese tonic herbs and blood circulation agents.

USING DIFFERENTIAL DIAGNOSIS Despite the fact that brain disorders can be described generally by the theoretical framework of traditional Chinese medicine, many physicians working in China continue to rely on differentiating cases. The particular disorder, Alzheimer's disease, may occur either from a variety of different causes or from a basic cause in a variety of constitutional situations. The primary differential categories used by Chinese doctors to describe senile dementia are: 1. Spleen qi deficiency, with phlegm and stagnating blood obstructing the orifices to the brain. 2. Liver qi stagnation, with entanglement of qi, accumulation of phlegm, and stagnating blood. 3. Hot phlegm clogging the orifices. 4. Spleen and kidney yang deficiency, with phlegm and stagnating blood obstructing the orifices to the brain. 5. Deficiency of liver and kidney yin, with phlegm and stagnating blood obstructing the orifices and with generation of internal wind. 6. Qi and blood stagnation, obstructing the orifices to the brain. According to the category that seems most appropriate, one may tonify qi, yin, and/or yang, disperse qi and blood, and resolve phlegm accumulation. The tonic herbs to be used are the same as those commonly found in traditional formulas to treat problems of aging: ginseng, astragalus, atractylodes, dioscorea, rehmannia, lycium fruit, cistanche, and morinda. For unclogging the orifices, acorus, polygala, arisaema, typhonium, and alum are used in various combinations. Acorus and polygala are said to restore proper communication between the kidney and heart;. Alum (an aluminum sulfate compound) and arisaema are considered remedies for "mental phlegm." Sedative herbs are sometimes included in prescriptions for dementia, including zizyphus, fu-shen, biota, dragon bone, and oyster shell. According to traditional Chinese medicine, the depletion of kidney-which is the dominant cause of symptoms associated with aging-can be largely overcome by regular ingestion of either Rehmannia Six Formula (Liu Wei Di Huang Wan ) or Rehmannia Eight Formula (Ba Wei Di Huang Wan). Stagnation of blood can be limited by daily ingestion of salvia wine, or some other salvia-based herbal preparation. The obstruction by phlegm can be largely overcome by reducing fat in the diet (a health-promoting strategy that is recommended by all physicians today) and by using herbal formulas that aid the digestive process, such as Six Major Herbs Combination (Liu Jun Zi Tang) or a formula that contains herbs such as crataegus and shen-chu. Saponins from ginseng (and from several traditional anti-aging tonic formulas) have been shown to improve memory function. Sleep disorders-which may respond to the use of herb therapies-are commonly reported among the elderly and may contribute to worsening mental function. A report in the Shanghai Journal of Traditional Chinese Medicine (1991) describes a study with 60 patients divided into a Chinese herb group and a control group (both used Western medications as needed). Six different herb formulas were used for the study, given according to the diagnosis of the patients' underlying conditions. Eighteen symptoms other than memory functions were monitored, including headache, dizziness, tinnitus, and head fullness; poor appetite and constipation; fatigue and leg weariness; fever and sweating; and so on. The Chinese medical treatment group showed improvements in all of the symptoms except tinnitus. There were also changes in the tongue (less redness) and tongue fur (less greasiness). When the symptom changes related to mental condition were compiled, 7 of 30 in the Chinese medical group showed marked improvement and 16 more showed some improvement. Thus, about 77% showed some degree of improvement, but there was no notable difference between these results for mental capabilities and those of the Western medical control group. The patients in this study were treated with herbs in capsules or tablets, in order to obtain good compliance, not higher-dosage decoctions as would have been preferred by the physicians. The dosage used began low and was increased gradually. Treatment time was six months, and the treatment then needed to be continued to maintain the benefits.

Based on a review of the literature on Alzheimer's disease and senile dementia, a general formula would be acorus, polygala, platycodon, ginseng, atractylodes, licorice, astragalus, citrus, pinellia, crataegus, shen-chu, curcuma, gastrodia, salvia, cnidium, red peony, zizyphus, rehmannia, lycium fruit, tang-kuei, cistanche, morinda, aconite, dioscorea, and hoelen (or fu-shen). Certain herbs could be deleted or added to focus the formulation on the exact needs of the patient. Among the contributors to aging disorders are the cumulative impact of oxidation reactions (including the accumulation of lipofuscin) and the decline of hormones (it was recently shown that estrogen aids memory in women). Numerous antioxidants have been identified and are readily available in convenient tablet or capsule form (flavonoids, carotenes, Vitamins C and E, and certain minerals, such as selenium, and amino acids, such as glutathione). Several Chinese herbs have been shown to have antioxidant effects and reduce levels of lipofuscin; these include the tonic herbs ligustrum, lycium, cuscuta, psoralea, atractylodes, codonopsis, epimedium, ganoderma, polygonatum, and ho-shou-wu. Some of these herbs function by increasing levels of antioxidant systems, such as SOD (super oxide dysmutase). In addition to using Chinese kidney tonic herbs to enhance the body's production of hormones, exogenous sources of many hormones are now available, including growth hormone, DHEA (dehydroepiandrosterone), and melatonin, which could be administered along with the herbs initially to obtain more obvious early effects from the treatment.

NEW PLANT DRUG FOR ALZHEIMER'S: HUPERZINE Huperzine, an anticholinesterase alkaloid, is divided into two chemical species, huperzine A and huperzine B, which have similar effects but differing activity levels (huperzine A being about 10 times as strong as huperzine B). Huperzine A was first isolated from the Chinese herb Lycopodium serratum in 1980 at the Zhejiang Academy of Medical Sciences and the Shanghai Institute of Materia Medica of the Chinese Academy of Sciences. Huperzine B was isolated five years later. The plant source, originally called Qian Ceng Ta , meaning thousand-layers pagoda (referring to the tall multi-leafed appearance of the plant), is also known in China as Jin Bu Huan, a term meaning "more valuable than gold," usually applied to plants that have potent analgesic actions. This herb should not be confused with the patent remedy called Jin Bu Huan made from tetrahydropalmatine. The plant has been reclassified botanically as Huperzia serrata from the new family Huperziaceae, rather than from the closely related family Lycopodiaceae. It is reported that the Lycopodiaceae have two medicinal genera: Lycopodium (now Huperzia) and Phlegmariurus. A common constituent is the alkaloid fordine, which is found in 14 species of Huperzia and has similar action to the huperzines. Huperzia, as it is now called, contains a wide variety of alkaloids, including lycodoline, lycoclavine, and serratinine, as well as the huperzines. The alkaloids are of a unique structure and have been called Lycopodium alkaloids. In general, they are comprised of four rings, though one of the rings may be opened. The huperzines, like many of the other lycopodium alkaloids, contain a nitrogen within one of the rings and an NH2 group attached to the ring structure (some of the Lycopodium alkaloids contain only a nitrogen within the ring structure). Huperzia is not much used as a crude herb in Chinese medicine: the dominant application is for blood disorders caused by trauma or acute ailment, such as hematamesis caused by overstrain, bruises, hemorrhoids, and lung abscess. In addition to alkaloids, it contains triterpenoids. Huperzines and other isolated alkaloids are increasingly used in Chinese medicine as an alternative to crude herb preparations.

PHARMACOLOGY AND CLINICAL APPLICATIONS OF HUPERZINE Huperzines A and B reversibly inhibit cholinesterase; huperzine A has a stronger action than huperzine B, which in turn has a stronger action than galanthamine (an alkaloid from Lycorus radiata that has been used for its anticholinesterase activity). Huperzine A has substantially stronger anticholinesterase activity than physostigmine or neostigmine (chinchona alkaloids obtained from Physostigma venenosum; neostigmine is a common drug for treatment of myasthenia at a dose of 1-2 mg by IM or 0.5 mg IV; physostigmine is also an approved anticholinesterase drug), but huperzine B is three to five times weaker than physostigmine. Huperzines A and B have greater effect on acetylcholinesterase (AChE) than on butyrocholinesterase (BuChE). Huperzine A, because of its cholinesterase inhibiting activity, has been used in myasthenia gravis patients in China, with apparent success. Both huperzine A and B have been shown to have memory-enhancing activities in animals. At 0.075 mg/kg for huperzine A or 0.5 mg/kg for huperzine B, IP administration to mice significantly facilitated spatial discrimination learning in a Y-maze study. At slightly higher doses (0.075-0.125 mg/kg for A and 0.6-0.8 mg/kg for B) the huperzines given prior to exposure of mice to carbon dioxide prevented hypercapnia-induced impairment of learning. Memory retention and retrieval could be enhanced in animals when the alkaloids were given immediately or 6-12 hours after training. Substantially lower or higher doses of huperzines are not effective. Huperzine has been used for Alzheimer's and senile dementia with positive results. In a double-blind trial with a group of 56 patients suffering from multi-infarct dementia or senile dementia and a group of 104 patients with senile and presenile memory loss, huperzine A was demonstrated to be effective for improving memory. It was given by intramuscular injection, 0.05 mg twice daily for four weeks to the first group and 0.03 mg twice daily for two weeks to the second group. The only side effect was slight dizziness experienced by a few patients. In rats, fordine, at 0.01-0.04 mg/kg IP, speeds up conditioned avoidance responses, reverses impairment of conditioned avoidance response, and antagonizes hippocampal and cortical EEG changes induced by quinuclidinyl benilate. Huperzine A has been evaluated at the Mayo Clinic in Jacksonville, Florida. According to Alan Kozikowski, a chemist who is heading the research there, Huperzine A is more effective and more specific than tacrine, another anticholinesterase drug. Interneuron Pharmaceuticals in Lexington, Mass. is testing Huperzine A in human clinical trials.

OTHER CHOLINESTERASE INHIBITORS FROM CHINESE HERBS Lycorus radiata (shisuan) contains the alkaloids lycorine, lycoramine, lycoreine, and galanthamine. Both lycoramine and galanthamine have been shown to be reversible cholinesterase inhibitors. Lycoramine is weaker than galanthamine, but equivalent to Nivalin. Galanthamine easily crosses the blood-brain barrier. It decreases cholinesterase activity of the cerebral cortex and medulla oblongata, and at high dosage shows an anticholinesterase activity in the thalamus. Lycorine produces a marked sedative action in mice and rats, and it prolongs sleep time in animals treated with pentobarbital. Lycorine could also potentiate the analgesic effects of morphine and corydalis. Macleaya cordata (boluohui) in the Papaveraceae family, contains several alkaloids including sanguinarine, chelerythine, protopine, and allocryptopine. The sulfates of these alkaloids have a more potent local anesthetic action than procaine. Sanguinarine inhibits

cholinesterase. The herb is mainly used for bacterial infections and trichomonas, and for killing maggots (the alkaloids cause excitation and then paralysis and death of larvae). Coptis chinenses (huanglian) contains berberine alkaloids, mainly berberine, but also coptisine, worenine, palmatine, and columbamine. Berberine is a cholinesterase inhibitor. When given to mice at 0.250 mg/kg, berberine enhances establishment of positive conditional reflex, but high dosages (10 to 20 times higher) inhibit it. Berberine exerts a dose-dependent biphasic effect on acetylcholine in animals and their isolated organs. Berberine antagonizes acetylcholine-induced bradycardia and ST segment depression in rabbits. Tetrahydroberberine, a berberine derivative, produces analgesia, sedation and muscle relaxation, with an effect that is three times more potent than that of meprobamate. Its action may be similar to that of tetrahydropalmatine; l-tetrahydroberberine, like ltetrahydropalmatine, appears to be a more potent tranquilizer than the d-isomer. Berberis species (sankezhen) are another source of berberine and also provide berbamine, palmatine, isotetrandrine, and jatrorrhizine. Palmatine was shown to have strong anticholinesterase activity. Isotetrandrine (also found in Stephania species), antagonizes ileal contraction induced by histamine or acetylcholine. Jatrorrhizine reduces spontaneous activity of mice and prolongs the animals sleep elicited by pentobarbital; it also induces sleep in mice given subthreshold doses of pentobarbital. Securinega suffruticosa (yiyiqiu) contains many alkaloids, mainly securinine and its derivatives. Securinine is a CNS stimulant that antagonizes the inhibitory action of meprobamate. Securinine inhibits cholinesterase activity, but it is weaker than galantamine. Solanum nigrum (longkui), contains solanine, salasodine, and related alkaloids. Salasodine reduces sensitivity of animals to pain. Solanine markedly decreases spontaneous activity of mice and prolongs the sleeping time induced by pentobarbital. Solanine has a strong anticholinesterase action that is attributed to its aglycone solanidine. Most of the herbs mentioned in this section inhibit bacterial growth and are used in tumor therapy. The isolated alkaloids often have the same effect as the crude herbs for these applications and are increasingly used in clinical practice. Clearly, there is reason to hope that one or more of the plant alkaloids will prove helpful to those with Alzheimer's and that these alkaloids might be administered with the herbs used by traditional doctors for the treatment of memory disorders so as to attain superior results.

SOURCES Except for the general information about the nature of Alzheimer's disease and its treatment with Western medicine, which is available from many sources, the information for this article was derived from three sources: Chang HM and But PPH, Pharmacology and Applications of Chinese Materia Medica, (2 vols.) 1987 World Scientific, Singapore (USA office: Teaneck NJ). But PPH, et al., (eds.), Abstracts of Chinese Medicine, 1986-1995, Chinese University of Hong Kong, Shatin, N.T., Hong Kong. This is a quarterly journal. Fu KZ and Fruehauf H, Senile Dementia and Alzheimer's Disease, 1995 Institute for Traditional Medicine, Portland, OR. This is a collection of unedited papers produced for ITM from a review of Chinese language literature. July 1996

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Abdominal Adhesions: Prevention and Treatment by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Adhesions are strands or of scar tissue (fibrin bands; see illustration, below) that form in response to abdominal surgery and extend beyond the specific site of incision, sometimes forming separately from the incision site within the peritoneum. Scar tissue that mends the incision is normal, but the adhesions form additionally under some circumstances that are not fully understood. There are specific features of a surgical procedure that help induce the formation of adhesions. For example, drying of the tissues during surgery increases adhesion formation, a situation remedied by paying attention to the arid conditions and correcting them during then procedures. Intentional drying of the tissues, by applying gauze, is an otherwise desirable procedure to aid the surgeon's view of the area, but because of increased adhesions, it must be minimized. Tissues that become dry should be quickly moistened and air (carbon dioxide) that is passed over the surgery site to maintain cleanliness also must contain adequate moisture to prevent rapid drying of the exposed fluids. Laparotomy (open abdominal surgery) is more likely to produce adhesions than surgery performed via laparoscopy in which a small scope with attached microsurgical instruments is inserted through a slit in the abdomen (1-3).

Left: a representation of a normal peritoneum, the transparent membrane that wraps the pelvic and abdominal organs. Right: after surgical trauma, fibrous bands of collagen grow as part of the normal healing process and form adhesions. Adhesions connect tissues or structures that are normally separate. Adhesions in the abdomen or pelvic area can lead to infertility, pelvic pain, small bowel obstruction, or the need for repeat surgery (1). The incidence of adhesions following abdominal surgery is cumulative with multiple surgeries and female gynecological surgeries give a particularly high rate of adhesions. In one study, autopsy investigations indicated a 90% incidence of adhesions in patients with multiple surgeries, 70% incidence of adhesions in patients with a gynecologic surgery, a 50% incidence of adhesions with appendectomy, and a greater than 20% incidence of adhesions in patients with no surgical history. Adhesions may occur as the result of tissue damage to the abdomen besides surgery, including traumatic injury, inflammatory disease, intraperitoneal chemotherapy, and radiation therapy (1). The most frequent problem with adhesions is a constriction of the small intestine, producing constipation (sometimes complete bowel blockage, requiring emergency treatments). Abdominal pain is another common symptom, caused when the bands of scar tissue bind up the internal organs so that movements pull on them. Linkage of menstruation to changes in bowel function (e.g., inducing diarrhea) may occur as the result of scar tissue attaching the uterus to the intestine. Adhesions may also impair fertility in women by causing blockage of the fallopian tubes. It has been estimated that: At least one-third of women who suffer from pelvic pain have adhesions as a cause of or contributor to the pain. Adhesions involving the ovaries or fallopian tubes are responsible for 15-20 percent of female infertility cases. Small bowel obstruction is often a surgical emergency and is particularly common after gynecological surgery. To prevent adhesion formation, surgeons may now apply a fine fabric barrier to surround the organs, thus isolating them from the scar tissue strands (the barrier dissolves after the surgery). Although adhesions can be removed by surgical intervention (adhesiolysis) using a laparoscopic technique (4), recent studies suggested that such surgery produces limited benefits that are often short-term. Many patients are treated with multiple adhesiolysis procedures in an attempt to improve the symptoms of adhesions. Each year, 400,000 adhesiolysis procedures are performed in the U.S., costing the health care system about $2 billion in hospitalization and surgeon expenses. Most times, adhesions cause few, if any, notable effects. But, for those who do suffer from their adverse effects, the question arises as to whether the adhesions can be reduced or eliminated by methods other than further surgery.

CHINESE HERB MEDICINE FOR ADHESIONS The problem of developing abdominal adhesions is noted in the Chinese medical literature. Dr. Fu Kezhi, at the Harbin office of ITM, carried out a literature search, yielding several studies summarized here. Chinese medicine has been applied both to prevention of adhesions and to their treatment when they cause bowel blockage. The

preventive measure involves relatively immediate post-surgical intervention. The basis of the preventive therapy is to treat the abdominal stasis that occurs following surgery. Normally, after an abdominal surgery, the bowels are virtually paralyzed for many hours, up to two days in older patients and complicated surgeries. Doctors and nurses check for the return of bowel sounds (indicating movements) after the surgery, to make sure recovery is proceeding. Since obstructive constipation is one of the primary responses to developing adhesions, concern about bowel stasis is a clear concern. In China, an herbal formula used for treating constipation is administered about 6 hours after surgery, to assure the action of the bowels in a relatively short time with continued bowel responsiveness, indicating lack of adhesion formation. The formulas are usually a derivative of the ancient prescription Da Chengqi Tang (Major Rhubarb Combination). The traditional formula has four ingredients: rhubarb and mirabilitum as purgatives and chih-shih and magnolia as qi regulating herbs. The modifications of the formula usually involve adding additional qi regulating herbs (notably saussurea) and blood vitalizing herbs (especially persica, red peony, and salvia) to promote the circulation of qi and blood in the abdomen and prevent formation of adhesions, which are seen as the result of prolonged stasis. An example is the administration of a formula called Tao Zhi Zhi Po Fang, comprised of rhubarb, magnolia, chih-ko (in place of chih-shih), saussurea, persica, carthamus, leech, and salvia, provided 6 hours after abdominal surgery (5). Compared to a control group not treated with these herbs, bowel sounds and bowel functions resumed many hours earlier and the incidence of adhesions (determined by typical symptoms of adhesions appearing within the next three years) was significantly lowered. In another report (6), a modified Major Rhubarb Combination was administered after surgery while during surgery a protective barrier fluid was used to isolate the organs and prevent adhesions. The authors noted: Treatment by integrating traditional Chinese medicine and western medicine has been adopted in many surgical departments, especially the application of Modified Major Rhubarb Combination. The formula has the properties of inducing purgation, promoting qi circulation, resolving blood stagnation, and assuring that the hollow viscera remain unimpeded; specifically, stomach-qi can move downward freely to eliminate fullness and distention, the qi in the abdomen can circulate freely, and the bowels remain open; it can stimulate early peristalsis of the bowels after surgery. When using the Modified Major Rhubarb Combination soon after surgery for adhesive bowel obstruction, it can markedly shorten the time period of intestine paralysis. Because the herbal treatment within hours after surgery is impractical for Western patients (and the use of purgatives would be objected to by the medical profession on grounds of it possibly causing damage), the question about treating existing adhesions arises. In Chinese investigations of this matter, the patients are usually those who have come to the hospital with a severe disorder, usually bowel blockage, for which surgery would be utilized. Patients may first be treated with herbs to see if this is successful in relieving the blockage, while surgery can be used as a back-up. The non-surgical treatment of adhesion-induced medical crisis is similar to that used for the preventive measure after surgery, at least in cases involving bowel blockage. For example, in one evaluation (7), patients were treated with a derivative of Major Rhubarb Combination made with: rhubarb (15 g), magnolia (10 g), chih-shih (10 g), mirabilitum (20 g), persica (10g), red peony (15 g), and stirfried raphanus (45 g). Raphanus (radish seed) is used to aid the downward flow of qi, normalize digestion, and alleviate abdominal pain. The herbs were administered in 1-2 batches a day, orally or through a stomach tube. Of 250 patients treated this way, 88% were able to avoid surgery. As with the method for preventing adhesions in the first place, there is some doubt that this approach would be used in the West, as there is concern about using strong purgative treatments when bowel blockage exists. In China, the patients are carefully monitored while pursuing this treatment as an inpatient and are referred to surgery if the problem is not promptly resolved. Another report of this type of treatment approach involved use of two slightly different decoctions, depending on the differential diagnosis (8); these were: Modified Major Rhubarb Combination: rhubarb (10-30 g), mirabilitum (6-15 g), magnolia (20 g), chih-shih (10 g), persica (10 g), red peony (10 g), and stir-fried raphanus seed (30g) Adhesion Lysis Decoction: cassia leaf (10g), mirabilitum (6-10 g), magnolia (10 g), lindera (10 g), persica (10 g), red peony (10 g), and stir-fried raphanus seed (10 g). These formulations could be modified: for severe pain, add 10 grams each of corydalis, frankincense, and myrrh; for a case with vomiting, add 10 grams pinellia and 30 grams raw hematite. As in the previous study, these formulas prevented the need for surgery in about 86% of cases. Presumably, these therapies could be applied to Western patients suffering from constipation that has not developed into full obstruction requiring hospitalization; the formulas are not inherently different from traditional herb prescriptions now administered for acute constipation. For example, Major Rhubarb Combination is routinely sold as a dried extract granule by several Chinese herb suppliers worldwide. A limitation of the purgative herb therapy is that while it relieves the immediate crisis, the problem can return, because the adhesions are not gone. An attempt to resolve this dilemma was designed on the basis of using Chinese herb therapy to treat the obstructive crisis and then using laparoscopic surgery to remove the adhesions to prevent further occurrences. By so doing, one can usually avoid emergency surgery as a result of intestinal obstruction; instead, the surgery can proceed at a time when the intestinal functions have normalized and a less invasive surgical technique (laparoscopic surgery) can be utilized. In one study using this two-stage method (9), patients received one of three basic herb therapies for the intestinal obstruction: Modified Major Rhubarb Combination: rhubarb, mirabilitum, chih-shih, magnolia, persica, red peony, and stir-fried raphanus seed; Euphorbia Obstruction-relieving Decoction: euphorbia (gansui), rhubarb, magnolia, saussurea, persica, achyranthes, and red peony; or Entero-adhesion Lysis Decoction: cassia leaf, mirabilitum, magnolia, saussurea, lindera, persica, red peony, and stir-fried raphanus

In these formulations, rhubarb, euphorbia, and cassia leaf all serve the same function of inducing peristalsis. The purgative herb is the central ingredient in treatment, while the others are supportive; in one study (10), euphorbia was used as a single herb to treat intestinal obstruction due to adhesions in order to prevent the need for surgery. The desire of most patients would be to alleviate the problem of adhesions before a crisis of bowel obstruction occurs, and to treat other manifestations of adhesions, such as abdominal pain and reduced fertility. The Chinese literature appears silent on this issue, but there are some possibilities to be considered.

CAN ADHESIONS BE MODIFIED OR REMOVED WITHOUT SURGERY? Doctors and researchers are aware that scar tissue is difficult to remove or alter. One method of degrading undesirable scar tissue that has shown promise is to apply hyaluronidase, a mucolytic enzyme. Hyaluronidase breaks down hyaluronic acid, an ingredient of connective tissue. It is injected into the scar and may work best if the scar if physically degraded by surgical means and then treated by the enzyme to prevent reformation of the original scar mass. A new application of hyaluronidase is to provide it during surgery: protective barriers infused with hyaluronidase are being tried in an effort to further reduce the formation of the adhesions.



Hyaluronidase is a body component that is normally present but may be produced in large quantities in response to some stimuli. It primarily acts on hyaluron, the structural component of the extracellular matrix, comprised of hyaluronic acid (pictured left; these units repeat in long chains), one of several glucosaminoglycans (GAGs) that comprise connective tissues. Hyaluronidase is an important component in natural repair processes of tissues, where hyaluron is broken down and reformed.

Hyaluronidase can be viewed as a softening and flow-promoting enzyme. Hyaluronidase is excreted by bacteria as a means of helping breakdown and penetrate cellular barriers so that infection can proceed. Tumor cells may take advantage of hyaluronidase, secreting it as a means of penetrating into the surrounding tissues and aiding metastasis. The enzyme is used pharmaceutically in administering certain drug therapies to help the drugs penetrate cells more easily. The fact that existing scars may be degraded somewhat by the enzyme action suggests the possibility that herbal therapies could contribute to alleviating adhesion symptoms by stimulating the body's production of hyaluronidase (or other enzymes of similar function) to perform this task. Even if scar tissue is not removed, if it can be softened (made more elastic), there may be relief from its physical manifestations such as bowel blockage, pain, and some cases of infertility. Herbs that are reputed to aid healing of injuries, soften abdominal masses, and alleviate abdominal pain of various origins may act, in part, by breaking down undesirable collagens to alleviate the symptoms. Antifibrotic and mass reducing herbs are used to treat abdominal disorders such as uterine fibroids and liver fibrosis, and are also used to treat skin masses in scleroderma; it is possible that they function by increasing the degradation of fibrous tissue via hyaluronidase. Key herbs for reducing fibrosis and masses are listed in Table 1 (11). TABLE 1. Key Herbs for Reducing Fibrosis and Masses. Herb Common Name (Pinyin)

TCM Functions

Uses and Potential Applications

Achyranthes (niuxi/chuanniuxi)

vitalize blood circulation, disperse swelling

blood stasis mass in the abdomen, abdominal pain

Arca shell (walengzi)

vitalize blood circulation, disperse masses, control pain

blood stasis and phlegm mass in abdomen

Carthamus (honghua)

vitalize blood, disperse stagnant blood

blood stasis mass in the abdomen, traumatic injury, abdominal pain due to stagnated blood

Cnidium (chuanxiong)

vitalize blood, promote qi circulation, control pain

abdominal pain, fibrosis

Frankincense (ruxiang)

vitalize blood, control pain

traumatic injury, abdominal pain

Myrrh (moyao)

vitalize blood, remove stagnant blood, control pain

blood stasis mass in the abdomen, abdominal pain

Persica (taoren)

vitalize blood

blood stasis mass in the abdomen, traumatic injury

Red peony (chishao)

vitalize blood, disperse stagnant blood, control pain

abdominal pain, accumulation in abdomen

Salvia (danshen)

vitalize blood

inhibit fibrin deposition, promote fibrinolysis

Sparganium (sanleng)

vitalize blood, promote qi circulation, disperse mass, control pain

blood stasis mass in the abdomen, abdominal pain

Succinum (hupo)

vitalizes blood, disperses stagnant blood

abdominal pain due to obstruction

Tang-kuei (danggui)

vitalizes blood

abdominal pain, promotes fibrinolysis

Turtle shell (biejia)

disperse stagnant blood, soften hardness, disperse accumulations

blood stasis mass in the abdomen

Zedoaria (ezhu)

vitalize blood, promote qi circulation, control pain

blood stasis mass in the abdomen, abdominal pain

SAMPLE FORMULATIONS AND TREATMENT STRATEGY The herbs from the table above are ingredients in traditional and modern formulas used in resolving problems that are relevant to fibrous masses and adhesions. For example, a traditional formula for treating pain due to old trauma, which may reflect existence of adhesions, is Sanleng Heshang Tang (12). It is comprised of 12 herbs for regulating circulation of qi and blood and alleviating pain; the formula includes sparganium, zedoaria, myrrh, frankincense, and tang-kuei. A formula for "movable or immovable mass in the abdomen," Huoluo Xiaoling Dan, is made with just four herbs: salvia, myrrh, frankincense, and tang-kuei. A modern formula developed for treating uterine fibroids, Gong Zheng Tang , includes sparganium, zedoaria, achyranthes, tang-kuei, and persica (13). A modern treatment for endometrial cysts is Nei Yi Wan (14), which includes succinum and turtle shell. Herbs used to relieve skin hardening in scleroderma include tang-kuei, red peony, and salvia (15). These same herbs were commonly applied to treatment of liver fibrosis secondary to hepatitis (see: Treatment and prevention of liver fibrosis). A treatment for existing adhesions would follow the pattern of treating any other abdominal mass or fibrotic condition, namely a high dose therapy administered for a period of 3-6 months. During this treatment, an effort to stretch the scar fibers, possibly stimulating the local response to softening the fibers, might be pursued via exercises and massage therapy. Care must be taken not to induce any damage during such efforts.

REFERENCES 1. Women's Surgery Group, Adhesions, http://www.womenssurgerygroup.com/conditions/Adhesions/overview.asp 2. Khaitan E, Scholz S, Richards WO, Laparoscopic adhesiolysis and placement of Seprafilm: a new technique and novel approach to patients with intractable abdominal pain, Journal of Laparoendoscopy and Advanced Surgical Techniques 2002; 12(4): 241-247. 3. Kavic SM, Adhesions and adhesiolysis: the role of laparoscopy, Journal of the Society of Laparoendoscopic Surgeons 2002; 6(2): 99-109. 4. Shayani V, Siegert C, and Favia P, The role of laparoscopic adhesiolysis in the treatment of patients with chronic abdominal pain or recurrent bowel obstruction, Journal of the Society of Laparoendoscopic Surgeons 2002; 6(2): 111-114. 5. Su Fachun, et al., Clinical observation on Tao Zhi Zhi Po Fang used for preventing intestinal adhesion after surgical operation, Chinese Journal of Surgery by Integrating Traditional Chinese Medicine and Western Medicine; 2000; 6(6): 404405 6. Sun Dechun, et al., A report on 6 cases of adhesive bowel obstruction treated with Major Rhubarb Combination and sodium hyaluronate, Chinese Journal of Surgery with Integrated Traditional and Western Medicine, 2001; 7(1): 32-33. 7. Chen Guifeng, 250 cases of adhesive intestinal obstruction treated by integrating Traditional Chinese Medicine and Western Medicine, Chinese Journal of Surgery with Integrated Traditional and Western Medicine, 2000; 6 (5): 325. 8. Zhang Jinfang and Wang Zhiqiang, Analysis on 102 cases of adhesive bowel obstruction treated by integrating Traditional Chinese Medicine and Western Medicine, Chinese Journal of Surgery with Integrated Traditional and Western Medicine 2001; 7(3): 160. 9. Wang Zhenyu, et al., Laparoscopy and combination of traditional Chinese medicine and Western medicine in adhesive intestinal obstruction, Chinese Journal of Surgery with Integrated Traditional and Western Medicine 2002; 8(1): 3-5. 10. Liang Desen, et al., Curative effect of Gansui (Euphorbia kansui root) in treating adhesive bowel obstruction, Chinese Journal of Surgery with Integrated Traditional and Western Medicine 2001; 7(1): 33-34. 11. Hsu HY, et al., Oriental Materia Medica, 1986 Oriental Healing Arts Institute, Long Beach, CA. 12. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin 13. Wu Dingyuan, Preliminary report of 136 cases of uterine myoma treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1982 (1): 64-70. 14. Wang DZ, Wang ZQ and Zhang ZF, Study on the treatment of endometriosis with removing blood-stasis and purgation method, Chinese Journal of Integrated Traditional and Western Medicine 1991; 11(9): 524-526. 15. Fruehauf H, Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, Institute for Traditional Medicine 1997, Portland, OR.

May 2003





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About the Institute for Traditional Medicine The Institute for Traditional Medicine and Preventive Health Care, Inc. (ITM), is a non-profit 501(c)(3) organization established in 1979, incorporated in 1983, and moved to its current head office in 1988. ITM was founded by and is directed by Subhuti Dharmananda, Ph.D. Traditional medicine refers to ideas, experiences, and substances that have been handed down generation to generation from ancient times, where the origins are obscure but where the continuity of basic understanding has been assured by a formal structure. Among the primary traditional medical systems still active today are the Chinese, Tibetan, and Indian (Ayurvedic). ITM enriches the lives of people seeking traditional medicine knowledge and services by clarifying the nature of traditional medicine and demonstrating how it can be utilized in the modern setting. To accomplish its goals, the Institute performs 6 basic functions: 1. It operates two clinical facilities, the Immune Enhancement Project (IEP) and the An Hao Natural Health Care Clinic (An Hao). IEP is a low cost treatment center providing acupuncture, Chinese herb therapies, and Zen shiatsu primarily for patients with serious ailments (such as cancer and HIV) that can clearly benefit from effective adjunctive therapies, though all are welcome so long as they follow program protocol. IEP serves as a charitable outlet for ITM's clinical activities. An Hao is a mixed therapies clinic offering naturopathic medicine, acupuncture, chiropractic, Zen shiatsu, Chinese herbs, and modern medicine. It is a demonstration clinic that illustrates a potential new model for integrative health care. In addition, ITM provides consulting to other clinics that wish to follow the presentation method or the therapies that are available at these clinics. Selected students at local acupuncture colleges, particularly of the Chinese medical department of the National College of Naturopathic Medicine, can get advanced training at these clinics. 2. It provides numerous educational materials, primarily articles written by Subhuti Dharmananda. Currently, over 2,000 pages of such articles are in the ITM archive. Dr. Dharmananda provides free consulting to practitioners who are members of the START Group, to aid in their understanding of



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Acupuncture Treatment of Asthma by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

INTRODUCTION A review of the literature about acupuncture therapy for asthma reveals that the methods adopted by modern acupuncturists are relatively simple and straightforward. For the most part, it is based on needling the areas of the chest and back that are over the lungs, particularly the upper part of the lungs with a small number of adjunctive points elsewhere. Although a fairly large number of acupuncture points at the front and back of the ribcage are traditionally indicated for alleviating asthmatic breathing, relatively few are frequently mentioned in acupuncture formulas recommended in textbooks and used in clinical trials. Since the traditional view is that asthma can arise in relation to disorders in the functions of the lung, stomach, and kidney (see Appendix A of Herbs and drugs for asthma), it is not surprising that the largest number of acupoints said to alleviate dyspnea are found on three meridians: the lung meridian; the portion of the stomach meridian that traverses the chest; and the portion of the kidney meridian that traverses the chest. Further, because the bladder meridian is used to treat all organs, and specifically to treat those that are in the area it traverses via the back shu points, there are several bladder points on the upper back that are used for treating asthma. These bladder points turn out to be amongst the most important for treating asthma, perhaps because it is a blockage in flow of qi in the back (sometimes reflected in the posture) that most strongly influences the severity of asthmatic breathing. Following is a brief review of the individual acupoints that are described as being useful in the treatment of asthma. The acupoints are presented in three groupings: points on the lung meridian; local points on other meridians; and distal points on other meridians. Point indications are mostly derived from Fundamentals of Chinese Acupuncture (1). After presenting these points, examples of acupuncture formulas from Chinese medical texts and from research reports are provided.

LUNG MERIDIAN The lung meridian, like that of the heart and pericardium, links the hand with the chest (see Figure 1). All of the lung meridian points are indicated for coughing and dyspnea. Progressing along the meridian from LU-1 to LU-11, the indications for the points tend towards increased heat syndrome. Thus, LU-1 and LU-2 are mainly indicated for cough, dyspnea, and chest pain, not necessarily accompanied by heat, but LU-3 through LU-11 are indicated for various heat syndromes that produce symptoms such as hemoptysis or nosebleed, pain and swelling in the throat, fever, and mania. In particular, LU-10 and LU-11 are indicated for feverish conditions and mania and are usually not used for asthma therapy. However, in Modern Clinic Necessities for Acupuncture and Moxibustion (2), in the section on bronchial asthma, it is said that "LU10 takes precedence over all others." Chronic asthma does not inherently involve these other heat conditions addressed by the lung meridian points, but the symptoms could arise in cases of lung diseases, such as bronchitis, which yield dyspnea as an acute symptom. Acupuncture texts that describe asthma treatment strategies and practitioners that report on their usual practices favor LU-5, LU-6, LU-7, and LU-9 (see formulas in the next two sections). LU-7 is a preferred point in asthma treatments used in modern times; although this point is said to treat heat in the palms, heat and pain in the shoulder and back, bloody urine, and other heat syndromes, it is also said to dispel cold. It is a releasing point that "courses the channels and frees the connecting vessels." LU-7 is the luo (connecting) point of the lung channel; it is physically close to PC-6 (neiguan), the luo point of the pericardium channel, which is sometimes substituted (both points are utilized to enhance the effects of other points needled at the same time). Interestingly, many acupuncture formulas for treating asthma do not include any points of the lung meridian. The points LU-2, LU-3, LU-4, LU-8, and LU-11 are not mentioned in any of the formulas described in the literature reviewed for this article.

LOCAL POINTS Acupuncture points that are on the chest and back may be considered local points for treatment of asthma because the needles are inserted close to the lungs. The stomach, kidney, spleen, and conception vessel channels all have points on the chest, while the bladder meridian and governing vessel have points on the back over the lungs. The stomach is understood to be related to asthma in two ways: 1. Failure of proper stomach function leads to phlegm accumulation that congests the lungs; 2. Uprising stomach qi may interfere with the downward motion of the lungs. Stomach meridian points ST-12 through ST-18 are indicated for asthmatic breathing (ST-17, at the nipple, is not used). These points run down from the clavicle along the front of the rib cage (see Figure 2). The kidney is understood to be related to asthma following the concept that the kidney system aids the downward movement of the lung qi (the kidney grasps the lung qi). Further, asthma that begins in early childhood and that which develops late in life are thought to reflect deficiencies of kidney essence. Modern research suggests that asthma is associated with deficiencies in adrenal corticosteroid production, which is occurs often in persons diagnosed as having kidney deficiency syndrome. Kidney meridian points KI-22-K-27 run up the chest, where the meridian ends at KI-27 (see Figure 3); these points are indicated in the acupuncture texts as beneficial for treating asthma. A portion of the spleen meridian also runs along the chest (see Figure 4). The points SP-17-SP-21 are indicated for cough, dyspnea, and chest distention. The points at the top of the spleen meridian, SP-20 and SP-21, are especially suggested for this purpose. The conception vessel runs up the center of the body, and traverses the chest from points CV-17 through CV-22 (see Figure 5); these points are indicated for asthmatic breathing. The points at the two ends of this segment, CV-17 and CV-22, are used in several acupuncture formulas for asthma. In general, points on the conception vessel treat the internal organs that are close by, though they also have other functions, and the treatment of lung and heart diseases are the associated functions of the points on the chest.

On the back, there are a large number of bladder points; the inner path of the bladder meridian has points along each of the spinal vertebrae. These points are understood to be associated with organ systems that are near their sites (a somewhat similar concept is applied in modern chiropractic therapy). BL-11-BL-17, running over the upper portion of the lungs (see Figure 6), are indicated for asthmatic breathing. In particular, BL-13 is heavily relied upon. Its name is feishu, translated as "lung hollow," and it is generally referred to as the back shu point of the lungs (it is the main association point for the lungs on the bladder meridian). It has been reported (see Acupuncture: A Comprehensive Text (3)) that "BL-13 will be sore to the touch on all asthmatics. Those patients who have received acupuncture at BL-13 with no result will be cured if moxibustion is performed there." This commentary derives from the Zhenjiu Zisheng Jing,, where it says (12): "If dyspnea is not caused by phlegm, then moxa feishu [BL-13]. If there is dyspnea and wheezing, press feishu and without exception there will be aching and pain. In that case, needle feishu and then moxa it and there will be a cure." Parallel to these inner-track bladder meridian points are the adjacent set of bladder points running along the edge of the scapula, BL-41-BL-46, which can also be used for asthma, especially BL-42-BL-45. BL-42 is known as pohu (po door), referring to the po soul that resides in the lungs (see Exploring yin and yang #4: Hun and po). BL-13 and BL-42 are parallel points. Of these points, only BL-43 is mentioned in the asthma formulas described in the next section. Finally, there is a pair of asthma points of more recent description that are based on clinical experiences and not the standard meridian pathways (see Figure 7). These are chuanxi ("gasping;" M-BW-1a) and dingchuan ("dyspnea stabilizer;" M-BW-1b) that are on the back and lateral to GV-14 (dazhui). Dingchuan is 0.5 inches to the side of GV-14, and Chuanxi is 1 inch to the side of GV-14. Some practitioners will treat at the same time the point at 1.5 inches to the side of GV-14, which is BL-11; however, it is more common to combine one or both of the extra meridian points with GV-14 (a common formula subset is GV-14 plus Dingchuan), or to simply use GV-14 instead of these off-meridian points. Dingchuan is one of the most frequently mentioned points in the modern literature on asthma treatment and it appears to replace BL-11 for treatment of asthma, as the latter is not mentioned in any of the modern point formulas, while the adjacent points BL-12 and BL-13 are commonly used. In some texts, chuanxi is not mentioned and dingchuan is instead described as being from 0.5-1.0 inches from GV-14, so that it replaces chuanxi. Dingchuan serves as an extension of the set of Huatuo points (see Figure 8).

DISTAL POINTS Aside from lung meridian points on the arm, relatively few distal points are used in treating asthma, at least as major points. Some are applied as an adjunct to treat specific manifestations of asthma. The large intestine point LI-4 is sometimes used when there is stagnation and accumulation syndrome (even though it is LI-18, which is not included in acupuncture formulas for asthma, that is specified in the medical texts as an asthma point). In cases of phlegm accumulation, ST-40 (on the leg) and/or CV-12 (on the abdomen) may be used; ST-40 is the most frequently selected. The all-around tonic point, ST-36, may be included for cases of qi deficiency or general weakness, sometimes along with a leg spleen point (SP-3, SP-6, or SP-9). KI-3 may be utilized in strengthening the kidney to alleviate asthma, and CV-4 and/or CV-6 may be used in tonifying both the spleen and kidney in order to benefit lung qi and alleviate wheezing. BL-23 is sometimes used to tonify the kidney in treatment of asthma; it is the back shu point of the kidney.

SAMPLE POINT FORMULAS Following are some examples of point formulas listed in acupuncture texts that have been published during the past 25 years. From An Outline of Chinese Acupuncture (4): Dingchuan, BL-13, CV-22, CV-17. From Essentials of Chinese Acupuncture (13): 1. Excess type: wind-cold: BL-13, LU-7, LI-4 phlegm-heat: Dingchuan, CV-22, LU-5, ST-40 2. Deficiency type: lung deficiency: BL-13, LU-9, ST-36 kidney deficiency: BL-23, CV-17, GV-4, CV-6. From Acupuncture: A Comprehensive Text (3): Dingchuan, CV-17, CV-21, CV-22; supplementary points: ST-40 (for much phlegm); GV-14 and LI-4 (for respiratory infection); CV-4 and ST-36 (for chronic asthma). From Chinese Acupuncture and Moxibustion (5): 1. For wind-cold type: BL-13, BL-12, CV-14, LU-7, LI-4 2. For phlegm-heat type: BL-13, Dingchuan, CV-22, LU-5, ST-40 3. Lung deficiency type: BL-13, LU-9, ST-36, SP-3 4. Kidney deficiency type: BL-13, BL-23, CV-17, CV-6, KI-3 From: Clinical Manual of Chinese Herbal Medicine and Acupuncture (6): 1. For retention of cold fluids in the lung: BL-13, BL-12, LU-5, LU-7, CV-17, ST-40 2. For retention of phlegm heat in the lung: LU-5, LU-7, CV-17, CV-22, GV-14, LI-4, ST-40. 3. For deficiency syndrome: dingchuan, BL-13, BL-43, LU-9, ST-36. From: Advanced Textbook of Traditional Chinese Medicine and Pharmacology (7):

1. For excess syndrome: wind-cold: Dingchuan, BL-13, BL-12, LU-5 phlegm-damp: LI-4, ST-40 asthma/dyspnea only: CV-22, PC-6. 2. For deficiency syndrome BL-13, BL-43, BL-23, BL-20, ST-36, KI-6. From: Chinese Acupuncture and Moxibustion (8): 1. For exogenous affection: BL-13, LU-7, LI-4 2. For endogenous affection: damp invading the lung: BL-13, LU-9, LV-13, SP-3, ST-40 liver burning the lung: BL-13, LU-5, GB-34, LV-3. From: Modern Clinical Necessities for Acupuncture and Moxibustion (2): Main points: BL-13, Dingchuan, GV-14, LU-7, LU-10. Secondary points: BL-12, CV-17, and PC-6. From English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (10) 1. Dormant cold in the lung: Dingchuan, BL-13, BL-112, LU-7, ST-9 2. Phlegm-heat retention in the lung: GV-14, LU-5, LU-6, CV-17, ST-40, LI-4 3. Asthma in remission stage: BL-13, BL-43, LU-9, ST-36, SP-3 4. Deficiency of the lung and kidney: BL-13, BL-23, CV-17, CV-4, KI-3. From: Handbook for Treatment of Acute Syndromes (20): 1. Acupuncture: Dingchuan, GV-14, CV-22, PC-6, LU-10, ST-9. 2. Moxibustion: GV-14, BL-13, BL-23, CV-17, CV-4, CV-6, ST-36. Certain aspects of point selection are evident from the several examples listed above: Lung meridian points are not suggested frequently; when they are, it is usually only one point that is selected, and, on rare occasions, 2 points (LU-7 and one other). The lung meridian points are mostly used as distal points, relying heavily on LU-5 and LU-7 on the forearm, rather than local points (i.e., LU-1, LU-2). In some acupuncture formulas LU-9 is selected in place of LU-7 for treating deficiency cases (usually with ST-36), this being the yuan (source) point for the lungs. However, this application does not otherwise fit the standard indications for use of this point (which is for clearing wind and phlegm and relieving heat and accumulation). Kidney and spleen meridian points along the chest that are indicated for asthma are not used; a kidney or spleen point on the leg may be included to help overcome deficiencies. Kidney and spleen tonification therapy is often addressed by using distal points on the conception vessel, such as CV-4 and CV-6; kidney tonification is also accomplished by treating BL-23 or a leg kidney point (KI-3 or KI-6). Points on the back are recommended more than those on the chest as local points, with bladder meridian points dominating (sometimes joined with dingchuan or GV-14 that are just above the commonly used bladder meridian points). Bladder-13 is the most frequently used point for treating asthma and the extra meridian point dingchuan (an inch closer to the spine than BL-11) is also used in several modern prescriptions. It is common to have treatments include two bladder meridian points, and sometimes even 3 or 4 bladder meridian points. The most usual combination is BL-13 with the adjacent BL-12; BL-13 is also combined with BL-43 (at the scapula and just below BL-13), or BL-23 (the kidney shu point). The most frequently recommended points on the chest area are along the conception vessel, particularly CV-17 and CV-22. Use of BL-13 with CV-22 is a traditional recommendation from the Compendium of Acupuncture; in the Ode to One Hundred Symptoms derived from that the second volume of that work it says simply (11): "Coughing and hoarseness, the Lung shu [BL-13] must meet with Heaven Rushing Out [CV-22]."

POINTS USED IN CLINICAL TRIALS FOR ASTHMA In clinical trials, the researchers often attempt to find the most effective point combination that they feel certain will perform well for a wide range of asthma cases. The points selected often reveal the core components of a larger formula that they might use in general practice. An extensive review of published clinical trials for asthma treatments with acupuncture (9) provided these protocols for body points: dingchuan, ST-36 dingchuan, BL-13, BL-15, BL-17, LU-1, CV-17 dingchuan, Chuanxi, GV-14, LU-7, CV-4 BL-13, CV-17, LU-1, LU-7, CV-4 dingchuan, CV-22, LU-7 ST-10 dingchuan, BL-13, CV-17, CV-4

dingchuan, Chuanxi, GV-14, LU-7, CV-4, ST-36 BL-13, BL-12, GV-14 LU-5, LU-9, CV-12, CV-4, BL-23, ST-36, KI-3 dingchuan, LU-6, KI-3, SI-14 dingchuan, BL-13, CV-17, LV-3 BL-13, CV-22, CV-17, CV-12, CV-11, CV-4, GV-20 dingchuan, LU-7, LU-6, CV-17 dingchuan, GV-14, ST-36, SP-9, GB-20, LI-11, KI-7 dingchuan, BL-13, CV-22. CV-17, CV-11, LU-9, ST-36, SP-6 There are some general differences between the acupuncture point formulas used in these trials compared to the textbook recommendations. These differences may reflect changes from traditional practice to modern practice. By far the most frequently mentioned points in the clinical trial formulas were dingchuan plus the other two points that are 0.5 inches on either side of it (GV-14 a n d Chuanxi) . There were fewer bladder meridian points used, with BL-13 still the most commonly selected on that meridian. Conception vessel points along the chest were also less frequently used in these studies compared to the textbook recommendations, with CV-17 the dominant choice, followed by CV-22 (sometimes the two are used together in one formula). As with the textbook examples, back points were used more frequently than chest points. LU-7 was the only point of the lung meridian that was mentioned with some frequency. Two adjunctive points were relied upon repeatedly: ST-36 and CV-4.

TREATMENT METHODS In general, as indicated in the following reports by individual practitioners or clinical research teams, asthma treatment is started with daily or every other day treatment. The treatment is then reduced in frequency to about twice per week when the symptoms are somewhat alleviated, ending up with seasonal treatment only at a frequency of about once per week to maintain the effect. Acupuncture may be followed up by moxibustion or cupping. Dr. Shao Jingming has been practicing Chinese medicine for more than 60 years; for prevention and treatment of asthma, this is a summary of his experience reported recently (14): Dr. Shao has the practice of regularly choosing certain main and adjuvant points. feishu (BL-13), dazhui (GV-14), and fengmen (BL-12) are selected as the main points; when used together, they can not only activate the function of the lung and relieve asthma, but also prevent the relapse of asthma, showing quite good therapeutic effect on simple bronchial asthma. During the paroxysmal period, puncturing the above points can lower the resistance of the intrapulmonary gaseous passages so as to alleviate asthma over time; during the remission period, the treatment may have an effect of regulating and improving the function of the lung to consolidate the long-term effect....some adjuvant points should be added according to the accompanying symptoms: chize (LU-5) and taiyuan (LU-9) for coughing; zhongwan (CV-12) and zusanli (ST-36) for profuse sputum; shenshu (BL-23) and guanyuan (CV-4) for shortness of breath and exacerbation of asthma after motion; jueyinshu (BL-14), xinshu (BL-15), neiguan (PC-6), and zusanli (ST-36) for palpitation and lip and nail cyanosis; and yuji (LU-10) for pharyngeal and tongue dryness. As for the acupuncture maneuvers, the depth of the needle at the three main points is as follows. For adult patients, a 1.5 cun long filliform needle is inserted vertically at dazhui (GV14) 1.3 cun deep; and 1 cun long filliform needles are inserted slowly at feishu (BL-13) and fengmen (BL-12) 0.5-0.8 cun deep to induce needling sensation....In case of deficiency of yang, acupuncture may be applied with moxibustion; in the case of deficiency of yin with internal heat, or of pulmonary infection with fever, acupuncture may be applied, followed by cupping....Clinical practice showed that treatment given in summer and autumn seasons for 3 years can basically control relapse." At the Henan Provincial Hospital of Traditional Chinese Medicine, Dr. Chen Anmin (15) reported that: Application of acupuncture and moxibustion during acute attacks can relieve asthma instantaneously and alleviate other symptoms. During the quiescent stage, it helps consolidate the therapeutic effect and prevent recurrence. The main points used are feishu (BL-13), dazhui (GV-14), and fengmen (BL-12). The adjunct points are chize (LU-5) and taiyuan (LU-9) for coughing; zhongwan (CV-12), zusanli (ST-36), and fenglong (ST-40) for profuse sputum; tiantu (CV-22) for oppressed sensation in chest and difficult expectoration. The needle is inserted perpendicularly in feishu (BL-13) and fengmen (BL12) for 0.5-0.8 cun; at dazhui (GV-14) for 1-1.3 cun; and the needles are retained for about 20-30 minutes with manipulation 2-3 times with the uniform reinforcing-reducing method. After acupuncture, cupping can be applied between dazhui (GV-14) and feishu (BL-13). Acupuncture can be applied once daily during attacks and once every other day after asthma has been relieved. In 1995, Hu Jinsheng, from the Institute of Acupuncture and Moxibustion in Beijing, traveled to Germany and performed acupuncture on patients with asthma who were steroid-dependent (15). His treatment involved applying acupuncture 4 times per week initially for two weeks, and then reducing to 3 times per week for the next two weeks, and then 2 times per week for several weeks. There were two basic acupuncture formulas; one which was a general tonification strategy that included zusanli (ST-36), sanyinjiao (SP6), shanzhong (CV-17), baihui (GV-20), and zhongfu (LU-1) aimed at improving lung functions. The other was an asthma-specific treatment that included dingchuan, Chuanxi, and dazhui (GV-14), along with feishu (BL-13) and several other bladder meridian points. Additional points were used to treat specific symptoms. The two basic recipes were alternated. As to the treatment method and results: The uniform reinforcing-reducing method was adopted after deqi (needling sensation) at all the above acupoints. dingchuan should be punctured to a depth of 1-1.2 cun, using a 1.5 cun long needle; and after the needling sensation was felt by the patient, a strong manipulation should be used, better with the needling sensation radiating into the chest.....the asthmatic symptoms in most of the patients began to be improved after several acupuncture treatments, with the dosage of the drugs gradually reduced. Generally, the dose of oral cortisone was decreased by 2 mg every 10 days, while that of the aerosol was controlled by the patients themselves according to the condition of the disease. The symptoms in most of the

patients were markedly improved after 15 treatments, but the treatment should be continued for another 10 times to consolidate the curative effect. Thus, each asthmatic patient needs to receive approximately 30 sessions of acupuncture treatment, lasting about 3 months. Thereafter, in order to prevent its relapse, the treatment should be administered 10 times each year in the summer season [that is, once per week for 10 weeks]....The 25 cases of hormone-dependent bronchial asthma were treated by acupuncture, yielding a markedly effective [no longer take corticosteroid or its aerosol, symptoms disappear] rate of 56%, with a total effective [all patients who lowered drug dose and had symptom improvement] rate of 96%....It is worthy to mention that, in this series, there was one female patient who suffered from anaphylactic asthma induced by dog's hair. She received 10 sessions of acupuncture treatment without any improvement. In this case, the acupuncture should not be given any longer." At the Zhejiang Institute of Traditional Chinese Medicine, Lou Baiceng reports (17): According to the characteristics of asthma, it should be kept in mind the basic treatment principle: relieve the manifest symptoms of the disease at the stage of attack and treat its root cause during the period of intermission. Lique (LU-7), hegu (LI-4), and dingchuan, are used as the main points for symptomatic relief, using the reducing maneuver by twisting and twirling. Ginger moxibustion is executed during the intermittent period of the disease. The moxibustion is applied on feishu (BL-13) and lingtai (GV-10) on the first day of treatment; on shenshu (BL-23) on the second day, and on shanzhong (CV-17) and tiantu (CV-22) on the third day. Treatment is given every day with the above three groups of points used in turn, with 5-7 moxa cones applied on each point for each session of treatment, 9 sessions constituting a therapeutic course. The therapy is effective for the majority of cases, especially for children. Two medical groups in Shanghai reported on the importance of patients experiencing the needling sensation and propagated sensation-the feeling that the needling sensation spreads beyond the local area being treated-in order to get good therapeutic results for asthma. In one report (18), asthma patients were treated at chize (LU-5), taiyuan (LU-9), and zusanli (ST-36). The authors evaluated the level of needle sensation and propagation from LU-5 and ST-36 (LU-9 was not considered to be a suitable site for attaining propagated sensation). The authors stated that: In general, most of the sensations analyzed radiated slowly. Most of those at chize (LU-5) radiated upward and 20% in both directions. Those at zusanli (ST-36) radiated downward....In treating bronchial asthma by acupuncture in which needling sensations were elicited and traveled along the channels, it was shown that when strong sensations are produced and traveled along the lung channel to reach the shoulder or the upper right chest, more ideal therapeutic results are obtained, and patients can immediately feel the alleviation of the choking sensation of the chest. At the onset of asthma attacks, the insertion and retention of needles for 15 minutes can alleviate asthma, ease the symptoms and make the lung impedance graph and respiratory waves tend to normal. After one course of treatment [acupuncture every other day, for 10 sessions], all indices improved. More than 80% of the patients showing good results had experienced strong sensations, while more than 80% of the patients with poor results had had no sensation traveling along the channel. The other group reported on treatment of children (ages 5-12 years) with asthma, using electro-stimulation of needles that were inserted superficially at the chosen acupuncture points (19). The doctors selected eight points: dingchuan, dazhui (GV-14), feishu (BL13), shanzhong (CV-17), tiantu (CV-22), gaohuang (BL-43), hegu (LI-4), and zusanli (ST-36); these were subdivided into three sets of points, with each set treated once per week, three treatments per week; this pattern was repeated for six weeks. Electrostimulation of the needles was adjusted to produce a numbness sensation at the points for 5 minutes. For analysis of results, the patients were divided into two groups: those who definitely experienced a propagated sensation versus those who did not experience this sensation. The authors reported a difference between these two groups in the therapeutic effects (asthmatic breathing) which correlated with changes in the measured parameters such as plasma cyclic nucleotides, cortisol, and IgE. In both groups, there were measurable improvements (increased cGMP with reduced cAMP; increased cortisol; decreased IgE), but the response of those with propagated sensation was somewhat better. Propagation of needling sensation was also emphasized by Zhu Mingqing (20) who is best known for his work with scalp acupuncture and treatment of acute syndromes. For treatment of asthma using body points, he states that the needle reaction attained at dazhui (GV-14) and dingchuan should spread to the shoulder, back, or chest; similarly, when treating tiantu (CV-22), the reaction should spread to the whole chest; and when treating neiguan (PC-6), the reaction should conduct upwardly along the medial aspect of the arms. In these cases, needling manipulation can be carried out over a period of 5-10 minutes, and the needles are not retained afterward.

CONCLUSION The impression conveyed by textbook presentations, clinical trials, and practitioner reports about acupuncture therapy for asthma is that although there is considerable diversity in treatment strategies, it appears especially valuable to utilize upper-back points. In particular, the most frequently relied upon points are those along the horizontal line of GV-14, dingchuan, and Chuanxi, and points that are just below that line, particularly BL-13 and, to a lesser extent, BL-12 and the outer point BL-43. In all but three of the point sets listed for the clinical trials above, either dingchuan or BL-13 (or both) were used; similarly, in all but three of the textbook recommendations listed in the previous section, either dingchuan or BL-13 (or both) were included. All of the published clinical trials proclaimed a positive outcome for the treatments as did the individual practitioner reports. Although the clinical trials were not conducted in such a manner as to succeed in proving the effectiveness of the treatments by modern standards, it is clear that practitioners deem these particular points to be reliable. In general, the front chest points used in treatment of asthma were limited to CV-17 and CV-22. The favored arm point was LU-7, though LU-5, LU-6, LU-9, and LU-10 were also used. Less frequently, PC-6 or LI-4, which are nearby the lung points (forearm/hand), were also used. Leg points that were favored were ST-36 and ST-40, occasionally with tonification points such as SP-6 or KI-3. The lower abdomen was sometimes treated, also as a tonification strategy, relying most heavily on CV-4 and CV-6, and the lower back was treated in some cases at BL-23. The use of adjunctive points to alleviate coexisting symptoms or constitutional conditions, as well as using additional asthmarelated points, may improve the outcome, but it is unclear how much improvement can be expected, given the low frequency with which the other points were deemed important enough to include in textbook recommendations and clinical trials. While there are numerous

acupuncture points on several meridians that are indicated for treatment of asthma in the standard texts, it appears that most acupuncturists do not rely on meridian-based therapies for asthma, but, instead, focus primarily on local points over the upper portion of the lungs, thus placing emphasis on the modern empirical point dingchuan and the lung shu point BL-13. These and the few other points mentioned in this literature review article can serve as a basis for designing an acupuncture formula for treatment of asthma. It is common practice in the West to treat patients on a once-per-week basis, regardless of the disease condition. As reported here, initial treatment frequency recommended by Chinese doctors is once per day or every other day, with decreasing frequency as success is attained. Thus, practitioners may learn from this review both the emphasis on using certain points and the frequency of applying acupuncture that is thought to yield the best results.

REFERENCES 1. Ellis A, Wiseman N, and Boss K, Fundamentals of Chinese Acupuncture, 1988 Paradigm Publications, Brookline, MA. 2. Zhang Ren and Dong Zhilin, Modern Clinic Necessities for Acupuncture and Moxibustion, 1990 China Ocean Press, Beijing. 3. O'Connor J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981, Eastland Press, Seattle, WA. 4. Chinese Academy of Traditional Chinese Medicine, An Outline of Chinese Acupuncture, 1975 Foreign Languages Press, Beijing. 5. Cheng Xinnong (chief editor), Chinese Acupuncture and Moxibustion, 1987 Foreign Languages Press, Beijing. 6. Zhou Zhongying and Jin Huide, Clinical Manual of Chinese Herbal Medicine and Acupuncture, 1997 ChurchillLivingstone, London. 7. Ming Shunpei and Yang Shunyi, Advanced Textbook of Traditional Chinese Medicine and Pharmacology, volume IV, 1997 New World Press, Beijing. 8. Qiu Maoliang (managing editor), Chinese Acupuncture and Moxibustion, 1993 Churchill-Livingstone, London. 9. Jobst KA, Acupuncture in asthma and pulmonary disease: an analysis of efficacy and safety, Journal of Alternative and Complementary Medicine 1996; 2(1): 179-206. 10. Xu Xiangcai (chief editor), English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, 1989 Higher Education Press, Beijing. 11. Bertshinger R, The Golden Needle, 1991 Churchill-Livingstone, London. 12. Cheng Danan, Acupuncture and Moxibustion Formulas and Treatments, 1996 Blue Poppy Press, Boulder, CO. 13. Beijing College of Traditional Chinese Medicine, et al., Essentials of Chinese Acupuncture, 1980 Foreign Languages Press, Beijing. 14. Zhu Yancen and Wang Minji, A brief introduction to Dr. Shao Jingming's experience in acupuncture, Journal of Traditional Chinese Medicine 1998; 18(2): 106-110. 15. Chen Anmin, Traditional Chinese medicine in treatment of bronchitis and bronchial asthma, Journal of Traditional Chinese Medicine 1998; 18(1): 71-76. 16. Hu Jinsheng, Clinical observation on 25 cases of hormone dependent bronchial asthma treated by acupuncture, Journal of Traditional Chinese Medicine 1998; 18(1):27-30. 17. Lou Baiceng, Personal experience on acupuncture treatment of asthma, Journal of Traditional Chinese Medicine 1990; 10(1): 13-16. 18. Sheng Lingling, et al., The effect of needling sensation reaching the site of disease on the results of acupuncture treatment of bronchial asthma, Journal of Traditional Chinese Medicine 1989; 9(2): 140-143. 19. Gong Bin, et al., Biochemical and immunological studies on treatment of asthmatic children by means of propagated sensation along channels, Journal of Traditional Chinese Medicine 1986; 6(4): 257-262. 20. Zhu Mingqing, A Handbook for Treatment of Acute Acupuncture Syndromes Using Acupuncture and Moxibustion, 1992 Eight Dragons Publishing, Hong Kong.

March 1999

Figure 1: Points on the lung meridian.

Figure 2: Points on the stomach meridian.

Figure 3: Points on the kidney meridian.

Figure 4: Points on the spleen meridian.

Figure 5: Points on the conception vessel meridian.

Figure 6: Points on the bladder meridian.

Figure 7: dingchuan and Chuanxi. The points are slightly closer to the GV line than they appear in this illustration.

Figure 8: dingchuan as an extension of the Huatuo points.

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ACUPUNCTURE AND HERBS FOR MIND AND BRAIN DISORDERS I. Acupuncture by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Acupuncturists know that a calming effect can often be obtained by simple acupuncture techniques. It is less well-known to what extent acupuncture can affect other aspects of mental function, including serious disorders that involve brain damage, such as stroke, Alzheimer’s disease, ALS, mental retardation, attention deficit disorder, Tourette’s syndrome, manic-depressive syndrome, cerebral palsy, and schizophrenia. Research into these areas has been ongoing in China and the claimed results are often quite good. However, there are so many acupuncture points and herbs that are said to be of some benefit that design of definitive research projects and treatment protocols becomes difficult and practitioners are left with relatively limited guidance. This article is aimed at drawing attention to the main acupuncture points used in the treatments for disorders that involve the brain and mental functions. Herbal therapies are described in Part II. There are three types of dysfunction of particular concern: brain damage and/or metabolic disorders that are present at birth or that develop during infancy, and persist throughout life; complex disorders involving emotional distress and unhealthy behavior patterns that lead to mental disorders; and mental deterioration that occurs in old age, often associated with poor blood circulation and/or degeneration of brain structures, sometimes triggered relatively early by genetic factors. In America, one of the dominant uses of acupuncture therapy, aside from pain relief, is to help people, particularly young and middle-aged people, with drug addiction problems. While these drug problems probably have part of their basis in a genetic tendency towards addictive behavior and/or sensitivity to certain drugs, they mainly reflect the emotional patterns and lifestyle choices of the individual (thus, this falls into the “complex disorder” category, above). In China, one of the important areas of traditional medical research is the use of acupuncture and herbs to treat the elderly who have had a stroke or suffer from senile dementia. Similar techniques have been applied to children who suffer from cerebral palsy, epilepsy, or mental retardation. To a large extent, Western practitioners have focused their therapeutic efforts aimed at treating drug addiction and emotional distress on the use of an acupuncture technique developed not in China, but in the West: ear acupuncture. In 1958, a French physician, Paul Nogier, introduced the concept of treating numerous points on the ear that were purported to have specific effects on each of the body structures and functions. Although the specificity of ear acupuncture points has never been clearly demonstrated, most acupuncturists agree that ear acupuncture has a calming effect. Indeed, the most frequently cited ear point used in treatments is called shenmen (spirit gate). In Handbook of Chinese Auricular Therapy, it is said that “It is used in numerous diseases of the neuro-psychiatric system....The application of this point is fairly extensive and flexible, covering no less than 30 kinds of diseases or ailments.” In this article, the use of standard body acupuncture for mind and brain disorders is discussed. It will be seen that only a limited number of points, on just a few of the acupuncture channels (meridians), are repeatedly relied upon to treat a variety of these disorders. This may reflect the unique effectiveness of at least some of these acupuncture points which appear to be grouped around the head, forearms, and lower legs. Similarly, herbal therapies for the disorders rely on a relatively small number of herbs, most of which can be grouped into just three therapeutic categories: tonics, sedatives, and phlegm-mist resolving herbs.

ACUPUNCTURE Researchers at the Zhejiang Academy of Traditional Chinese Medicine undertook an extensive review of traditional medical literature and determined the acupuncture points most consistently relied on to treat disorders of the mind and brain (1). That is, they searched for points (called, in their English translation, “intelligence points”) that were repeatedly mentioned in the traditional literature for certain disorders, such as dementia, poor memory, and loss of consciousness. A review of traditional literature offers the opportunity to see what experienced physicians have recommended and claimed to be of benefit in the past. The authors said that they “read up all the literature on acupuncture before the Ming Dynasty and most of the relevant literature of the Ming and Qing Dynasties, and collected together 29 intelligence points.” For each of the major medical texts consulted, the authors present a listing of the points mentioned that are relevant to treating mental conditions. For example, in the Huangdi Ming Tang Jing , the points listed are tianfu (LU-3), lieque (LU-7), neiguan (PC-6), ximen (PC-4), yongquan (KI-1), and youmen (KI-21). They then determined the frequency of mention of the points among all the texts in relation to treating certain conditions (see Table 1), yielding a total of 17 points mentioned in more than one text. It should be noted that there is not much meridian specificity to the treatment of the various disorders. A total of 10 meridians (out of the basic group of 14) are included, and only one meridian (kidney) has more than 2 of the points.

The fact that a point may be repeatedly mentioned in the literature does not, in itself, confirm the efficacy of treating that point. The repeated mention does, at the least, imply that many generations of doctors did not come up with many alternatives to a point that was determined early on. Acupuncture formulas listed in texts were also collected in an effort to determine the utilization of the points for various disorders of the mind and brain. Frequency of reliance on individual points within the numerous formulas yields a somewhat different result, since formulas are constructed with main and secondary points as well as adjunctive points (supportive therapy that may not be normally directed at treating mental disorders). In the prescriptions, the main points mentioned (5 times or more) were shenmen (HT-7), xinshu (BL-15), baihui (GV-20), and lieque (LU-7). Two adjunctive points were mentioned at least 3 times: zusanli (ST-36) and houxi (SI-3). The International Acupuncture Training Centers and other organizations in China, such as the Academy of Traditional Chinese Medicine, compiled an acupuncture text: Chinese Acupuncture and Moxibustion (2), published in 1987. In the section on zangfu syndromes, there is a series of descriptions for insomnia, poor memory, heart palpitations, manic-depressive disorders, epilepsy, dizziness (not listed below), and melancholia. The acupuncture points, which were presented in small formulas or groups as main points, are presented in Table 2. Shogo Ishino, at the Oriental Medicine Research Center of the Kitasato Institute in Japan, reported on acupuncture treatment for senile psychic disorders (3). As a main source text, he relied on the book Highly Valuable Commentaries on Acupuncture and Moxibustion: Grand System of Medical Classics on Acupuncture and Moxibustion, an encyclopedic collection published in China in 1978. The points mentioned in that text are listed in Table 3. A recently published (1998) Western textbook, Manual of Acupuncture (4), presents summations of uses of the acupuncture points. In one index, for each of several symptoms or diseases, point designations are provided that have those conditions as one of their indications. For disorders of the brain and mind, Table 4 presents the points mentioned in this index (some indications were combined in preparing the table). In a few cases, particularly epilepsy and mania, there were so many points listed in the index that there would be no benefit derived from examining the collection. Perhaps almost any point will help, or, perhaps, numerous points have been recommended with none being particularly effective. A number of the conditions listed here may seem of minor importance, such as apprehension, anxiety, and worry, but in the practice of acupuncture in China (which is the basis for this textbook), patients usually only seek treatment when the condition is quite severe, beyond what is normally encountered in daily life. Thus, patients with that type of emotional or stress conditions would probably be treated, when relying on Western medicine, with potent drug therapies, including anti-depressants. Based on this summary of point indications, it becomes evident that certain points are relied upon for a wide range of mind-brain disorders. Combining the information from the literature cited above yielded the list in Table 5, which presents the main acupuncture points utilized in treatment of mind-brain disorders. Two “extra points,” sishencong (M-HN-1) and yintang (M-HN-3), have become popularized in recent years for treatment of mental disorders though these points received relatively little mention in the literature reviews; they are included in the table to more completely reflect current practice. While there are only a few points for each of the channels represented, it is evident that there is much emphasis on treating the back (along the spinal column) to address mind and brain disorders. A large number of points along the bladder channel and the governing vessel are mentioned in the literature, even if most of those points are suggested only once or twice. The governing vessel continues along the spine over the top of the head, where baihui (GV-20) and its surrounding points (sishencong; four points on each side) are utilized. This vessel continues over to the face where the extra point yintang is located (between the eye brows) to the end of the channel at renzhong (GV26). Needling points along the spinal column and on the head, including fengchi (GB-20), may provide a relatively direct means (proximate treatment) of stimulating the central nervous system and affecting the brain. The technique of scalp acupuncture (see: Synopsis of scalp acupuncture), which has been applied in the treatment of stroke patients as the primary use, mainly involves strong stimulation of points along the governing vessel at the top of the head. Points on the arms and legs may well function via different mechanisms than those associated with the spine and head. The actions of two such distal points, zusanli on the leg and neiguan on the arm, have been described in detail (see: Zusanli and Neiguan). There is a collection of points listed in Table 5 that are located in the interval from the wrist to the elbow, including three pericardium points, two heart points, two large-intestine points, and the main lung point, lieque (LU-7); this grouping extends to the hand with two more pericardium points. Another hand point, hegu (LI-4) is frequently used as an adjunctive point in many modern treatment protocols for these mind-brain disorders. Similarly, there is a group of points on the lower leg, including two kidney points, three stomach points, and two spleen points, and continuing to the foot with the liver points and one more kidney point, yongquan (KI-1). These groupings of points may reflect an ability to stimulate release of certain neural transmitter substances by applying needles or moxibustion to specific peripheral regions of the body. Of the points listed in Table 5, few points seem to diverge from the pattern of treating the spinal column and head or treating the distal portions of the limbs: namely, two conception-vessel points and the lung point on the upper arm, tianfu (LU-3). Table 1: Frequency of mention of a point for the listed condition in the comprehensive collection of traditional acupuncture texts examined by the researchers in Zhejiang (1). Only those points that are mentioned at least 2 times in the literature search for these disorders are included in the table. The points are listed according to total number of references, in descending order (23 references for baihui for two disorders to only 2 references for dazhong for one disorder). Point

Poor Memory

Deficiency Loss of of Spiritual Consciousness Qi

Deficiency of Heart Qi

Dementia

baihui (GV-20)

13

10

Xinshu (BL-15)

4

14

Zhongchong (PC-9)

7

Ximen (PC-4)

7 13

Lieque (LU-7)

12

Gaohuangshu (BL-43)

11

Youmen (KI-21)

11

Neiguan (PC-6) Tianfu (LU-3)

10

Shendao (GV11)

9

Yongquan (KI1)

8

Shenmen (HT-7)

4

Jiuwei (CV-15)

9

1

2

2 6

Juque (CV-14)

5

Quchi (LI-11)

4

Dacheng (SP15)

3

Dazhong (KI-4)

2

Table 2: Main points listed for treatment of specified disorders in Chinese Acupuncture and Moxibustion. Insomnia

shenmen (HT-7), sanyinjiao (SP-6), anmian (M-HN-54)

Poor memory

sishencong (M-HN-1), xinshu (BL-15), pishu (BL-20), zusanli (ST-36), shenshu (BL-23), zhaohai (KI-6)

Palpitation

xinshu (BL-15), juque (CV-14), shenmen (HT-7), neiguan (PC-6)

Depression

xinshu (BL-15), ganshu (BL-18), pishu (BL-20), shenmen (HT-7), fenglong (ST-40)

Manic disorder

dazhui (GV-14), fengfu (GV-16), shuigou (GV-26), neiguan (PC-6), fenglong (ST-40)

Epilepsy (during shuigou (GV-26), jiuwei (CV-15), jianshi (PC-5), taichong (LV-3), seizure) fenglong (ST-40) Epilepsy (after seizure)

xinshu (BL-15), yintang (M-HN-3), shenmen (HT-7), sanyinjiao (SP-6), taixi (KI-3), yaoqi (extra)

Melancholia

Differentiated into four categories (liver qi stagnation, transformation of stagnant qi into fire, stagnation of phlegm, and insufficiency of blood). Main point: taichong (LV-3), included in three of four syndromes.

Table 3: Points listed in Highly Valuable Commentaries on Acupuncture and Moxibustion for selected disorders. The points in the text were differentiated according to whether the treatment should be acupuncture or moxibustion or both, but this distinction is not presented here. Apoplexy

tianjing (TB-10), shaoshang (LU-11), shenmai (BL-62), renzhong (GV26), baihui (GV-20), fengshi (GB-31), dazhui (GV-14), jianjing (GB21), jianshi (PC-5), quchi (LI-11), zusanli (ST-36)

Unconsciousness

zhongchong (PC-9), dadun (LV-1), baihui (GV-20)

Melancholia

gaohuang (BL-43), shedao (GV-11), ganshu (BL-18), burong (ST-19), liangmen (CV-21)

Amnesia, absentmindedness, palpitations

shenmen (HT-7), saling (PC-7), juque (CV-14), shangwan (CV-13), zusanli (ST-36), jianyu (LI-15), feishu (BL-13), sheshu (BL-23), pishu (BL-20)

Epilepsy

renzhong (GV-26), baihui (GV-20), shenmen (HT-7), jinmen (BL-63), juque (CV-14), kunlun (BL-60), jinsuo (GV-8), yongquan (KI-1), shangwan (CV-13), yanggang (BL-48), yintang (M-HN-3)

chize (LU-5), shenmen (HT-5), jianshi (PC-5), tiangjing (TB-10), baihui (GV-20), zohgwan (CV-12), chengshan (BL-57), fengchi (GB20), quchi (LI-11), shangwan (CV-13)

Insanity

Table 4: Points listed for each of the specified disorders in the index to Manual of Acupuncture. Epilepsy and mania are not included in this listing because the number of points presented was so large as to be uninformative. Chinese point names (pinyin) are not included due to large number of points listed. Agitation

LU-4, ST-23, ST-41, SP-1, SP-2, KI-1, KI-4, PC-4, PC-7, CV-19, plus other points for combined syndromes (e.g., with heat in the chest)

Anger

CV-14, ST-36, LU-10, KI-9, CV-8, GB-39, BL-18, KI-4, PC-8, LV-2, LV-13, KI-7, KI-1, GV-12, CV-14, HT-5

Anxiety and worry

BL-15, GB-39, KI-12, CV-12, LV-1, LV-5

Apprehension

PC-5, PC-6, PC-8

Aversion to people talking

ST-37, ST-44, GB-17, CV-15

Coma

PC-8, GV-26, CV-1

Dementia

HT-7, BL-15, KI-4

Depression

HT-5, LV-5

Epilepsy, childhood fright

LU-7, SP-5, GB-13, GV-8, GV-12, GV-21

Fear and fright

LI-13, HT-7, HT-8, ST-7, PC-6, LV-5, GV-4, CV-4, plus other points for specific types (e.g., sudden fright)

Hallucination (seeing ghosts) LI-5, LI-7, ST-40, ST-41, BL-10, BL-61, GV-12 Laughter, abnormal

PC-7, PC-8, LI-7, GV-26, ST-40, HT-7, ST-36, LU-7, LI-5, SP-5, KI-7

Loss of consciousness, stroke LU-11, LI-1, HT-9, SI-1, KI-1, LV-1, GV-15, GV-26, CV-6, CV-8 Mad walking

ST-23, SI-5, SI-8, BL-8, BL-9, LV-13, GV-19, BL-13

Madness

BL-5, BL-9, BL-60, KI-1, KI-9, TB-10, TB-12, TB-13, GB-9 LV-2

Melancholy

PC-4, LU-3, SP-5

Memory loss

LU-7, LI-11, HT-3, HT-7, BL-15, BL-43, KI-1, KI-21, KI-3, PC-5, PC6, GB-20, GV-11, GV-20, CV-14, M-HN-1, PC-6

Mental retardation

KI-4

Ranting and raving

KI-14, LI-7, ST-36, KI-9, TB-2, GV-12, LI-6

Sadness and weeping

LU-3, ST-36, SP-1, SP-15, HT-7, KI-6, PC-6, PC-7, PC-8, TB-10, LV2, LU-10, HT-1, SI-7, GV-11, GV-20, HT-4, GV-16, HT-5, ST-41, HT8, SP-7, GV-13, LU-5, BL-15, PC-9

Stroke

LI-10, LI-15, ST-36, BL-15, BL-23, BL-40, PC-6, PC-8, PC-9, GB-2, GB-13, GB-15, GB-21, GB-40, LV-2, GV-16, GV-20, CV-4, M-UE-1, M-HN-1

Table 5: Summary of 34 main points relied on for mind and brain disorders according to both traditional and modern literature. The indications presented here are from Manual of Acupuncture, selecting only those conditions associated with mind and brain disorders. To be listed in the table, the point had to be mentioned frequently in the literature cited above (1, 2, 3, 4) and/or in the medical reports listed below, and the indications for use had to include several different types of mind and brain disorder. Taichong (LV-3) was added to reflect modern applications of the point now often used in place of xingjian (LV-2) that is mentioned repeatedly in the traditional literature; similarly fengchi (GB-20) was added to this table because of the high frequency of its use for these applications in modern practice. Some of the points, such as sanyinjiao (SP-9) and zusanli (ST-36) are mainly used in formulas for treatments that require tonification therapy, rather than being chosen for specific effects on mind and brain disorders. Other adjunctive points that are sometimes employed in formulas, such as the hand points hegu (LI-4) and houxi (SI-3), are not included in the table because they have few indications for mind and brain disorders and are not mentioned in the traditional literature in that context, though they are used in modern practice. Point

Relation to Channels/Indications Related to Mind/Brain Disorders GOVERNING VESSEL (GV)

Meeting point of the GV, LI, and ST channels. Sudden loss of consciousness, renzhong (GV-26) coma, childhood fright, stroke, mania-depression, epilepsy, inappropriate laughter, unexpected laughter and crying. baihui (GV-20)

Meeting point of the GV, BL, GB, TB, and LV channels. Dizziness, blindness, stroke, loss of consciousness, epilepsy, fright palpitations, poor memory, lack of mental vigor, disorientation, much crying, sanity, and crying with desire to die, mania.

Shenzhu (GV-12)

Mad walking, delirious raving, seeing ghosts, rage with desire to kill people.

Shendao (GV-11)

Sadness and anxiety, poor memory, fright palpitations, timidity, epilepsy. HEART (HT)

Tongli (HT-5)

Luo point of the Heart channel. Frequent yawning and groaning with sadness, vexation and anger, sadness and fright, depressive disorder, fright palpitations.

Shenmen (HT-7)

Shu, yuan, and earth point of the HT channel. Insomnia, frequent talking during sleep, poor memory, mania-depression, epilepsy, dementia, desire to laugh, mad laughter, insulting people, sadness, fear and fright, disorientation, fright palpitations. BLADDER (BL)

Xinshu (BL-15)

Shu point of the heart. Fright palpitations, poor memory, anxiety, weeping with grief, frightened and cautious, insomnia, excessive dreaming, disorientation, delayed speech development, mania-depression, epilepsy, dementia, mad walking, stroke.

Gaohuang shu (BL-43)

Shu point of the vital region. Poor memory, insomnia, phlegm-fire mania, dizziness. KIDNEY (KI)

Yongquan (KI-1)

Jing and wood point of the KI channel. Epilepsy, childhood fright, dizziness, cloudy vision, agitation, insomnia, poor memory, propensity to fear, rage with desire to kill people, madness.

Dazhong (KI-4)

Luo point of the KI channel. Agitation, dementia, mental retardation, somnolence, propensity to anger, fright, fear, and unhappiness, desire to close the door and remain at home.

Zhubin (KI-9)

Xi point of the yin linking vessel. Madness, mania, mania depression disorder, raving, fury and cursing, tongue thrusting. CONCEPTION VESSEL (CV)

Juque (CV-14)

Front mu point of the heart. Mania disorder, mania-depression, tendency to curse and scold others, ranting and raving, anger, disorientation, loss of consciousness, epilepsy, fright palpitation, poor memory, agitation.

Jiuwei (CV-15)

Luo point of the conception vessel. Epilepsy, mania, mad walking, mad singing, aversion to the sound of people talking, fright palpitations. PERICARDIUM CHANNEL (PC)

Ximen (PC-4)

Xi point of the PC channel. Agitation, insomnia, melancholy, fear and fright of people, insufficiency of spirit qi, epilepsy.

Neiguan (PC-6)

Luo point of the PC channel. Fright palpitations, insomnia, epilepsy, mania, poor memory, apprehension, fear and fright, sadness, loss of memory following stroke.

Daling (PC-7)

Shu, yuan, and earth point of the PC channel. Insomnia, epilepsy, mania, manic raving, propensity to laugh (without ceasing), agitation, weeping with grief, sadness, fright, and fear.

Laogong (PC-8)

Ying and fire point of the PC channel. Loss of consciousness, epilepsy, maniadepression, fright, sadness, propensity to anger, apprehension, ceaseless laughter.

Zhongchong (PC-9)

Jing and wood point of the PC channel. Stroke, loss of consciousness, night crying in children. LUNG CHANNEL (LU)

Tianfu (LU-3)

Window of heaven point. Somnolence, insomnia, sadness, weeping, disorientation and forgetfulness, ghost-talk, melancholy, crying.

Lieque (LU-7)

Luo point of the LU channel. Stroke, epilepsy, fright, loss of consciousness, poor memory, palpitations, propensity to laughter, frequent yawning and stretching. STOMACH CHANNEL (ST)

Zusanli (ST-36)

He and earth point of the ST channel. Mania-depression, manic singing, raving, abusive talk, anger, fright, tendency to sadness, outrageous laughter.

Fenglong (ST-40)

Luo point of the ST channel. Dizziness, plumpit qi, mania-depression, mad laughter, great happiness, desires to ascend to high places and sing, discards clothing and runs around, restlessness, seeing ghosts, indolence, epilepsy.

Jiexie (ST-41)

Jing and fire point of the ST channel. Epilepsy, mania, agitation, sadness and weeping, fright palpitations, raving, seeing ghosts. SPLEEN CHANNEL (SP)

Shangqui (SP-5)

Jing and metal point of SP channel. Mania-depression, agitation, excessive thinking, propensity to laughter, nightmares, melancholy, fright, stroke.

Sanyinjiao (SP-6)

Meeting point of SP, LV, and KI channels. Heart palpitations, insomnia, fright, dizziness. GALLBLADDER CHANNEL (GB)

fengchi (GB-20)

Meeting point of the GB and TB channels. Dizziness, stroke, insomnia, loss of memory, epilepsy. LIVER CHANNEL (LV)

Xingjian (LV-2)

Ying and fire point of the LV channel. Propensity to anger, sadness, propensity to fright, closes eyes and has no desire to look, excessive fright, propensity to fear as if seeing ghosts, madness, insomnia, epilepsy, loss of consciousness, stroke.

Taichong (LV-3)

Shu, yuan, and earth point of the LV channel. Dizziness, childhood fright, sighing, insomnia, easily fearful.

Ligou (LV-5)

Luo point of the LV channel. Plumpit qi, depression, fright palpitations, fear and fright, worry and oppression. LARGE INTESTINE CHANNEL (LI)

Wenliu (LI-7)

Xi point of the LI channel. Tongue thrusting, frequent laughter, raving, seeing ghosts.

Quchi (LI-11)

He and earth point of the LI channel. Manic disorders, poor memory, tonguethrusting, dizziness. EXTRA POINTS

sishencong (MHN-1)

Stroke, epilepsy, manic-depression, insomnia, poor memory.

yintang (M-HN-3)

Fright, insomnia, agitation, restlessness.

RECENT PROTOCOLS: CHILDHOOD AND EARLY ADULT DISORDERS The modern Chinese medical literature includes a number of reports of treating children with acupuncture. This approach may not be easily applied in the West, but the point selection should be informative. In a small evaluation involving 8 patients with childhood epilepsy (ages 5-16 years), the children were treated to control immediate symptoms (effects reported to occur within 10 minutes) at the Hospital for Mental Diseases in Anhui Province (5). Treatment involved the following collection of points as the main ones, of which a few were selected according to the particular case and some others might be added: hegu (LI-4), taichong (LV-3), renzhong (GV-26), baihui (GV20), yongquan (KI-1), shixuan (M-UE-1), jianshi (PC-5), daling (PC-7), shenmen (HT-7), guanyuan (CV-4), fenglong (ST-40), yintang (M-HN-3), fengchi (GB-20), and sanyinjiao (SP-6). This point collection includes 7 points from Table 5 and also several of the points listed for epilepsy (during seizure) in Chinese Acupuncture and Moxibustion. Treatment surrounding baihui was done by threading the needles, somewhat like the method of scalp acupuncture; the author reported: “We found the method very effective in treatment of neural and psychic diseases.” The physicians also used blood letting at the fingertip points (shixuan, M-UE-1). A study of acupuncture for pediatric cerebral palsy was reported from the Children’s Hospital at Shanghai Medical University (6). The 117 children treated were in the age range of 10 and under, mostly in the range of 3-7 years. The main points selected were yamen (GV-15), shenshu (BL-23), fengchi (GB-20), zusanli (ST-36), dazhui (GV-14), and neiguan (PC-6). Auxiliary points could also be added. Injection of fluids (glutamine solution or a combination of blood vitalizing herbs) into the head points was used. Significant improvement was claimed for just over half of the patients. The authors pointed out that the points shenshu and zusanli were selected to tonify the kidneys and benefit the marrow (which includes the brain in TCM theory). The use of the group of points surrounding baihui (GV-20), called sishencong (M-HN-1), was the subject of a report from the Hospital of Scalp Acupuncture in Anhui Province (14). Six cases were cited as examples of successful protocols, including headache and Meniere’s syndrome, and the following that fit the subject of the current article, in which the points added to sishencong are indicated: Schizophrenia: taichong (LV-3) and sanyinjiao (SP-6); Neurosis: taichong (LV-3), sanyinjiao (SP-6), neiguan (PC-6), renzhong (GV-26), and anmian (N-HN54); Epilepsy: “epilepsy controlling area” of scalp acupuncture zone system; and Cerebral palsy: five points on the forehead according to the scalp acupuncture zone system. A study on treatment of schizophrenia, involving acupuncture and herbs, was reported from a hospital in Mongolia (7). Acupuncture was performed with three groups of points, with one group treated each day consecutively, then repeated. The point groups were: renzhong (GV-26), shangxing (GV-23), neiguan (PC-6), xuangzhong (GB-39); yintang (M-HN-3), hegu (LI-4), taichong (LV-3), yanglingquan (GB-34); and baihui (GV-20), shanzhong (CV-17), quchi (LI-11), yongquan (KI-1). Several of the points were treated by acupuncture through to a nearby point, such as neiguan through to waiguan, or hegu through to houxi. The authors claimed that all patients were cured by the treatment, though the

condition recurred in 11 cases of 53, which could then be controlled by 1-2 courses of additional treatment. A course of treatment lasted one week to one month, depending on the patient, with daily acupuncture. Tourette’s syndrome in children aged 6-15 was treated at the affiliated hospital of the Tianjin College of Traditional Chinese Medicine (8). The patients were divided into two groups depending on whether they were classified as having yangming stagnant heat, in which case the main points used were neiting (ST-44), quchi (LI-11), pianli (LI-6), and sibai (ST-2), or if they had deficiency of kidney and heart, in which case the main points used were yamen (GV-15), lianquan (CV-23), shenmen (HT-7), and fuliu (KI-7). According to the report, 73% of the 156 patients were relieved of the syndrome with ability to terminate previous medication. Mental retardation in children aged 8-14 was reported by the Institute of Acupuncture at the Academy of Traditional Chinese Medicine (9). Three groups of acupuncture points were selected and each group was applied once every other day during the course of a month, followed by the second group the second month and the third group during the third month: taichong (LV-3), shenmen (HT-7), baihui (GV-20), and sishencong (M-HN-1); kunlun (BL-60), daling (PC-7), fengfu (GV-16), tongtian (BL-7), and shangxing (GV-23); and zhaohai (KI-6), neiguan (PC-6), and scalp points in the scalp acupuncture zones. The effects of treatment were relatively modest, with 9 of 128 cases showing marked effect, but any improvement that was noted (about 2/3 of cases had some improvement) appeared to be retained over the follow-up period of one year. Regarding the selection of points, the authors stated: Since the lesion of mental retardation is in the brain, the acupoints in the head and neck regions are selected for its treatment. The governing channel goes into the medulla and brain as the sea of yang channels, and the urinary bladder channel goes into the brain from the top. Besides the mental and physical development of children are also related to the heart, kidney, and liver, so effective acupoints on the governing, bladder, heart, liver, and kidney channels are selected for regulating the visceral functions to promote the brain functions.

RECENT PROTOCOLS: SENILE DEMENTIA AND NEUROTIC PSYCHOSIS IN THE ELDERLY The term senile dementia has been largely disposed of in modern medical practice, with the ability to distinguish different causes, including Alzheimer’s Disease, atherosclerosis, and stroke. Recent evaluations have indicated that some degree of mental impairment is present in virtually all persons who pass the age of 90. In China, the medical facilities are insufficient to fully diagnose most cases of mental dysfunction in the elderly, so the general term senile dementia is applied and usually refers to cases of obvious impairment before the age of 90. A summary of recently published acupuncture protocols is presented in Table 6. Table 6: Summary of results from translated Chinese medical journal reports published after 1995. Various adjunct points were used for some patients. Study Group/Treatment Duration

Points Used

Outcome Measures, Claimed Results

Improved symptoms, mainly shenting (GV-24), hegu (LI-4), 40 patients aged 60-88; treated vertigo, dizziness, headache, shenmen (HT-7), jianshi (PC-5), every other day for 30 treatments palpitation, fidgets, and zusanli (ST-36), sanyinjiao (SP(10). numbness of limbs. Improved 6), taichong (LV-3) score on mental health exam. 26 patients aged 61-87; 10 consecutive days treatment; 2 day break; total of 32-40 treatments (11).

shigou (GV-26), baihui (GV-20), dazhui (GV-14), fenchi (GB-20), Mental state recovered in 9 cases, neiguan (PC-6), taixi (KI-3), improved markedly in 11 cases. xuanzhong (GB-39).

46 patients with history of cerebrovascular disease aged 53sishensong (M-HN-1), fengchi 80; 5 consecutive days treatment; (GB-20), neiguan (PC-6) 2 days break; total of 35 treatments (12).

Mental function assessments improved significantly; reduction of blood free-radicals. Short term marked improvement in only 2 cases.

hegu (LI-4), neiguan (PC-6), dazhui (GV-14), fengfu (GV-15), 29 patients, aged 55-83; 28 shenmen (HT-7); adjunct points: consecutive days treatment; zusanli (ST-36), jiexi (ST-41), break of 3-5 days, then repeat up taichong (LV-3), fenglong (STto 5 times (13). 40), xinshu (BL-14), ganshu (BL18), baihui (GV-20).

Marked improvement in mental functions in 5 patients. Some changes in CT scan and blood lipids (improvements).

The data in Table 6 illustrates that the number of acupuncture treatments is at least 30, and the frequency of treatments is daily or every other day, with short breaks of 2 or more days between groups of several daily treatments. Most of the points used in these treatments are listed in Table 5. Improvements were noted in several measures for the patient groups overall, but marked effectiveness of the treatment, where the individual patient response (in terms of mental performance change) was substantial and obvious, usually did not involve more than one-third of patients.

Acupuncture was applied in the treatment of depression and psychosis in aged patients at the Institute of Mental Hygiene in Beijing (14). The patients were aged 50-74 and suffered from conditions such as manic-depressive psychosis, reactive psychosis, and neurosis. The treatment focused on baihui (GV-20) and yintang (M-HN-3), using electroacupuncture stimulation. Of 30 patients treated, it was claimed that marked effects were observed in 19 (about 2/3). The claimed improvements were in depressed mood, suicidal intention, anxiety, insomnia, and irritability, as well as alleviation of some accompanying physical symptoms. Anxiety neurosis was treated at the Qindao Medical University using acupuncture in 80 patients, some of which were young students (aged 18 or over), but most were older workers, up to age 72 (15). The main points used were zusanli (ST-36), neiguan (ST-25), taichong (LV-3), shenshu (BL-23), mingmen (GV-4), and quchi (LI-11). Treatment was every other day for 10 treatments, with a break of 3-7 days before beginning another course of treatment, up to 40 treatments. The therapy was reported to be highly effective, with 55 of the patients showing obvious alleviation of symptoms. Dementia due to traumatic injury to the head was treated at the General Hospital of Chengdu (17). 32 patients were treated by acupuncture, which was initiated one to three months after the traumatic event. Two points were used: shenmen (HT-7) and houxi (SI-3). It was reported that 15 of the patients showed marked improvements after 20 daily acupuncture treatments. Post-stroke depression was treated at the Qiaoli Hospital of Traditional Chinese Medicine in Zhuhai (18). A group of three needles was inserted along the hair line, with one in the center at shenting (GV-24) and the others on either side by about 10 cm, at benshen (GB-13). Additionally, three needles were applied to each side for neiguan (PC-6), shenmen (HT-7), and laogong (PC-8). Adjunct points were used according to syndrome such as qihai (CV6), zusanli (ST-36), and sanyinjiao (SP-6) for qi and yin deficiency, or the combination of fengchi (GB-20), taichong (LV-3), and baihui (GV-20) for wind-phlegm disorder. The authors commented that: The influence of depression on patients after stroke is sometimes more serious than the functional disturbance of the limbs and can impact the progression and prognosis of stroke. Many antidepressant drugs produce several severe side effects and the patients had difficulty tolerating those therapies. The ’three intelligence needles’ [scalp points] and hand intelligence needles [forearm/hand points] are frequently used for the treatment of post stroke disorders and also for weak mental function in children by professor Jin Rui at Guangzhou University of Traditional Chinese Medicine. The intelligence needles at the head directly impact the functional activity of the cerebral frontal lobe and the mind and check the liver and calm wind. The hand points are the important ones for treatment of mental diseases: they can regulate the mental state, open orifices, tranquilize the mind, clear the pericardium, and help sleep. Acupuncture can improve the blood flowing in the brain or can promote absorption of hematoma in the brain, leading cerebral cells to be awakened and to gain recovery of functions, speeding up the repair of the injured brain tissues. Acupuncture can also promote release of a large quantity of serotonin in the brain and noradrenalin in the spinal cord.

SUMMARY OF ACUPUNCTURE THERAPY Though there are numerous acupuncture points that are theoretically useful for patients with mind-brain disorders, only a few are relied upon frequently, both in traditional and modern practice, and might serve as guidance to practitioners and researchers. The most heavily used points are on the head (mainly GV-20), the upper back (mainly BL-15), the forearm (mainly PC-6 and HT-7), and the lower leg (mainly LV-3 and a variety of points on the stomach, spleen, and kidney channels that appear to be used with about equal frequency). It is unclear whether selection of other points in these same regions of the body will yield any better or lesser results, though the principles of acupuncture therapy may dictate selecting one over another based on symptoms, signs, and constitutional factors that lead to a specific diagnostic category (especially affecting the leg points to be selected). In China, needling is performed daily or every other day, and at least 30 treatments within a period of about two months is typical for a course of therapy that leads to notable improvements in many, but certainly not all, of the patients. The mechanism of action, from the Western viewpoint, appears to be regulation of blood circulation to the brain and release of valuable neurotransmitter substances that can affect brain function to aid recovery.

REFERENCES 1. Chen Yongcan and Yang Meiling, Literature research on screening of the nucleus acupoints for treating of intellectual disturbances, Journal of Traditional Chinese Medicine 1999; 19(2): 83-88. 2. Cheng Xinnong (chief editor), Chinese Acupuncture and Moxibustion, 1987 Foreign Languages Press, Beijing. 3. Shogo Ishino, Treatment of senile psychic disorders with acupuncture and moxibustion , International Journal of Oriental Medicine, 1999; 24(3): 149-154. 4. Deadman P and Mazin AK, A Manual of Acupuncture , 1998 Journal of Chinese Medicine Publications, East Sussex, England. 5. Yang Jinan, Treatment of status epilepticus with acupuncture , Journal of Traditional Chinese Medicine 1990; 10(2): 101-102. 6. Shi Bingpei, Bu Huaidi, and Lin Liyu, A clinical study on acupuncture treatment of pediatric cerebral palsy, Journal of Traditional Chinese Medicine 1992; 12(1): 45-51. 7. Wu Fengqi, Treatment of schizophrenia with acu-moxibustion and Chinese medicine , Journal of Traditional Chinese Medicine 1995; 15(2): 106-109. 8. Wu Lianzhong, Li Huimin, and Kang Ling, 156 cases of Gilles De La Tourette’s Syndrome treated by

acupuncture, Journal of Traditional Chinese Medicine 1996; 16(3): 211-213. 9. Tian Lingdi, et al., Composite acupuncture treatment of mental retardation in children , Journal of Traditional Chinese Medicine 1995; 11(1): 34-37. 10. Shen Weidong and Li Ding, A preliminary clinical study on senile dementia treated by acupuncture and moxibustion, Shanghai Journal of Acupuncture and Moxibustion 1996; 15(5): 5-6. 11. Yang Xiangtan, 26 cases of senile dementia treated with acupuncture by resuscitation method , Chinese Acupuncture and Moxibustion 1996; 11: 3. 12. Lai Xinsheng, et al., Analysis of near-term effect of electroacupuncture in treating vascular dementia, Journal of Traditional Chinese Medicine (Chinese) 1997; 38(6): 340-343. 13. Liang Zhong, et al., 115 cases of senile dementia treated by a combination of acupuncture and Chinese herb therapies, Chinese Acupuncture and Moxibustion 1998; 12: 712-714. 14. Liu Guangzhi, et al., Electroacupuncture treatment of presenile and senile depressive state , Journal of Traditional Chinese Medicine 1992; 12(2): 91-94. 15. Liu Guizhen, et al., Observation on the curative effect of acu-moxibustion plus systemic desensitization on anxiety neurosis, Shanghai Journal of Acupuncture and Moxibustion 1998; 17(4): 17-18. 16. Liu Hechun, Illustrative cases treated by the application of the extra point sishencong, Journal of Traditional Chinese Medicine 1998; 18(2): 111-114. 17. Zhang Anren, et al., Effect of acupuncturing houxi and shenmen in treating cerebral traumatic dementia, Chinese Journal of Integrated Traditional and Western Medicine 1995; 15(9): 519-521. 18. Liang Yue, Intelligence three needles and hand intelligence needle applied to treat depression after cerebral apoplexy, Shanghai Journal of Acupuncture and Moxibustion 1998; 17(2): 27. May 2000

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CHINESE HERBAL TREATMENT FOR ATTENTION DEFICIT DISORDER by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Attention Deficit Disorder (ADD) is a broad syndrome that may include hyperkinetic syndrome, hyperactivity, and Attention Deficit Hyperactivity Disorder (ADHD). Although hyperactivity is commonly observed, it is not necessarily a component of ADD. There is likely to be a group of related problems, with some different etiologies, encompassed by the term ADD. In some instances, ADD might be a misdiagnosis for behavioral problems that are related to home and social situations without an underlying physiological dysfunction. The most common manifestation of ADD is a combination of inability to remain at rest while awake, less total sleep time, and difficulty concentrating on a particular activity. The disorder may be somewhat apparent at birth (or even in utero) with excessive movement of the arms, legs, and head, but is usually not diagnosed until lack of concentration at school is deemed a problem, typically in the first or second grades (ages 7 to 8). As much as 10% of the U.S. population is believed to be affected; if that is the case, then ADD is one of America's most prevalent mental disorders. Males are at least four or five times as likely as females to have the disorder. This differential is probably partly genetic in nature, though hormones clearly play a role. The hormonal component of the expression of ADD is revealed in the fact that puberty may alter the course of the symptoms. Furthermore, thyroid hormone disorders are frequently found in persons with ADD. A genetic basis for the disease is suggested by the fact that children with ADD are more likely to have fathers who suffered from the disorder. But, there are probably preventable environmental factors that lead to developing ADD, a disorder which seems to be occurring in much greater frequency now than just a few decades ago. It is possible that some cases of ADD arise from exposure in utero to harmful chemicals, such as from smoking, alcohol consumption, prescription and illicit drugs, and environmental pollutants, all of which have become wide-spread problems for women during the past four decades. Nutritional deficiencies might also contribute to the development of ADD. It appears that ADD arises from a neurological defect, with abnormalities in the brain tissue or neuron biochemical functions. ADD is found more often in children who have other brain defects, such as those leading to mental retardation, cerebral palsy, or temporal lobe epilepsy. While for many children affected by ADD there is some reduction in the symptoms as the child enters puberty, the disorder will often continue for the rest of the individual's life, and the impact of the disorder on early childhood behavior, which often includes impulsiveness, recklessness, irritability, aggression, and poor emotional development, in itself produces effects felt throughout life even if the ADD is in remission. Sometimes, puberty brings about a switch from hyperactivity to persistent sluggishness, depression, and moodiness, which is liable to be equally disruptive. Children who suffer from ADD are much more likely, as adults, to be involved in crime, have unsuccessful marriages, and difficulty keeping a steady job, than those who do not experience this disorder. The primary treatment for ADD is the administration of stimulant drugs. This strategy may seem paradoxical in the context of a hyperactivity disorder. However, it is postulated that the controlling action of certain mid-brain activities may be deficient in these individuals and therefore a stimulant is able to bring about the desired control. The stimulation of brain function may enhance alertness and concentration. The primary drug used for this disorder is methylphenidate (Ritalin), a relatively mild derivative of amphetamine. Ritalin is also used in the treatment of mild to moderate depression, emotional withdrawal in the elderly, and narcolepsy. This drug can have side effects, mainly the problems seen with amphetamine use: nervousness and insomnia. It may also encourage epileptic seizures in those with latent epilepsy, and can reduce red blood cell and platelet counts. Many parents of children with ADD appreciate the effects of Ritalin but worry about the potential harm of continued administration of a drug; some note obvious adverse effects and seek alternatives. Ritalin is ineffective in about 30% of cases diagnosed as ADD.

CHINESE HERBAL THERAPIES In China, the same attention deficit problem has been noted, and Ritalin has been used as a therapy. From the traditional Chinese medical viewpoint, ADD is caused by a kidney essence deficiency that affects brain development. Further, the yin aspect of the kidney is most deficient, leading to excessive expression of yang: this is manifest as the hyperactivity and wandering of the mind. Accordingly, it is to be treated by nourishing the kidney yin, opening the heart orifices (which are the passages that affect the brain function), and settling the agitated yang. There have been numerous studies of the effects of Chinese herbs on ADD, with a remarkable degree of consistency in the selection of herbs used to treat this condition. Some Chinese physicians rely on differential diagnosis, with selection of somewhat different formulas for each syndrome classification, while others use a standard preparation with few or no modifications. From the traditional perspective, the marrow and essence is the foundation of the brain, and the early problems with mental development indicate deficiency of the vital essence. The main herbs used for nourishing the kidney in children with this syndrome are rehmannia, tortoise shell, deer antler gelatin, lycium, and cornus. These are ingredients of the traditional Zuo Gui Wan (Left Restoring Pill) used to treat kidney yin deficiency when there are deficiencies of "marrow and essence." Phlegm obstruction of the heart orifices usually leads to confusion, inability to concentrate, and poor memory. It occurs for a variety of reasons, but often because of weak digestion and/or poor diet, coupled with emotional disorders, especially agitation. The main herbs for clearing the heart orifices and enhancing the mental function are acorus, polygala, curcuma, and alpinia. Acorus is said to "open the orifices, vaporize phlegm, and quiet the spirit." Polygala is said to "expel phlegm and clear the orifices, calm the spirit and quiet the heart." Curcuma, which promotes movement of qi and invigorates the blood, is used to "treat hot phlegm that obstructs the heart orifices when there are symptoms of anxiety, agitation, or mental derangement." The Chinese name for alpinia, yizhiren, means "the seed that benefits intelligence." It aids digestion (preventing phlegm accumulation), astringes the kidney to restrain the essence, and prevents the development of heat from deficiency of kidney; the deficiency heat can cause phlegm to become a "mist that obstructs the heart orifices." To settle the agitated yang energy (which may manifest as hyperactivity and insomnia) the so-called "heavy sedating agents" are

used. The traditional concept is that these mineral-rich substances bear down on the rising and disordered yang. The main substances given for ADD by Chinese doctors are dragon bone or dragon teeth, oyster shell or mother of pearl, succinum, and cinnabar. In some cases, herbs to purge deficiency fire that accompanies yin deficiency syndrome might be employed. Phellodendron and anemarrhena are the most commonly used items for this purpose. As an example of applying these methods, 30 children with ADD were treated with a syrup, along with a powder, for two to four months, with the result that 22 of them (73%) showed improvements. The syrup was made with alpinia, ho-shou-wu, lycium, dragon bone, oyster shell, acorus, curcuma, and salvia, boiled down to a thick liquid and preserved with benzoic acid. Three times per day, the children would take 25 ml of the liquid and 2 grams of deer antler powder. A similar method was used in a study of 50 children with ADD who consumed a decoction of acorus, polygala, dragon bone, and oyster shell, modified by adding three to six herbs according to symptoms, and who also consumed a powder of succinum. The duration of therapy was not specified but 38 of the children (76%) showed improvements. Excellent results were claimed in a small study of 15 children treated with a decoction of ligustrum, peony, lycium, mother-of-pearl, and polygonum stem (each ingredient 10-15 grams), modified with addition of some herbs for specific symptoms of blood deficiency (add rehmannia and gelatin), spleen deficiency (add hoelen and atractylodes), or restless sleep (add zizyphus). The total daily dose was about 60 grams of herbs, the decoction taken in three divided doses. All 15 children were apparently cured with treatment times of 15 to 60 days, and no recurrence within six months. Another high dosage decoction, based on the traditional Sanjia Fumai Tang , containing raw rehmannia, ophiopogon, tortoise shell, peony, pseudostellaria, gelatin, baked licorice, curcuma, polygala, cnidium, oyster shell, acorus, and dragon bone, each ingredient 6-12 grams (except 20 grams oyster shell), was given to 68 children with ADD. This combination, with over 120 grams of crude herbs per day, taken as a single dose, was said to improve the condition of 64 of 68 children treated (with 61 declared "cured"). In a large scale study of 326 cases of ADD (267 boys and 59 girls), three different formulas were used; two were decoctions and the third a large honey bolus (six grams per pill). The overall effective rate was 93%, with 103 claimed to be cured. One formula, as decoction, was basically a qi tonic prescription, with astragalus, codonopsis, atractylodes, dolichos, licorice, cinnamon, oyster shell, and dragon bone. The other decoction was a formula for resolving phlegm-dampness, with pinellia, arisaema, agastache, acorus, polygala, eupatorium, soja, hoelen, coptis, and gardenia. The pill was a kidney tonic, with rehmannia, tortoise shell, dioscorea, cornus, hoelen, phellodendron, anemarrhena, polygala, acorus, and dragon teeth. The large honey pills and bitter and acrid decoctions, as well as the syrups and powders, would not be acceptable in the West, but it is instructive to see that these methods can be used in China with good results: 70-100% of cases treated were said to be improved or cured. An example of a potentially more practical approach is manufacture of a sugar paste. Two formulas were made in this form, Zhili Tangjiang, comprised mainly of acorus and polygala, and Kangyi Tangjiang, which contains those two herbs plus tortoise shell, hoelen, dragon bone, alpinia, dioscorea, and lotus seeds. The dose of these pastes was 10-15 ml each time, and they were taken two to three times per day. Of 170 cases (two studies), 132 (77%) were improved. Treatment time was about one month. It was pointed out that the paste could be encapsulated for purposes of easier administration. Since the herbs recommended for ADD are non-toxic and readily available in the West, the main problem with adopting these methods is managing the dosage and administration. The high dosage decoctions may serve in China as a source of mineral substances (e.g., calcium and magnesium) which are more readily administered in the West through nutritional supplements and/or by direct ingestion of natural substances rich in those minerals given in capsules or tablets. Careful selection of ingredients in an herb formula can help to minimize the total amount to be ingested. Children in Western countries may be willing to take small tablets or capsules, tinctures, or syrups, especially if the number of daily doses and the amount taken at each dose is small. Early in 1993, ITM prepared an experimental small tablet (Acorus Tablets, 300 mg) based on the work done in China for treatment of ADD. The formula contains acorus, polygala, fu-shen, alpinia, curcuma, raw rehmannia, dragon bone, dragon teeth, oyster shell, bamboo sap, tortoise shell, and succinum. In contrast to Ritalin, the formula contains no stimulants. Several reports of its use have been favorable, though much more study needs to be done to determine the extent of response. As a general rule, herb powders are taken in a dose of 1/10 to 1/5 that of decoctions. Since 60 grams (or more) is typical for ADD decoctions in China-mainly given to children 7-13 years old-a daily dose of about 6 grams of the tablets (20 tablets) would be a reasonable minimum for this age range. The dosage method developed at ITM is to give one tablet per year of age (up to a maximum of 7-8 tablets) each time, three times per day. For older children and adults, larger size tablets (700 mg) have been prepared, with a recommended dosage of 3-6 tablets each time, three times daily. Seven of the small tablets contain the same amount of herbal material as three of the large tablets. It is important to note that one formula, even if well designed, will not be ideal for all children. Following the traditional differential diagnosis, phlegm-resolving, fire purging, qi-tonifying, or other combinations may be necessary as adjuncts or substitutes for a basic ADD formulation. Treatment times reported in the Chinese literature are generally two weeks to two months. When using a low dosage form, one would expect to undertake a longer term of treatment, perhaps four months. Fortunately, some degree of improvement is said to be observed in a relatively short time, so a decision to continue such therapy might be made after just one month (as is the cases with Ritalin). Among reports received by ITM regarding effects of Acorus Tablets or similar herbal preparations, the beneficial effects are noted during the first month of therapy. Significant adverse effects have not been reported with use of Acorus Tablets. A small number of individuals have reported tiredness after using them. However, it is not clear whether this is an adverse effect of the herbs or a withdrawal symptom from Ritalin or the result of feeling an underlying tiredness from lack of adequate sleep that might not have been brought to awareness with the hyperactivity. NOTE: The clinical trials mentioned in this paper were described in Chinese language literature. Rough translations of the information were prepared by Heiner Fruehauf, Ph.D., L.Ac., at the Institute for Traditional Medicine.

August 1996

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TREATING ADVANCED ARTHRITIS WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND During the past year, serious concerns have been raised about one of the most important pharmaceutical therapies for persistent arthritis, the selective COX-2 inhibitor drugs. These non-steroidal anti-inflammatory drugs (NSAIDS) are potent analgesics that were developed specifically to avoid the gastrointestinal and renal side effects common to previously used drugs by focusing on a particular pathway: reducing the prostaglandins produced by the action of COX-2 enzyme (cylooxygenase-2) without inhibiting the COX-1 enzyme. The COX-2 metabolites have functions other than contributing to pain, such as the beneficial effects of limiting thrombosis and promoting vasodilation. As a result, when COX-2 is strongly inhibited by high doses of the drugs used over an extended period of time in the absence of simultaneous COX-1 inhibition, they can increase the risk of vascular events such as heart attack and stroke (1). Some of these drugs were pulled off the market abruptly, though a return to market with significant warnings is likely because of the symptomatic relief the drugs have provided to people with advanced arthritis. A number of arthritis sufferers who have been on these drugs are likely to seek alternative remedies, looking to natural therapies that might have less risk. Although great progress has been made in recent years towards making the herbal therapies safer, ancient remedies are not themselves inherently safe. So, when examining traditional medicine approaches to treating advanced arthritis, some herbs listed in potentially useful formulas have to be avoided. For example, an herb that had been widely used in Chinese arthritis remedies, stephania, had to be removed from the market a few years ago because its most common source material, a species of Aristolochia, contains aristolochic acid, a substance that could, in rare cases, cause renal damage and renal failure (2). In an attempt to avoid herbs that might sometimes have Aristolochia as a source, other Chinese herbs frequently used for arthritis, such as clematis and sinomenium (which are rarely substituted by Aristolochia), and herbs in the Aristolochiaceae family that may contain aristolochic acid (e.g., asarum), have been removed from most products and are only available from a few suppliers who are willing to go through the steps necessary to assure absence of aristolochic acid. Other Chinese materials included in arthritis formulas might be safe to use in their traditional form, but are classified as toxic and should not be used; examples are scorpion and scolopendra (which are toxic as live animal stings, but far less toxic when ingested orally) and strychnos (the processed seeds used in Chinese formulas contain 1/10 the strychnine of the toxic raw seeds). Adverse cardiac effects have been associated with ephedrine from ma-huang, an herb that is traditionally used in some arthritis treatments; the reactions have not been associated with complex Chinese herb formulas. Some Chinese prescriptions specify use of raw aconite, which is toxic; processed aconite is safe to use and is the only aconite referred to in this article. With these herbs left out, the formulas are safe for most users. Nonetheless, prolonged reliance on high dosage of herbs for arthritis should be accompanied by adequate monitoring, as is often done with drug therapies. Thus, for example, one should be alert to warning signs of rare adverse reactions. A potential advantage of using herbs is that, in addition to alleviating arthritis pain, they may provide some positive effects that are not attained from drugs aimed solely at reducing pain due to inflammation. For example, there is an established herbal benefit of improved circulation, just the condition that could be impaired by the COX-2 inhibitor drugs. In fact, improving circulation to the limbs may be one of the important therapeutic approaches for alleviating arthritis pain. Persons with advanced arthritis often have limited capability for physical exercise, which contributes to worsening circulation in the limbs, which might be partly countered by herbs. The authors of an investigation into blood flow in arthritis patients noted (3): The results revealed that the disorder of limb blood circulation clearly exists in patients with rheumatoid arthritis. This disorder was closely related to endovasculitis and increased blood viscosity, which interact and facilitate thrombosis of the microvenous system to bring about a series of clinical manifestations. Rheumatoid arthritis belongs to the category of stubborn rheumatism in traditional Chinese medicine….The authors lay stress on the application of blood activating and stasis removing drugs in treating rheumatoid arthritis. In a previous article by the current author, numerous traditional and modern formulas for arthritis were analyzed to reveal the most commonly used ingredients (4). Generally, those formulas were especially suitable for treating newly diagnosed cases of arthritis or cases of mild to moderate severity in which "external pathological factors" affecting a person with deficiency syndrome is the dominant etiology. A tablet formulation called Chiang-huo 13 was produced to follow the common approach, and has been in use for many years with no adverse effects reported. A feature of this type of formulation is reliance on herbs that are categorized as dispelling wind-chill or wind-damp, such as chiang-huo, siler, cinnamon twig, chin-chiu, and tu-huo. Persistent severe arthritis is more difficult to treat and usually involves a focus on different therapeutic principles and herbs, particularly those that fit the Chinese therapeutic categories of vitalizing blood and resolving "hidden phlegm" or "phlegm turbidity" that obstructs the channels. It was pointed out in another article by the current author that the "hidden phlegm" syndromes often correlate with what we think of as blood stasis syndromes (5).

FOUR TRADITIONAL-STYLE FORMULAS This article briefly reviews the work with four sample formulations based on a new approach to treatment: Wangbi Chongji ; Shuguan Wenjing Chongji and Shuguan Qingluo Chongji; and Fengshi Xiandan. The term "chongji" in the first three formula names refers to the form of preparation: these are instant tea granules, produced by making the extract of the herbs and then combining it with sugar and forming into large granules that will dissolve when hot water is applied; the fourth formula is made into pills (dan).

Wangbi Chongji This formula was developed by the famous physician Jiao Shude, who is widely known for his work in the treatment of arthritis. Western practitioners may know of him through the popular work Ten Lectures on the Use of Medicinals from the Personal Experience of Jiao Shude (6). Jiao was born in Hebei Province in northeastern China in 1922. He began studying medicine as a child with his grandfather. In 1941, at the age of 19, Dr. Jiao opened a medical practice in his hometown and simultaneously entered the Tianjin Medical College. In 1946 he passed his medical examinations and was officially licensed. In 1950 he began to work in Beijing as a doctor of internal medicine and in 1958, Jiao joined the Beijing Chinese Medical College faculty where he taught and practiced for the next 27 years. In 1984 he began working at the newly established China-Japan Friendship Hospital in Beijing, where he continues to practice. He is also a visiting lecturer and practitioner at other facilities in Beijing. Jiao further developed traditional ideas in the diagnosis and treatment of rheumatic joint disease (bi syndrome; literally: obstruction syndrome) in the light of modern knowledge. Working from the traditional categories of gubi (bone bi or, as commonly used, bony bi; see etiology diagram) and wanbi (stubborn bi), both of which often involve joint deformity and is understood to involve phlegm obstruction of the meridians, he described a new type, which he calls wangbi (the character used for wang is similar to one used to denote crooked, bent or distorted). The disorder is characterized by changes in the joint's physical form, along with deterioration of the bone and difficulty extending the limbs. Its basis is blood stasis that is worsened by kidney yang deficiency (which also contributes to weakness of the bones) along with the usual factors that induce bi syndrome, such as cold, damp, and wind. The etiology is similar to that clearly presented for wanbi (which can include deforming rheumatoid arthritis, gout, and ankylosing spondilitis) in the text Rheumatology in Chinese Medicine (7): When painful obstruction is chronic, the channels' blood and qi are slowed down and obstructed by the presence of external pathogenic influences. This causes stasis of blood and [accumulation of] turbid phlegm, which settle deeply in the joints. At this point they are very difficult to eradicate. Phlegm and blood stasis meld together, further aggravating the blockage… the pain becomes stabbing and excruciating. Jiao emphasized the blood stasis aspect, and considered that by warming the kidney yang, the flow of qi and blood would be restored. In 1983, the China National Chinese Internal Medicine Association chose wangbi, along with Dr. Jiao's methodology for treating it, to be investigated nationwide at numerous provincial hospital sites. The patent formula used to treat this pattern, Wangbi Chongji, has received national awards. Following five years of study, in 1986, a second generation of formulas was created on the basis of Jiao's model, called Wangbi Health Restoring Formula 1 and 2. These formulas also received national awards for excellence (8). Dr. Jiao has published articles about his concepts of arthralgia, such as Personal Experience in the Diagnosis and Treatment of Rheumatoid Arthritis and Pattern Identification and Treatment Differentiation as Applied to Wangbi. The precise formulation for Wangbi Chongji has not been published, and this is a common procedure when the manufacturer wishes to protect their special formulations from being copied. Also, at least three formulations are mentioned above: the original and two modifications. The following ingredients have been listed for the formula; they are presented here divided into therapeutic categories for ease of interpretation (not all ingredients are in a single formulation): Kidney tonic and warming herbs: rehmannia, drynaria, dipsacus, psoralea, epimedium, aconite Blood vitalizing herbs: carthamus, peony, red peony, achyranthes, pangolin scales Wind-chill and wind-damp dispelling herbs: tu-huo, clematis, siler, red atractylodes, ma-huang, cinnamon twig, pine node, lycopodium Other: anemarrhena, gleditsia, scolopendra The dominant therapeutic approaches here are tonifying the kidney, warming the body, and vitalizing blood; some of the standard herbs for dispelling wind-chill and wind-damp, used in the anti-arthralgia formulas designed for early and intermediate stage arthritis, are also included. Of the items listed, ingredients that are usually avoided in Western practice are ma-huang, clematis, and scolopendra; pangolin scales are sometimes not available due to endangered species concerns (in China there is a plentiful supply because the animals are raised on farms). The formula is produced by the Benxi Third Pharmaceutical Factory. It comes in packets of 10 grams, and is taken 1-2 packets each time, three times a day. In clinical work, the formula is mainly used for arthritis and gout. For arthritis, data for 332 patients collected from the medical units in China suggest its effectiveness (some degree of improvement in symptoms) for about 70.8% of those who use it (9). A report on use of a similar formulation for treating wangbi involved an extract of epimedium, curculigo, morinda, cibotium, dipsacus, rehmannia, pine node, carthamus, and sparganium (10). These herbs were extracted and dried, and put into capsules; patients took 4 capsules, three times daily for 60 days. It was claimed that all but 4 of 43 patients so treated had improvement in their clinical condition, especially for pain, swelling, and morning stiffness. The potential role of phlegm obstruction in advanced rheumatoid arthritis is still important to consider. Wei Song wrote an article on treating wanbi, emphasizing this aspect (11). He noted that: Invisible stubborn phlegm plays an important role in the pathogenesis of wanbi. If stubborn phlegm isn't eliminated, wanbi won't be healed. Based on the principle of warming transformation (wenhua), the author treated the disease with sinapis, typhonium, silkworm, arisaema, etc. This approach can markedly improve the curative effect of treatment and restrain the condition of wanbi. This method of therapy, based on resolving phlegm with these herbs, is briefly described by Yang Yifan in her book comparing the effects of various Chinese medicinals (12): The herbs that transform wind-phlegm are arisaema, typhonium, sinapis, silkworm, gastrodia, pinellia, bamboo sap, and bamboo silica. These herbs are used in clinical practice to treat cramp, numbness, tingling, heaviness and pain in the limbs, facial paralysis, facial spasm, epilepsy, hemiplegia, migraine, neuralgia, and arthritis. They are often used together with herbs that regulate the qi and blood, expel wind-dampness, and extinguish internal wind.

In the above list, the last four herbs are primarily given for the problems of facial paralysis and spasm, epilepsy, and hemiplegia. The Wangbi Chongji formula includes one herb specifically for resolving phlegm, gleditsia (see photos). In the book on his lectures, Jiao mentions use of gleditsia for arthritis: When I am treating enduring and severe illnesses such as arthritis, wind strike with hemiplegia, or rheumatoid arthritis, I often add gleditsia to the formula prescribed for the pattern, whether it be in pill, powder, or other forms. Adding an appropriate amount of gleditsia spine not only increases the formula's ability to quicken the blood and channels, it also guides the medicinals "directly to the site of disease," which definitely increases the effectiveness of the formula. Of all the yang tonifying herbs that are used for this condition, Jiao emphasizes the use of epimedium, pointing out that "it is warm in nature and acrid in flavor, dispels wind-cold, supplements the liver and kidney, and strengthens the sinew and bone." By eliminating the external pathogenic factors and supplementing the weakened organs and bone, epimedium is ideal for the treatment of wangbi (and the conditions of gubi and wanbi) when combined with herbs that resolve phlegm (e.g., gleditsia) and vitalize blood (e.g., red peony, carthamus, and achyranthes).

Shuguan Wenjing Chongji and Shuguan Qingluo Chongji The Shuguan formulas (shuguan means to clear away the obstacles) were mentioned in articles by a research group about a single study published both in the Journal of Traditional Chinese Medicine (13) and the Chinese Journal of Integrated Traditional and Western Medicine (14). The formulas were given to advanced arthritis patients; the matched control group received the already well-established Wangbi granules. The ingredients mentioned in the articles for these two formulations were: Shuguan Wenjing: epimedium, dipsacus, aconite, rehmannia, clematis, sinapis, eupolyphaga, scolopendra, and millettia Shuguan Qingluo: rehmannia, ho-shou-wu, photinia, chin-chiu, campsis, euonymus, arisaema, wasp nest, earthworm The first formula was given to patients diagnosed primarily as having yang deficiency, while the second was given to those with yin deficiency. Since the patients were specifically selected for having advanced arthritis, the level of response to treatment was less than that reported above, but was in the range of 36-44%, with the Wangbi formula having the higher total effective rate, though on some categories of symptom evaluation, the Shuguan formulas performed somewhat better than Wangbi granules. While Shuguan Qingluo includes several ingredients not commonly found in the other formulas for arthritis, Shuguan Wenjing has characteristics similar to the Wangbi formula, in tonifying kidney, warming the body, and vitalizing blood (for information on unique ingredients, see table). The use of sinapis and arisaema illustrates the approach of resolving hidden phlegm to treat advanced arthritis. The Shuguan formulas were manufactured for the clinic conducting the study and are not commercial products. It was reported that 16.5 grams of crude herbs were extracted for each packet of the granules, and the dosage used was one packet each time, three times a day; this corresponds to the decoction of about 50 grams of herbs per day. A course of treatment was three months, which was the observation period. Outside China, the ingredients scolopendra and wasp nest are usually avoided due to concerns for toxicity.

Fengshi Xiandan Formulation principles along the lines outlined above continue to be advocated, even for earlier stages of arthritis. In a 2003 article in the Journal of Traditional Chinese Medicine (15), a formula called Fengshi Xiandan was evaluated for rheumatoid arthritis (fengshi means wind-damp and is the ancient designation of arthritis; xiandan is the ancient term for special pills of the immortals, indicating a highlyvalued remedy). The formula ingredient list given was: epimedium, curculigo, morinda, cibotium, rehmannia, scrophularia, peony, anemarrhena, carthamus, sappan, viola, taraxacum, scorpion, scolopendra, arisaema, and sinapis. Here, both arisaema and sinapis are included, along with yang tonics and blood vitalizing herbs; the formula is warming in nature. Its unique feature is adding two "antitoxin" herbs, viola and taraxacum, which are mainly used in cases of early stage arthritis (13 of the 53 patients treated had cases of recent onset, and only 4 had late stage arthritis). Anemarrhena and scrophularia are examples of herbs that help nourish the yin and prevent the strong warming and dispersing herbs from further weakening the kidney yin; the formula reportedly produced no side effects. Fengshi Xiandan was produced by grinding the herbs to powder and forming them into pills. The pills were administered orally, 10 grams each time, three times per day, with three months as a course of therapy; the patients were treated for two courses. A control group was given indomethacin, and the result of treatment outcome was claimed to show that the herb treatment provided significantly better results than the drug, with fewer adverse reactions (all the adverse reactions reported for the herbs involved gastro-intestinal responses, and these occurred only about only about 1/4 as frequently as with the drug, which also produced other types of side effects). The herb formula's benefits were especially noted in reducing the duration of morning rigidity (from an average of 49 minutes to about 19 minutes), greatly reducing the tenderness of the joints, and improving both walking speed and grip strength of the hands.

NOTES ON SOME KEY INGREDIENTS Sinapis is commonly used in the formulas for advanced arthritis. In an extensive article on treatment of bi syndrome (16), the functions of this herb were described: Sinapis is spicy and warm; it disperses cold, dissolves wetness, opens the meridians, and reaches the luo vessels; it reduces swellings and relieves pain; it is the essential herb for reducing swelling and for analgesia in the treatment of rheumatoid arthritis. Of the numerous yang tonics employed along with the key herb epimedium, the frequently used ingredients are dipsacus, morinda, curculigo, and cibotium. Yang Yifang compares these ingredients and notes that Morinda is an excellent herb for tonifying the kidney yang because its warm-sweet nature will not bring about harsh, drying, or cloying side effects. Comparing morinda to curculigo and epimedium, it is the best one for tonifying the kidney yang and treating weakness of the legs and knees, chronic bi syndrome, and sexual disorders….Cibotium's function is

similar to that of dipsacus, but it is stronger in expelling wind, dampness, and cold, and regulating the qi and blood. It is used for pain and stiffness of the joints and muscles in chronic bi syndrome. She notes that curculigo is slightly toxic and should not be used for a prolonged treatment (however, a literature review of curculigo fails to reveal toxic components, so this issue is worthy of further investigation). Cibotium is currently restricted for importation due to endangered species concerns for the ferns, of which this is one. Dipsacus, which is stronger at vitalizing blood circulation might be used as an alternative to cibotium for the late stage of arthritis. For persons who suffer from evident coldness, addition of aconite and/or psoralea will increase the warming effect of the treatment.

SUMMARY Rheumatoid arthritis is often described in the traditional Chinese system as stubborn bi (wanbi) or bone bi (gubi) and the advanced cases are characterized by deformity of the joints with deterioration of the bone structure, which Jiao Shude has dubbed wangbi. Though wangbi-and the herb therapy used to treat it- overlaps with osteoarthritis, it is a description aimed at patients with rheumatoid arthritis. Treatment of these rheumatic conditions is addressed through nourishing the kidney (and liver) to strengthen the bones and tendons and to relax the stiffness, warming the meridians and dispersing hidden phlegm and stagnant blood to reduce swelling and alleviate pain, and by dispersing wind-damp and wind-chill which represent the external influence that aggravates the disease. Key herbs in the treatment include epimedium (with a variety of other yang tonics, such as dipsacus), rehmannia, peony, carthamus, and sinapis. In China, it is common to incorporate animal materials (which are thought to penetrate more readily the obstructed meridians) with reliance on scolopendra, scorpion, pangolin scales, earthworm, and eupolyphaga; the last two are still commonly used outside of China, being nontoxic and plentiful in supply. The effect of the therapies may be to reduce the inflammatory processes while also invigorating the circulation, and this may be a potential solution to those who try Chinese herbs as an alternative to the COX-2 or other anti-inflammatory drugs.

REFERENCES 1. Segev G and Katz RJ, Selective COX-2 inhibitors and risk of cardiovascular events, Hospital Physician 2004; 40(2): 39-46. 2. Dharmananda S, Are Aristolochia plants dangerous? START Manuscripts 2001. 3. Li Shangzhu, et al., Changes in blood flow in the extremities in patients with rheumatoid arthritis and treatment with integrated traditional and western medicine, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(2): 115-116. 4. Dharmananda S, An analysis of Chinese herb prescriptions for rheumatoid arthritis; START Manuscripts 2000. 5. Dharmananda S, What is phlegm-mist affecting the heart?, START Manuscripts 2004. 6. Mitchell C, et al. (translators), Ten Lectures on the Use of Medicinals from the Personal Experience of Jiao Shude, 2003 Paradigm Publications, Brookline, MA. 7. Guillaume G and Chieu M, Rheumatology in Chinese Medicine, 1996 Eastland Press, Seattle, WA. 8. Anonymous, About Professor Jiao and his texts, http://www.paradigm-pubs.com/html/JiaoBio.html 9. NHIondemand, Rheumatoid Arthritis, http://content.nhiondemand.com 10. Ji Haiwang, et al., TCM Treatment of rheumatoid arthritis by supplementing the kidney and invigorating the blood circulation, Journal of Traditional Chinese Medicine 2001; 21(4): 252-255. 11. Wei Song, Wanbi treated by eliminating phlegm, Journal of Anhui Traditional Chinese Medical College, 2000; 19(3): 4-7. 12. Yang Yifang, Chinese Herbal Medicines Comparisons and Characteristics, 2002 Churchill Livingstone, London. 13. Zhou Xueping, et al., Intermediate and late rheumatoid arthritis treated by tonifying the kidney, resolving phlegm and removing blood stasis, Journal of Traditional Chinese Medicine 2000; 20(2): 87-92. 14. Zhou Xueping, et al., Clinical and experimental study on treatment of mid-late stage rheumatoid arthritis with Shuguan Granules, Chinese Journal of Integrated Traditional and Western Medicine 1999; 5(3): 165-170. 15. Shen Yujie, Qu Quanwei, and Wang Dajun, Clinical observation on treatment of rheumatoid arthritis with Fengshi Xiandan in 53 cases, Journal of Traditional Chinese Medicine 2003; 23(1): 21-26. 16. Lin Jiehou, Bi-entity (arthritis): Clinical experience of master physician Wang Weilan, Journal of the American College of Traditional Chinese Medicine 1983; 3: 3-28. 17. Vangermeersch L and Sun Peilin, Bi-Syndromes, 1994 SATAS, Brussels, Belgium.

Etiology and Pathology of Bone Bi (16) Herbs mentioned in formulas that are infrequently used (see reference 4 for commonly used ingredients) Herb



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Campsis lingxiaohua

vitalizes blood, breaks up stagnation, cools blood, dispels wind

Campsis is used for blood stasis syndromes combined with invasion of wind; it is not commonly used for treating arthritis.

Euonymus weimao

regulates blood, removes stagnation, alleviates pain

Euonymus is used for pain associated with blood stasis, and is applied in cases of postpartum abdominal pain and arthritis.

Lycopodium shenjincao

eliminates wind and dampness; relaxes tendons and unblocks luo vessels

Lycopodium is used in cases of arthralgia in which there is tightness of the fingers or limbs associated with contraction of the tendons. It is also used for trauma that causes or worsens the disorder. Gleditsia is in the same plant Family.

Photinia shinanye

eliminates wind, nourishes kidney

Photinia is used in arthritis associated with kidney deficiency, typically used for low back and leg pain, and when there is weakness of the tendons and bones. Often Piper puberulum, or other Piper species are used in place of photinia.

Pine node songjie

dispels wind and dries dampness, analgesic

Pine node is given for severe pain, usually associated with cold blockage and advanced arthritis. It is also used for pain due to trauma.

Gleditsia sinensis Gleditsia spine, zaojiaci, is used by Jiao Shude for resolving phlegm obstruction in treatment of advanced arthritis. Other physicians may rely instead on arisaema or sinapis for that purpose.

May 2005

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TREATMENT OF ALS WITH CHINESE MEDICINE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Note: This article first appeared in March 1999, but additional information has been gained since then, particularly about the treatment method of Cheng Yongde, who specializes in treating ALS in China. In addition, drug therapies that had looked promising just a few years ago have turned out to be disappointing, making use of Chinese medicine of continued special interest.

BACKGROUND ALS (amyotrophic lateral sclerosis) was first identified about 130 years ago. During the past 60 years it has been called Lou Gehrig's disease, named for the most famous of its victims (1903-1941), who had been a popular and vigorous baseball player until the disease struck. However, as memory of his life fades, the term ALS has become the preferred designation. This is a rare disease: in the U.S. it affects about 1-2 persons per 100,000 each year, with a cumulative total of about 25,000-30,000 living with the disease at any one time. It most often occurs in persons over 50 years of age (rarely before age 40), with more men than women affected. It is a degenerative disorder of the central nervous system that leads to weakening and wasting of the muscles. Depending upon which neurons are first affected, the disease will manifest differently among individuals, but eventually all four limbs become involved and there may be considerable cramping and stiffness that develops with the partial loss of nervous control over the muscles. A normal course of disease progression is to reach the point that respiration is affected within 5 years after the initial symptoms and diagnosis, causing death. There is about a 5% rate of survival past 12 years, and some people live more than 20 years, while others have rapid disease progression within just 2 years. Riluzole was the first drug for ALS approved by the U.S. FDA. The drug inhibits glutamate release; glutamate is one of the major neurotransmitters and is an essential part of nervous system function. Excess levels of this amino acid are thought to be involved in ALS and some other neurological diseases, by causing nerve damage and death. Riluzole is far from an ideal therapy: it can have side effects (nausea, vomiting, or worsening of disease condition), it is quite expensive, and the survival effects are an average 2-3 month extension in life span. New drugs have been disappointing. For example, Myotrophin (insulin-like growth factor-I) had been used as an off-label application for ALS since 1991, apparently slowing the progression of muscle deterioration. Submitted for drug approval for ALS treatment five years ago, the FDA delayed granting approval because it did not have adequate evidence of efficacy and this drug appears to be out of further development for ALS, having displayed only modest results at best. Another example is BDNF (brain-derived neurotrophic factor), which appeared to slow the deterioration in breathing capacity, but further tests failed to confirm the result and research on it has been discontinued. A growing body of research suggests that ALS, especially the hereditary type that appears at younger age, is associated with a defect in the enzyme called superoxide dysmutase (SOD), an antioxidant system, in which the SOD produced by the body changes from an antioxidant (that is protective to nerves) to a pro-oxidant that damages the nerves. Thus, antioxidant therapies might help slow progression of the disease, at least in individuals with this genetic defect. The possibility of beneficial effects from antioxidants has been proposed, but has not been confirmed. Indeed, many people with ALS turn to taking nutritional supplements rich in antioxidants but do not report significant improvements; formal studies have yet to be undertaken. Due to the limited impact of readily available therapies, patients and their families may opt to seek out Oriental medical assistance, which is becoming more accessible every year as the number of practitioners grows (now at about 15,000 in the U.S.). Practitioner experience with ALS, due to the rareness of the disease, has been limited; fortunately, there is some information from China available to help guide treatment strategies.

ACUPUNCTURE Acupuncture is thought to influence physiological functions via the nervous system, and especially by promoting blood circulation (see: Introduction to acupuncture). Nervous system disorders, including various paralytic diseases, such as stroke, traumatic paraplegia, and progressive myodystrophies, are treated by acupuncture in China. It is thought that promoting the microcirculation (capillary bed circulation) to the spinal cord can enhance the natural regenerative capabilities that exist. From the traditional medicine point of view, acupuncture can open the blocked meridians, including the one running through the spinal column known as the dumai or governing vessel (d u = govern, supervise, direct; mai = channel, vessel, meridian). Whether neurons are damaged by physical trauma, blocked circulation of blood (as occurs in stroke), or by biochemical processes (e.g., oxidation reactions, excess glutamate), the principle of treatment via acupuncture remains the same. Two techniques are especially relevant to central nervous system diseases: scalp acupuncture and spinal acupuncture. Both involve treatments on or along side the governing vessel, which runs up the spine to the head, running over the center of the scalp (see Figure 1). Scalp acupuncture (see: Synopsis of scalp acupuncture) is applied in the treatment of all neurological disorders. Most experience with this technique has been in treatment of stroke, but scalp acupuncture has shown some promise in treating degenerative neurological diseases as well. Zhu's Acupuncture Medical and Neurology Clinic in San Jose, California (www.scalpacupuncture.org), headed by Zhu Mingqing, provides scalp acupuncture treatments. Many acupuncturists in the U.S. have learned this method of treatment and can administer it closer to the home of the person with ALS, who will need treatment regularly for many months. The scalp acupuncture technique is best applied while movement is still close to normal, as the effects are most dramatic when the person moves of the affected body parts while the scalp needles are being manipulated. While there are several zones for treatment on the scalp, a major focal point of this acupuncture technique is threading needles along the scalp on either side of the Governing Vessel at the top of the head near the point baihui (GV-20). For spinal acupuncture, two doctors have given some detailed recommendations: Wang Leting (1894-1990), whose method is described in the book Golden Needle Wang Leting (1) and Cheng Yongde, a specialist in encephalatrophy, Parkinson's disease, and ALS, currently working at the Municipal Hospital of TCM of Haimen (near Shanghai) in Jiangsu Province. Cheng published an article

on treating 46 patients with ALS in a 1998 issue of the Shanghai Journal of Acupuncture and Moxibustion, with a shortened version published in the English-language edition of that journal. An extended version of the article was published in the Zhejiang Journal of Integrating Traditional Chinese Medicine and Western Medicine in 1999.

THE METHOD OF WANG LETING Spinal treatment focuses on points of the governing vessel on the back, mainly from fengfu (GV-16), a point on the neck about 1 inch into the hairline, down the spine to yaoyangguan (GV-3), at the lower lumbar region of the spine (between L4 and L5 of the lumbar vertebrae). Fengfu is the point at which the governing vessel is said to enter the brain. Wang Leting performed acupuncture in many cases of stroke and paraplegia utilizing these spinal points. His work on paraplegia is relevant to ALS, because the basis for the treatment is not dependent on the precise cause of the disorder, but, rather, its location of the pathology in the spine. His main methods for treating paralytic disorders is to administer acupuncture to a group of points on the governing vessel as well as a group of the Hua Tuo points on either side. The set of points he recommends for treating the governing vessel includes baihui (GV-20) at the top of the head and changqiang (GV-1) just below the tip of the coccyx, and then this series along the spine: fengfu (GV-16) dazhui (GV-14) taodao (GV-13) shenzhu (GV-12)

shendao (GV-11) zhiyang (GV-9) jinsuo (GV-8) jizhong (GV-6)

xuanshu (GV-5) mingmen (GV-4) yaoyangguan (GV-3)

This group of 13 points constitutes one treatment, which can be treated along with and alternated with other point sets that are deemed necessary, especially the Hua Tuo points. Administering acupuncture each day, alternating treatment between two sets of points so that the treatment on two consecutive days is not a repetition, is standard practice in China for treating serious diseases. Wang preferred treating the Hua Tuo points slightly closer to the spine than their usual location, namely, at 0.3 cun rather than 0.5 cun lateral to the spine (see: Hua Tuo). He would treat every other vertebral site, starting with the lower edge of the second thoracic vertebra down to the 4th lumbar vertebra, a total of 16 points treated bilaterally. This needling on both sides of the governing vessel is supposed to have the effect of promoting qi circulation that crosses the damaged area. The same basic tactic was used in a recent clinical report on treating traumatic paraplegia (4), in which the main points chosen were the Hua Tuo points and the bladder channel points that lie lateral to them, just a little further from the spine (1.5 cun), on the back.

THE METHOD OF CHENG YONGDE Cheng Yongde noted that in the past Chinese physicians mainly relied on the ancient doctrine of the Niejing Suwen (ca. 100 A.D.) in treating diseases where the muscles atrophy. The basic approach they take when encountering a disease that causes the muscles to weaken and atrophy is to direct treatment at enhancing the function of the stomach/spleen system, rooted in the concept that the spleen governs the muscles. By treating the associated meridians (e.g., yangming meridian), the muscles would be nourished and invigorated. Cheng believes, instead, that ALS is due to a blockage of the governing vessel, leaving it unable to regulate the qi and blood flowing to the viscera; then, the limbs are not adequately nourished by the flow of qi and blood. Therefore, using acupuncture to unblock the governing vessel is the key to therapy. This is his 1999 report (edited slightly). ALS is an illness of the motor neurons. The pathological alteration affects mainly the anterior kerato-cell of the spinal cord, motor neural kernel of the lower brain stem, and the motor cortex corpus-vertebral cell of the brain. As a result of a degenerative change of the myelolateral cord, the spinal cord becomes atrophic and smaller; further, degenerative damage of the anterior kerato-cell and the motor neural kernel of the medulla oblongata and pons varolii occurs. The muscles then atrophy due to lack of control by the nerves that influence their function. Traditional Chinese medicine ascribes it to the category of wasting syndromes (weizheng). The author had treated total of 46 ALS patients from 1980 to 1996, and this is the clinical report. The group of patients comprised 27 males and 19 females (3 patients were aged 21-30 years, 4 aged 31-40, 10 aged 41-50, 25 aged 51-60, and 4 aged over 61). As judged by initial symptoms, two patients had the bulbar type, 8 had the cervical medulla type, 13 had the lumbar medulla type, and 23 had the mixed type of ALS. Pathogenesis after initial appearance of the disease shows cryptic and gradual progression, with clinical symptoms associated with the lesions of either the upper and lower motor neurons or both; the electromyogram displayed lesions of the motor neuron. The indicators for this group of patients were in accord with the diagnostic criteria for ALS, so the diagnosis was clear and definite. Acupuncture was performed in a manner unique to each individual but the acupoints were mainly fengfu (GV-16), dazhui (GV-14), and the Hua Tuo points, used together with both local and distal points (mainly jing points) on the meridians traversing the muscular atrophic part. The acupoints were arranged in groups, using one set one day, and another set the next day, and then repeating this basic treatment. For Hua Tuo points, about eight points would be needled bilaterally along the area of the spine affected by the disease. Needle stimulation was adjusted to apply tonification or draining with the needle directed along or against the direction of the meridians, the technique selected to enhance and normalize the flow of meridian qi. The first course of treatment for each patient was 1-3 months, needling once per day or every other day; this was followed by the second and the third course administered according to the patient needs (in terms of frequency of treatment and overall number of courses). Patients also took the formula Sanqi Fuwei Ruansuo Wan (Atrophy Restoring and Cord Softening Pill) designed by the author, comprised of tien-chi ginseng, deer horn glue, and processed pangolin scale as the main ingredients. The herbs are ground to powder, made into pills and taken 10g a time, 3 times a day, for a duration of 6-24 months. After applying acupuncture to open the governor vessel, and using the herb pill to tonify and disperse slowly, physical exercise therapy was employed to promote restoration of physical function. Patients were trained to undertake an improved Ba Duan Jin Qi Gong (literally, eight pieces of brocade exercises) with emphasis on concentrating one's mind at the dantian (just below the umbilicus). These physical exercises, which included having the patients make some wide circular motions with the arms and torso and performing some deep breathing exercises, could promote restoration of the atrophic muscles and sustain normal functions of the non-atrophic muscles.

The results of therapy were classified into four categories: clinical remission, where atrophic muscles were largely restored, the patient then being able to manage daily activities and take place in social activities, or being able to survive with the disease more than ten years after diagnosis; markedly effective, where the ability of managing daily activities was enhanced somewhat, or being able to survive more than five years after diagnosis; fairly effective, muscular atrophy slows down, with survival over three years; ineffective, symptoms do not significantly improve with survival less than three years. Of the 46 patients, 6 appeared to have clinical remission; for 11 the treatment was markedly effective; for 24 it was fairly effective, and for 5 it was ineffective (the patients died within a few months time). ALS is a recalcitrant atrophic disease. In ancient times, many practitioners treated the atrophic syndrome from the point of view that since the spleen governs the muscles, "choose the yangming meridian alone" as the therapeutic principle, originally described in the Neijing where it was taught that deficiency in this meridian yielded flaccid paralysis. This viewpoint emphasizes only the nutritional role of the spleen on the muscles (extracting the essence of food and water), but neglects modulating the distribution of the vital essence to the governing vessel. The governing vessel is an extra meridian, independent of the visceral main meridians. So, to treat certain atrophic syndromes, especially ALS, by the spleen tonification method seems quite hopeless. Planning the treatment for atrophy through the governing vessel goes beyond the limited framework of "choose the yangming meridian alone" and reliance on the doctrine that "the spleen governs the muscles." It has opened up a new way for the treatment of ALS, consistent with our modern knowledge that the disease affects the spinal cord first, not the muscles first. The limbs are the root of all yang, which are in close relationship with governing vessel being the sea of yang channels running through the vertebra to govern all meridians. If the limbs are not regulated through the governing vessel, the visceral qi and blood are unable to nourish the limbs through the main meridians. In the case where the governing vessel becomes gradually blocked, its ability to control the limbs would be limited progressively, and the muscles of the limbs become withered due to insufficient nourishment by the visceral qi and blood. Eventually modulation by the governing vessel is abolished, the limbs, and even all the other muscles of the body, become atrophied. So, the treatment of ALS is based upon opening the governing vessel. The governing vessel is nourished by the meridian qi of the central viscera. If the viscera become weakened, the essence of the main meridians becomes deficient and is unable to nourish the governing vessel sufficiently, and this process will result in debility. It is a well-known doctrine that "the site with extreme deficiency is the usual place of invading pathogens." The external pathogens include the six excesses (wind, cold, summer-heat, dampness, dryness, and fire) that exploit bodily weaknesses to invade into the governing vessel and are retained, unable to leave. This retention of pathologic influence as a result of weakness of the governing vessel induces accumulation of phlegm and dampness, stasis of qi and blood, and toxicity and heat lingering for a long time. In such case, there is a deficiency of the normal qi and excess of the pathogenic factors (external evils). By this mechanism, the governing vessel becomes blocked; it then loses its ability to regulate the muscles, thus resulting in amyotrophy. "Treatment of diseases ought to be aimed at their roots." One must first dredge the governing vessel, relying upon this meridian to regulate and improve the nutrition of the muscles. This approach should effectively limit the development of sclerema of the lateral cord, to limit, halt or even reverse the progressive amyotrophy in this disease. The principal therapeutic means employed in these cases was acupuncture that was focused on dredging the governing vessel. The major acupoints were needled very deeply, that being a key to dredging the governing channel. The author needled the fengfu (GV-16) point slowly and deeply, to a depth of up to 10 cm (aimed downward to pass along the spinal cord) more than thousand times without having any accidents. However, the acupuncture practitioner must pay much attention to the details of the needling [see note below]. Dazhui (GV-14) was also needled slowly and deeply. The administration of herb pills and use of physical exercises should adhere to the principle of getting the governing vessel strong and being dredged. The three therapeutic measures-acupuncture, herbs, and exercises-should be carried out successively to get the desired results, though whether the latter two means are essential for getting better results with ALS is suggested but needs further clarification. Noted by the journal editor: needling of the fengfu (GV-16) acupoint to a depth of around 10 cm (more than 3 cun) was solely used in clinical practice by the author of this article and is not common practice. The editors consider that needling at the fengfu point with an excessive depth might put the patient at the great risk; if readers want to adopt this acupuncture therapeutic method, they must contact the author first before attempting to employ this needling maneuver in clinical practice. Usual needling of fengfu is to a depth of 0.5-0.8 cun, though points along the spinal column are sometimes needled to a depth of 1.0-1.5 cun (see Figure 2 for a similar type of deep needling at GV-15); even at this depth, special training in needed and precautions must be taken. In the book Acupuncture Treatment for Paralysis (4), the therapy for paraplegia due to spinal injury is somewhat similar to that recommended by Wang Leting and Cheng Yongde. The authors recommend needling the governing vessel just above and just below the site of injury and needling the Hua Tuo points on both sides. Adjunctive points are treated for the specific areas or body functions affected, or for the general purpose of promoting the production and circulation of qi and blood.

HERBS Herbal therapies for ALS are aimed at nourishing the kidney to benefit the marrow and spinal cord, and at vitalizing blood to soften the sclerosis and to invigorate the circulation to the affected muscles. The traditional formula most often mentioned for treatment of wasting syndrome is Huqian Wan (Hidden Tiger Pill), which is sometimes modified by adding additional tonic herbs (see: Chinese herbal treatment of multiple sclerosis and other flaccidity syndromes ). A key herb in this formula is tortoise shell, which is used for flaccidity and debility, especially of the lower limbs. However, the basis for the design of Huqian Wan is the concept that a heat-type disease damages the yin fluid, leading to the atrophy of muscles. For this reason, Huqian Wan contains rehmannia, tortoise shell, and peony to nourish and retain the yin essence, and anemarrhena and phellodendron to quell the deficiency fire of the kidney that threatens the remaining yin. Although this mechanism may apply to some cases of ALS, there is no clear evidence that a heat-type syndrome precedes its development or that yin deficiency heat dominates the syndrome. Thus, treating flaccidity as if it is due to yin deficiency with heat may-like the idea of treating it as if it is due to spleen deficiency, with failure to nourish and generate the muscles-be inadequate for diseases of the spinal cord. So, other ideas must also be considered.

Regeneration of the damaged nerves and bones is often attempted with deer antler or its gelatin, which is considered one of the main herbs for tonifying the governing vessel. Tortoise shell and antler gelatin were used in a case study involving ALS. The formula, provided to a small number of patients, had deer antler gelatin, tortoise shell, rehmannia, tiger bone, dipsacus, cuscuta, eucommia, atractylodes, licorice, (with astragalus added for a later prescription), eucommia, achyranthes, tang-kuei, peony, phellodendron, anemarrhena, and citrus (5). As described in the case of paraplegia due to injury (6): "The governing vessel travels along the back and is in charge of the yang qi of the whole body. Damages in the governing vessel cause yang deficiency." For this reason, many modern formulas for flaccidity and wasting, such as this one, also include yang tonic herbs, such as dipsacus, deer antler, cuscuta, and eucommia. A formula Yisui Tang (Boost the Marrow Decoction) used for progressive spinal myodystrophies, including ALS, is similarly formulated: it is made with tortoise shell, deer antler gelatin, rehmannia, dipsacus, cuscuta, atractylodes, licorice, astragalus, psoralea, cibotium, achyranthes, tang-kuei, peony, millettia, phellodendron, and anemarrhena. This combination, given as a decoction with 9-15 grams of each ingredient (except only 5 grams each of phellodendron and anemarrhena), was used to treat 110 patients, of which 30 were diagnosed as having ALS (7). As pills, the herbs are taken in doses of 3-9 grams each time, 2-3 times daily (total dose 9-18 grams per day), while the decoctions are taken in high dosage of 150-180 grams per day. The clinical reports in which the herbs were utilized claimed benefits for ALS patients, though the small number of patients involved makes it somewhat difficult to interpret the results. A disadvantage of herb-only protocols in the West is that it is too easy for a patient to become discouraged if there are a few difficult days and then stop taking the herbs. This easy discontinuance of therapy occurs especially because herbal therapy is not a routine practice here, so there is little support for continuing treatment. With regular office visits for acupuncture, it is easier to adjust the herbal treatment as needed and to give immediate symptom relief with the acupuncture while, at the same time, encouraging compliance with the herbal protocol.

REFERENCES 1. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1996 Blue Poppy Press, Boulder, CO. 2. Cheng Yongde, Formulating a therapeutic program with the governing vessel in treating 46 cases of ALS, Shanghai Journal of Acupuncture and Moxibustion 1998; 17(5): 43. (in Chinese) 3. Cheng Yongde, Clinical observation on 46 cases of amyotrophic laterial cord sclerema (ALS) in consideration of the treatment principle breaking through the Dumai (GV), Zhejiang Journal of Integrating Traditional Chinese Medicine and Western Medicine 1999; 9(1): 16-17. (in Chinese) 4. Kong Yaoqi, Ren Xingsheng, and Lu Shaokang, Acupuncture Treatment for Paralysis, 1996 Science Press, Beijing. 5. Zhang Jianguo, Chronic progressive spinal lateral sclerosis, Journal of the College of Traditional Chinese Medicine 1985 (4): 66-67. 6. Gao Xipeng, et al., Acupuncture treatment of complete traumatic paraplegia, Journal of Traditional Chinese Medicine 1996; 16(2): 134-137. 7. Fruehauf H, Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 ITM, Portland, OR.

APPENDIX. ITM FORMULARY A version of Huqian Wan is produced as Tortoise Shell Tablets (Seven Forests); Antler 8 (Seven Forests) provides a significant dose of deer antler, and additional deer antler is available in White Tiger Pantosterone. Tien-chi Ginseng (Pine Mountain) is available as a single herb tablet, and herbs for tonifying the governing vessel are included as major ingredients of Eucommia 18 (Seven Forests). Antioxidants are obtained with the White Tiger formulas Quercenol, Cartaequin, Calmagnium, and Alpha-Curcumone.

Figure 1: Points on the Governing Vessel (Du Mai). The points are labeled either DU, as in this illustration, or GV, as in the text.

Figure 2: Location for needling yamen, a point on the governing vessel midway between fengfu (DU-16) above it and dazhui (DU-14) below it. This illustration shows the maximum depth of needling and the position of the patient (sitting up, with head bent forward) commonly used during this treatment. Deeper needling is done at an angle, so that the needle does not penetrate the spinal cord. Practitioners should avoid deep needling of these points unless adequate training has been undertaken.

July 2003

DO HERBS, VITAMINS, AND ANTIOXIDANTS ADVERSELY AFFECT CANCER THERAPIES? preliminary report by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

For more than 30 years now, Chinese herbs and materials derived from the herbs, such as long chain polysaccharides, have been used as adjunct therapies for cancer patients. This modern application was first developed clinically in China and Japan during the 1970s and was relayed to the rest of the world in 1983 through an international conference in Beijing which was followed up by press reports in English and other languages (see: Physiological responses to immunologically active polysaccharides) . The Institute for Traditional Medicine (ITM) made an effort to alert practitioners of Chinese medicine in the U.S. to this promising role for Chinese herbs immediately after that conference, with updated information provided as available over the years. The utilization of Chinese roots, leaves, and fruits (e.g., astragalus, gynostemma, ligustrum, and lycium), and several mushrooms (e.g., coriolus, ganoderma, cordyceps, and lentinus) for cancer patients is now a routine procedure when these patients visit acupuncturists, naturopathic physicians, and others offering adjunctive cancer health care. Within the past couple of years, however, an increasing number of patients have been told by their oncologists to avoid herbs, and to more generally avoid supplements (such as vitamins), or, even more broadly, simply avoid anything with antioxidant potential while they are undergoing cancer therapies. The admonition itself is difficult to interpret, since all foods contain antioxidants and vitamins, and they also contain most of the other substances offered in dietary supplements. Most fruits, vegetables, beans, and nuts differ only slightly from herbs. A more specific recommendation is needed. But first, the question arises: why are doctors giving these instructions? What kind of information is being released to the public? I have attempted to trace back the origins of the restrictions imposed by some oncologists, and it seems that the primary instigator of the concern was Dr. David Golde at the Memorial Sloan-Kettering Cancer Center, even though he was not the first to raise the matter (but within a few months of being first). The main issue he raised was the use of high doses of vitamin C, a therapy that has nothing directly to do with herbs. Herbs usually have little or no vitamin C; still, vitamin C is commonly prescribed or recommended as a supplement by practitioners involved in natural healing. In a June 19, 2000 report of WebMD Medical News, the use of high doses of vitamin C to prevent heart disease, cancer, and other disorders, was called into question, and Dr. Golde's research and comments were relayed (1, 2): The first of two recent studies that called this notion [of taking high doses of vitamin C as a disease preventive] into question was carried out by David Golde, MD, physician-in-chief at Memorial Sloan-Kettering Cancer Center in New York City, and described at an American Cancer Society meeting in March 2000. Golde and his colleagues transplanted human cancer cells into mice, injected the mice with vitamin C, and then measured the amount of the vitamin in the cells. They found that cancer cells seem to soak up large amounts of vitamin C by converting it into a form that's easier to absorb. The results, Golde says, raise the possibility that cancer cells may use vitamin C to shield themselves against radiation and chemotherapy. The second study, performed by James Dwyer, Ph.D., an epidemiologist at the University of Southern California, caused an even bigger stir. Dwyer told an American Heart Association meeting in March 2000 that middle-aged men who took 500 milligrams of vitamin C supplements daily showed a rapid narrowing of their carotid arteries, which supply blood to the brain. The studies sound alarming, but experts warn against making too much of them. While Golde says that cancer patients shouldn't take large doses of the vitamin, other researchers say it's far too early to make that recommendation. There's no evidence yet that C actually shields cancer cells from treatment, says Mark Levine, MD, an endocrinologist and Vitamin C expert at the National Institutes of Health. The cancers tested in Golde's research, he says, may simply have grown from tissues that normally take in large amounts of the vitamin. As for the heart disease finding, Dwyer himself cautioned that it is preliminary. The study lasted only 18 months and included just 573 men. And Robert Jacob, Ph.D., a research chemist with the U.S. Department of Agriculture, points out that previous studies suggested just the opposite-that vitamin C reduces the narrowing of carotid arteries. From these very modest beginnings in Spring of 2000, the worry about antioxidants and cancer therapies grew, despite several warnings about the interpretation of data, such as those mentioned in the above analysis, and almost everyone who wished to provide a basis for the antioxidant and vitamin worry seemed to harken back to Dr. Golde's very preliminary research. A pharmacist, John Russo, Jr., wrote the following to caution his readers about the possible interaction of antioxidants with brachytherapy (radiation therapy where the radiation source is placed inside the body) for prostate cancer (3): How might an antioxidant adversely affect brachytherapy? The precise role that the antioxidant, vitamin C, plays in tumors is not known, but recent studies have shown possible interactions between dietary antioxidants and cancer treatment. We know that vitamin C is a powerful antioxidant. It consumes free radicals, the toxic substances in the body that can be generated by chemotherapy agents to destroy cancer cells. "It is possible," according to Dr. David Golde, Physician-inChief at Memorial Sloan-Kettering Cancer Center, "that taking large amounts of vitamin C could interfere with the effects of chemotherapy or even radiation therapy." These therapies often kill cells, in part, by using oxidative mechanisms. it's conceivable then, that vitamin C might make cancer treatment less effective, and it is reasonable that cancer patients undergoing chemotherapy avoid taking large amounts of this vitamin." Building on past research Earlier research by Dr. Golde and his colleagues established that specific glucose transporter molecules carry vitamin C into cells. This occurs once vitamin C, which is used by cells in the form of ascorbic acid, is converted into

dehydroascorbic acid and transported into the cell. Once inside, the vitamin is converted back to ascorbic acid. Applying this information to patient care According to David Agus, an oncologist at Memorial Sloan-Kettering Cancer Center, we now know that tumors acquire and retain large amounts of vitamin C. And their nutritional needs appear to be similar to healthy cells that take in large amounts of the vitamin." However, what cancer cells do with the vitamin C after it is absorbed is not known. This will have to be determined before guidelines for the complementary use of antioxidants during chemotherapy and radiation become established. Furthermore, research from University of Tubingen, School of Medicine in Germany suggests caution in applying this knowledge to all antioxidants in all types of malignancies. Examination of the modulation of drug-induced cytotoxicity and clonogenic cell death of glioma cells by three structurally unrelated antioxidants revealed that these antioxidants inhibit acute cytotoxicity and clonogenic cell death induced by cisplatin. However, they had little effect on the toxicity of other cancer drugs including BCNU, doxorubicin, vincristine, cytarabine, or camptothecin. In the discussion of brachytherapy, the pharmacist carries the implications over to chemotherapy agents, but mistakenly states that these function by producing free radicals. In general, this is not the case, and only applies to radiation (see explanation of mechanism, Appendix). The research cited here about an inhibition of cisplatin therapy by antioxidants (but, notably, no effect of the tested antioxidants on several other chemotherapy drugs) was published in 1998 (4), and did not produce much interest at the time, nor has a follow-up report been published to date (end of 2002). Glioma cells (a type of brain cancer) are normally resistant to the effects of chemotherapy, and the authors were examining factors influencing this already poor response. They determined, in their study, that cisplatin did not rely on freeradical formation to damage glioma cells, so antioxidant activity working directly against cisplatin effects was not an issue. Rather, the substances tested in this in vitro study appeared to function by some other unknown mechanism. By contrast, another platin drug, oxaliplatin, was used in a double-blind, placebo controlled clinical trial along with administration of the antioxidant glutathione (GSH; see Figure 1). The authors concluded (5): "This study provides evidence that GSH is a promising drug for the prevention of oxaliplatin-induced neuropathy, and that it does not reduce the clinical activity of oxaliplatin." This is an important finding, because it had been proposed that cancer cells could become resistant to platin drugs (e.g., cisplatin and carboplatin; see Figure 2) due to changes in the cancer cell membrane, where the resistance may be caused by the binding of platinum to intracellular thiols, such as glutathione. This possibility, based on in vitro studies, implies that the interaction between platinum and GSH could prevent the active compounds from reaching the DNA nucleus. It is unclear at this point, whether administering glutathione can be recommended (as is often done by proponents of its protective effects), but this substance does not appear to have any direct interference with oxaliplatin when used clinically based on the recent clinical trial. In vitro studies indicate that high intracellular glutathione levels protect cancer cells from the effects of chemotherapy, but this may not carry over to the clinical situation. A related concern about chemotherapy drug resistance has been raised about using antioxidants with cyclophosphamide, a particularly toxic anticancer drug. When the literature was reviewed, it was found that, if anything, the substances were beneficial for patients on cyclophosphamide therapy. Here is the interaction caution about this drug as relayed in Healthnotes (6-10): Interactions with Dietary Supplements Antioxidants Cyclophosphamide requires activation by the liver through a process called oxidation. In theory, antioxidant nutrients (vitamin A, vitamin E, beta-carotene and others) might interfere with the activation of cyclophosphamide. There is no published research linking antioxidant vitamins to reduced cyclophosphamide effectiveness in cancer treatment. In a study of mice with vitamin A deficiency, vitamin A supplementation enhanced the anticancer action of cyclophosphamide. Another animal research report indicated that vitamin C may increase the effectiveness of cyclophosphamide without producing new side effects. Preliminary human research found that adding antioxidants (beta-carotene, vitamin A, and vitamin E) to cyclophosphamide therapy increased the survival of people with small-cell lung cancer treated with cyclophosphamide. It is too early to know if adding antioxidants to cyclophosphamide for cancer treatment is better than cyclophosphamide alone. Vitamin A can be toxic in high amounts. Intravenous injections of the antioxidant, glutathione, may protect the bladder from damage caused by cyclophosphamide. Preliminary evidence suggests, but cannot confirm, a protective action of glutathione in the bladders of people on cyclophosphamide therapy. There is no evidence that glutathione taken by mouth has the same benefits. As reported here, when laboratory animal and clinical evaluation is the basis for the information, the potential benefits of antioxidants appear. One could say that there has been some backlash at the anti-antioxidant stance promoted by those who quote Dr. Golde and extend his vitamin C research to imply that all antioxidants are problematic for cancer patients. At the Rush Presbyterian St. Luke's Medical Center, the suggestion that vitamin E might inhibit radiation effects was discounted. A press report stated (11): Vitamin E Does Not Protect Cancer Cells Against Radiation New York. 15 January 2000 (posted 19 March, 2001). Cancer patients who take vitamin E are probably not hindering the desired effects of radiation, according to a laboratory study done by radiation oncologists at Rush-Presbyterian-St. Luke's Medical Center in Chicago. Researchers at Rush were concerned that patients who take vitamin E may be inadvertently providing protection for the cancer cells that are the target of radiation therapy. Radiation damage is one form of oxidation, and vitamin E's antioxidant properties presumably extend to cancer cells. To determine if this were true, Rush researchers, led by Dr. Ed Blazek, director of radiation biology in the Rush department of radiation oncology, grew cells originating from human breast and prostate tumors in nutrient solutions

containing several concentrations of vitamin E. The cells were then irradiated with the same daily doses used for patients. The Rush team found that the tested concentrations of vitamin E did not interfere with the desired killing of cancer cells by radiation. An important limitation of this study, however, is that the level of vitamin E taken up by the cancer cells in laboratory culture has not yet been measured, and might be smaller than the level taken up by cells of a tumor in the patient's body. If so, it is still possible that vitamin E might worsen treatment outcomes. Although no undesirable protection of cancer cells was found, the researchers issued a caution to those taking vitamin E and other alternative therapies. "Any drug that is taken during cancer radiotherapy or chemotherapy should be tested to prove that it does not protect the tumor cells, defeating the intended effect of the treatment," Blazek said. Natural extensions of this work would include the addition of the drug pentoxifylline to vitamin E, since this combination has been reported to partially reverse radiation damage to normal tissue, the testing of vitamin C for radioprotection, and the testing of both vitamins E and C for protection from representative cancer chemotherapy drugs. This research, performed by Drs. Alex Perez and Katherine Baker together with Dr. Blazek, was presented at the annual meeting of the Radiological Society of North America in Chicago. Then, in a follow-up report from the same hospital, this time including vitamin C (12, 13): Vitamins C and E Fight Side Effects of Pelvic Radiation for Cancer March 20, 2001. A small study of 20 men and women suffering from chronic radiation proctitis has shown that daily vitamins E and C substantially reduced or eliminated their symptoms. Proctitis has traditionally been treated with antiinflammatory agents, without satisfactory results. Radiation therapy is one treatment option for men with localized prostate cancer and for women with cervix and endometrial cancers. Radiation therapy is effective in killing cancer cells. But the therapy damages also any normal, noncancerous cells within range of the beam. Complications are especially common in patients who are treated with older equipment. New, 3D conformal, Intensity Modulated or Proton beam equipment (available in the USA and some other countries) targets the beam much more precisely. Higher doses can be given to tumor with less damage to bladder and rectum. Most patients take vitamins-does this interfere with killing cancer cells? Even under the best conditions patients want to do everything possible to protect themselves from radiotherapy side effects. Many patients who undergo cancer treatments take vitamins and supplements. Until recently, oncologists seldom asked patients about this. Doctors still have almost no evidence on which to advice cancer patients about common supplements. But a previous, laboratory study by radiation oncologists at Rush-Presbyterian-St. Luke's Medical Center found that "Cancer patients who take vitamin E are probably not hindering the desired effects of radiation." Dr. Keith Bruninga, gastroenterologist at Rush-Presbyterian-St. Luke's has now looked to see how much protection vitamins E and C actually offer patients irradiated for prostate, cervical or endometrial cancer. The effect of the vitamins in the treatment of chronic radiation proctitis had not been studied before, Dr. Bruninga said. In normal bowel and rectal tissues exposed to radiation for cancer in the pelvis, oxygen radicals form and patients experience the symptoms of proctitis, he said. The condition starts with swollen, inflamed tissue, and it increases with dose. The symptoms, which may include diarrhea, pain, bleeding and incontinence, usually clear up within a few weeks of the last radiation treatment. However, the symptoms do not clear up in 10-20 percent of patients. Some patients develop symptoms months or years after the initial radiation exposure. "Our study showed that we can harness the potent antioxidant properties of the vitamins to repair cell damage and bring relief to many people who suffer from the persistent, lifestyle-altering symptoms of chronic radiation proctitis," Dr. Bruninga says in a paper published in the April issue of The American Journal of Gastroenterology. Oxygen free radicals form from cells that have been injured. Oxygen free radicals are highly active molecules that react with cells by changing or damaging their structure. The formation of the oxygen free radicals increases the amount of injury to the cells and results in a chronic condition as blood flow to the cells is decreased. Vitamin E is a potent antioxidant that can react with damaging oxygen free radicals. Vitamin C in combination with E increases the effects of vitamin E. The researchers believe that the antioxidant treatment regimen using the vitamins counteracts and can prevent oxygen free radical injury and increase blood flow to the injured cells of patients with chronic radiation proctitis. Patients in the study, ten men and ten women with chronic radiation proctitis, took one 400 IU vitamin E tablet along with one 500 mg vitamin C tablet three times each day for eight consecutive weeks. Patients purchased the vitamins themselves at the store of their choice. Each patient in the study rated their symptoms in terms of severity and frequency before and after treatment with the vitamins using a questionnaire developed by the researchers. The impact of the symptoms on the lifestyle of the patients was also assessed using a questionnaire. Ten of the patients were assessed again after one year to determine if their initial responses were sustained. The assessments showed a significant improvement in bleeding, diarrhea and urgency after taking the vitamins. Patients with rectal pain did not improve significantly. Thirteen patients reported an improvement in their lifestyle including seven whom reported a complete return to normal. All of the ten patients who were assessed after one year reported a sustained improvement in their symptoms while

continuing to take the vitamins. The Rush physicians believe that the actual incidence of the ailment is greater than the estimated 10-20 percent of radiation patients. They feel that many patients, relieved and grateful that their cancers are remission, are embarrassed to tell their physicians about the symptoms of radiation proctitis. Currently, the Rush physicians are seeking additional individuals with chronic radiation proctitis to conduct a larger, double-blinded study of the effectiveness of antioxidants in the treatment of the illness. "If our continued research shows that the antioxidant regimen is successful in treatment of this illness, we plan to investigate its use to prevent chronic radiation proctitis," said Dr. Bruninga. Results of the study appear in April 2002 issue of The American Journal of Gastroenterology.

THE ALTERNATIVE: AVOIDING EVEN NORMAL LEVELS OF ANTIOXIDANT INTAKE One of the early complaints about vitamins and chemotherapy was this one, described just four months before Dr. Golde made his comments at an American Cancer Society Meeting, summarized by a report on prostate cancer (13): Vitamins and Chemotherapy Although the antioxidant vitamins A, C, and E help repair damaged cells, it is probably not a good idea to take large amounts during radiation treatment. One object of chemotherapy is to damage cancer cells. Antioxidants, however, appear to counteract the process, according to Dr. Rudolph Salganik's report to the annual meeting of the American Society for Cell Biology (December 1999). He pointed out that "Almost all anticancer drugs kill cancer cells by way of apoptosis, and antioxidants like vitamin A and vitamin E dramatically reduce apoptosis in cancer cells." Patients should therefore avoid taking any more than a normal amount of these vitamins during chemotherapy treatment. This sounds like reasonable advice-just don't add to normal intake-but Dr. Salganik's own suggestion went further: indicating that an antioxidant-depleted diet could improve cancer therapies. The study referred to above was reported on as follows (14): Study: avoiding vitamins A, E might improve cancer therapy By David Williamson, UNC-CH News Services CHAPEL HILL-Vitamins A and E, which normally boost human health in numerous ways, also appear to keep cancer cells from dying through the natural protective process scientists call apoptosis, new University of North Carolina at Chapel Hill research shows. As a result, giving patients those vitamins may prevent cancer cells from self-destructing and work against cancer therapy, scientists say. Researchers at UNC-CH's schools of public health and medicine presented their findings Monday (Dec. 13) during a news conference at the American Society for Cell Biology's annual meeting in Washington, D.C. Drs. Rudolph Salganik, research professor of nutrition, and Terry Van Dyke, professor of biochemistry and biophysics, directed the studies. "We believe this work is important because it may make cancer treatments more effective," Salganik said. "It suggests that cancer patients, especially those undergoing chemotherapy or radiation therapy, may do better on an antioxidant-depleted diet." The scientist and his colleagues study reactive oxygen species (ROS), which play a central role in the series of signals that allow cells to kill bacteria and viruses, destroy toxins and trigger the apoptotic "suicide" of defective cells such as cancer, he said. Antioxidants, such as vitamins A and E, protect normal cells from the damaging effects of ROS but apparently also can prevent the targeted apoptotic death of cancer cells that threaten humans and other mammals, the new work suggests. Other researchers involved were Drs. Craig D. Albright, research assistant professor of nutrition; and Steven H. Zeisel, professor of nutrition and pediatrics and chair of nutrition. The UNC-CH experiments involved putting mice that were predisposed to developing brain tumors on specially modified diets that were either supplemented with standard amounts of antioxidants or were antioxidant deficient for four months. Researchers then carefully monitored the rodents' health and their brain tumors, if any, to see how the animals fared on the different diets. Mice receiving extra vitamins A and E showed no benefit in either the size or incidence of brain tumors, Salganik said. They also had relatively short lives. "Interestingly and more importantly, in animals that received antioxidant-depleted diets, brain tumors were significantly reduced in size because of induction of oxidant stress due to what are commonly called free radicals in the brain tumors," Albright said. "Higher levels of cell death was restricted only to the brain tumors, while normal tissues were not affected by depletion of antioxidants in the mouse diets." In mice getting low levels of vitamins A and E, no negative effects were seen in normal cells, but about 19 percent of tumor cells showed evidence of apoptosis. In those ingesting normal quantities of antioxidant vitamins, only about 3 percent of tumor cells were apoptotic. The group's findings may explain two previous clinical studies showing that heavy smokers who ate a diet high in betacarotene antioxidants had significantly higher rates of lung cancer, Salganik said. "These new studies raise important issues regarding the advisability of ingesting high levels of antioxidants as a potential anti-cancer benefit," Albright said. "Clearly, more studies are needed at the clinical level in human populations to address the real value of antioxidant supplements or antioxidant depletion in people at risk of developing cancer." Salganik said he hoped clinical studies would begin within a year or two. Van Dyke is a member of the UNC Lineberger Comprehensive Cancer Center.

Up to this point, no clinical study results along these lines have been reported. The suggestion of starving antioxidants, however, runs contrary to most of the information currently available. The study referred to above, involving heavy smokers and beta-carotene intake has already been the subject of considerable controversy and it appears there were unique factors in this population of heavy smokers in Finland that were studied. Findings to the contrary are common. For example, in a recent evaluation of the risks of lung cancer in relation to various carotenoids ingested. The conclusion was (15): Lower risks of lung cancer were observed for the highest versus the lowest quintiles of lycopene (28%), lutein/zeaxanthin (17%), beta-cryptoxanthin (15%), total carotenoids (16%), serum beta-carotene (19%), and serum retinol (27%). These findings suggest that high fruit and vegetable consumption, particularly a diet rich in carotenoids, tomatoes, and tomatobased products, may reduce the risk of lung cancer.

SHOULD HERBS BE WORRISOME ADJUNCTS TO CANCER THERAPIES? There is only one herb that has been implicated in a potential adverse effect on chemotherapy, and its effect has nothing to do with antioxidant activity of the herb. This one herb has been implicated in lowering the dose of a wide range of drugs because it strongly activates the drug-metabolizing enzyme cytochrome P450 CYP3A4. This is St. John's wort (16), which was commonly used for treating depression during the 1990s, but has since become little used due to the concerns for drug interactions (as well as some question about its efficacy). No other herb has been identified as a potential inhibitor of chemotherapy drugs. Although many herbs have some antioxidant potential, their influence over oxidative reactions is low due to the low dosage commonly employed. Unlike vitamin C, which is presented as a pure or nearly pure compound in dietary supplements, herbs contain little vitamin C (in relation to Dr. Golde's concern) and low levels of antioxidant substances. Further they contain little, if any, of the substances that appeared to inhibit cisplatin cytotoxicity in cultured glioma cells. There are no pharmacology or clinical studies showing problems with herbs other than St. John's wort in relation to chemotherapy or radiation therapy. By contrast, the widespread use of herbs and herb extracts to minimize cancer therapy side effects in the Orient is accompanied by extensive favorable reports.

REASONABLE PHYSICIAN'S ADVICE Cautions that can reasonably be forwarded by physicians are these: 1. The use of herbs and dietary supplements, including vitamins and antioxidants, as adjuncts to modern cancer therapies, is an area of ongoing research and, at this time, little is known about the clinical effects. 2. Concerns have been raised about use of antioxidants, mainly high doses of vitamin C and high doses of glutathione, based on laboratory experiments suggesting that these substances might impair the full effect of cancer therapies. Clinical studies have not yet revealed any adverse effects, but the concern persists on a theoretical basis, backed up by the laboratory reports; there are also laboratory and clinical reports that suggest that vitamin C and glutathione have positive effects in relation to cancer therapies. 3. There is a wide range of recommendations for patient actions based on interpretations of the data available so far. These range from recommendations to administer herbs, vitamins, and other supplements to reduce the adverse effects of cancer therapies without impairing the benefits of the cancer therapies, to maintaining normal healthy dietary recommendations without adding anything, to specifically avoiding antioxidant substances, including those that are normally present in a healthy diet. 4. Most medical experts agree that one should not pursue high doses of nutritional supplements or herbs because not enough is known about their potential impact on cancer therapies; their purported benefits may not be confirmed, while there could be risks. However, the only substances for which a strong caution has been repeated are St. John's wort, which may lower the dose of chemotherapy drugs in the body (no impact on radiation therapy is expected), high doses of vitamin C, which might have some protective effect for cancer cells during the therapy, and the antioxidant glutathione, which if taken continuously in large dose might aid cancer cell drug resistance. In making these comments, physicians should recognize that a wide range of therapies are offered to patients and that the meaning of "high dose" or "continuous use" may vary. For example, physicians should recognize that some proponents of high dose vitamin C therapy recommend huge doses of the vitamin specifically for purported anti-cancer effects. The amounts involved are difficult to consume in one day (e.g., orally consumed up to bowel tolerance, which is typically in the range of 6-12 grams per day). Indeed, some have recommended a continuous vitamin C intravenous drip (8 hours a day) to try inhibiting cancers that are resistant to standard medical therapies (this is after chemotherapy has been suspended). Such huge doses of vitamin C are unproven for effectiveness and could conceivably reduce the impact of concurrent cancer therapies by a number of mechanisms because very high blood levels are attained. However, most nutritional supplements that involve high doses of vitamin C provide less than 2 grams of the vitamin each day, usually spread over 2 to 3 doses. Blood levels do not rise very much by oral administration, as the vitamin is absorbed gradually and excreted within hours (see Figure 3). There is no evidence that these amounts of oral vitamin C would be harmful for cancer patients. Most proponents of nutritional supplementation, relying upon extensive reports on vitamin C, currently recommend doses of 500-1,500 mg/day. Patients could be cautioned to limit their intake of this particular vitamin to no more than that range. It is important to note that if cancer cells have a mechanism for absorbing large amounts of vitamin C, and if this is helpful to the growth of cancer cells or to protect against anti-cancer therapies, the amount of vitamin C available in the body normally (baseline of about 60 micromoles/liter) should be sufficient to satisfy the cancer's appetite for it. Aside from the projected problems with high-dose vitamin C (Dr. Golde did not show inhibition of cancer therapies, only high uptake of vitamin C by cancer cells), there simply is no evidence that other antioxidants (except possibly glutathione), nutritional supplements, or herbs (except St John's wort) inhibit cancer therapies or worsen overall outcomes. To the contrary, they appear to improve outcomes. In the case of St. John's wort, this herb was not proposed as either a treatment for cancer nor a treatment for cancer therapy side effects; rather, it has been used incidentally in the treatment of depression. Thus, no herbs intentionally used as adjuncts to cancer therapy have been implicated in adverse effects clinically.

Even in the case of glutathione, there is reason to believe this substance is not problematic in clinical practice. A concern was raised earlier about supplementation with glutamine, an amino acid that is used to produce glutathione in the body and which is considered a "glutathione-sparing" agent: as glutamine levels increase, glutathione levels are maintained at high levels. Several studies have indicated that glutamine might be a valuable aid to cancer patients, recommended to prevent neuropathy from high dose chemotherapy, to protect the heart from damage due to doxorubicin therapy, and to protect the bowel from damage due to radiation or chemotherapy, but the concern was raised that it would also benefit cancer cells. The studies conducted to date do not support a negative effect for glutamine in relation to cancer. To the contrary, glutamine appears to improve the retention of the chemotherapy drug methotrexate by tumor cells. In one report on this subject, it was concluded that: "These data suggest that oral glutamine supplementation will enhance the selectivity of antitumor drugs by protecting normal tissues from and possibly sensitizing tumor cells to chemotherapy treatment-related injury." The mechanism of action was proposed to be the increase in cellular glutathione related to elevated glutamine levels (18). Dr. VS Klimberg, of the Department of Pharmacology, University of Arkansas, has been a leading researcher in the use of glutamine as a protective agent for cancer patients and has reported widely on its effects. Glutamine and glutathione are currently recommended by many who advocate the use of adjunctive cancer therapies. Physicians who wish to approach the issue with the most conservative viewpoint could caution patients about extreme therapies, with multiple high dose antioxidants, but cannot with any clinical evidence argue against moderate use of herbs, vitamins, or antioxidants. In fact, the evidence, limited as it may be, is that moderate use of antioxidants is a reasonable approach for patients who are concerned about chemotherapy side effects. In a recent review of the subject, Kedar Presad and colleagues at the Center for Vitamin and Cancer Research, Department of Radiology, Health Sciences Center, University of Colorado, described the differing views and, as a summary, they pointed out (19): Radiation therapy is one of the major treatment modalities in the management of human cancer. While impressive progress like more accurate dosimetry and more precise methods of radiation targeting to tumor tissue has been made, the value of radiation therapy in tumor control may have reached a plateau. At present, two opposing hypotheses regarding the use of antioxidants during radiation therapy have been proposed. One hypothesis states that supplementation with high doses of multiple micronutrients including high dose dietary antioxidants (vitamins C and E, and carotenoids) may improve the efficacy of radiation therapy by increasing tumor response and decreasing some of its toxicity on normal cells. The other hypothesis suggests that antioxidants (dietary or endogenously made) should not be used during radiation therapy, because they would protect cancer cells against radiation damage. Each of these hypotheses is based on different conceptual frameworks that are derived from results obtained from specific experimental designs, and thus, each may be correct within its parameters. The question arises whether any of these concepts and experimental designs can be used during radiation therapy to improve the management of human cancer by this modality. Based on the review of literature, the authors concluded that vitamin C, vitamin E, carotene, and other antioxidants could be useful as a safe adjunct to radiation therapy. Matt Brignall, of the Seattle Cancer Treatment and Wellness Center, where adjunctive therapies are emphasized, also pointed to the evidence supporting the benefit of antioxidants during cancer therapy, saying (20): Critics of the concurrent use of antioxidants and chemotherapy often point to the lack of clinical trials in humans. Previous preliminary clinical trials, however, have concluded that the antioxidants ginkgo (Ginkgo biloba), melatonin, coenzyme Q10, and N-acetylcysteine did not appreciably reduce the effect of cancer therapies. Pharmaceutical antioxidants, such as amifostine and mesna, have also been extensively studied in conjunction with chemotherapy and radiation, and have not appeared to cause a negative interaction. Many prominent cancer scientists believe that the dietary and pharmaceutical antioxidants prevent some of the worst side effects of cancer treatments. Further, a common antioxidant now recommended to cancer patients is green tea, which contains an amino acid (theanine) that appears to help retain doxorubicin and other chemotherapy drugs within cancer cells (21). Thus, while it can be reasonable for physicians to offer some limited cautions about use of herbs, vitamins, and antioxidants, they must also be careful not to warn people away from potentially usefully adjunct therapies.

December 2002

REFERENCES 1. Leslie M, Vitamin C: How much do you really need?, WebMDHealth, June 19, 2000. 2. Cancer tumors shown to consume large amounts of vitamin C. Researchers are cautious about cancer patients taking vitamin C supplements. Memorial Sloan-Kettering Cancer Center, 1999. http://www.mskcc.org/mskcc/html/1166.cfm. 3. Russo J, Potential interaction between antioxidants and cancer treatment, http://www.medcomres.com/articles/antioxidants_cancer.htm. 4. Roller A, Weller M, Antioxidants specifically inhibit cisplatin cytotoxicity of human malignant glioma cells, Anticancer Research 1998; 18(6A): 4493-4497. 5. Cascinu S, et al., Neuroprotective effect of reduced glutathione on oxaliplatin-based chemotherapy in advanced colorectal cancer: a randomized, double-blind placebo-controlled trial, Journal of Clinical Oncology 2002; 20(16): 3478-3483. 6. Health Notes, 2000 Healthnotes, Inc.: http://www.hollandandbarrett.com/Drug/Cyclophosphamide.htm. 7. Ghosh J, Das S, Role of vitamin A in prevention and treatment of sarcoma 180 in mice, Chemotherapy 1987; 33: 211-8. 8. Taper HS, de Gerlache J, Lans M, Roberfroid M, Non-toxic potentiation of cancer chemotherapy by combined C and K3 vitamin pre-treatment, International Journal of Cancer 1987; 40: 575-9.

9. Jaakkola K, Lahteenmaki P, Laakso J, et al., Treatment with antioxidant and other nutrients in combination with chemotherapy and irradiation in patients with small-cell lung cancer, Anticancer Research 1992; 12: 599-606. 10. Nobile MT, Vidili MG, Benasso M, et al., A preliminary clinical study of cyclophosphamide with reduced glutathione as uroprotector, Tumori 1989; 75: 257-8. 11. Rush Presbyterian St. Luke's Medical Center, Vitamin E does not protect cancer cells against radiation, January 15, 2000, PSA Rising Magazine, http://psa-rising.com/medicalpike/ebr/andvitEC031901.shtml. 12. Rush Presbyterian St. Luke's Medical Center, Vitamins C and E does fight side effects of pelvic radiation for cancer, March 20, 2001, PSA Rising Magazine http://psa-rising.com/medicalpike/ebr/vitE-C-proctitis031901.shtml. 13. Dykes B, Hypertext Guide to Prostate Cancer, Chemotherapy: vitamins and chemotherapy, 2001, http://www.hypertext.org/ENGLISH/ADVANCED.html. 14. Williamson D, Study: Avoiding vitamins A, E might improve cancer therapy, University of North Carolina News Services, December 13, 1999, http://www.unc.edu/news/newsserv/research/dec99/salganik121399.htm. 15. Holick CN, et al., Dietary carotenoids, serum beta-carotene, and retinol and risk of lung cancer in the alpha-tocopherol, beta-carotene cohort study, American Journal of Epidemiology 2002; 156(6): 536-547. 16. Mathijssen RH, Effects of St. John's wort on irinotecan metabolism, Journal of the National Cancer Institute 2002; 94(16): 1187-1188. 17. Levine M, et al., Criteria and recommendations for vitamin C intake, Journal of the American Medical Association 1999; 281:1415-1423. 18. Rouse K, Glutamine enhances selectivity of chemotherapy through changes in glutathione metabolism, Annals of Surgery 1995; 221(4): 420-426. 19. Prasad KN, et al., Pros and cons of antioxidant use during radiation therapy, Cancer Treatment Reviews 2002 28(2): 79-91. 20. Brignall M, Is it safe to use antioxidant supplements with chemotherapy?, Healthnotes Newswire, October 10, 2002. 21. Sadzuka Y, et al., Enhancement of the activity of doxorubicin by inhibition of glutamate transporter, Toxicology Letters 2001; 123(2-3): 159-67.

APPENDIX 1. BASIC UNDERSTANDING OF THE CANCER THERAPIES The precise mechanisms of cancer therapies are not fully worked out, though considerable information is available. The following is an overview, based on the author's understanding, indicating the potential role of herbs, vitamins, and antioxidants in preventing side effects of cancer therapies without impairing anticancer treatment. Radiation Standard external radiation therapy pinpoints a beam of intensely energetic photons (x-rays, gamma-rays or beta-rays) to a tumor site (see Figure 4). The radiation dose at the focal point is lethal to the cells. Some of the radiation directly breaks up cellular DNA and other components in the target area; it is estimated that about one-third of the damage is direct destruction of critical molecules, leading to inability of the cell to reproduce or to prompt cell death. The primary damage to the tumor, however, comes from generation of a huge number of free radicals that interact with cellular components and disrupt them. These free radicals are mostly generated from water, because it is the most abundant substance in the cells. Because of the beam intensity at the focal point, no amount of antioxidant activity from orally ingested supplements is likely to be able to save these cells. External radiation therapy is usually administered over an extended period, with several treatments spaced out with many days interval between. The reason that the whole task is not performed with one treatment is that the collateral damage from the radiation would be so severe as to threaten the patient's survival. As it is, when the beam enters the body on its way to the tumor site and exits beyond the tumor, and spreads a bit on either side of the target, the collateral damage is notable and can be extreme. The skin becomes burned and delicate internal organs can become severely damaged and almost unusable. For example, radiation to the throat area can make swallowing virtually impossible; abdominal radiation can cause intestinal ulceration that doesn't heal for months if at all. Still, these off-target tissues are able to repair somewhat between the treatments thanks to the more limited damage at these sites compared to at the tumor itself. As the distance from the beam's focal point increases, there is greater chance to protect the cells with antioxidants that are able to handle the small number of free radicals that are generated. There are other types of radiation therapy, including brachytherapy, in which radioactive material is inserted into the tumor (as commonly employed for prostate cancer): the radiation spreads out around radioactive "seeds" and kills all cells in the surrounding area, with reduced damage the greater the distance from the radiation source. There are now proton and neutron beams that have a higher proportion of damage caused by direct strikes at DNA and other cellular components, with less reliance on free radical generation. It is a desired outcome that the collateral damage from all radiation techniques be minimized, which is a potential valuable role for antioxidants. The chances of antioxidants protecting the tumor cells are minimal; there is simply too much radiation at the target. Failures of radiation therapy are mostly attributable to metastasis of the cancer cells (before radiation begins) rather than failure of the radiation to destroy every cancer cell at the target tumor site. No amount of antioxidant therapy nor the reverse-complete avoidance of antioxidant therapy during radiotherapy-will have an impact on this metastasis that has occurred before radiation therapy. Metastatic cells can not be detected by current means and may not reveal themselves for months or even years, which is why cancer therapies are not considered a true success until 5 years pass without sign of new tumor growth, usually at a different site. One cannot know for certain what effect-good or bad-antioxidants will have on the effects of radiation therapy, without extensive clinical testing that may take years. The concept that tumor cells can be protected is largely based on the assumption that antioxidants are extremely efficient. They would have to clean up the reactive oxygen species as fast as they are produced. Yet, the very large amount of antioxidant research conducted over the past decade clearly shows that these substances have limited impact for several diseases. Where they were thought to have the potential to treat diseases, they have not been very successful, and where they are thought to prevent diseases, they appear effective so long as the exposure to the antioxidants is for years and years, having a continuous mild impact.

Antioxidants can be expected to provide some aid to cells unintentionally caught in the periphery of radiation therapy, but, even there, complete protection is not expected due to limited effects. Chemotherapy As with radiation therapy, chemotherapy is administered over an extended period, often (though not always), with a duration of several days or weeks between treatments. As with radiation therapy, the task cannot be accomplished all at once, because a lethal chemotherapy dose for the entire tumor would also be lethal for the patient. In fact, one of the key measures of the patient's ability to continue chemotherapy is recovery of the white blood cell count that has been impaired by the drug therapy (this does not apply to some of the new immune based and genetic therapies). Chemotherapy is usually not as focused as radiation therapy on the tumor, and affects the entire body (commonly causing hair loss, distress of the gastro-intestinal system, white blood cell depletion, and fatigue). An adjunctive treatment that protects non-target cells (normal cells) might also protect cancer cells. However, as occurs with radiation therapy, there is a difference between the intensity of the drug action on cancer cells and on other cells, such as bone marrow cells. Otherwise, once the cancer was destroyed successfully, the bone marrow would also be destroyed (which is, in fact, one of the radical chemotherapy approaches, but not the first line treatment). Chemotherapy drugs are selected for clinical use on the basis that they have a more potent action on cancer cells than on other cells. Thus, after the cancer is destroyed, hair grows back, digestion returns to normal, and the immune system functions fully once again. Protection that helps the bone marrow does not necessarily have the potency to protect the cancer cells. Failure of chemotherapy is often the result of the presence of some resting cells, usually cells outside the active tumor mass, that do not respond to chemotherapy drugs. The drugs usually interact with replicating DNA and might miss such individual metastatic cells that are quiescent. Polysaccharides from herbs have been used for protecting the bone marrow in cancer patients undergoing chemotherapy in China, Japan, and other countries for many years. The clinical study reports indicate improved outcomes (better survival) in patients who utilize this adjunct therapy. It can be argued that the study methodology is inadequate to support the improved survival, and it can be argued that the valid outcomes might be clinically insignificant, so that there is little or no interest in pursing this approach here. But, there is no evidence that bone marrow protection leads to negative effects in terms of tumor destruction or survival rates. A positive role for antioxidants in the case of chemotherapy drugs is protection against a variety of undesired secondary effects, particularly neuropathy and cardiac damage. The chemotherapy drugs do not function as oxidants, but, rather, influence the cellular DNA and RNA (see Figures 5-6). Except in one in vitro study cited above for glioma cells that are normally resistant to chemotherapy, there is no evidence that antioxidants worsen the outcome of cancer chemotherapies. To the contrary, there is some evidence of protection for secondary effects. Dr. Golde's in vitro research on vitamin C did not show that this substance impaired cancer therapies, only that cancer cells seem to "soak up" the vitamin. His results may not translate to an impairment of the effects of radiation therapy or chemotherapy. The essential factor in both radiation therapy and chemotherapy is the specificity of the treatment for cancer cells. Antioxidants, herbs, and other kinds of natural supplements are being applied to protect cells that are unintentionally damaged by cancer therapy where the damage is substantially less severe than that caused to the cancer cells. The ability to provide protection for non-target cells without interfering with the damage to cancer cells is based largely on the differential. One may expect that where a cancer therapy is equally lethal to target and non-target cells, that a therapy protective of the non-target cells might also be protective of the target cells. Despite the apparent protection offered by antioxidants and herbs to non-target cells, their abilities to provide that protection are limited. Patients still experience side effects; they are only reduced in intensity. The ability of these same substances to protect target cells is far less, which explains why there hasn't been a sudden failure of cancer therapies during the past decade when millions of people have turned to routine use of supplements with vitamin C, vitamin E, and other antioxidants.

Figure 1. Glutathione

Figure 2. Platin drugs; cisplatin, top; carboplatin, middle; and oxaliplatin, bottom.

Figure 3. Vitamin C bioavailability in plasma after IV administration (black dots) and oral administration (white dots) with 200 mg (top graph) or 1,250 mg (bottom graph).

Figure 4. Computer modeling of radiation therapy beam focusing for treatment of a brain tumor.

Figure 5. Mechanism of 5-FU, a common chemotherapy drug. 5-FU is activated by metabolism to RNA and DNA forms, which then incorporate into the cellular RNA and DNA, inactivating it or producing toxic rather than normal products.

Figure 6. Oxaliplatin (represented by hexagon units with two prongs) attaches to DNA strands and blocks their replication, halting cellular reproduction and leading to cell death.

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AN ANALYSIS OF CHINESE HERB PRESCRIPTIONS FOR RHEUMATOID ARTHRITIS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

INTRODUCTION Arthritis is a general term for joint (Greek: arthron) inflammation (Greek: itis). The main symptoms are pain, swelling, and stiffness. The cause of the disorder is an immune-based disturbance primarily affecting the joint fluids. There are several types of arthritis, but there are two basic forms mentioned in modern literature that occur frequently: rheumatoid arthritis and osteoarthritis. Rheumatoid arthritis is characterized by autoimmune attacks that usually come and go, and it may be influenced by numerous factors that alter the immune functions, including infections, dietary components, and stress. Osteoarthritis also involves some autoimmune responses, but is characterized by a gradually worsening degradation of the joint spaces, leading to sharp, fixed pain that persists. Although both disorders can begin at any of the joints, rheumatoid arthritis most often affects the upper body first (fingers are frequently the first site), while osteoarthritis most often affects the lower body first (hips and knees are commonly affected). Rheumatoid arthritis tends to be felt for the first time at a somewhat earlier age than osteoarthritis, with rheumatoid arthritis usually starting before age 50 and osteoarthritis usually starting after age 50. Women are more likely than men to suffer from arthritis of both types. Arthritis has been a recognized medical condition since ancient times, and the Chinese had developed numerous formulas for its treatment. Chinese herbal formulas were not specifically designed for either of the two major types of arthritis defined today. The basis for Chinese doctors differentiating arthritis into subgroups was not the microscopic details of the pathology. Instead, arthritis was divided into traditional medicine categories: hot and cold types, upper and lower body involvement, deficiency or excess syndrome, pain characteristics (such as variability and severity), and whether the site of the arthritis was fixed or "moving." Both rheumatoid arthritis and osteoarthritis fall under the heading of bi syndrome, a disorder of qi and blood circulation that leads to symptoms of pain, numbness, swelling, and stiffness. Rheumatoid arthritis fits most closely those syndromes characterized by the Chinese as wind-damp invasion affecting the joints. Osteoarthritis more closely fits the syndrome of liver/kidney deficiency syndrome causing weakness and stiffness in the legs with painful joints. In China, syndromes similar to rheumatoid arthritis were an area of special concern, generating considerable literature on the subject, since the condition could arise suddenly and could rapidly become severely debilitating. Osteoarthritis, on the other hand, tended to be lumped together with other disorders of aging, in which stiffness and pain, especially of the legs, was considered just one part of the gradual deterioration of body functions that occurs with old age. As such, it is usually not the subject of much discussion separate from antiaging therapies. The formulas described in this article mainly fit the category of rheumatoid arthritis treatments. There are three key pathological factors addressed by the formulas: wind, damp, cold: Wind (feng) refers to the sudden onset of the disease, mobility of the affected site (mobile bi syndrome), variability of the manifestation of symptoms, and sensitivity to changes in the environment (see: Drawing a concept: feng). Wind-dominant arthralgia most often affects the upper body and corresponds to the early stage of rheumatoid arthritis. Deficiency of qi and blood allows wind to more easily penetrate the body and cause pain. Damp (shi) refers to the worsening of the symptoms in damp weather, the initiation of the disease or worsening of symptoms after spending time working in a wet environment (such as wading in water or sleeping on damp ground), and the accumulation of fluid in the joints and/or nearby areas of the limbs (see: The six qi and six yin). Dampness-dominated arthralgia most often affects the lower part of the body and is characterized by swelling and stiffness of the joints, and accompanying sensations of numbness; it may correspond to a middle stage of rheumatoid arthritis (that is, after the disease has become chronic, with less variability of affected joints). Disorders of fluid metabolism, especially a weakness of spleen function, will aggravate dampness and the resulting joint dysfunction. Cold (han) refers to the worsening of symptoms with exposure to cold, improvement by applying heat (including liniments that cause increased local circulation), and impaired circulation associated with declining kidney yang that most often occurs with aging (see: Exploring yin/yang #6: cold and heat). Cold-dominated arthritis especially affects the extremities (hands and feet) where circulation is poorest, as well as the lower back-the site of the kidneys. The kidney yang, if deficient, is unable to dispel chilliness. Exposure to cold may initiate arthritis; however, the more common association is with advanced arthritis in which the internal metabolism (qi and yang aspects) are debilitated by chronic disease and aging, yielding a cold syndrome. More rarely, there can be a hot type arthralgia, initiated perhaps by excess exposure to the hot sun during the summer, and manifesting with redness of the joints. The closest traditional Chinese medicine term to rheumatoid arthritis is fengshi bing which literally means wind-damp disease. The wind and damp factors can complex with either cold or heat factors to yield arthralgia. Almost all of the traditional approaches apply to the complex involving cold factors rather than heat. Gout, which has some characteristics in common with arthritis, usually fits the colddominated category or the cold-damp category of bi syndromes. Cold, wind, and dampness cause stagnation of circulation within the channels (meridians; blood vessels). According to the Chinese medical concept, when these pathological factors are dispelled, the circulation returns to normal and the disease goes into remission. If the disease has been experienced for a long period of time, the blood becomes static (a more severe condition than poor circulation). Eventually, the initiating factor (wind) becomes less prominent and the stagnation dominates, with blood stasis an increasing concern. Therefore, in the treatment of the chronic and advanced disease, there is more emphasis on overcoming static blood than when treating an earlier and more variable phase of the disease.

BASIS OF THE ANALYSIS

One can use the traditional Chinese description of arthritis to suggest herbs and formulas to use for each patient. However, rather than devising unique formulations for each patient, it is common practice throughout the Orient to make use of a relatively small group of arthritis formulas that are believed be very successful. In this article, 31 such formulas that are in the current literature and based on the traditional approach are analyzed to reveal their commonly used ingredients and the patterns of formulation that have been relied upon. The sources of the prescriptions were as follows: 1. Two publications of the Oriental Healing Arts Institute (OHAI): the compendium Commonly Used Chinese Herb Formulas with Illustrations (1) and the journal articles in OHAI Bulletin devoted to rheumatism and gout and their Chinese herb treatment (2). 2. The English-language rheumatology books Bi Syndromes (3) and Rheumatology in Chinese Medicine (4) based on traditional Chinese herb prescriptions. 3. The formula reference books Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (5) and Chinese Herbal Medicine Formulas and Strategies (6). 4. The books on patent remedies available in English, Chinese Herbal Patent Formulas (7), Handbook of Prepared Chinese Herbal Formulas (8), and Chinese Patent Medicines (9). In addition, one Japanese patent remedy based on a popular Chinese patent and approved by the Japanese Ministry of Health, was also included in the listing (10). Formula selection was based on two main factors: The indications for the prescription suggest that it could be used in the treatment of arthritis associated with any combination of wind, damp, and cold factors. Formulas specifically designed for unusual cases of arthralgia, such as heatdominated arthritis, were not included. The presence of common Materia Medica items in the prescriptions, with non-toxic ingredients being the dominant components of the formulas. The selection of formulas will have some influence on the outcome of the analysis, so an effort was made to include formulas that were described in several different texts, indicating their importance to the study of traditional Chinese medicine. Table 1: Arthritis Formulas. This table displays the names of the formulas, the list of ingredients, and some comments about each of the formulas. In the first column, the pinyin transliteration of the Chinese formula name is given first, followed by the common name (OHAI system) if available, and then the references to the source texts (which have been listed above). In the ingredients column, the herbs have been listed in order from the most frequently used to the least frequently used (see Tables 2 and 3), followed by a short list of some rarely used items (after "plus"). The final column gives the Chinese traditional source text (STNA denotes source text not available) and some comments about the use and application of the formulas. Formula Name: Pinyin, Common Name, References

Ingredients: Most Frequently Used Herbs/Additional Herbs

Source Text (with Author, Date), and Comments

Sanbi Tang Chin-chiu and Tu-huo Comb. (1-6)

tang-kuei, siler, licorice, cinnamon, cnidium, peony, achyranthes, chin-chiu, tu-huo, hoelen, rehmannia, eucommia, ginseng, astragalus, asarum; plus dipsacus

Furen Liangfang (Chen Ziming 1237 A.D.). This formula nourishes qi and blood and addresses the three bi factors: wind, damp, and cold.

Shujing Houxue Tang Clematis and Stephania Comb. (1, 2)

tang-kuei, siler, licorice, chiang-huo, atractylodes, cnidium, peony, achyranthes, chin-chiu, hoelen, ginger, rehmannia, angelica, clematis, stephania, persica; plus citrus

Wanbing Huichun (Gong Tingxian 1587 A.D.). This formula is widely used in Japan and Taiwan for lower limb arthralgia, and for lumbago and sciatica; it clears the meridians and vitalizes blood.

Duhuo Jisheng Tang Tu-huo and Loranthus Comb. (1-6)

tang-kuei, siler, licorice, cinnamon, cnidium, peony, achyranthes, chin-chiu, tu-huo, hoelen, rehmannia, ginseng, eucommia, asarum; plus loranthus

Qianjin Yaofang (Sun Simiao 652 A.D.). This is perhaps the best known and most widely used formula for arthralgia; also sold as a patent remedy; it tonifies liver/kidney.

Da Qinjiao Tang Major Chin-chiu Combination (1-6)

tang-kuei, siler, licorice, chiang-huo, atractylodes, cnidium, peony, chin-chiu, tu-huo, hoelen, rehmannia, angelica, asarum, scute; plus gypsum

Suwen Bingji Yiqi Baomingji (Zhang Yuansu 1186 A.D.). This formula is usually considered when there is muscle contraction and stiffness accompanying joint pain.

Da Fangfeng Tang Major Siler Combination (1-6)

tang-kuei, siler, licorice, chiang-huo, atractylodes, cnidium, peony, achyranthes, ginger, rehmannia, aconite, eucommia, ginseng, astragalus; plus jujube

Hejiju Fang (Imperial Medical Dept. 1085 A.D.). This formula was designed for pain and weakness in the legs due to downward flow of cold fluid; knee swelling may occur in such cases.

Shujing Lian San Clematis and Carthamus Formula (1, 2)

siler, licorice, chiang-huo, atractylodes, cnidium, achyranthes, chin-chiu, tu-huo, hoelen, rehmannia, aconite, angelica, stephania, clematis, citrus, carthamus, persica, scute, phellodendron, others

Wangbing Huichun (Gong Tingxian 1587 A.D.). This formula is mostly used in Japan, where it is given to patients with recalcitrant arthritis producing severe pain.

Jianbu Huqian Wan (3, 4, 6)

tang-kuei, siler, chiang-huo, atractylodes, peony, achyranthes, tu-huo, hoelen, rehmannia, aconite, ginseng, eucommia, astragalus, chaenomeles, coix, phellodendron; plus lycium, others

Shoushi Baoyuan (Gong Tingxian 1615 A.D.). This formula is designed for cases of kidney/liver deficiency resulting in weakness, stiffness, and pain in the lower body. The formula has been made into a patent medicine as well.

Shufeng Houxue Tang Stephania and Carthamus Comb. (1-4, 6)

tang-kuei, cinnamon, chiang-huo, atractylodes, cnidium, hoelen, ginger, angelica, clematis, stephania, carthamus, phellodendron; plus arisaema

Shenshi Zunsheng Shu (Shen Jinao 1773 A.D.). This formula is used in cases of excess syndrome, with red, swollen joints.

Shangzhong Xiatong Yongtong Feng Cinnamon and Angelica Formula (1-6)

cinnamon, chiang-huo, atractylodes, cnidium, chin-chiu, angelica, clematis, stephania, persica, carthamus, phellodendron; plus arisaema, shen-chu

Xifang Jijie (Wang An 1682 A.D.). This formula is used to treat arthralgia that is due to an excess syndrome; therefore, it lacks most of the tonic herbs used in other formulas.

Fangfeng Tang Siler Combination (2,3,5)

tang-kuei, siler, licorice, cinnamon, chiang-huo, chin-chiu, hoelen, ginger, ma-huang, scute; plus pueraria, apricot seed, jujube

Xuanming Lunfang (Liu Wansu 1172 A.D.). This formula is given to patients with wind-type arthritis, where the symptoms may vary considerably in intensity and site.

Shiweicuo San Astragalus and Aconite Formula (1, 2)

tang-kuei, siler, cinnamon, atractylodes, cnidium, peony, hoelen, rehmannia, aconite, astragalus

Yijianfang (Wang Shuo, Song Dynasty). This formula is designed to treat weakness and stiffness; it has a warming quality to treat cold-sensitive arthralgia.

Guizhi Shaoyao Zhimu Tang Cinnamon and Anemarrhena Comb. (1-6)

siler, licorice, cinnamon, atractylodes, peony, ginger; aconite, ma-huang; plus anemarrhena

Jingui Yaolue (Zhang Zhongjing 220 A.D.). This formula is used for treating those with swollen, stiff joints, especially if warm to the touch.

Yiyiren San Coix Formula (1)

tang-kuei, siler, licorice, cinnamon, chiang-huo, atractylodes, cnidium, tuhuo, ginger; ma-huang, aconite (wutou), coix

Mingyi Zhizhang (Huang Fuzhong 1502 A.D.). This formula is aimed at treating cold-dominated arthralgia.

Yiyiren Tang Coix Combination (1-6)

tang-kuei, licorice, cinnamon, atractylodes, peony, ginger, ma-huang, coix

Mingyi Zhizhang (Huang Fuzhong 1502 A.D.). This formula is used for patients with moisture dominant rheumatic disorder; it is widely used in Japan.

Shufeng Liushi Yin Clematis and Chin-chiu Comb. (1)

STNA. This formula is mostly used in siler, peony, achyranthes, chin-chiu, Japan, where it is given to patients with hoelen, angelica, clematis, stephania; plus moisture accumulation as the dominant capillaris, moutan disorder; the syndrome may cause numbness.

Danggui Niantong Tang Tang-kuei and Anemarrhena Comb. (1-6)

tang-kuei, siler, licorice, chiang-huo, atractylodes, ginseng, scute; plus cimicifuga, polyporus, alisma, capillaris, pueraria, sophora, anemarrhena

Lanshi Micang (Li Gao 1276 A.D.). This formula was designed to treat dampness accumulation in the lower body, causing swelling and pain.

Shentong Zhuyu Tang Cnidium and Chiang-huo Comb (1-6)

tang-kuei, licorice, chiang-huo, cnidium, achyranthes, chin-chiu. persica, carthamus; plus myrrh, pteropus, earthworm, cyperus

Yilin Gaicuo (Wang Qingren 1830 A.D.). This formula is designed to treat a blood stasis syndrome, which is generally associated with fixed location of stabbing pain.

Quhanbi Tang (3)

tang-kuei, licorice, cinnamon, peony; maSTNA. This formula is used for cold type huang, atractylodes, asarum, carthamus, arthralgia, marked by worsening with chaenomeles; plus typhonium, strychnos, exposure to cold. frankincense, myrrh

Hanshibi Tang (3)

cinnamon, chiang-huo, atractylodes, STNA. This formula is used for coldachyranthes, chin-chiu, aconite, clematis, damp arthralgia with symptoms of joint chaenomeles; plus piper, pangolin, swelling and stiffness. drynaria, sinomenium

Qufeng Tang (3)

tang-kuei, siler, cinnamon, peony, mahuang, aconite, angelica; plus zaocys, typhonium, schizonepeta

STNA. This formula is used for winddominant arthralgia, with the location of pain changing.

Juanbi Tang Chiang-huo and Turmeric Comb. (1-6)

tang-kuei, siler, licorice, chiang-huo, peony, ginger, astragalus; plus turmeric

Yixue Xinwu (Cheng Guopeng 1732 A.D.). This formula is often selected for pain in the neck, shoulder, and upper back.

siler, licorice, chiang-huo, cnidium, tuhuo; plus kao-pen, vitex

Nei Wai Shangbian Huolun (Li Gao 1247 A.D.). This formula is especially used when the patient reports a sensation of heaviness.

Fangji Huangqi Tang Stephania and Astragalus Comb. (1-6)

licorice, atractylodes, ginger, stephania, astragalus; plus jujube

Jingui Yaolue (Zhang Zhongjing 220 A.D.). This formula treats dampness accumulation in patients with a weak constitution; used especially for knee arthralgia.

Siwu Qinjiu Tang Chin-chiu Four Combination (2)

tang-kuei, cinnamon, cnidium, peony, chin-chiu, rehmannia, carthamus; plus morus twig

STNA. This formula is used for vitalizing blood circulation, a therapy applied in cases of fixed location stabbing pain.

Qing Huang San Schizonepeta and Ma-huang Formula (2)

tang-kuei, siler, licorice, cinnamon, STNA. This formula is given in cases of chiang-huo, atractylodes, cnidium, peony, moisture accumulation and for pain in the tu-hou, ma-huang; plus schizonepeta, upper body and arms. pueraria, cimicifuga

Mugua Wan Chaenomeles Pill (9)

tang-kuei, cnidium, achyranthes, angelica, This is a patent medicine that is indicated aconite, ginseng, clematis, chaenomeles; primarily for numbness and pain in the plus cibotium, millettia lower body.

Baixianbi Jianbu Wan (10)

tang-kuei, siler, chiang-huo, atractylodes, peony, achyranthes, rehmannia, This formula is used in Japan, where it is eucommia, ginseng, astragalus, known as Kenpo-gan, for general phellodendron; plus lycium, sinomenium, rheumatoid arthritis treatment. cuscuta, dioscorea, psoralea, others

Guanjieyan Wan (7)

cinnamon, atractylodes, achyranthes, chin-chiu, tu-huo, ginger, ma-huang, stephania, coix; plus erythrina

Fengshi Pian (8)

siler, cinnamon, licorice, achyranthes, tu- This is a patent medicine indicated for huo, ma-huang, eucommia; plus scorpion, arthralgia associated with stiffness and strychnos numbness of the limbs.

Duzhong Fengshi Wan (7)

tang-kuei, siler, cinnamon, cnidium, achyranthes, chin-chiu, tu-huo, hoelen, eucommia, ginseng (codonopsis), asarum; plus loranthus

This is a patent medicine mainly used for pain in the lower body.

Zhuifeng Huoxue Pian (8)

siler, cinnamon, licorice, chiang-huo, achyranthes, tu-huo, ma-huang, eucommia; plus frankincense, myrrh, homalonema, chaenomeles, illicium, pyritum

This patent medicine is indicated for weakness, coldness, and pain in the legs and lower back. It is a blood vitalizing formula, used in treating sharp pain.

Qianghuo Shengshi Tang Chiang-huo and Tu-huo Comb. (1-6)

This is a patent medicine aimed at treating dampness-dominant arthralgia, which usually affects the legs.

MAIN HERBS IN THE SELECTED FORMULAS Table 2 lists 8 herbs as "standard herbs" for arthralgia syndromes. They are broadly used in constructing arthralgia formulas and were included in at least half of the formulas listed in Table 1. There were another 21 herbs, listed in Table 3, that serve as adjunctive therapies; they each were present in at least 4 of the formulas. Each of these 29 herbs are described in some detail below, with the herbs presented from most frequently mentioned (21 times for tang-kuei and siler) to least frequently mentioned (4 times for coix, persica, scute, and phellodendron). In both Tables, the common name and pinyin name for the herb is given in the first column, followed by the botanical name and the plant family (in parentheses) in the second column. Traditional actions are from Oriental Materia Medica (11) and only include those that are related in some way to treatment of arthralgia. Table 2: Standard Herbs. The following herbs are routinely used in arthritis treatments and are not specific for a location or type of arthritis. In some cases, more than one variety of an herb can be used. For example, with cinnamon, the twig is most often utilized, but cinnamon bark, considered more warming, is included in some formulas; white atractylodes, which serves as a qi tonic, is more often used than red atractylodes (for clearing dampness), but sometimes both are included in the formulation; white peony, the blood-tonifying herb, is more often used than red peony, which may be substituted when a stronger blood-vitalizing action is desired. Herb Name: Common/Pinyin

Botanical Source/Family

Traditional Actions/Uses

Comments

Tang-kuei danggui

Angelica sinensis (Umbelliferae)

By nourishing blood and moving blood, tang-kuei supplements and moves prevents external factors of wind, cold, and damp blood from entering the vessels and causing disease.

Siler fangfeng

Ledeborella divaricata = Siler divaricata (Umbelliferae)

dispels wind, resolves surface, removes dampness

Siler is important because it not only dispels wind and damp, but it also tonifies the spleen to aid in circulation of dampness.

Licorice gancao/zhigancao

Glycyrrhiza uralensis (Leguminaceae)

supplements spleen, replenishes qi, harmonizes all drugs

Licorice is included in the formulas mainly to support the tonic action of other herbs and to harmonize the various herbal components; additionally, it has powerful antiinflammatory actions that have been demonstrated in laboratory experiments.

Cinnamon guizhi/rougui

Cinnamonum cassia (Lauraceae)

resolves surface, warms and promotes the flow of channels, removes obstruction of qi

Cinnamon twig is traditionally used in formulas to resolve the surface and normalize circulation; cinnamon bark may be used in cold-dominant arthralgia syndromes.

Chiang-huo qianghuo

Notopterygium forbesii or Angelica pubescens (Umbelliferae)

dispels wind, resolves surface, expels winddamp, controls pain

Chiang-huo is highly aromatic and is thought to quickly break through blockages in the surface.

Atractylodes baizhu/cangzhu

Atractylodes macrocephala [baizhu] and Atractylodes lancea [cangzhu] (Asteraceae)

baizhu: supplements spleen, tonifies qi, directs dampness; cangzhu: dries dampness, strengthens spleen, removes winddampness

Atractylodes is mainly used to tonify the stomach/spleen system in order to properly distribute moisture and generate healthy qi; red atractylodes is sometimes selected for dampnessdominated arthralgia when the fluid retention is obvious.

Cnidium chuangxiong

Ligusticum walichii or Cnidium officinale (Umbelliferae)

invigorates blood circulation, promotes the flow of qi, dispels wind, controls pain

Cnidium has a sedative action in laboratory experiments.

Paeonia lactiflora (Ranunculaceae)

baishao: supplements blood, controls pain; chishao: invigorates blood circulation, disperses stagnancy

Peony is used along with tang-kuei to nourish blood and along with cinnamon to regulate the surface; red peony is selected for blood-stasis type arthralgia, usually in the advanced stages.

Peony baishao/chishao

Table 3: Adjunctive Herbs. The herbs in this section are used for particular types of arthralgia or particular constitutional conditions of the patient. The herbs may be selected to address the dominance of one of the three factors contributing to bi syndromes: wind (e.g., use ma-huang or angelica); damp (e.g., use tu-huo, hoelen, clematis, stephania, or coix); or cold (use aconite or asarum). Further, the herbs may be selected for deficiency syndromes: for weakness add astragalus; for kidney/liver deficiency add rehmannia, eucommia, and achyranthes; for blood-stasis syndrome add persica and carthamus; for stiffness add chin-chiu and chaenomeles; for underlying heat syndrome, add scute and phellodendron. Herb Name: Common/Pinyin

Traditional Actions/Uses

Comments

Achyranthes niuxi/chuanniuxi

Achyranthes bidentia [niuxi] and Cyathula capitata [chuanniuxi] (Amarantheae)

niuxi: removes stagnant blood, disperses swelling, supplements kidneys and liver; chuanniuxi: removes wind, promotes water metabolism, invigorates blood

Achyranthes is mainly utilized as a blood tonic for cases of liver/kidney deficiency; for this purpose it is usually combined with rehmannia and/or eucommia. Cyathula is used in cases of bloodstasis type arthralgia.

Chin-chiu qinjiao/longdancao

Gentiana macrophylla [qinjiao]; Gentiana scabra [longdancao] (Gentianaceae)

qinjiao: removes wind and dampness; longdancao: expels dampness-heat

Chin-chiu is usually selected in cases of deficiency-type arthralgia, added to formulas comprised of many tonic herbs. It is especially selected when there is stiffness; gentiana is used instead when there is an excess-type arthralgia, with stagnation being the dominant condition.

Tu-huo duhuo

Angelica pubescens or A. laxiflora (Umbelliferae)

This herb is closely related to chiang-huo and removes windsometimes interchangeable. Tu-huo is preferred dampness, promotes for dampness-dominated arthralgia, while chiangcirculation of meridians, huo is preferred for wind-dominated arthralgia; expels dampness they are often combined together in formulas.

Hoelen fuling

Poria cocos = Pachyma promotes diuresis, hoelen eliminates dampness, (Polyporacea) strengthens spleen

Ginger shengjiang/ganjiang

Botanical Source/Family

Zingiber officinale (Zingiberaceae)

shengjiang: resolves surface, warms stomach and spleen; ganjiang: warms middle warmer, reinvigorates yang

Hoelen is preferred for dampness dominated arthralgia, where it is often combined with either atractylodes or stephania or both. Fresh ginger (shengjiang) is usually used in arthralgia formulas to resolve the surface and benefit the spleen; dry ginger may be substituted in cold-dominated arthralgia. Laboratory studies reveal an antiinflammatory action.

Ma-huang is especially used for the early stage of arthralgia where there are intense but shortduration inflammatory reactions and where the site of inflammation varies.

Ma-huang mahuang

Ephedra sinensis (Ephedrae)

resolves surface, regulates water metabolism

Rehmannia dihuang

Rehmannia glutinosa (Scrophulriaceae)

shoudi: nourishes blood, Cooked rehmannia (shoudi) is usually used in supplements liver and arthritis formulas, as a tonic, almost always with kidneys tang-kuei, to nourish the liver.

Aconite fuzi/caowu

Aconitum charmichaeli (Ranunculaceae)

restores yang, warms spleen and kidneys, dispels cold, controls pain

Angelica baizhi

Angelica dahurica (Umbelliferae)

removes wind, dissolves Angelica is primarily used in formulas for early surface, controls pain, stage arthritis, where the site of inflammation dries dampness varies, and in arthralgia affecting the upper body.

Eucommia duzhong

Eucommia ulmoides (Eucommiaceae)

supplements liver and kidneys

Eucommia is mostly used for arthralgia affecting the lower body.

Ginseng renshen

Panax ginseng (Araliaceae)

replenishes and supplements qi, expels evil qi

Ginseng is used to tonify the spleen and improve the qi and blood conditions. In patent medicines, it is substituted by Codonopsis pilosula (Campanulaceae)

Clematis weilingxian

Clematis chinensis (Ranunculaceae)

removes winddampness, promotes meridian flow, controls pain

Clematis is mainly used in cases of dampnessdominated arthralgia, which usually affects the legs, especially the knees.

Stephania fangji

Stephania tetrandra [hanfangji] (Menispermaceae) or Aristolochia fangji [guangfangji] (Aristolochiaceae)

promotes diuresis, disperses swelling, expels wind, relieves pain

Stephania is mainly used in cases of dampnessdominated arthralgia, usually in combination with hoelen. Recently, Aristolochia plants have been removed from the herb trade due to rare but serious kidney toxicity problems.

Astragalus haungqi

Astragalus membranaceous (Leguminosae)

supplements qi, Astragalus is mainly included in formulas for increases yang, delivers weakened patients. It is used along with ginseng, water atractylodes, and other tonic herbs.

Asarum xixin

Asarum heterotropoides; Asarum sieboldii dispels cold and wind (Aristolochiaceae)

Asarum is mainly used in formulas for colddominated arthralgia; it is often combined with aconite for that purpose.

Chaenomeles mugua

relaxes muscles and Chaenomeles lagenaria meridians, harmonizes (Rosaceae) the stomach, removes dampness

Chaenomeles is usually used in dampnessdominated arthralgia and especially when there is stiffness of the limbs.

Coix yiyiren

Coix lacryma-jobi (Gramineae)

relieves water retention, dispels dampness, Coix is usually used for dampness-dominated strengthens the spleen, arthralgia and for accompanying numbness. soothes numbness

Persica taoren

Prunus persica (Rosaceae)

stagnated blood accumulated in the meridians

Persica is used for blood-stasis syndrome, which contributes to fixed stabbing pain; it is often combined with carthamus for this purpose.

Scute huangqin

Scutellaria baicalensis (Labiatae)

dries moisture

Scute is used in cases where there is some internal heat or localized heat; the herb is selected because it also dries dampness.

dries dampness

Phellodendron is used in cases where there is some internal heat, especially in cases of kidney deficiency syndrome. For this purpose, it is combined with rehmannia.

Phellodendron Phellodendron huangbai amurense (Rutaceae)

Aconite is used in cold-dominated arthralgia; it has marked analgesic action when used in higher doses (or if unprocessed roots are used), but toxicity concerns lead to limiting the dosage and using it to restore yang.

CHARACTERISTICS OF THE COMMONLY USED HERBS There are at least three important characteristics of the herbs listed in Tables 2 and 3 in relation to treatment of arthritis: the common nature and taste of most of the herbs; the fact that several of the listed herbs are components of widely used traditional tonic formulas; and the reliance on herbs from a particular plant family with a similar group of active constituents. As to the nature and taste of the herbs, nearly all are warming, or at least neutral (exceptions: peony, stephania, coix, scute, and phellodendron are cold-natured), and most are spicy (exceptions: licorice, peony, achyranthes, hoelen, rehmannia, eucommia, stephania, astragalus, chaenomeles, coix, persica, scute, and phellodendron). Even among the herbs that stand as exceptions to this rule, only very few of these are used frequently in the formulas that were analyzed, namely: licorice, peony, and achyranthes, all of which serve the role

as tonics. The warm quality dispels cold, and the spicy quality dispels wind; the warm-spicy action disperses dampness accumulation and resolves stagnation at the surface (i.e., limbs, skin, flesh; not internal organs). As to the correspondence of several key herbs to traditional base formulas, the following two formulas contribute several of the herbs that are used with high frequency: 1. Tang-kuei Four Combination (Si Wu Tang), which contains tang-kuei, peony, cnidium, and rehmannia; Tang-kuei Four Combination nourishes and vitalizes blood circulation; and 2. Four Major Herbs Combination (Si Junzi Tang), which contains ginseng, atractylodes, licorice, and hoelen. Four Major Herb Combination invigorates the stomach/spleen functions, tonifies qi, and promotes moisture circulation. Deficiency of qi and blood flowing through the meridians makes the body susceptible to external pathological factors, such as wind, cold, and dampness. Qi deficiency further makes the body susceptible to developing internal chilliness or moisture accumulation that will merge with external cold and damp factors to worsen arthralgia. Blood deficiency will allow the development of internal wind secondary to liver dryness, which will merge with external wind to worsen arthralgia. The herbs in these two formulas are not specific for arthralgia, but, instead, are aimed at treating internal deficiencies that contribute to susceptibility to this and other diseases and that allow further progression of the diseases rather than spontaneous remission. The plant family that dominates this group of herbs is the Umbelliferae, sometimes known as the "celery family" because it includes this well-known plant. The herbs in this family mentioned in Tables 2 and 3 are: tang-kuei (see Figure 1), siler (see Figure 2), chianghuo, cnidium, tu-huo, and angelica. In all cases, the root material is used. The roots are fragrant, and there is a certain similarity in their odor that is attributable to the common active constituents. By contrast, the three Ranunculaceae herbs (peony, aconite, and clematis), the two Rosaceae herbs (chaenomeles and persica), and the two Leguminoseae herbs have only remotely related substances within each family group that contribute to their actions in the arthritis formulas (i.e., it is a coincidence that they fall into the same plant family). The common active constituents of interest belong to the chemical category of benzopyrone derivatives, mainly the coumarins (e.g., osthenol) and the furanocoumarins (e.g., bergapten). These compounds have been claimed to reduce protein-rich edematous swellings (see: Chinese herbs for lymphedema) and they have some antiinflammatory actions that have been revealed in laboratory animal experiments. Of the formulas listed in Table 1, all but one formula contains at least one of the Umbelliferae herbs (Da Qinjiao Tang contains all six of them); the exception is Stephania and Astragalus Combination, an ancient formula for leg edema that has been adopted to treat arthralgia of the knee.

REPRESENTATIVE FORMULAS There are five formulas presented in Table 1 (the first five listed) that are comprised almost entirely of the commonly used herbs for treatment of arthralgia and might be considered representative formulas: 1. Sanbi Tang (Chin-chiu and Tu-huo Combination) 2. Shujing Huoxue Tang (Clematis and Stephania Combination) 3. Duhuo Jisheng Tang (Tu-huo and Loranthus Combination) 4. Da Qinjiao Tang (Major Chin-chiu Combination) 5. Da Fangfeng Tang (Major Siler Combination) Each of these formulas contains at least 14 ingredients from Tables 2 and 3, but few additional ingredients not listed in the Tables. All of these formulas contain Tang-kuei Four Combination (Siwu Tang: tang-kuei, peony, cnidium, and rehmannia) plus siler and licorice. Of these, Sanbi Tang and Duhuo Jisheng Tang are the most commonly referenced formulas in the modern literature devoted to traditional herb formulas for treatment of arthritis.

RESEARCH EFFORTS The most recent Chinese medical literature on rheumatoid arthritis treatments, including English language publications as found in the Journal of Traditional Chinese Medicine and the Journal of Integrated Western and Traditional Medicine, reveal that there is much experimentation still going on with herbal recipes for rheumatoid arthritis. The new formulas may treat heat syndrome, blood stasis, phlegm accumulation, or other disorders that were not the principal targets (wind, cold, damp) of the more traditional approaches. In addition, they may utilize ingredients that are toxic and cannot be used in Western practice, such as the immune-inhibitor tripterygium or the powerful muscle stimulant strychnos. Such ingredients may have a more profound effect than the commonly used and gentle components of the formulas described above. Since Western patients are usually seeking treatments to substitute for the modern drugs that cause unacceptable side effects, the herbal prescriptions used must be essentially non-toxic. Due to concerns about the quality of design, conduct, and reporting of clinical trials for Chinese herbs, rather than reviewing the broad range of reports that can be found by searching the literature, an example will be provided here to illustrate the claimed results and the duration of therapy that was indicated as sufficient to yield those results. The study was selected for its large number of patients enrolled. The tableted formula Fengshi Hantong Pian (Rheumatism Cold Pain Tablets) was given to 310 patients suffering joint pain (12). The prescription included tang-kuei, chiang-huo, cinnamon, red peony, aconite, astragalus, clematis, coix, scute, sinemonium, deer antler, lycium, and corydalis. According to the report, after a course of treatment lasting ten days, marked pain relief was experienced by about 70% of the patients, with pain being the main arthritic symptom of concern. A 30 day course of this therapy produced normalization of ESR (erythrocyte sedimentation rate) and RF (rheumatoid factor) values in about half of the patients that were followed up (31 of 61 had normal ESR; 24 of 38 had RF turn from positive to negative). This report, and information garnered from other Chinese studies, suggest that alleviation of pain may be expected during the first week of treatment, blood chemistry changes may be expected as early as the first month of treatment, and remission may occur from one month to several months after treatment begins in some patients. Since rheumatoid arthritis can have periods of spontaneous remission,

the possibility that the herbs bring on an earlier or more complete remission can only be determined by very careful testing with large treatment and control groups. Unlike steroid drugs that powerfully inhibit the immunological component of the disease and can produce results within 24 hours, the herbal compounds may need to first reach a certain blood concentration that requires two or three days of regularly consuming the herbs, and then there may be another few days in which the changes in metabolism and immune function eventually result in a reduction of the inflammatory process. Still, if given in adequate dosage and if the formula ingredients are suited to the individual, some improvements (most alleviation of severe pain) could be reasonably expected in the first 3-7 days. Patients should not need to pursue the therapy for several weeks to determine if it has any influence on their condition. Other effects may take longer. For example, with benzopyrones in the treatment of protein-rich edemas, it has been indicated that a treatment time of several months is required to markedly reduce the swelling. Typically, Chinese herbal therapies for chronic diseases, such as rheumatoid arthritis, are given for several weeks or several months to attain substantial improvements. This duration of time is consistent with traditional Chinese theories of treatment of deficiency syndromes that underlie the disorder: it simply takes time to overcome the visceral weaknesses so that pathologic factors can be expelled.

MECHANISM OF ACTION Chinese researchers have attempted to elucidate how the herbs used in traditional arthritis formulas alleviate the symptoms-from the modern viewpoint-by carrying out numerous studies of the blood constituents of patients. According to studies that have been carried out recently (13, 14, 15), the mechanism of action that may be dominant in the situations with good therapeutic results is a reduction in the levels of pro-inflammatory cytokines, such as interleukin-1 (IL-1). The effect is then to alter the levels of T-cells and the production of activated antibodies and other components. In addition, or as a result, the properties of the blood and its circulation also change, with lowered sedimentation rate and improved circulation to the extremities. The herbs may also act on the prostaglandin synthesis and degradation pathways, yielding a lower level of pro-inflammatory prostaglandins.

REFERENCES 1. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations , 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA. 2. Hsu HY, Neuralgia, rheumatism, and gout and their Chinese herb treatment, Bulletin of the Oriental Healing Arts Institute, 1979; 4(4): 16-27. 3. Vangermeersch C, and Sun Pei-lin, Bi-Syndromes, 1994 SATAS, Belgium. 4. Guillaume G and Chieu M, Rheumatology in Chinese Medicine, 1996 Eastland Press, Seattle, WA. 5. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 1, 1993 Heilongjiang Education Press, Harbin. 6. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. 7. Fratkin J, Chinese Herbal Patent Formulas: A Practical Guide, 1986 Shya Publications, Santa Fe, NM. 8. Chun-Han Zhu, Clinical Handbook of Chinese Prepared Medicines, 1989 Paradigm Publications, Brookline, MA. 9. Chen Keji (editor), Chinese Patent Medicines, 1997 Hunan Science and Technology Press, Hunan, China. 10. Tsung PK and Hsu HY, Arthritis and Chinese Herbal Medicine, 1987 Oriental Healing Arts Institute, Long Beach, CA. 11. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 12. Wang Zhaoming, et al., A report on 310 cases of articular rheumatism treated with Fengshi Hantong Pian, Chinese Journal of Integrated Traditional and Western Medicine 1985; 5(5): 284-285. 13. Zhou Xueping, et al., Clinical and experimental study on treatment of mid-late stage rheumatoid arthritis with Shuguan Granules, Chinese Journal of Integrated Traditional and Western Medicine 1999; 5(3): 165-170. 14. Xu Desheng, et al., Clinical and experimental study on RA Mixture in treatment of rheumatoid arthritis, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(3): 178-183. 15. Li Shangzhu, et al., Changes in blood flow in the extremities in patients with rheumatoid arthritis and treatment with integrated traditional and western medicine, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(2): 115-116.

August 2000



Figure 1. Angelica sinensis; tang-kuei.

Figure 2. Ledeborella divaricata; siler.

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AUTISM by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Autism is characterized by profound disturbance in the emergence of social relations, apparent as early as the first months of life and almost always by age three years (1). Disturbances in brain maturation appear to be a cause of this syndrome, which may be exacerbated by deficiencies in certain nutrients (e.g., vitamin B6 , magnesium, glycine, glutamine), by allergies to foods, and other factors. The severity of symptoms can vary markedly between individuals and in response to treatment. The relationship of serotonin to autism has been investigated extensively, but the implications remain unclear due to conflicting findings. Serotonin levels in autistic individuals tend to be elevated (2, 3, 8), as are the levels of the serotonin precursor tryptophan (11), with apparent increase in symptom severity correlated with the tryptophan levels. In fact, a hypothesis has been put forward (2) suggesting that there is a maturation defect in the monaminergic systems in autism. Alternatively, however, it may be that the defect in serotonin metabolism is a marker for tendency to experience autism but is not a cause of the disorder. Relatives of autistic children are found to have a variety of serotonin-metabolism disorders, but not the mental disorder (9). A serotonin lowering drug, fenfluramine, was tested (10) in a double-blind placebo-controlled trial, but no obvious therapeutic effect was noted. On the other hand, a test (12) of both the dopaminergic antagonist (amisulpride) and the dopaminergic agonist (bromocriptine) did show some effects that might indicate a role of the monoamines in autism symptoms. The evidence thus far points to a role of monoamines in the severity of autism symptoms but it appears that the biochemical imbalance is not the sole disorder leading to autism. Autism has been correlated with other childhood disorders that are related to brain function, such as attention deficit disorder (ADD), mental retardation, epilepsy, and learning disabilities (4). While the specific mechanisms and manifestation of these disorders differ significantly, there is a relatively high incidence of one or more such disorders occurring simultaneously and a similar benefit is claimed to using certain nutritional approaches, such as administering nutritional supplements and avoiding allergens. Chinese books on pediatrics do not mention autism, and this subject does not appear in the modern Chinese medical journal literature either. In the book Clinical Experiences (5), a condition is described as follows: disturbance in mental development, apathy, tardiness of speaking...” which is described as a syndrome of “heart blood” deficiency and the suggested treatment is an herbal formula given as a decoction, consisting of 10 grams each ginseng, ophiopogon, and acorus, 6 grams each of tang-kuei and polygala, 5 grams of frankincense, 3 grams of cnidium, and 1.5 grams of cinnabar. This formula nourishes the heart qi, yin, and blood, vitalizes the heart blood, removes phlegm obstructing the orifices of the heart, and calms the agitation of the heart spirit (shen). This prescription might be compared with the formula recommended in the pediatrics volume of the Encyclopedia of Traditional Chinese Medicine (6) for treatment of hyperkinetic syndrome in patients who display symptoms of “changeable interests, divided attention, amnesia, dreaminess, stutter, or problems in formation of phrases and sentences....” The formula is as follows: 12 grams each of pseudostellaria and astragalus, 9 grams each of hoelen, atractylodes, tang-kuei, polygala, acorus, and schizandra, with 15 grams of wheat, 6 grams of licorice, and 10 pieces of jujube. This is basically a combination of Licorice and Jujube Combination (Gan Mai Da Zao Tang ), and Astragalus and Zizyphus Combination (Yang Xin Tang ), two traditional formulas used for mental disturbance. The new formula tonifies the qi and blood, removes phlegm obstruction of the orifices, and calms the spirit. In an article (7) reviewing basic Chinese medical treatments for mental syndromes, the classical division of mental disorders into “dian” and “kuan” types is made. The dian type refers to taciturn and uncommunicative behavior, dementia, lack of sympathy, apathy, and soliloquy; it refers to the person who turns inward. This is closest to the autistic condition. The kuan type, by contrast, is very aggressive; it refers to the person who acts out, loudly and sometimes violently. The famous physician Zhou Danxi stated “Dian belongs to yin and kuan to yang...both conditions are caused by the entanglement of phlegm in the heart...” The ancient texts also attribute the dian and kuan states to congestion of the seven emotions which generate phlegm and mask and obstruct the orifice of the heart. A general formula for alleviating the phlegm obstruction is made by combining pinellia, magnolia bark, perilla fruit, hoelen, arisaema, curcuma, acorus, polygala, perilla leaf, sinapis, raphanus, bamboo juice, and styrax (liquid). Deficiency of qi and blood also gives rise to the dian condition; for symptoms and signs that include spiritlessness, suspiciousness, melancholy mood, refusal of food, soliloquy, and tendency to cry, the formula recommended contains codonopsis, atractylodes, astragalus, tang-kuei, licorice, polygala, fu-shen, saussurea, ginger, jujube, wheat, nardostachys, fu-shou, citrus, zizyphus, albizzia, polygonum stem, and dragon bone. In the book Clinic of Traditional Chinese Medicine (13), a formula for dian type condition (stagnancy of phlegm and qi), the indications include apathy, dementia, muttering to oneself, and the treatment is 12 grams of curcuma, 10 grams each of citrus, pinellia, hoelen, arisaema, chih-shih, polygala, acorus, and cyperus, and 6 grams of licorice. In the review article (15) on the classification and treatment of mental disorders, early Chinese writings about various mental syndromes are mentioned. Among them is this commentary attributed to Li Peng in the Ming Dynasty book Entering the Door of Medicine: The mental disorders is described in but one word: phlegm. These diseases are mostly caused by internal injury and only extremely rarely due to external pathogenic influences. The internal trauma, excessive wetness, inappropriate diet, food stagnation, could produce phlegm fire. Then uprising phlegm fire masks the heart orifices. When the person was frightened or fearful or worried or thinking too much, the fire will become more vigorous and then the spirit will not be able to reside in its house. Then the phlegm would suffocate the empty house. The formulas described above clear out the accumulated phlegm and help prevent formation of additional pathological phlegm. It is important to recognize, however, that adverse dietary practices can overcome the impact of the herbs. Discussing specifically the dian type of mental condition, it is said (13, 15) that it is mostly caused by traumatic injury to the seven emotions. The injured emotion will lead to heart fire, obstruction of liver qi, and failure of the ascending of the spleen qi. When qi becomes stagnated, the body fluid will accumulate and condense to form phlegm. The uprising of phlegm will interfere with and cloud the spirit. As an example of a specific treatment, the following herbs are suggested: 12 grams of hoelen, 9 grams each of pinellia, citrus, chih-shih, bamboo, cyperus, and polygala, 6 grams each of curcuma, acorus, saussurea, and licorice, plus 3 slices of fresh ginger. To what extent might these theories and treatments for a yin-type mental disorder apply to the autistic child or adult? Many of the discourses on mental disorders by Chinese doctors refer to people who develop the mental syndrome after being relatively normal, but

are then influenced by some events. While this may be the case in some autistic children, current Western investigations suggest that there is a physical and biochemical disorder present at birth. However, the severity of symptoms can be modulated in many children by diet, nutrition, and drugs, and therefore Chinese medical treatments for similar symptoms acquired in individuals through various experiences (which would affect the biochemistry rather than the physical structures of the brain) may be applicable. Which particular combination of herbs, though, might work best for an autistic child? One can not know until something has been tried. The only report available to us on treatment of autism with Chinese herbs is an informal communication from a medical doctor in Belgium who had studied with this Institute. He claimed that he had obtained a notable favorable response in several autistic children using the prepared Bamboo and Ginseng Combination (Zhu Ru Wen Dan Tang ). This formula contains bamboo, licorice, coptis, bupleurum, hoelen, ginger, pinellia, ginseng, cyperus, citrus, and chih-shih. As with the formulas mentioned above, it includes digestion-promoting, phlegm-resolving, and sedative herbs. Unlike some of the above, it contains none of the blood tonic herbs. The report of effectiveness was made several years ago, and the Institute does not have current contact with this physician. More recently, a formula for treatment of ADD was developed by ITM, called Acorus Tablets (21), and several informal reports of effectiveness were obtained from practitioners who gave it to their patients. This formula contains acorus, polygala, fu-shen, alpinia, curcuma, rehmannia, dragon bone, dragon teeth, oyster shell, bamboo sap, tortoise shell, and succinum. Like the above formulas, it contains herbs for resolving phlegm, sedatives, and blood tonics, but it contains only one herb for promoting digestive functions (alpinia). This formula was based on the claimed effective use of similar combinations for the treatment of ADD in China. In the treatment of epilepsy in children, similar formulations are used, with an emphasis on resolving phlegm obstruction. Another combination (21) produced by ITM, Cyperus 18, was designed to treat mental depression that arose from the syndrome of heart fire, liver qi stagnation, and poor conductance of food essence by the spleen, with resultant phlegm obstruction. This formula contains cyperus, perilla leaf, bamboo, uncaria, saussurea, bupleurum, aurantium, fu-shen, pinellia, chih-shih, coptis, ginseng, ophiopogon, tang-kuei, cnidium, ginger, arisaema, and licorice. Informal reports have indicated that it is often successful. As an example, a patient at our own clinical facility (under treatment for multiple sclerosis) had used antidepressive drugs for eight years, but was able to discontinue the drugs after use of this formula for less than six months. Given the limited experience thus far and the commentaries from ancient and modern writers about treatment of mental disorders, including childhood problems such as ADD, mental retardation, and epilepsy, it would appear that the most likely approach to prove helpful is to utilize the phlegm-resolving herb compounds. It is possible that the digestion-promoting and qi and blood tonic therapies used in China accomplish a function similar to the use of vitamin and amino acid therapies in the West. Since the latter have been tested and appear safe and somewhat effective, one may decide to utilize the Western nutritional approach and the Chinese method of removing “phlegm obstruction.” The most frequently used herbs for treating phlegm obstruction that causes mental disturbance are polygala and acorus. Polygala has a long-standing reputation in China for improving mental conditions. According to British doctors (16) who visited China during the previous century, polygala “is supposed to have a special effect upon the will and mental powers, giving strength and character, improving the understanding, strengthening the memory, and increasing the physical powers.” Acorus is reported (17) to be effective in the treatment of epilepsy of the phlegm-dampness and phlegm-heat types, being of benefit in 80% and 55% of cases respectively. It is similarly reported that if acorus is added to a basic sedative formula, it is effective in treating melancholia and that “patients abandon the idea of suicide by taking about 7 doses of the decoction.” In a book (18) reviewing the current uses of commonly prescribed Chinese herbs, both acorus and polygala are mentioned as treatments for epilepsy and mental disorders, with acorus specifically mentioned as valuable in the treatment of children. In another book (19) reviewing the modern use of herbal formulas, it is mentioned that the combination of arisaema, polygala, and acorus are added to other formulas for the symptomatic treatment of “spiritual inertia.” Of course, when a skilled practitioner is available to access the needs of the autistic child, it might be determined that qi and/or blood tonics, or other herbs are needed. These would especially be suggested if the child is growing slowly, is pale, or has a weak pulse. A suggested herbal combination based on the above considerations would be comprised of ginseng, hoelen, pinellia, citrus, ginger, jujube, licorice, acorus, polygala, tang-kuei, fu-shen, and bamboo. For convenience of obtaining herb supplies and administering herbs in pill form (if desired), this combination could be approximated by using Er Chen Wan (traditional formula made as a patent medicine) plus Acorus Tablets (child size tablets). Some Chinese herbs have been shown to reduce serotonin levels or inhibit the action of serotonin (20). Serotonin is a mediator of pain signals, and analgesic herbs sometimes function via reducing the signal transmission. Diterpene alkaloids, such as aconitine (from aconite) and methysergide, block the effects of serotonin. Rauwolfia alkaloids, such as reserpine and rhynchophylline (from uncaria), deplete serotonin. Volatile oils from asarum and acorus also lower serotonin levels (the active constituent in acorus is asarone). Of these herbs, only acorus is frequently mentioned in the formulas above, though uncaria is often used in treating mental disorders (included in Cyperus 18), and is used in children’s remedies. A formula comprised of aconite, dry ginger, cinnamon bark, and licorice was utilized (14) in treating dian-type schizophrenia characterized by little change in facial expressions, dull eyes, decrease in self-initiated movements, inability to love, talking little and having sentences with little content or unfinished, and lack of interest in socializing. the recommended dosage of aconite was quite high. It is possible that the serotonin-inhibitors reduce the symptoms of the dian type mental disorders. To obtain a serotonin-inhibiting action, the dosage of the herbs may need to be higher than is often recommended for treating other disorders. The need to use high dosages is also the situation with nutritional supplements applied in Western studies of autism. In a review of vitamin B6 and magnesium supplementation trials provided by the Autism Research Institute, the dosage of the vitamin administered covered a wide range, but was typically 30 mg/kg/day up to about one gram per day, and magnesium dosage was typically 10–15 mg/kg/day, up to about 500 mg. These levels far exceed what is available from dietary sources. Glycine, in the form of dimethylglycine, is recommended in dosages of 125–500 mg/day, starting with a low dose and increasing gradually to minimize the occurrence of hyperactivity in response to initial dosing. Due to the lack of familiarity of most Westerners with Chinese herbs, leading to questions about their safety, efficacy, method of application, and duration of use, it can not be expected that Chinese herb formulas will be widely utilized in the treatment of autism, especially in young children. However, there is sufficient evidence that Chinese physicians have had experience and some success in treating mental disorders similar to autism (perhaps sometimes autism itself), so that it is a method that should be pursued with due caution along with the recommended dietary and nutritional approaches. There are several herbal formulas which have been used extensively in the West without significant adverse effect that can be used as the starting point for experimental treatments.

References 1. Cohen DJ, et al., Integrating biological and behavioral perspectives in the study and care of autistic individuals in the future, Journal of Psychiatry and Related Sciences 1993; 30(1): 15–32. 2. Rolf LH, et al., Serotonin and amino acid content in platelets of autistic children, ACTA Psychiatry Scandinavia 1993; 87(5): 312– 316. 3. Cuccaro ML, et al., Whole blood serotonin and cognitive functioning in autistic individuals and their first-degree relatives, Journal of Neuropsychiatry and Clinical Neuroscience 1993; 5(1): 94–101. 4. Rimland R, ARI recommendations on treatments for autistic and other mentally and neurologically handicapped children , Autism Research Institute 1993; 49. 5. Shang Xianmin, et al., Practical Traditional Chinese Medicine and Pharmacology Clinical Experiences , 1990 New World Press, Beijing. 6. Xu Xiangcai, et al., English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, 1990, Higher Education Press, Beijing. 7. Peng Zheling, Seven treatments for mental patients, Journal of the American College of Traditional Chinese Medicine, 1992; 4: 12– 17. 8. Naffah-Mazzacoratti MG, et al., Serum serotonin levels of normal and autistic children, Brazilian Journal of Medical and Biological Research 1993; 26(3): 309–17. 9. Cook EH, et al., Platelet serotonin studies in hyperserotonemic relatives of children with autistic disorder , Life Sciences 1993; 52(25): 2005–2015. 10. Leventhal BL, et al., Clinical and neurochemical effects of fenfluramine in children with autism , Journal of Neuropsychiatry and Clinical Neuroscience 1993; 5(3): 307–315. 11. Hoshino Y, et al., Blood serotonin and free tryptophan concentration in autistic children, Neurophyschobiology 1984; 11: 22–27. 12. Dollfus S, et al., Amisulpride versus bromocriptine in infantile autism: a controlled crossover comparative study of two drugs with opposite effects on dopaminergic function, Journal of Autism and Developmental Disorders 1992; 22(1): 47–60. 13. Zhang EQ, et al., Clinic of Traditional Chinese Medicine, 1988; Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai. 14. He Shaoqi, Xiandai Zhongyi Neike Xue 1991; Zhongguo Yiyao Keji, Beijing. 15. Cheng Jianxu, Classification and treatment of mental disorders by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1987; 3: 31–62. 16. Smith FP and Stuart GA, Chinese Medicinal Herbs; reprinted 1973, Georgetown Press, San Francisco, CA. 17. Dong ZL and Yu SF, Modern Study and Application of Materia Medica, 1990, China Ocean Press, Beijing. 18. Ou Ming, editor, Chinese-English Manual of Commonly Used Herbs in Traditional Chinese Medicine , 1989 Joint Publishing Company, Guangdong. 19. Wang Qi and Dong ZL, Modern Clinic Necessities for Traditional Chinese Medicine, 1990, China Ocean Press, Beijing. 20. Dharmananda S, Analgesic components of herbs and their mechanisms of action, START Group 1993, Institute for Traditional Medicine, Portland, OR. 21. Dharmananda S, A Bag of Pearls, 1994 Institute for Traditional Medicine, Portland, OR. August 1997

Autoimmune Diseases and the potential role of Chinese Herbal Medicine by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND TO THE DISEASE CATEGORY Autoimmune diseases are chronic disorders that have been difficult, and often impossible, to cure. There can be remission of symptoms —spontaneously or as the result of applied therapies—but the potential for return of the disease remains in almost all cases. The characteristic of these diseases is immune system targeting of body components, so that these components are damaged, either temporarily or permanently, or their activities are altered. The autoimmune diseases almost always have a significant genetic component; in addition many of the diseases in this category appear to have a viral or other infectious agent as a trigger for onset of the autoimmune status. There may be a variety of other factors that are important to finally set off a pattern of symptomatic disease so that its first manifestation may be after age 20 (there are also late-onset autoimmune diseases). In fact, if the disease appears much earlier than that (i.e., prior to the teen years), it is usually a very aggressive form with a strong genetic component. There are dozens of diseases that are classified as involving autoimmune responses or suspected of having an autoimmune basis. In many of the diseases, there is a significant difference in incidence among men and women; overall, women are about 3 times as likely as men to suffer from autoimmune disorders (however, in some disorders, such as MS, men appear to have a more severe disease pattern). If the initial symptoms are mild or if the disease progresses slowly or develops its symptoms in an unusual pattern, diagnosis is difficult. Some patients relay experiences of pursuing medical diagnosis and treatment for a decade before getting a definitive disease name. A greater number of tests that can suggest or confirm presence of an autoimmune disease have become available so that it is now easier to make a diagnosis than ever before, but some disorders suspected of being autoimmune diseases still lack reliable tests, especially for their early stages. The incidence of autoimmune diseases in the U.S. has been estimated to be just over 3%, with a current affected population of about 10 million people. Societies representing people suffering from autoimmune diseases consistently over-report the incidence rates, using the upper limits from the highest estimate ranges; thus, the incidence rates given in these circumstances—often relayed by the news media—must be interpreted cautiously. Some of the common autoimmune disorders are outlined below.

Connective Tissue Diseases The most prevalent autoimmune disorders are connective tissue diseases, accounting for nearly half of all the cases; rheumatoid arthritis is the dominant one. The main connective tissue diseases are:

RHEUMATOID ARTHRITIS This is a systemic disorder in which immune cells attack and inflame the membrane around joints (it also can affect the heart, lungs, and eyes, though rarely). The incidence in women is far higher than men for younger individuals, but the difference is less with disease onset after age 50. Symptoms: Inflamed and/or deformed joints, loss of strength, swelling, pain.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) SLE can affect virtually any organ system, producing inflammation. It is up to 9 times more common in women than men and occurs in black women 3 times as often as white women. Symptoms: 90% of patients experience joint inflammation similar to rheumatoid arthritis. Fifty percent develop a classic “butterfly” rash on the nose and cheeks. Raynaud's phenomenon (extreme sensitivity to cold in the hands and feet) appears in about 20 percent of people with SLE. Other symptoms include fever, weight loss, hair loss, mouth/nose sores, malaise, fatigue, and brain disorders. Exposure to UV light can promote the disease process.

SYSTEMIC SCLEROSIS (SCLERODERMA) Scleroderma results from attack of immune cells that produce scar tissue in the skin, internal organs, and small blood vessels. It affects women three times more often than men overall, but increases to a rate 15 times greater for women during childbearing years, and appears to be more common among black women. Symptoms: In most patients, the first symptoms are Raynaud’s phenomenon and swelling and puffiness of the fingers or hands. Skin thickening follows a few months later. Other symptoms include skin ulcers on the fingers, joint stiffness in the hands, pain, sore throat, and diarrhea.

SJÖGREN'S SYNDROME Sjögren's syndrome is a chronic, slowly progressing inability to secrete saliva and tears, and is usually a late-onset disease. It can occur alone or with rheumatoid arthritis, scleroderma, or SLE. About 90% of cases occur in women, most often at or around the menopausal years. Symptoms: Dryness of the eyes and mouth, swollen neck glands, difficulty swallowing or talking, unusual tastes or smells, thirst, tongue ulcers, and severe dental caries (which occur because of the lack of saliva). The other autoimmune diseases fall into several groupings, among the most common are these:

Neuromuscular Diseases The neuromuscular diseases are mainly those involving immune attack affecting the nerves, which has the result of impairing muscle responses. The primary response is usually muscular paralysis, but there can also be tremor and/or tonic spasm where nerve transmission is partially blocked.

MULTIPLE SCLEROSIS (MS) A disease of the central nervous system that usually first appears between the ages of 20 and 30, and affects women twice as often as men. MS is the leading cause of disability among young adults, and it causes irreversible scarring of the myelin sheath to varying extents. The primary form is remitting/relapsing, but there is also a “progressive” form, which worsens regularly. Symptoms: Numbness, weakness, tingling or paralysis in one or more limbs, impaired vision and eye pain, tremor, lack of coordination or unsteady gait, and loss of control of urination.

MYASTHENIA GRAVIS

This is characterized by gradual muscle weakness, often appearing first in the face, particularly at the eyes and then affecting the mouth and throat. Symptoms: Drooping eyelids, double vision, and difficulty breathing, talking, chewing, and swallowing.

Endocrine Diseases The endocrine diseases involve attack of the immune system against one of the glands, sometimes with rapidly progressing destruction (as in diabetes or Addison’s disease). However, in Grave’s disease, antibodies attach to a hormone stimulating receptor on thyroid cells and don’t destroy the cells but rather stimulate their production of thyroid hormone.

HASHIMOTO'S THYROIDITIS This is a type of autoimmune disease in which the immune system destroys the thyroid gland. It is primarily a disease suffered by women (50 times more often than men). Symptoms: Low levels of thyroid hormone cause mental and physical slowing, greater sensitivity to cold, weight gain, coarsening of the skin, and goiter (a swelling of the neck due to an enlarged thyroid gland).

GRAVES' DISEASE Graves' disease is one of the most common autoimmune diseases, affecting about 1% of people in the U.S, frequently appearing during childhood, and affecting women 7 times as often as men. Patients with Graves' disease produce an excessive amount of thyroid hormone. Symptoms: Weight loss due to increased energy expenditure; increased appetite, heart rate, and blood pressure; tremors, nervousness and sweating; frequent bowel movements.

INSULIN-DEPENDENT (TYPE 1) DIABETES Type 1 diabetes is caused by autoimmune attack against the pancreatic islet cells that produce insulin, resulting in very low levels of insulin production, usually too little to survive without providing exogenous sources (insulin shots). The disease usually occurs in children and young adults (differentiated from Type 2 diabetes that does not originate from autoimmune processes, and most often affects those who are obese), and affects boys and girls at about the same rate, a slightly higher incidence in boys. Symptoms: Increased thirst, increased urination, weight loss, fatigue, nausea, frequent infections.

Other Autoimmune Diseases Some of the more common disorders that don’t fit the above categories are mentioned here. These occur in roughly equal rates for men and women.

INFLAMMATORY BOWEL DISEASE Inflammatory bowel disease refers primarily to two autoimmune disorders of the small intestine—Crohn's disease and ulcerative colitis. Symptoms of Crohn's disease: Persistent diarrhea, abdominal pain, and general fatigue. Symptoms of ulcerative colitis: Bloody diarrhea, pain, urgent bowel movements, joint pains, and skin lesions. In both diseases, there is a risk of significant weight loss and malnutrition.

HEMATOLOGIC AUTOIMMUNE DISEASES Blood cells can be affected by autoimmune disorder. In autoimmune hemolytic anemia, red blood cells are prematurely destroyed by antibodies; in thrombocytopenic purpura (usually described as ITP), the immune system attacks the platelets, and in autoimmune neutropenia (destroying a group of white blood cells, neutrophils). These diseases often occur in children and are believed to be triggered by a viral infection in many instances.

UNDERSTANDING THE DISEASES Many times, autoimmune disorders are mistakenly described as excessive responses of the immune system or deranged responses of the immune system (“the immune system has broken down”). In fact, this depiction is misleading. A portion of the immune system has been targeted to attack specific parts of the body, in the same manner that it would target a pathogen; it may be functioning normally and without disorder, other than the “target,” which was established by genetics and certain events. Thus, even if the immune system is in all other ways normal, this response gives rise to the disease symptoms. What is of particular interest is the fact that for several of the autoimmune diseases the activity of the immune system may come and go, so that there are periods of “remission” and periods of “exacerbation.” For these diseases, if a method for maintaining remission can be found, then even though the underlying condition isn’t completely eliminated, it is not producing new symptoms or progressing. And, a discovery for significantly prolonging remission may result in developing strategies for addressing other, more consistently active autoimmune diseases. The medical method of treating many of these diseases that has been available for about a century is with potent anti-inflammatory and immune-inhibiting drugs. The therapy usually provides a very quick beneficial result (noted within hours of the first dose) but then there is the conundrum that most of these drugs are not well suited to long-term therapy, so there has been a difficult risk-benefit balancing to help keep people symptom free to the extent possible without them suffering too many side-effects or adverse events. Overall, the results have been remarkably good, but far from satisfactory. An example of the unusual steps that may have to be taken to maintain results is in Grave’s disease, which involves an antibodyinduced stimulation of the thyroid gland rather than inflammation. Absent a good method to inhibit the immune system’s role in overproduction of thyroid hormone, a treatment commonly used is to eliminate the thyroid tissue by administering radioactive iodine and then provide an exogenous source of thyroid hormone for life. This method saves lives and helps people lead a life free of the serious Grave’s disease symptoms, but one would prefer to eventually resolve the antibody problem instead and preserve the thyroid gland. Modern research has aimed at two ways of addressing the basic problem: one is trying to interrupt the specific immune attack (rather than using broad immune suppression) by determining which substances can interact with the involved portion of the immune system; the other is to find ways to modulate the immune response so that there is less likely to be an attack against the body (but still leaving the immune system fully capable of fending off infections or inhibiting other pathological processes). Other approaches to treatment will develop with genetic engineering, use of stem cells, and upcoming techniques yet to be evaluated. An example of the immunological approach is use of IVIG (intravenous immunoglobulin) for ITP. This treatment is based on extraction of human blood plasma, which is rich in immunoglobulins that interfere with the destruction of platelets by the autoimmune process. The treatment is fast acting, but does not cure the disease, and little is known about its mechanism. IVIG is currently very

expensive and reserved for emergency cases, though its use is becoming more prevalent with favorable experience. The standard therapy is to use prednisone, which is inexpensive, also has quick response, but can not be maintained long term (spleen removal also helps reduce the severity of the disease, but rarely halts its progression for long). Another example is an experimental approach to treating MS in early stages of investigation. In this disease, T-cells are involved in the attack against the myelin sheath of the nerves of the central nervous system. The T-cells appear to be controlled by exposure to large amounts of the myelin proteins they normally would attack, so by intravenous administration of these proteins, the MS attacks might be impaired. Currently, MS patients take drugs that are derivatives of interferon which modifies the immune response in a manner not fully understood, but results in reduced frequency of exacerbations for the remitting/relapsing type of MS. If there is success in the endeavors to interrupt the autoimmune attacks, patients my not need to turn to Chinese medicine as a potential method of alleviating autoimmune responses. However, medical research is several years away from finding reliable treatments, and even where some success has been attained, there are limitations. Thus, patients with these diseases will for many years be seeking help through adjunctive methods, such as traditional Chinese medicine.

CHINESE MEDICINE AND AUTOIMMUNE DISEASES The long tradition of Chinese medicine that has led up to its modern practice did not have a concept that clearly correlates with what we know today as autoimmunity. Possibly the closest concept was related to the idea of trapping a pathogenic force inside the body (for example, by closing the pores rather than dispelling pathogens through sweating), or by providing conditions that would invite such a pathogen to remain in the body (e.g., interior nourishment and dampness, but weak defense), so that a disease would continue far longer than it should. Xu Dachun (1) described a condition where the body’s own qi merges with that of the pathogen; he used the analogy of oil poured into flour: the ingredients can not be separated. In such situations, the body’s normalizing efforts may end up participating in the problem, and this reminds us of the case where the immune system is participating in an attack against the body itself. He also mentions a situation where a disease appears to have been cured, but then suddenly it seems to come back and may even end in death; he likens the situation to a fight between two tigers, where one wins (that is, the body wins; the pathogen is defeated), but in doing so, it has exhausted all his strength and eventually succumbs as well. This can remind us of a remitting and relapsing autoimmune disease. Although there are some intriguing parallels with autoimmunity in these kinds of stories, the fact is that the ancient Chinese depictions are too general for us to use in any practical way. Generally, the traditional Chinese medical ideas became fixed upon the concept of external pathogens (which can be climactic influences, such as cold and wind) entering the body; they might then be successfully expelled. With autoimmunity, one part of the body (an invisible immune system component) is attacking another part (such as connective tissue), and there may be no foreign disease component involved at the time (even if one served as a trigger years earlier) and nothing to “expel.” Thus, the analogies remain limited. Most times, the description of diseases in the pre-20 th century literature of China gives us insufficient information to associate them with specific modern diseases. That is because the literature would often leave out key elements we need to make the correlation, such as how long the disease has lasted and how it has varied over time (months). More typically the descriptions in the Chinese texts involve the immediate situation: the symptoms as presented and how the disease has changed over just a few days. Then, it is impossible to know if this was a case of exacerbation of an autoimmune disease, or if it was an infectious disease, or some other condition. Still, we are able to turn to the centuries of Chinese medical experience for insights into at least one of the autoimmune diseases: rheumatoid arthritis. It seems evident from the Chinese literature that this disease existed in the past; we have the traditional descriptions which show a distinct overlap—in terms of symptoms and disease progression—with the modern depiction. The textual evidence points to rheumatoid arthritis among other painful disorders of the joints, muscles, tendons, ligaments, blood vessels, and other tissues: the bi syndromes. In the Neijing Suwen, it is indicated that the pathological entities of wind, cold, and wetness could lead to such a “bi” syndrome, at least one of which had characteristics of rheumatoid arthritis. It was said in that ancient record that when the wind component dominated, the symptoms would migrate; when cold dominated, the condition would be especially painful; when dampness dominated, the site of the affliction would become fixed (today, Chinese literature often attributes this localization to blood stasis and/or phlegm accumulation). During the 20th century, Chinese doctors began routinely incorporating modern medical diagnostics into the field of traditional medicine. Immunology didn’t develop significantly anywhere in the world before the 20 th century, and it came to China somewhat late, but was immediately applied to discussion of traditional disease categories and to the use of herbs or their active components for treatment of the disorders. Chinese publications in the late 1970s and into the 1980s showed awareness of immune system components in the autoimmune diseases, but there was lack of clarity as to what role they might play. Then, during the 1990s, as Western literature was more readily accessed, Chinese studies began to concentrate on specific immune system components and the role of mediators of immune responses, which brings us to the current situation.

TRADITIONAL APPROACHES INTO THE MODERN TIME The development of traditional Chinese medicine over the centuries led to a focus on treating patients individually according to the “signs and symptoms” (syndrome) rather than according to a disease name. The exception to the general principle is that certain herbs or acupuncture points might be deemed especially “good for” a disease type, such as bi syndrome, and included for that reason primarily. As Chinese medicine was modernized during the 20 th century, great emphasis was still placed on this approach of “differential diagnosis.” Reports of diagnostics and treatments based on this method shed only limited light on the basis for Chinese herb treatment of autoimmune diseases, because of the great variability in treatment from patient to patient and even from visit to visit of the same patient, and also because of the lack of specific diagnosis. Thus, for example, a report on treating rheumatoid arthritis might involve patients with several different diseases that could have been distinguished by modern means, because the focus of attention was on the Chinese medicine syndromes. Also, the claims of resulting improvements as the result of treatment were not reliable due to a number of political, social, and educational factors prevalent during this period. An example of a report from this field may suffice to reveal the difficulties. In the 1983 Journal of the American College of Traditional Chinese Medicine (2), a lengthy article by Lin Jiehou on rheumatoid arthritis—as treated by one of China’s leading physicians Wang Weilan—was presented. Wang Weilan is to this day a medical doctor at the Beijing Municipal TCM Hospital. This is

how the disease was described: Rheumatoid arthritis is a generalized chronic disorder. It usually has a prolonged course with complicated manifestations. The existence of hot, cold, excess, deficiency and the persistence of the bi entity eventually involve the yin, yang, qi, blood, and the five solid organs [zang]. In the struggle between the evil and normal qi of both the hot and cold types of rheumatoid arthritis, the flourishing of either of the evils will generate a state of deficiency. The pertinent tonification of the deficiency, supporting the normal qi, and the dissipating of the evil are critical in a proper treatment. Clinically, it is recognized that there is qi deficiency, blood deficiency, and deficiency of the organs. For qi deficiency, herbs for tonifying qi are used; for blood deficiency, herbs for tonifying blood are used; for yin deficiency, the principle used is to moisten the yin; for yang deficiency the principle used is to tonify the yang.....From the wholistic point of view, although rheumatoid arthritis usually manifests as a local lesion, the disease process is intimately related to the entire integrated defense mechanism of the body, which is explained by the following: “The normal qi must be deficient before the evil can take the opportunity to invade....The internal existence of normal qi will prevent the interference by the evil.” Therefore, the deficiency of the normal qi is the basis of the internal factor and leads to the looseness of the cutaneous tissue [body surface] and the lowering of the body’s resistance. If the external factor is the contraction of cold in the winter, then the cold evil can take the opportunity to enter the weak and deficient body and to directly strike at the ligaments and the bones, thus causing: internal damage to the blood and the meridians, qi stagnation, blood stasis and ecchymosis, and limitation of movements. The prolongation of the disease course will cause the cold evil to transform into heat and form toxins; thus, there will be the appearance of both cold and hot, and the existence of both deficiency and excess symptoms which creates a very complicated situation. This description fits the generally recognized theories of traditional Chinese medicine. While the authors is admitting to a “complicated situation,” one can see in the analysis reference to virtually every category of pathology: wind, cold, heat, damp, blood stasis, normal and evil qi, blood, yin/yang, five internal organs, deficiency, excess, toxins, etc. This seeming state of disarray or lack of focus in the description of the disease, its pathology, and its treatment, reflects two important features of traditional Chinese medicine: 1. The tradition developed in the absence of modern analysis of disease. Attempting to apply the traditional concepts to a modern disease category (such as rheumatoid arthritis) is very difficult because the origins and nature of the descriptions are so different. There are claims often made by Western practitioners of Chinese medicine that they are able to target the underlying problem to resolve the disease (while modern medicine can only suppress symptoms), because they identify the syndrome and target it. In fact, it is a complicated matter to pin down a specific pattern, as displayed in the above description, and many times practitioners rely instead on selecting from a small number of set formulas for the disease; perhaps one for people sensitive to cold, another for those with joints that feel hot, one for upper body manifestation, and another for the lower body. However, such selection is really aimed at the “branch” of the disease, rather than the “root.” 2. While Traditional Chinese medicine presents therapeutic methods that correspond directly to the diagnostic categories (hence; the comments by the above quoted author: for qi deficiency, tonify qi; for blood deficiency, tonify blood, etc.), there had been no specific claims for success in the past. Instead, Chinese authors would usually simply state that for a certain syndrome one should apply a certain corresponding remedy. Thus, it is possible that these treatments might be given with only moderate or temporary improvements. Then, as medical doctors and researchers began treating patients in the modern setting, they found that the responses were not as clear cut as hoped, so that they would express the fact that the situation was complicated. The above explanation must be taken in context: rheumatoid arthritis (as is the case with most autoimmune diseases) is not easily understood by modern medicine and although initial treatments are usually simple, over time, the situation becomes quite complex. On the other hand, broad categories, such as qi, blood, yin, and yang and their corresponding tonics is far less precise that the modern medical knowledge of the disease and the treatment options. Medical journals presenting clinical reports in China began appearing from all the major hospitals, medical colleges, and research institutes (which were often grouped into giant complexes). For rheumatoid arthritis, many of the reports described “new” agents, such as the active components of Tripterygium wilfordii (leigongteng), which is a toxic plant (though it can be used without apparent adverse effects by many patients). It has potent immunosuppressive activity from it glycosides similar to that attained with steroids, but without the usual steroid side-effects. Other isolated active ingredients, such as the alkaloids of Sinomenium, were indicated as helpful, but these alkaloids could cause serious side-effects in a significant portion of the treated patients. There were also numerous reports of using ordinary decoctions. As an example, Li Jun, at the Ministry of Health in Gansu, reported on treatment of 46 cases of rheumatoid arthritis with a decoction (3). The formula he used was comprised mainly of herbs that vitalize blood (such as achyranthes, cyathula, persica, cnidium, tang-kuei, carthamus), but it was modified according to differential diagnosis for each patient. He claimed that “12 patients were cured, 25 markedly improved, and 7 improved.” This appears a remarkable result; according to modern medical analysis, this disease is almost never cured, yet here more than one in four patients was said to be cured; in addition, more than half the remaining patients were markedly improved (this category was explained: “signs and symptoms basically disappeared). One would think that with such results, this formulation would be studied further and developed into a modern drug or health product or a routine therapy at one or several of the hospitals, especially since none of the ingredients reported to be used were toxic in normal dosage. However, this report was never followed up, and though many other doctors in China have reported using blood-vitalizing herbs, their formulas were apparently based on their own ideas, rather than pursuing what Li Jun had accomplished in Gansu. Why? There are two primary answers to this: 1. The results reported in many such publications were, in fact, unreliable and other researchers in China were aware of this. Under the conditions that prevailed at the time of Li Jun’s work (in the 1980s, published in 1988), clinical reports were often exaggerated. Therefore, no follow-up was called for. 2. A highly competitive situation existed (and still exists) in this field; each doctor has his favored recipes and is interested in working

with his own formulation(s) and reporting their success, rather than following-up a prior study with a formula of someone else’s design. This is an unsatisfactory situation that is only gradually improving. The lack of adequate progress is easily noted in the English language publications from China, such as the Journal of Traditional Chinese Medicine and the Chinese Journal of Integrative Medicine. In relation to the first point, it has been noted that virtually all TCM clinic reports issued in Chinese journals provide positive results, often extremely positive; negative results are rare, and usually involve only a “control” substance, which might be a commercial product that the researcher is pointing to as inferior to his test formulation. In relation to the second point, frequently researchers provide very limited information about the formula, hiding ingredients, not disclosing proportions, and giving incomplete details of dosing, thus protecting their personal recipes, but also preventing others from pursuing the apparently promising research further. Today, the study techniques are getting better, and therapies thought to be of benefit are more often being subjected to pharmacological analysis to verify activity and determine a mechanism of action. As an example, in a report in the 2000 issue of Journal of Traditional Chinese Medicine (4), the authors presented six data tables showing characteristics of the patients, comparison of overall therapeutic results, analysis of the symptom and sign changes, and the changes in laboratory measures of the patients’ blood, such as immunoglobulins, rheumatoid factor, sedimentation rate, T-cell subsets, and changes in hemoglobin and red blood cells. There were two treatment groups, with some details given about the herbs used (one for yang deficiency; one for yin deficiency), and a control group using an established herbal formula on the market. In that report, as with other studies, there is a remarkable result claimed: of 87 cases treated with the research formulations, 9 were said to be “clinically cured,” and 58 showed that the treatment was “markedly effective.” Only 13 cases were said to show the treatment ineffective. Yet, up to this time (six years later), further research on these particular formulas has not been presented. The authors, led by Zhou Xueping and Zhou Zhengying at Nanjing University of TCM, ventured an explanation of the disease: Rheumatoid arthritis is a chronic obstinate disease that involves multiple joints all over the body. Because of its diversity in classification and therapeutic principles in TCM, there has been confusion whether it is a deficiency or excess in nature. We hold that deficiency of the liver- and kidney-yin, stagnancy of qi due to accumulation of pathogenic cold in channels and collaterals, and phlegm stagnation combined with blood stasis are the main pathogenesis, of intermediate and late rheumatoid arthritis. The cardinal viscera being deficient is the kidney, the syndrome belongs to the category of deficiency in origin and excess in superficiality, or deficiency intermingled with excess, which also has the differences of cold and heat, yin and yang in nature. If one suffers from insufficiency of the yang-qi and invasion of pathogenic cold and dampness from the outside for a long time, manifestations of yang insufficiency, cold in the interior, stagnation of phlegm, and blood stasis would occur. If one has yin deficiency, the pathogenic wind, dampness, and heat would take advantage of the yin deficiency and invade into the body. In this case, treatment with drugs too warm and too dry in nature, the stagnating cold would transform to heat, resulting in damp-heat syndrome, a pathogenic factor causing too much consumption of yin and blood. Therefore, tonifying kidney, resolving phlegm, and removing blood stasis are the primary principles in the treatment.... There is a slightly more focused presentation than in the earlier analysis quoted, but this is partly because the authors have decided here to focus on more advanced cases, thus eliminating some of the variables associated with also considering more recent disease onset. While these explanations are instructive in revealing the way these physicians thought, they are far from definitive. Descriptions like these are so broad and lacking in evidence to support them, that it is difficult to apply practically. The same lead authors presented another paper in the same journal in 2004 (5), reporting on another formulation, claimed to be derived from one of the formulas used in the prior report, but containing almost no overlapping ingredients other than rehmannia and wasp’s nest. This was given to patients with rheumatoid arthritis of the yin deficiency type with “heat in the collaterals.” As with the above paper, they claimed a similar level of effectiveness with 9.5% cured, 38.1% markedly effective and only 9.5% ineffective, with better results than a control group treated with Tripterygium. They explained: In rheumatoid arthritis (RA), though arthralgia due to cold is commonly seen clinically, arthralgia due to heat is also frequently seen. RA of the type of yin-deficiency and heat in the collaterals is caused by the following factors: weak body constitution, deficiency of yin and blood, invasion of exogenous heat, improper use of drugs, and so on. If yin is deficient, the evils of wind, dampness, and heat would invade through the weak points, and then channels and collaterals would become obstructed. If yang is in excess there would be excessive heat in the body. After invading into the body, the evils of wind, cold, and dampness will produce heat with the help of the excess of yang. When these evils remain in the body, their stagnation would cause damp-heat. Furthermore, if the drugs too warm and dry in nature or hormones are taken for a long term, yin and blood might be consumed. This disease manifests as excessive in superficiality at the beginning, but there is deficiency in origin at the same time. Deficiency of the kidney is the root cause of the occurrence of RA of the type of yin deficiency and heat in the collaterals, which is the pathogenic basis for long-term arthralgia.... In the formulation revealed by the authors, raw rehmannia and loranthus were included to nourish the kidney yin; the main focus was on treating inflammation with sinomenium, silkworm, wasp’s nest, and other herbs that have such a reputation; the selected ingredients do not necessarily treat heat or yin deficiency. The basic theory presented by the authors is that the weak body allows for invasion of exogenous factors, which, in this case, produce a heat syndrome. There is a surprising lack of commentary about the unusually good results in this and the other reports, other than the apparent superiority to the control treatments. In this case, because Trypterigium is so potent, a further analysis and discussion would seem essential. While Chinese medical reports indicate the presence of clear-cut syndromes in the patients, there are difficulties in lack of consistency in diagnostics among Western practitioners. Studies have shown that if the same patients are presented to different experienced practitioners of traditional Chinese medicine, the diagnosis will often not be in agreement among them. This was confirmed recently in the analysis of patients with rheumatoid arthritis (6). Three American practitioners of Chinese medicine who each had at least 5 years experience were presented with 40 rheumatoid arthritis patients. The average agreement rate for the individual patient diagnostic category among the practitioners was just 31.7%. However, when they prescribed textbook remedies (standard formulas, such as Duhuo Jixue Tang ), they had a high level of agreement in their recommendations, about 91.2% of the time. This evaluation

demonstrates, as described earlier, that there are a few basic formulas that practitioners will rely upon, and they are usually applied without much reliance on refined diagnostics, but instead turning to certain obvious and general conditions. Despite the difficulties with the Chinese literature, we may be able to distill some valuable lessons from the intensive work done in China. It is a matter of sorting through the various concepts and reports to follow the theories and practices. I have chosen to focus on rheumatoid arthritis for the analysis given above because of its higher frequency of occurrence than other autoimmune disorders and the fact that it has a long history of analysis and treatment in China. The results that could be obtained by examining the Chinese literature for numerous autoimmune disorders would be beyond what can be presented here. Some analysis of the literature on rheumatoid arthritis and other autoimmune diseases have been set forth in other ITM publications, which are available on the ITM web site (www.itmonline.org); these include: ulcerative colitis, Raynaud’s syndrome, scleroderma, lupus, multiple sclerosis, and ITP.

UNDERLYING DISORDER Autoimmune disorders, because of their chronic nature are understood to be based on an underlying deficiency syndrome, as was explained by Lin Jiehou and Zhou Xueping. In brief, it is the deficiency that permits the pathology to manifest. If the vessels were full of qi and blood, and the organs working properly and full of their essences, the person would be healthy, or might, at the worst, suffer minor and short term diseases. Instead, the deficiency condition allows external pathogenic influences to enter, and permits the disease to progress, transform, and become serious because of inadequate resistance to this process by the normalizing qi. Genetic factors involved in diseases are often associated with the Chinese concept of essence deficiency (specifically, a kidney deficiency); diseases that progress with aging are also attributed to deficiencies of kidney and liver and involve the “essence” deficiency (jingxu). The potential role of viruses or other infectious agents in triggering the disease process (as indicated by some modern investigations) corresponds, in part, to the failure to repel the external pathogen. As underlying contributors to disease, one would expect the deficiencies to be evident prior to the initiation of the autoimmune disease. On the other hand, there might be little chance to observe this because the deficiencies might involve only those aspects of qi, blood, and essence that regulate resistance to certain disease conditions, so that more obvious signs of deficiency, such as pallor, fatigue, imbalances of heat and cold, etc., might not be especially pronounced for such individuals. Still, one would expect that by undertaking a careful diagnosis prior to the onset of the autoimmune symptoms, some deficiencies would be observed. Otherwise, the TCM theory would have to be relinquished. In order to more firmly establish the presence of such underlying deficiencies, it would be necessary to obtain medical histories (including information oriented to reveal the standard “signs” recognized by TCM practitioners) from persons who were recently diagnosed with an autoimmune disease. That way, they might be able to reliably recall preceding conditions, particularly those in months before the first clear evidence of the disease. Such an investigation has not yet been done. Most attention is naturally focused upon treatment of persons who are seeking relief from an existing disease, one which may have been present for some time already since early symptoms are often easily controlled by modern drugs while Chinese herbal medicine is sought out if the disease is inadequately controlled by that means or if the drugs are not well tolerated. According to common TCM approaches to disease treatment, tonification of the deficiencies would be a part of the therapy throughout treatment, since the effect of other therapeutic approaches would be boosted by the presence of adequate qi, blood, and essence. For example, to vitalize circulation of blood, the qi must be adequate, according to the Chinese theory. Tonification would be especially important during any phases of remission where there would not be an immediate requirement to intensively alleviate inflammation, pain, and other acute symptoms, while it would usually be a secondary part of the treatment if the acute syndrome is present.

BRANCHES Each autoimmune disorder manifests differently, and often one disease appears entirely unrelated to another, despite a common basis in immune attack. For example, early onset diabetes (type I) results in hunger, weight loss, excessive urination, fatigue, and other symptoms, while connective tissue diseases may result in pain, stiffness, swelling, and redness; ITP results in spontaneous bleeding (or risk of it), and Sjogren’s disease results in dryness. Put simply, the symptoms of the autoimmune disease—and the TCM analysis of them—will depend on which cells in the body are the subject of attack by the immune system. Nonetheless, there are some secondary patterns that are relatively consistent. First, any of the diseases that reach an advanced stage appear to manifest at least two imbalances defined in TCM. One is the deficiency of kidney that may be at the root of the disease but may also come about from the damage caused by the disease process or even by the drugs previously used to control the disease. This deficiency may manifest as cold or hot symptoms (depending on whether yin or yang is most severely affected), weakness of limbs, fatigue, changes in bowel and urination patterns, dryness or excess moisture. The other is development of blood stasis (which is considered a type of “excess” pattern). Blood stasis can occur directly as part of the local disease manifestation (for example: the autoimmune attack causes inflammation, which damages the capillary beds in the affected area) or as a later effect (for example, high blood sugar in diabetes over time causes circulatory disorders, with damage to both the capillary beds and the larger vessels). In the case of advanced rheumatoid arthritis described by Zhou, it was suggested that in addition to kidney deficiency and blood stasis, phlegm accumulation was involved. Even so, in the treatments used for those arthritis cases, each formula had only one herb specific for resolving phlegm accumulation (sinapis in one formula and arisaema in the other). Certainly, in each disease, one has to consider that there will be additional factors, aside from kidney damage and blood stasis, though the kidney imbalance may explain many of those additional factors (e.g., kidney cold leads to accumulation of phlegm in the channels). Treating the kidney system successfully may help resolve these other secondary disorders. The presence of obvious hot or cold symptoms is a major reason for modifying formulas; it is common to use cinnamon, aconite, and other warming herbs that benefit the kidney yang for cold disorders, and to use raw rehmannia and moutan along with other herbs to clear heat in the blood, for the hot disorders.

MODERN ANALYSIS Many herbs and isolated active components of herbs, when evaluated in model systems (such as cell cultures or laboratory animals), are

shown to have anti-inflammatory activities or immune-regulating functions. Unfortunately, it is often difficult to project from the laboratory studies to the effects that might be attained in the complex autoimmune diseases as they manifest in humans. Still, it may be worth mentioning here an example where the results are intriguing. Some Chinese herbs that are frequently used in treatment of autoimmune diseases have been analyzed for active component groups, which are then tested to demonstrate a possible mechanism of action in autoimmune disorders. Testing in models of arthritic inflammation is relatively easy and it is in demand because of the high frequency of the disease. We can begin the examination with the central herb for kidney tonification, a common ingredient in formulas for chronic diseases, particularly autoimmune disorders, and used in formulas for cold and for hot syndromes: rehmannia. Rehmannia used in most kidney tonic formulas, such as Rehmannia Six Formula (Liuwei Dihuang Wan ) and Rehmannia Eight Formula (Bawei Dihuang Wan), has as primary active components a class of chemical substances called iridoid glycosides. Iridoids, a type of monoterpene, have the basic structure shown here; which often has a glucose molecule attached, making it a glucoside (general term: glycoside). Iridoid glycosides are among the main active components for two ingredients of these formulas: rehmannia (dihuang) and cornus (shanzhuyu). And, for those formulas containing the yang tonic cistanche (roucongrong), there are additional iridioids that it provides. Iridoid glycosides are also found as major components of some of the heat-clearing herbs, such as gardenia, scrophularia, picrorhiza, plantago seed, and chin-chiu (qinjiao) that are sometimes included in treatment of autoimmune disorders. For example, in a report on lupus therapy by integrated traditional and modern medicine (7), patients received Lingdan Pian, which included at least three herbs with iridoid glycosides: chin-chiu (qinjiao), rehmannia, and scrophularia; the formula also contains ching-hao, moutan, turtle shell, buffalo horn, licorice, and other herbs. In a treatment for ITP (8), the main ingredients of a formula included at least two herbs with iridoid glycosides: gardenia and raw rehmannia; the formula also contains red peony, moutan, tang-kuei, and astragalus. In the treatment of rheumatoid arthritis of the yin deficiency type described in the first report by Zhou, the formula included the iridoid-containing herbs rehmannia and chin-chiu; other formula ingredients were ho-shou-wu, campsis, and earthworm.

Recent studies revealed that geniposide, and other iridoids from gardenia fruits (see sample structure illustrations above, the glucose molecule is at the bottom right of each structure), showed pharmacological action consistent with suppressing immune inflammatory processes. For example, the compounds produced significant inhibition of IL-2 secretion, thus reducing antibody-stimulated activation of human peripheral blood T cells (9). In another study (10), it was shown that geniposide could lower serum IL-1β and TNF-α levels in rheumatoid arthritis rats, which was suggested to be related to its clinical effects of inhibiting development of rheumatoid arthritis. In another study, extract of chin-chiu (Gentiana macrophylla) was used in animal models of inflammation (11). It was noted in the abstract that: The anti-inflammatory activity observed in Gentiana macrophylla is comparable to that observed in prednisone. These observations suggest that Gentiana macrophylla displays considerable potency in anti-inflammatory action and could be used as an anti-inflammatory agent in the control of inflammation of rheumatoid arthritis. Chin-chiu extract tablets were used in previous Chinese clinical work in the treatment of lupus (SLE). It was claimed to be especially effective for nephropathy, arthralgia, and erythema, and contributed to improvement in blood parameters indicating immune status (12). This kind of work—with clinical evaluations, chemical analysis, and pharmacological investigations—may help elucidate the role of traditional medicine in autoimmune diseases and point to efficacious treatments relying on selected herbs or their active components. Such efforts would not necessarily overshadow the potential benefits of using additional herbs to treat “constitutional” or other aspects of a disease, but would aid in the process of selection from the huge number of herbs that are currently in use. The applicatiion of herbs and their active components for autoimmune diseases would rarely be cause for concern when combining this type of therapy with modern drugs. Very few cases of interactions that would be detrimental have been observed with use of herbs and drugs, and those few cases are mainly restricted to certain drugs (e.g., Warfarin) and certain herbs (e.g., St. John’s Wort) that are not routinely used in these cases (13). Thus, there is a good possibility for utilizing Chinese medicine for patients with autoimmune diseases relying on both traditional concepts and modern developments.

REFERENCES Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. Lin Jiehou, Bi-entity (arthritis): Clinical experience of master-physician Wang Weilan , Journal of the American College of Traditional Chinese Medicine 1983; (3): 3–28. Li Jun, Treatment of 46 cases of rheumatoid arthritis with modified Shentong Zhuyu Tang , Beijing Journal of Traditional Chinese Medicine 1988; (6): 35–36. Zhou Xueping, et.al., Intermediate and late rheumatoid arthritis treated by tonifying the kidney, resolving phlegm, and removing blood stasis, Journal of Traditional Chinese Medicine 2000; 20(2): 87–91. Zhou Xueping, et. al., Clinical study of Qingluo Tongbi Granules in treating 63 patients with rheumatoid arthritis of the type of yin deficiency and heat in collaterals, Journal of Traditional Chinese Medicine 2004; 83–87. Zhang GG, et. al., Variability in the traditional Chinese medicine (TCM) diagnoses and herbal prescriptions provided by three TCM

practitioners for 40 patients with rheumatoid arthritis, Journal of Alternative and Complementary Medicine 2005; 11(3): 415–421 Zhong Jiaxi, et. al., 25 cases of systemic lupus erythematosus treated by integrated traditional Chinese medicine and Western medicine , Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine 1999; 19(1): 47-48. Fruehauf H, The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 ITM, Portland, OR. Chang WL, et. al., Immunosuppressive iridoids from the fruits of Gardenia jasminoides, Journal of Natural Products 2005; 68(11): 1683– 1685. Zhu J, et. al., Effect of geniposide on serum IL-1beta and TNF-alpha of rheumatoid arthritis rats, Chinese Journal of Traditional Herbal Drugs 2005; 30(9): 708–711. Yu F, et. al., Inhibitory effects of Gentiana macrophylla extract on rheumatoid arthritis of rats, Journal of Ethnopharmacology 2004; 95(1): 77–81. Yuan ZZ and Feng JC, Observation on the treatment of systemic lupus erythematosus with a Gentiana macrophylla complex tablet and a minimal dose of prednisone, Chinese Journal of Integrated Chinese and Western Medicine 1989; 9(3): 156–157. Dharmananda S, Checking for possible herb-drug interactions, START Manuscripts 2003, Portland, OR. September 2006

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A BRIEF REVIEW OF AYURVEDIC CONCEPTS with examples of essential Ayurvedic herbs and useful formulas by Subhuti Dharmananda, Ph.D., Institute for Traditional Medicine, Portland, OR

Ayurvedic medicine is one of the major traditional medicine systems of the world, second only to Chinese medicine in terms of the extent to which it is used today. It has influenced Chinese medicine by virtue of the transfer of several herbs native to India to China for incorporation into the Chinese system. Much of that transfer was accomplished over a thousand years ago. Chinese medicine and India's medicine have been combined into Tibetan medicine to help produce yet another major traditional medical system. India's tradition has also combined with that of the Greeks to help form the modern Unani medicine as practiced in Pakistan and surrounding areas. There is no licensing for the practice of Ayurvedic medicine in the United States (or most other countries outside those where it has been a central part of the healing tradition for centuries). It is provided by health professionals who have studied the subject independently (a few medical doctors, naturopathic physicians, acupuncturists, etc.), or interested persons may obtain herbs and formulas on their own by self-selection of remedies sold in stores or via the internet. Ayurvedic medicine is of some interest to these practitioners and the general public for several reasons, aside from its long history of use, such as: Ayurvedic suppliers are becoming a strong force in the nutriceutical industry, providing concentrated extracts or isolated components from major Ayurvedic herbs. These are coming to the attention of the public at large as well as many practitioners. While all traditional medical systems emphasize the importance of diet in health and use of certain foods as medicines, the Ayurvedic system is especially known for this and offers some practical advice. The modern emphasis on scientific evaluation of traditional remedies means that there is increasing desire to use "proven" substances, regardless of which medical system they have been derived from. Thus, those who have studied Chinese medicine or Western herbs will still find any well-studied Ayurvedic herbs of value to know, understand, and possibly use. In trying to grasp the meaning and application of traditional and modern medicine concepts, it is helpful to see the differences between medical approaches around the world so that one does not become confined to a single cultural model. In this document, there are a few pages devoted to depicting the basic Ayurvedic system, with focus on the dominant tridosha framework. This is followed by an exposition of 12 of the key Ayurvedic herbs, with examples of one formula each that have them as their primary ingredients. These formulas are available for use in convenient tablet form. Many other Ayurvedic formulas, both traditional and modern, also rely on these key herbs, so that the explanations provided here should be helpful in understanding other formulations that may be encountered.





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INTERNET JOURNAL OF THE INSTITUTE FOR TRADITIONAL MEDICINE AND PREVENTIVE HEALTH CARE Herbal Therapy for Benign Prostatic Hypertrophy

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Web Posting Date: May 2002 Key medical terms: bph, prostate, prostatitis, dihydrotestosterone, 5-alpha reductase Key Chinese medical references: lin syndromes, blood vitalizing therapy, dampheat, kidney deficiency Drugs: Finasterid, Doxazosin Western herbs: saw palmetto, pygeum, pumpkin seeds, nettle root Chinese herbs: vacarria, plantago seed, rehmannia Chinese formulas: Guizhi Fuling Wan, Niu Che Shenqi Wan, Jingui Shenqi Wan, Tonglong Tang, Dahuang Mudan Tang Chemical constituents: sterols, aucubin, iridoids, triterpenoids SUMMARY: BPH (benign prostatic hypertrophy; an enlarged prostate) occurs with aging in most men and may be symptomatic, especially after age 60, with obstructed urinary flow. The disorder appears to be stimulated by dihydrotestosterone (DHT). Herbal medicines have been suggested as helpful for this condition, with particular attention to saw palmetto (Seranoa serrulata or Seranoa repens). Chinese herb formulas have been suggested to be helpful as well, including Rehmannia Eight Formula (Jingui Shenqi Wan) and its derivatives, as well as herbs specific for vitalizing blood (e.g., vaccaria) and for getting rid of damp-heat (e.g., plantago seed). Herbal products for BPH are readily available for over the counter purchase and Chinese herb therapies can be formulated for the individual by licensed acupuncturists and other prescribers. The dosage of saw palmetto extract used in clinical studies is 320-480 mg per day; pygeum extract is used in amounts of 100-200 mg/day. Treatment time is 45-90 days for symptom relief and 6 months for a complete therapeutic regimen.

Herbal Therapy for BPH by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

RECENT MEDICAL RESEARCH Benign prostatic hyperplasia (BPH) is a common problem of aging for men. It has been proposed that the disorder has two phases, one that involves no clinical signs and the other that manifests as disorders of urination resulting from urinary tract obstruction by an enlarged prostate (1). In the first phase, there are microscopic changes within the prostate that may occur as early as the fourth decade of life and these may then be followed by macroscopic changes, namely enlargement of the prostate that typically begins during the fifth or sixth decade of life. However, clinical signs of the disorder occur only if the enlargement is substantial and becomes complicated by other disorders, such as prostatitis, or if the gland becomes hardened or deformed. The progression to clinical disease is most often seen after age 60. It is further suggested that while nearly all men will experience the microscopic changes in the prostate if they live long enough, only about half will experience prostate enlargement, and, of those, only about half will develop clinical symptoms. The question then arises: what causes the relatively common occurrence of prostate changes that lead to clinical disease? Epidemiological studies have demonstrated that many of the same risk factors associated with cardiovascular diseases apply as risk factors for BPH. These risk factors include obesity, hypertension, and diabetes. The diabetes connection is considered especially strong; the risk is with non-insulin dependent diabetes mellitus (NIDDM), which often involves excessive insulin levels, a possible direct contributor to the growth of the prostate (2, 3). As with cardiovascular disease, both exercise and moderate alcohol consumption appear to be protective for BPH. The influence of cigarette smoking on BPH has been unclear: some studies indicate a protective effect (there is a protective effect of smoking for ulcerative colitis that is well-established, so this result is not to be rejected out of hand), but other studies indicate a negative impact, at least for heavy smokers (4, 5). Cigarette smoking has so many adverse health effects, that it should be discouraged regardless of its role in this particular ailment. Hormones affect the development and progression of BPH. Men with liver cirrhosis have a lower incidence of BPH than those who have normal liver function, probably because the liver damage reduces the metabolism of hormones to compounds that adversely influence BPH. Not all hormonal influences on BPH have been determined, but sex hormones (estrogen, testosterone, prolactin) and insulin have been shown to have an effect thus far. In particular, it is thought that the

conversion of testosterone to 5-alpha-dihydrotestosterone (DHT) may be a significant risk factor for BPH (6). The drug Finasteride suppresses DHT production by inhibiting the enzyme (5-alpha reductase) that converts testosterone to DHT, and this drug has been shown effective in reducing symptoms of BPH. DHT, produced in sebaceous glands, is also a contributor to male-pattern balding. It is not known whether herbal, nutritional, or drug treatments for cardiovascular disease would also have a direct impact on BPH. However, the alpha-adrenoceptor agonist drug (Doxazosin) used for treating hypertension also appears to have therapeutic value for BPH (7). Certainly, lowering risk factors for cardiovascular disease would be important for everyone, including aging males with BPH.

ORIENTAL MEDICINE Chinese medical literature has been relatively silent on the problem of BPH (8). Disorders of urination have been noted since ancient times, classified as "lin" syndromes, which involve obstruction of urinary flow. In descriptions of the lin syndromes, most times the obstruction of urination is described as accompanied by symptoms that are not characteristic of BPH, such as blood in the urine or passing of stones or cloudy urine. Therefore, while BPH may have been experienced and treated as one of the lin syndromes, it is unclear whether any of the therapies were specific for BPH. In Japan, BPH has been described by medical doctors who prescribe herbal therapies (Kampo practitioners). These physicians rely on a relatively small set of formulas from which one or two are selected for administration according to differential diagnosis by constitutional factors. Dr. Toyohiko Kikutani described his knowledge of such treatment methods for prostate disorders and this information was relayed by Hong-yen Hsu of the Oriental Healing Arts Institute. According to Kikutani, the most commonly used formula for BPH is Rehmannia Eight Formula (Bawei Dihuang Wan, also called Jingui Shenqi Wan ; see Appendix 1). This formula is commonly used for disorders of aging, and is also applied in Japan for treating hypertension. The main alternatives to Rehmannia Eight Formula are prescriptions for blood stasis (impaired blood circulation, often associated with chronic inflammation or injury), such as Moutan and Persica Combination (Tonglong Tang ) and Rhubarb and Moutan Combination (Dahuang Mudan Tang). These formulas include the tree peony, moutan, which is also an ingredient in Rehmannia Eight Formula. The primary descriptions for applications of these latter two formulas fit better with acute prostatitis rather than BPH, but this acute prostatitis may trigger the persistent clinical manifestation of a pre-clinical case of BPH. Sometimes the two approaches are combined: Dr. Domei Yakazu told of three patients receiving both Rehmannia Eight Formula and Moutan and Persica Combination. In an update by Dr. Hsu (9), he further mentioned combining Rehmannia Eight Formula with another blood vitalizing prescription, Cinnamon and Hoelen Formula (Guizhi Fuling Wan ), and use of Achyranthes and Plantago Formula (Niu Che Shenqi Wan ), which consists of achyranthes and plantago added to the base of Rehmannia Eight Formula. Achyranthes and Plantago Formula is also used in Kampo medicine to treat diabetes, including nephritic and neurological effects of the disease. Modern journals of Chinese medicine remain relatively silent on the subject of BPH. For example, no articles on BPH treatment have appeared in the English language Journal of Traditional Chinese Medicine or Chinese Journal of Integrated Traditional and Western Medicine. By contrast, the Western literature has numerous reports on therapies for BPH based on herbs. Chinese clinical researchers have addressed the problem of prostate disorders, but usually include a broad range of problems-dominated by acute prostatitis-in the study group, for which differential diagnosis is applied. Typical therapeutic categories are (10): qi and blood stasis (obstructed circulation), damp-heat accumulation (swelling and fluid accumulation), and kidney deficiency syndrome (problems of aging; weak function of the kidneys). The formulas administered vary considerably, but most formulations for treating qi and blood stasis include vacarria (wangbuliuxing); virtually all formulations for treating damp-heat and urinary obstruction include plantago seed (cheqianzi). Kidney deficiency formulations (subdivided into yin and yang deficiency categories) for prostate disorders usually incorporate herbs for treating blood stasis and damp-heat as secondary components (19). It is possible that the microscopic changes in the prostate in the early development of the disease process are consistent with microcirculation changes that are normally treated with blood vitalizing herbs. Prostate enlargement is consistent with a damp-heat syndrome, since this syndrome is commonly associated with non-painful swelling in the lower abdomen. The final development of clinical symptoms of urination disorders corresponds closely with Chinese depictions of significant blood stasis and damp-heat coupled with weakening kidney qi. Thus, the three main diagnostic categories for prostate disorders described in the Chinese medical literature may have relevance to BPH in terms of its development over several decades, with a progression of each of the three syndromes. Based on such a scenario, the therapy for clinical BPH with Chinese herbs would involve a combination of treating kidney deficiency syndrome as a solution for the constitutional disorder associated with aging, along with blood vitalizing and damp-heat removing herbs as a treatment for the swollen prostate. In accordance with traditional Chinese medicine doctrine, each patient should be treated on the basis of his actual syndrome rather than by a set formula. For example, yin deficiency fire (treated by

modification of Zhi Bai Dihuang Wan) or spleen and lung qi deficiency (treated by modification of Buzhong Yiqi Tang ) could each be factors contributing to urinary disorders such as those seen with BPH. Nonetheless, most cases of BPH in essentially healthy men are likely to correspond to the disorder categories generalized above. Although the Chinese herb formulas appear to have the potential to increase testosterone levels (see Appendix 2), this change may not be sufficient to adversely affect BPH, especially if the herbs can also suppress conversion of testosterone to DHT, as suggested for Western herbs used in treating BPH.

WESTERN HERBAL MEDICINE The treatment of BPH became a medical issue during the same time that cardiovascular disease therapy came to the fore, mainly during the 1970s. In Germany, where herbal therapy (phytotherapy) was still pursued by the pharmaceutical industry, the use of herbs was investigated at the same time that other researchers pursued surgical and drug options. Dr. Hildebert Wagner, one of the leading proponents of phytotherapy (working at the Institute for Pharmaceutical Biology at the University of Munich), proposed investigation of the active components in Sabal serrulata for BPH in 1981 (11). This herb, now referred to as Serenoa serrulata or, more commonly, as Serenoa repens, had been popular in the U.S. during the 19th century as a treatment for a variety of urino-genital disorders and had been mentioned as a treatment for prostate problems as early as 1899 (12). The fruit of the plant, a small palm called saw palmetto (palmetto is Spanish for small palm; it has sharp, saw-like leaves) that is abundant in Florida, was used as a food for farm and ranch animals and as a medicine for humans. Research into the effects of Serenoa in Germany, and subsequently in many other European countries, appeared to confirm a positive action on BPH, so that this became the principal use of the herb. By 1995, saw palmetto had become one of the 10 most extensively-used Western herbs, with almost all of the commercial supplies going into products for BPH. The fruit is rich in sterols, which appear to be the primary active constituents. Although various proposals have been made as to how the sterols might affect BPH, the mechanism of action is still not clearly established. It is thought that the sterols may have, as one mechanism of action, the inhibition of DHT production (15). At the same time, other Western herbs were investigated, with most attention falling to pumpkin seeds (Cucurbita pepo), nettle root (Urtica dioica or Urtica urens), bee pollen (particularly that from the rye plant), African potato (tubers of Hypoxis rooperi), and the large high-altitude African tree Pygeum africanum, also known as Prunus africanum (13, 14). In most cases, but particularly with pumpkin seeds and African potato, the main active components are understood to be the sterols, such as beta-sitosterol, which has been used as a therapeutic agent for BPH by itself (18). Triterpenoids in pygeum have also been proposed to be active components, potentially having the action of reducing prostate swelling (17). Among the Chinese herbs recommended for BPH, the iridoid glycosides may be the active components: these include aucubin from plantago seed, catalpol from rehmannia, and morroniside from cornus (an ingredient in the rehmannia formulas). Iridoids have not been found in the Western herbal therapies for BPH and represent a potential new area for future investigation. Iridoids are the recognized active constituents of the Western herb chaste tree berry, Vitex agnus costus, which has been shown to reduce prolactin levels in women (20); elevated prolactin may be a risk factor for prostate enlargement in men. Triterpenoids found in vaccaria and alisma (an ingredient in rehmannia formulas) could contribute to their therapeutic effects, in a manner similar to those suggested for pygeum. Today, products for BPH remain one of the primary commercial successes in the field of herbal medicine. The herbs are sold either individually or in combination products with 2 or 3 of the ingredients. The two most commonly-used substances, both as single herbs or in combination products, are saw palmetto and pygeum. The National Institutes of Health (NIH) have taken note of this and proposed to fund a large study of saw palmetto and pygeum (see Appendix 3). The usual amount of saw palmetto provided in clinical studies is 320-480 mg of extract per day, in two divided doses (16). The usual amount of pygeum extract used in clinical trials is 100-200 mg/day (17). Treatment time is from 45 to 90 days to obtain significant improvement in symptoms; treatment time of 6 months has been reported to have a lasting effect for at least 18 months (18). Adverse effects of the herb therapies for BPH have not been reported.

REFERENCES 1. Isaacs JT, Etiology of benign prostatic hyperplasia; European Urology 1994; 25 (1; Supplement): 6-9. 2. Hammarsten J, and Hogstedt B, Clinical, anthropometric, metabolic, and insulin profile of men with fast annual growth rates of benign prostatic hyperplasia, Blood Pressure 1999; 8(1): 29-36. 3. Hammarsten J, and Hogstedt B, Hyperinsulinemia as a risk factor for developing benign prostatic hyperplasia, European Eurology 2001; 39 (2): 151-158. 4. Platz EA, et al., Alcohol consumption, cigarette smoking, and risk of benign prostatic hyperplasia, American Journal of Epidemiology 1999; 150(3): 321-323. 5. Meigs JB, et al., Risk factors for clinical benign prostatic hyperplasia in a community-

based population of healthy aging men, Journal of Clinical Epidemiology 2001; 54(9): 935-944. 6. Barsch G, Rittmaster RS, and Klocker H, Dihyrdotestosterone and the concept of 5alpha-reductase inhibition in human benign prostatic hyperplasia, European Urology 2000; 37(4): 367-380. 7. Fulton B, Wagstaff AJ, and Sorkin EM, Doxazosin: An update on its clinical pharmacology and therapeutic applications in hypertension and benign prostatic hyperplasia, Drugs 1995; 49(2): 295-320. 8. Hsu HY, Chinese herb therapy for benign prostatic hypertrophy, Bulletin of the Oriental Healing Arts Institute, 1982; 7(1): 31-34. 9. Hsu HY, Treatment of prostatomegaly with Chinese herbal medicine, International Journal of Oriental Medicine 2000; 25(1): 45-47. 10. Zhang Jilun, Prostatitis and traditional Chinese medicine, International Journal of Oriental Medicine 1992; 17(2): 112-113. 11. Wagner H and Flachsbarth H, A new antiphlogistic principle from Sabal serrulata, Planta Medica 1981; 41(3): 244-251. 12. Bennett BC and Hicklin JR, Uses of saw palmetto (Serenoa repens) in Florida, Economic Botany 1998; 52(4): 381-393. 13. Dreikorn K and Schonhofer PS, Status of phytotherapeutic drugs in treatment of benign prostatic hyperplasia, Urology 1995; 34(2): 119-129. 14. Bracher F, Phytotherapy of benign prostatic hyperplasia, Urology 1997; 36(1): 10-17. 15. Van Coppenolle F, et al., Pharmacological effects of the lipidosterolic extract of Serenoa repens on rat prostate hyperplasia induced by hyperprolactinemia: comparison with finasteride, Prostate 2000; 43(1): 49-58. 16. Bone K, Saw palmetto-A critical review, European Journal of Herbal Medicine, 1998; 4(1): 15-24. 17. Bombardelli E and Morazzoni P, Prunus africana; Phytotherapy 1997;68(3): 205-218. 18. Berges RR, Kassen A, and Senge T, Treatment of symptomatic benign prostatic hyperplasia with beta-sitosterol: an 18 month follow-up, British Journal of Urology International 2000; 85(7): 842-846. 19. Zhou Zhongying and Jin Huide, Clinical Manual of Chinese Herbal Medicine and Acupuncture, 1997 Churchill-Livingstone, London. 20. Milewicz A, et al., Vitex agnus castus extract in the treatment of luteal phase defects due to latent hyperprolatinemia, Drug Research 1993; 43(7): 752-756. 21. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations , 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA. 22. Shibata Y and Wu J, Kampo Treatment for Climacteric Disorders, 1997 Paradigm Publications, Brookline, MA. 23. Dong Zhilin and Jiang Jingxian, 100 Famous and Effective Prescriptions of Ancient and Modern Times, 1990 China Ocean Press, Beijing.

APPENDIX 1. REHMANNIA EIGHT FORMULA AND ITS INGREDIENTS Rehmannia Eight Formula is presented with some variations among the Chinese texts. The following is a representative formulation that can be used as a starting point for discussion of the ingredients and their effects: Pinyin Name shudi wuzhuyu shanyao zexie fuling mudanpi fuzi guizhi

Common Name Rehmannia Cornus Dioscorea Alisma Hoelen Moutan Aconite Cinnamon

Proportion 24% 16% 16% 12% 12% 12% 4% 4%

The lead ingredient is cooked rehmannia, which is described in the Chinese tradition as a nutritive agent, alleviating dryness and promoting the functions of the liver and kidney systems (see Appendix 2 for further details). The remaining herbs of the formula can be understood as supporting the function of rehmannia. The small amounts of processed aconite and either cinnamon bark (rougui) or cinnamon twig (guizhi) serve as the hallmark of this particular rehmannia formula, one of numerous rehmannia-based combinations relied upon by Chinese doctors.

The characteristics of rehmannia, for which the processed form (shudi) is used here, are: rich and moist quality, sweet taste, and warming nature. Rehmannia would be too thick and rich to offer as a single herb: it is said to have a "cloying" quality (being very sweet and moist). Therefore, the herb is combined with others that can balance and harmonize its actions. In particular, three of the herbs in this formula help to balance the rich, moist quality of rehmannia: alisma, hoelen, and dioscorea. These herbs: promote the function of the digestive system (thus helping it handle the rich tonic, which is otherwise somewhat difficult to digest, like a rich dessert); get rid of any excess moisture that may already be present (which, when combined with the moist rehmannia, would make an uncomfortable condition of fullness and tiredness); and assist the functions of the kidney system in a manner that compliments the tonic effect of rehmannia, namely by promoting its draining action (aiding elimination via urination). Chinese doctors point to the role of alisma in dissolving greasiness, which is useful in countering the thick, moist quality of rehmannia; additionally, it removes (via urination) turbid materials that accumulate in the body. Dioscorea also helps the body to eliminate excess moisture, especially from the digestive tract (where diarrhea can occur if the moisture accumulates). Hoelen is depicted as absorbing moisture, like a sponge, from places of accumulation, to deposit it where it is needed (e.g., to areas that are dry or areas that will lead to its elimination). The book Commonly Used Chinese Herb Formulas with Illustrations (21) gives a listing of the Kanpo applications for Rehmannia Eight Formula as follows: 1. Nephritis (nephrosclerosis, nephrolithiasis, nephrotuberculosis), pyelitis (nephroatrophy), albuminuria, and edema. 2. Cystitis, cystolithiasis, cystotuberculosis, senile cystoatrophy, prostatomegaly, dysuria, urinary incontinence, and nocturia. 3. Diabetes and urinary incontinence. 4. Cerebral hemorrhage, arteriosclerosis, hypertension, and hypotension. 5. Neurasthenia, amnesia, nocturnal emission, uncontrolled emission, impotence, and inappropriate erection of the penis. 6. Lumbago, sciatica, deformed vertebra, numbness of the legs, and beriberi. 7. Cataract, glaucoma, decrease of eyesight, and keratitis. 8. Eczema, tinea, senile itching, vaginal itching, dry skin, and urticaria. 9. Chronic gonorrhea, rectoptosis, climacteric disturbance and related disorders. The first three groups of indications are related to urinary system disorders (diabetes is included as a cause of frequent urination). In the original text presentations (Shanghan Lun a n d Jingui Yaolue), the principal applications of the formula were for syndromes that included urination disorders. The underlying causes of these urinary disorders were described in terms understood many centuries ago; today, it is believed that various diseases of the kidney, bladder, and prostate are responsible for most of the changes in urination. For the most part, the other indications given for the formula (items 4-9) are more recent applications (developed during the past 50 years). Some of these indications can be predicted on the basis of the herb ingredients and Chinese medical theories. For example, the kidney system is said to control sexual function and influence the lower back and legs (e.g., symptoms of impotence, low back pain, sciatica, and knee swelling would often be interpreted as arising from dysfunction of the kidney system), thus helping to explain most of the items listed in 5 and 6. Disorders that typically arise as part of the aging process, such as the cardiovascular diseases (item 4), the eye disorders (item 7), and the dry skin problems (item 8), are addressed, according to Chinese doctrine, by nourishing the kidney and liver, as accomplished by the rehmannia-based formulas. In the book, Kampo Treatment for Climacteric Disorders (22), Rehmannia Eight Formula is described as one for "conditions marked by degenerative changes and decline in functions, commonly associated with aging...." As a major indication, "limpness or pain in the lumbar region or knees" is cited, along with sensitivity to cold, abnormal urination, and a variety of symptoms such as impairment of vision or hearing, decline in mental abilities, dry itchy skin, and shortness of breath. The authors claim that the formula "can be more effective than conventional drug therapy in controlling and preventing complications of diabetes, such as peripheral neuropathy, nephropathy, and retinopathy." While the focus of their book is on climacteric syndrome (menopause), they also mention the "male menopause" conditions of impotence, prostatitis, and prostate hypertrophy as additional applications of the formula. In the book 100 Famous and Effective Prescriptions of Ancient and Modern Times (23), which depicts the practices in mainland China, Rehmannia Eight Formula is said to have the following indications:

Insufficiency of kidney yang marked by lumbago, lassitude of the feet, cold feelings in the lower part of the body, cramping sensation in the lower abdomen, difficulty in urination or plenty of urination, impotence, pale and thick tongue proper, weak and fine pulse, as well as cough due to phlegm retention, diabetes, edema, chronic diarrhea...etc. For modern indications, the book relates a list somewhat similar in nature, though shorter, than that given by Kanpo practitioners: chronic nephritis, hypertension, diabetes, prostatic hyperplasia, postpartum retention of urine, pulmonary emphysema, neurosis, menopausal syndrome, and senile cataract. The book goes on to mention two clinical trials of the formula, one for treatment of cataract and the other for dysuria (due to prostatic hyperplasia); both are claimed to show positive results.

APPENDIX 2. REHMANNIA ACTIVE INGREDIENTS The main active constituents of rehmannia are iridoid glycosides. These are monoterpenes that have a glucose molecule attached. Catalpol was the first of these isolated from rehmannia (in 1969), and is the one present in largest amounts. There are more than a dozen iridoids that have been isolated from rehmannia, but the others are present in relatively minor quantities. In a study of several samples of rehmannia, it was found that catalpol makes up about 3-11% of the undried root content (depending on the growing conditions), with considerably less (about 1-2%) in the dried root: the drying process evidently destroys this component, converting it into another compound that may or may not be active. The pharmacological action of catalpol and the other iridoids is not fully established, but it appears that their main function is to stimulate production of adrenal cortical hormones. These hormones have anti-inflammatory action (explaining the claimed benefits of rehmannia for asthma, skin diseases, and arthritis) and are involved in the production of sex hormones (explaining the claimed benefit of treating menopause, impotence, and other signs of hormone deficiency). It is possible that anti-inflammatory effects could explain its early use in mending injuries, and the androgens that the adrenal gland might yield could increase muscle mass. The adrenal steroids may then serve as precursors to production of sex hormones. Rehmannia Eight Formula was tested in aged rats. It was shown to increase estradiol level of the serum in female rats and to raise serum testosterone in male rats. One of the iridoid glycosides that is found in small amounts in rehmannia and scrophularia is aucubin. It is very similar to catalpol and is also an active ingredient of the rarely used herb Acuba japonica, a close relative of cornus (which contains secoiridoid glycosides) that is used in many rehmannia formulas; aucubin is also present in the more commonly used plantago seed. Both aucubin (14) and geniposide (15) have been shown to have liver-protective actions.

APPENDIX 3. NIH ANNOUNCEMENT (January 16, 2002): Alternative Therapies for Benign Prostate Symptoms-Clinical Trials Consortium The Division of Kidney, Urologic and Hematologic Diseases (DKUHD) of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the National Center for Complementary and Alternative Medicine (NCCAM), and the Office of Dietary Supplements (ODS) invite cooperative agreement grant applications to establish a research consortium to conduct a randomized controlled clinical trial of Serenoa repens (saw palmetto) and Pygeum africanum in men with benign prostatic hyperplasia (BPH). The plan is to spend $29 million over the next seven years. As the population ages the number of men with lower urinary tract symptoms indicative of BPH is expected to increase substantially. The segment of the United States population that utilizes alternative and complementary approaches to disease prevention and management is also increasing rapidly, including the use of phytotherapy to control the symptoms of BPH. The most common phytotherapeutic agent is Serenoa repens or saw palmetto. Pygeum africanum is also frequently used in this country for the same purpose. Little is known, however, about the long-term effects of these agents on the lower urinary tract symptoms experienced by men with BPH since rigorously conducted clinical trials for these agents have not been conducted. In order to determine the effect of Serenoa repens a n d Pygeum africanum on the clinical progression of BPH the NIDDK and the NCCAM plan to establish a clinical trial consortium to conduct a large simple placebo-controlled clinical trial of these two agents comparing saw palmetto to placebo, and Pygeum to placebo. A secondary analysis will include head-to-head comparison of the two phytotherapy agents. The collaborative research group will consist of Clinical Evaluation and Treatment Centers (CETCs) to design and conduct the clinical trial and a single Data Coordinating Center (DCC) to collect, store, and analyze data generated by the CETCs. More than one-half of the men 50 years of age or older have lower urinary tract symptoms associated with the development of benign prostatic hyperplasia (BPH). The condition accounts for at least 1.7 million office visits per year in the United States with estimated health care costs exceeding $4 billion a year. In addition, these symptoms have been shown to have a significant negative impact on patient-reported quality of life and psychological well-being. The use of alternative therapeutic agents to relieve the symptoms of BPH is increasing very rapidly. In 1996 extracts of the saw palmetto berry was the 9th most common herbal remedy sold in the U.S increasing to the 5th most common in 1997. It is anticipated that the use of alternative therapies for BPH will continue to increase substantially as the U.S. male population continues to age.

Despite the widespread use of phytotherapy for BPH in the United States, most physicians are reluctant to either discuss or recommend their use since only a modest number of published reports have appeared in the peer-reviewed medical literature about their efficacy. Moreover, very few have met rigorous standards for reporting the results of clinical trials. Nonetheless, the available literature supports the hypothesis that these compounds may have some beneficial effects on BPH symptoms. This is supported by a recent meta-analysis that suggests that Saw palmetto improves urinary flowrate and nocturia in men with symptoms of BPH. However, there are no statistically significant reports of rigorously conducted clinical trials on the long-term effects (both beneficial and adverse) and on patient-reported outcomes. The objective is to determine if Serenoa repens and Pygeum africanum prevent the clinical progression of BPH, as defined by the development of one of the following: acute urinary retention, renal insufficiency (due to BPH), recurrent urinary tract infections, incontinence, or an increase in the American Urological Association (AUA) symptom score index of four or more points. This definition of the clinical progression of BPH is identical to that used in a soon-to-be-completed clinical trial supported by the NIDDK, the Medical Therapy of Prostatic Symptoms (MTOPS) Trial. Results from the MTOPS Trial, in particular the event rate among the placebo group, will be made available to investigators participating in this consortium to assist in refinement of the trial design. The investigators participating in this consortium will design and conduct a large simple clinical trial. It is envisioned that the clinical trial will require a total of approximately 3,100 men with BPH who will be randomized over a two-year period. The clinical trial will be double-masked and placebo controlled. It is expected that each CETC will recruit and follow-up 300 men for the duration of the trial. Men will be followed for a minimum of four (4) years and a maximum of six (6) years postrandomization. Innovative methods will be required to implement this clinical trial including recruitment of a large number of men with symptoms of BPH, use of multiple strategies to promote long-term adherence to these agents, maintenance of high rates for clinic visits, and complete ascertainment of endpoints For full details visit this NIH website: http://grants.nih.gov/grants/guide/rfa-files/RFA-DK-02026.html ACCESS: Find a practitioner who can prescribe Chinese herbs here Further information links: To provide your comments [no medical consultations can be offered], e-mail: [email protected]

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Perimenopausal Brain Fog Acupuncture and Herbs to Stimulate Brain Activity by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

During perimenopause and menopause, mental functions are usually affected by the hormonal changes, and conditions arise involving both mood lability and poor memory, the latter sometimes referred to as "brain fog" because of the obscuration of memory and clear ideation. This condition can persist into the postmenopausal years. It has been suggested that early intervention with hormone therapy might protect memory (1), but the publicized risks of hormone therapy have deterred many women and their physicians from pursuing this route. The precise nature of brain fog is somewhat unclear, as tests for simple memory tasks often show little change; there may be some subtle shifts in memory function that especially affect complex tasks or reduce memory retrieval when the mind is not focused on the objective. Estradiol stimulation of the brain's acetylcholine may be important to rapid recall (2) and the estrogens may influence the health of the nerve endings (3, see illustration below). The common herb remedy recommended for memory deterioration with aging, Gingko biloba leaf extract, which is believed to act primarily by enhancing circulation (and, to a lesser extent by affecting acetylcholine levels), showed only minor effects in a six week treatment period (4).

Estrogen's role in memory may be due in part to its affect on the tiny knobs called spines that protrude from a neuron's message receiving ends, known as dendrites. Spines are where important connections between neurons are made. The above images demonstrate that doses of estrogen resulted in a two-fold increase of the number of spines in rat embryo brain cells (left) compared to those without the supplements of estrogen (right). The cells were taken from brain areas responsible for memory processes. Images by Diane Murphy, Ph.D., National Institutes of Health.

ACUPUNCTURE THERAPY In a recent report in the Journal of Traditional Chinese Medicine (5), an acupuncture protocol was described for treatment of menopausal syndrome that focused on attempting to improve mental activities. The treatment was claimed to have a notable beneficial effect and also to alter the levels of key menopause-related hormones: E2 (estradiol), FSH (follicle stimulating hormone), and LH (luteinizing hormone). The primary therapy was based on a set of four acupuncture points, three of them along the center line of the body (governing and conception vessels) and one as a pair of points on either side of the spine (bladder meridian): baihui (GV-20) needled posteriorly and horizontally 0.5 cun with reinforcing-reducing method fengfu (GV-16) punctured slowly toward the mandible 1 cun with reinforcing-reducing method qihai (CV-6) needled perpendicularly 1.5 cun with reinforcing-reducing method shenshu (BL-23) needled by twirling obliquely toward the spine 1.5 cun with the reinforcing method A number of adjunctive points were chosen and one or two were selected for treatment of individual symptoms or constitutional conditions (examples are sanyinjiao, taixi, zusanli, taichong, and sishencong). Needle retention was for 15-20 minutes with manipulation twice during the retention time. Treatment was administered daily for four weeks (6 days acupuncture, 1 day break for each week). The basis of the therapy was described by the authors, who utilized a modern TCM description and associated the hypothalamus and hypophysis (pituitary) glands with the brain and the ovaries with the kidney system: TCM holds that climacteric syndrome is a condition in which the hypofunction of the ovary and the decreased secretion of

estrogen may cause imbalance of the hypothalamus-hypophysis-ovary axis. So, the occurrence of the syndrome is the result of the disturbance of the brain-kidney activities. In normal conditions, the brain vitality goes down to stimulate and control the kidney, while the kidney essence goes up at the same time to nourish the brain vitality. Based on this theory, we developed a strategy of regulating the mental activities and reinforcing the kidney to treat the disease. In the prescription, fengfu (GV-16) and baihui (GV-20), pertaining to the D u (governing) channel that connects the brain and kidney, are essential points. Needling them has the actions of refreshment and regulating the mental activities, freeing the Du channel to bring about communication between the brain and the kidney. Needling the point shenshu (BL-23), where the kidney essence and kidney-qi converge and transport from, has the actions of supplementing the kidney and replenishing the essence, engendering the marrow, and nourishing the brain. Qihai (CV-6), a point pertaining to the Ren (conception) channel, has the actions of reinforcing the primordial qi, supplementing the kidney, and balancing the Du channel with the Ren channel. All but one patient showed significant improvement in symptoms with this treatment. According to the data presented, the following changes in hormone levels were noted (E2 in pg/ml; FSH and LH in IU/L): E2 Before

E2 After

FSH Before

FSH After

LH Before

LH After

Control

40.12

38.97

27.81

29.01

18.02

19.92

Acupuncture

38.14

52.23

27.34

20.69

15.26

10.12

Group

In the developing menopausal condition, FSH and LH elevate and E2 declines, but the acupuncture treatment has reversed this trend. Unlike use of external sources of hormones, this therapy yields hormonal levels that stay within the normal physiological range and retain a balance of the different hormones, not just an increase in the estrogens. One of the adjunctive acupuncture points suggested was taixi (KI-3), which is employed when there are signs of yin deficiency. A treatment for postmenopausal women with taixi, shenshu (BL-23), and guanyuan (CV-4), rather than qihai (CV-6; which has actions similar to CV-4) along with administration of calcium supplements was said to have a marked effect on bone mineral density (6). The treatment was given once every other day for three months, followed by a ten day break and then another three month course of therapy. The authors noted that laboratory animal studies had been conducted to reveal the mechanism of action, stating that: Modern studies have proved that acupuncture at shenshu (BL-23) and guanyuan (CV-4) can increase the gonadal hormone level and the weight of adrenal cortex so as to exert a compensatory effect for the hyposecretion of gonadal hormone caused by hypo-ovarianism, thus inhibiting bone resportion and promoting bone formation to increase the bone mineral density. In other words, the acupuncture treatment promotes the ovarian production of estrogens, thus helping to reverse osteoporosis. The two studies taken together suggest that acupuncture at shenshu plus a point of the lower conception vessel may aid endocrine function and normalize hormone levels, while the governing vessel points on the neck (at GV-16) and head (at GV-20) may specifically augment the treatment effects for improving mental function. Following is a summary of the actions of the acupuncture points mentioned (7): Point Designation

Brief Description

Baihui (GV-20)

Meeting point of all the yang qi of the body; nourishes the sea of marrow, benefits the head, brain, and sense organs, calms the spirit.

Fengfu (GV-16)

Nourishes the sea of marrow, benefits the head, and calms the spirit; it is the point at which the governing vessel enters the brain.

Shenshu (BL-23)

One of the principal acupuncture points to strengthen the kidney system, fortify yang, nourish yin, and benefit essence.

Guanyuan (CV-4)

Fortifies the original qi and benefits essence; tonifies and nourishes the kidney yin; warms and fortifies the spleen; benefits the uterus.

Qihai (CV-6)

Similar action to guanyuan (CV-4); has greater effect on qi, less effect on nourishing yin.

Taixi (KI-3)

The stream and source point of the kidney channel; nourishes kidney yin, tonifies kidney yang.

FOLLOW-UP TREATMENT AND HERBS Although the authors of the first study did not comment on what would be done following this initial one month of treatment, standard practice in China is to maintain the results through additional, but less frequent, acupuncture (e.g., once or twice per week depending on the patient needs) and with herb therapies. One of the suitable herb therapies for brain fog is Bu Nao Wan (Brain Tonifying Pills), which are made with several different recipes, but an example is this one (8), produced by ITM (Pine Mountain), and similar to a popular patent remedy which was known as Cerebral Tonic Pills: wuweizi suanzaoren danggui roucongrong gouqizi boziren renshen

schizandra zizyphus tang-kuei cistanche lycium biota ginseng

20% 16% 10% 8% 8% 6% 4%

yizhiren yuanzhi shichangpu tiannanxing hupo longchi tianzhuhuang

alpinia polygala acorus arisaema succinum dragon tooth bamboo sap

4% 4% 4% 4% 4% 4% 4%

As can be seen, the formula is dominated by schizandra and zizyphus, two herbs that stabilize the mental functions. In Pharmacology and Applications of Chinese Materia Medica (9) it is noted that: "Human intellectual activity can be enhanced by schizandra so that work efficiency is increased. Schizandrin [a major active component of the herb, illustration below] at 5-10 mg could improve certain activities requiring concentration, fine coordination, sensitivity and endurance...." Zizyphus is the primary sedative herb used in Chinese medicine, but it produces a mild calming effect rather than a heavy sedating activity, and thus is often taken during the day, not just as night. Both schizandra and zizyphus help alleviate excessive sweating that may occur with menopausal flushing.

Bu Nao Wan includes several herbs that treat the condition called "phlegm-mist" or "phlegm-turbidity" which affects mental functions. As an example, the physician Jiao Shude (10) mentions that "acorus is frequently used to open and free the orifices of the heart, diffuse qi, and eliminate phlegm, thereby arousing the brain and clearing the spirit...phlegm turbidity and qi depression affect the heart spirit and result in palpitations, forgetfulness, fright and fear, and disquieted essence-spirit…." He further notes that polygala "promotes heart-kidney interaction, supplements the heart and boosts the kidney, and tends to be used for fright palpitations, forgetfulness, insomnia, and spiritlessness. In the Clinical Handbook of Chinese Prepared Medicines (11), Bu Nao Wan is described as being useful for symptoms of "poor memory, uneasiness, palpitations, and insomnia."

REFERENCES 1. Sherwin BB, Estrogen and memory in women: how can we reconcile the findings? , Hormones and Behavior 2005; 47(3): 371-375. 2. Daniel JM, Hulst JL, and Lee CD, Role of hippocampal M2 muscarinic receptors in the estrogen-induced enhancement of working memory, Neuroscience 2005; 132(1): 57-64. 3. Ariniello L, Estrogen's influence on the brain, Brain Briefings, Society for Neuroscience, http://web.sfn.org/content/Publications/BrainBriefings/estrogen.html 4. Elsabagh S, Hartley DE, and File SE, Limited cognitive benefits in Stage +2 postmenopausal women after 6 weeks of treatment with Ginkgo biloba, Journal of Psychopharmacology 2005; 19(2): 173-181. 5. Shen Xiaoming, et al., Acupuncture for treatment of climacteric syndrome, Journal of Traditional Chinese Medicine 2005; 25(1): 3-6. 6. Ouyang Gang, et al., The effect of acupuncture on bone mineral density in postmenopausal women, Journal of Traditional Chinese Medicine 2002; 22(1): 9-11. 7. Deadman P and Al-Khafaji M, A Manual of Acupuncture, 1998 Journal of Chinese Medicine Publications, Hove, England. 8. Dharmananda S, A Bag of Pearls, 2004 Institute for Traditional Medicine, Portland, OR. 9. Chang HM and But PPH (editors), Pharmacology and Applications of Chinese Materia Medica, 1986 World Scientific, Singapore. 10. Mitchell C, et al. (translators), Ten Lectures on the Use of Medicinals from the Personal Experience of Jiao Shude, 2003 Paradigm Publications, Brookline, MA. 11. Zhu CH, Clinical Handbook of Chinese Prepared Medicines, 1989 Paradigm Publications, Brookline, MA.

May 2005

HOW EMOTIONS MAY CONTRIBUTE TO CANCER by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The traditional Chinese medical view of cancer etiology holds that there are several possible contributing factors, and that one of the principal causes is internal factors, namely emotions (see: Oriental perspectives on cancer and its treatment, and Emotions and health). For example, Sun Binyan writes in his book Cancer Treatment and Prevention (1): According to our understanding of the tumor patient, most have suppression of the emotions. They tend to hold in their anger. Although some patients have good results after treatment, emotional stimulation may cause them to decline again and then the previous treatment would have been in vain. Some people have a severe phobia about cancer. Before they know the real disease, they have a lot of suspicion. Once they know they have the cancer, their whole spirit breaks down. This kind of spiritual state is very bad for the treatment. In the book Prevention and Treatment of Carcinoma in Traditional Chinese Medicine (2) Jia Kun gives 10 recommendations for prevention. In addition to good environment and personal hygiene, proper levels of work (exercise) and rest, good eating habits and proper food, avoiding smoking, and timely treatment of all ailments, he states that: Emotional changes, such as worry, fear, hesitation, anger, irritation, and nervousness should be prevented. Mental exhaustion is harmful and life should be enriched with entertainment. Shi Lanling and Shi Peiquan mention the etiology of various cancers in their book about Experience in Treating Carcinomas with Traditional Chinese Medicine (3), as regards the effect of emotions: The etiologic factors of the disease involve chiefly the disturbance of the seven emotions, especially melancholy, anxiety, and anger, which are liable to impair the spleen and the liver. Impaired by melancholy and anxiety, qi will be stagnated and the spleen will lose the function of transformation and transportation, leading to disturbance of water metabolism and the subsequent accumulation of phlegm-dampness, while, impaired by anger, the liver qi will be stagnated. The stagnated liver qi, as qi is the commander of blood, may give rise to blood stasis if not relieved in time. Thus, emotional disturbance, incoordination between the ascending-descending movement of qi of the zangfu organs, sluggish flow of qi and blood, and the ensuing obstruction of dampness, phlegm, and blood stasis are the fundamental pathogenesis of the disease. The authors go on to mention other contributors, such as consumption of food that is "rough, hot, or hard," indulgence in smoking, alcoholism, traumatic injuries, and chronic ulceration. In their section on treatment of breast cancer, the authors refer to a discussion in a Ming Dynasty text by the surgeon Chen Shigong (1555-1636 A.D.) indicating that breast cancer "results from anxiety, emotional depression, and overthinking which impairs the liver, spleen, and heart and causes the obstruction of the channels." This text is also mentioned in The Treatment of Cancer by Integrated Chinese-Western Medicine (4), translated this way: Breast cancer is due to worry and melancholy. Lots of ideas hanging around make one feel dissatisfied. Perverse flow of liver qi to the spleen leads to the obstruction of the channels and collaterals and congealations due to excessive accumulation. Pan Mingji, in his book Cancer Treatment with Fu Zheng Pei Ben Principle (5), presents a section on etiology of cancer, listing 5 contributing factors. The first item mentioned is emotional disturbance: TCM embodies changes of spirit and sentiment as the seven emotions: pleasure, anger, grief, fear, yearning, sorrow, surprise, all of which are emotional, physiological reactions of an organism towards external changes in its environment. Emotional disturbance refers to reactions, either excessive (excitation) or insufficient (inhibition) which will ultimately lead to disturbances in the flowing of qi and blood and the visceral functions, with subsequent illness. TCM claims rage harms the liver, excessive stimulation harms the heart, grief harms the spleen, great sorrow harms the lungs, and fear harms the kidneys. Though not necessarily precise, this belief definitely points out that emotional injury will effect the physiological functions of the qi, blood, viscera, and channels, and lower the body resistance, resulting in disease. The human body is susceptible to cancer when under emotional stress or disturbance. This is mentioned early in Chinese medical classics, such as Yellow Emperor's Canon of Internal Medicine and Golden Mirror of Original Medicine. This Oriental view that emotions contribute to cancer formation differs from that adopted by Western scientists, who regard cancer as a change in DNA that is induced by a chemical agent, radiation exposure, or insertion of viral genes (in a few cases, the abnormal DNA may already be present in the genetic heritage of the individual; this situation usually leads to cancer at earlier age). In order for the induced DNA change to lead to cancer, it is first not properly repaired by certain DNA repair proteins and then the abnormal cell is not destroyed by a natural cell death process (apoptosis). Cancer initiating factors act within the environment of the individual-which includes the person's genetic background and nutritional status-to trigger the development of cancer. Thus, lung cancer is often caused by breathing carcinogens such as those contained in cigarette smoke; stomach and colon cancer are often caused by carcinogens in the food supply; skin cancer may be induced by excessive exposure to the ultraviolet light of the sun; and leukemia may be induced by exposure to industrial chemicals, to radiation, or to a virus that resides in the bone marrow. Traditional Chinese doctors were aware of this type of etiology. For example, they recognized that cancer occurred more often in certain places and was attributed to something in the drinking water, or that cancer could be induced by rotted food and, in modern times, by smoking. Yet, it was the emotions that were often regarded as the most significant factor. At the least, the excessive and/or suppressed emotions would cause disruption of the internal organs and flow of qi and blood, and then the external factors would more easily induce further damage. Western researchers have not undertaken detailed study of the possibility that persistent or repeated experience or suppression of emotions contributes to the risk of cancer for several reasons. Aside from a low motivation to undertake the study because other factors are considered more important, such research is extremely difficult to perform properly. One would have to recruit a very large number of people into the study, have some reliable method of measuring emotional status over a long period of time, and then find some way to

quantitate the emotional condition (as it varied over time) so as to compare with the actual incidence of cancer among individuals under study. Still, the fledgling field of psychoneuroimmunology (the study of how psychological states, as detected in activity of the nervous system, impact the immune system), has developed some evaluations that suggest emotional stress increases a person's susceptibility to cancer (12). The emotional status of patients after receiving a diagnosis of cancer has been studied extensively, though even that has proven difficult. In one recent study in Denmark (6), women who had just been diagnosed with breast cancer that was considered to have a low risk of recurrence (easily treated, not metastasized) were compared with women from the general population. A frequently relied-upon study questionnaire (hospital anxiety and depression scale: HADS) was used to determine the level of anxiety and depression in these two groups. To their surprise and consternation, the authors found that the women diagnosed with breast cancer, albeit a low risk breast cancer, had an average anxiety and depression level lower than that of the general population. They suggested that the HADS questionnaire might not be suitable for questioning the general population (as it had been developed for studying people hospitalized with various ailments). One might expect that if women with breast cancer tended to have a life-long history of depression and anxiety that helped lead to formation of the tumor, or if these emotional conditions were recent and had some role in inducing the cancer, then this group would have a higher than typical level of depression and anxiety compared to the general population, even if receiving the diagnosis of breast cancer did not worsen their mental condition. The results may simply reveal the difficulty of designing and carrying out a meaningful study, since other studies have found that anxiety and depression in cancer patients tends to be a significant problem. In China, one published study (7) involving a huge population (750,000 people in Beijing) attempted to find out if psycho-social factors contributed to the incidence of primary lung cancer. They reported that their study showed three factors positively associated with occurrence of lung cancer: 1. Burst of emotion that could not be controlled. 2. Poor working circumstances, including poor relationship with coworkers 3. Depressive feeling for a long time. Poor relationship with coworkers would generally suggest that there is emotional tension during the work day, so all of these could indicate emotional disorders associated with higher incidence of cancer. When "depressive feeling for a long time" was analyzed further, it was found that this was a significantly stronger risk factor for women than men. This study supports the traditional Chinese contention that emotions can contribute to cancer incidence, but it would need to be verified by a tightly controlled trial in order to convince Western researchers that the results could have important implications for understanding the etiology of cancer.

A POSSIBLE BIOCHEMICAL MECHANISM INVOLVING CHRONIC EMOTIONAL STRESS If the contention that emotions contribute to cancer formation is to gain acceptance outside the field of traditional Chinese medical practitioners, finding a biological mechanism of action that could be measured in the short-term would be an important contribution. For example, if during a period of emotional stress there occurs a biochemical or physiological change that is understood to contribute to oncogenesis (cancer formation), then one could reasonably contend that emotions may be causing or working with other factors to cause some cases of cancer. One of the biological mysteries that has faced researchers in recent years is the relationship of estrogen to breast cancer (see: Estrogen dependent tumors and herbs). For years, concerns have been raised about giving estrogen in hormone replacement therapy to women who were considered at risk for breast cancer due to familial history (genetic background). In fact, the familial history of breast cancer is a contraindication to using hormone replacement therapy after menopause. Based on a variety of research findings, it appeared as if estrogen, whether produced by the body or given as a pill, might cause the cancer, which seems peculiar, in that it is a normal component of the body. Recent findings shed light on how estrogen is involved in oncogenesis and provides a model for a possible role of emotions (this model is highly speculative at this time, and is only used as an illustration). Estrogen is converted into different metabolites prior to elimination. There are two major metabolites-products of enzymes acting on estrogen-one of which can get to the DNA and actually induce cancer, and another which may help prevent cancer (8). One might say that there are "good" and "bad" estrogen metabolites. It is a situation that is reminiscent of the "good" and "bad" cholesterol in relation to heart disease. With cholesterol, it is actually the carrier molecules that are different: high density lipoproteins (HDL) and low density lipoproteins (LDL). HDL helps to prevent heart disease, while LDL contributes to it, because they have differing roles in transport and deposition of the cholesterol. Researchers have found that exercise, which is a normal healthy activity, increases the HDL and decreases the LDL, thereby reducing the risk of heart disease. What if emotions, perhaps certain types of emotions (anxiety, depression) stimulate the enzymes directing more of the estrogen to the "bad" type of metabolite, rather than the "good" one? This would result in increased cancer risk; the risk would be substantially increased if the estrogen levels were unusually high (as when giving hormone replacement therapy), since there would be much more estrogen to be converted to the carcinogenic form. Differences in metabolism of substances have been proposed as a basis for why some individuals develop cancer. In the book How to Discover Cancer Through Self-Examination (9), an example is given: Polycyclic aromatic hydrocarbon is a very strong chemical carcinogen; but when it enters the human body, it will only cause cancer when functioning in the cell through the transformation of polycyclic aromatic kinase. If the content of kinase in the human body is high, it is easy to engender cancer when in contact with the chemical substance; to the contrary, the probability of cancer incidence is lower if the content of kinase is low, even if the person contacts the chemical. Potential contributors to the level of enzymes (both those that transform chemicals into carcinogens and those that transform carcinogens into non-carcinogens) include genetic background, stimulation of the enzymes by other chemicals (e.g., alcohol and some other substances stimulate the liver to produce a large group of enzymes in substantial amount), nutritional status (some enzymes are affected by trace elements and vitamins that act as coenzymes), tissue injury (liver damage may affect enzyme production), and other factors. It is possible that stress hormones released in response to emotional changes can affect the levels of enzymes.

Certainly, the levels of the estrogens themselves vary markedly among individuals. In a study of estriol, estrone, and estradiol at days 10-14 of the menstrual cycle in women with regular menstrual cycles, it was found that estradiol levels were as low as 11-31 pg/ml (picograms per milliliter) in women with low levels but as high as 157-189 pg/ml in those with high levels (16). Since estradiol is currently considered a major hormonal contributor to breast cancer risk, this marked variation shows that the factors (as yet unidentified) that influence the hormone levels can have a substantial impact. At this time, there is no direct evidence that emotions cause such a shift in estrogen metabolism that might lead to higher risk of cancers, such as breast cancer. But, there is no question that emotions can impact the physiological functions, and this model is just one example of how they might translate into a higher cancer risk that could be detected by a properly designed study.

A POSSIBLE MECHANISM INVOLVING SHORT-TERM EMOTIONAL STRESS The Chinese physicians who comment about the role of emotions in cancer formation point to the fact that the internal viscera become weakened, thus increasing the opportunity for pathologies of all types, including cancer. Western research has already supported the idea that depression can impair immune system functions (perhaps indirectly, such as by repeatedly impairing a good night of sleep, with sleep contributing to maintenance of the immune system). It has been shown that tumor-relevant lymphocyte subpopulations, such as natural killer cells (NK cells; these can directly attack cancer cells), have receptors for various neuropeptides, including those released during stress. This finding indicates how NK cell activity could be modulated by a person's emotional responses. The level of NK cell activity has been found to be a reasonably good predictor of breast cancer outcome; further, a portion of the loss of this activity in cancer patients was shown to be correlated with psycho-social measures such as patient "adjustment" (avoiding showing distress at the cancer diagnosis/treatment), lack of social support, and symptoms of fatigue/depression (14). Along these lines, the immune system may regulate the activities of enzymes, such as aromatase, that converts estrogens to estradiol in breast tissue (17, 18). Cytokine changes (as occur with infection and inflammation) have been observed in cases of major depression, and have been suggested to be a potential cause of depression (19, 20). In fact, some antidepressant drugs are tumor necrosis factor (TNF) inhibitors; this being one of the cytokines that causes considerable adverse effects in cancer patients and those with lifethreatening infections, such as HIV. It is also possible that depression, and other emotional disorders, will affect the cytokines. In the book Why We Get Sick (10), which is based on the premise that most of our body (and mental) functions have been determined by evolutionary factors, the author explains how a potentially helpful feeling (anxiety) can have harmful physiological effects: Everyone must realize that anxiety can be useful. We know what happens to the berry picker who does not flee a grizzly bear, the fisherman who sails off alone into a winter storm, or the student who does not shift into high gear as a term-paper deadline approaches. In the face of threat, anxiety alters our thinking, behavior, and physiology in advantageous ways....Because anxiety can be useful, it might seem optimal to adjust the mechanism so that we are always anxious. This would be distressing, but natural selection cares only about our fitness, not our comfort. The reason we are sometimes calm is not because discomfort is maladaptive, but because anxiety uses extra calories, makes us less fit for many everyday activities, and damages tissues. Why does stress damage tissues? Imagine a host of bodily responses that offer protection against danger. Those that are "inexpensive" and safe can be expressed continually, but those that are "expensive" or dangerous cannot. Instead, they are bundled into an emergency kit that is opened only when the benefits of using the tools are likely to exceed the costs. Some components are kept sealed in the emergency kit precisely because they cause bodily damage. Thus, the damage associated with chronic stress should be no cause for surprise....In fact, recent work has suggested that the "stress hormone" cortisol may not defend against outside dangers at all, but instead may mainly protect the body from the effects of other parts of the stress response. Just as Chinese therapeutic dogma holds that one can use a powerful remedy that may weaken the individual temporarily in order to gain an advantage over a disease, the body also can sacrifice some of its well-being, temporarily, to save itself. However, if the "emergency kit" is left open for an extended period of time, by living in a situation that the body and mind deems unsafe, then progressive damage to the tissues can occur. This damage may then cause or exacerbate chronic disease or a life-threatening event (e.g., stroke, heart attack, incurable cancer). Indeed, it is possible that even a single period of intense stress lasting months, such as occurs with a divorce, death of a family member, loss of job, or other life-changing event, rather than decades of habitual emotional distress, might lead to serious damage to the tissues which could trigger the development of cancer. The stress hormones might themselves stimulate latent cancer cells into reproduction; the hormones or their metabolites might transform a normal cell to a cancer cell; or the damage to the tissues may lead to failure of normal cancer-control mechanisms. In this way, a diagnosis of cancer may be encountered a year or two after such an event (it takes that long for the cancer to develop enough to yield evident symptoms or a diagnosable lump). Such a correlation-between stressful events and subsequent cancer diagnosis (13) or recurrence of previously treated breast cancer (15)-has been supported by early studies that still require replication. If severe emotional stress (of the type that is likely to be mentioned during questioning) does sometimes give rise to cancer soon after the stress is experienced, this would certainly explain the observation made by traditional practitioners: that emotions are a cause of cancer.

REFERENCES 1. Binyan Sun, Cancer Treatment and Prevention, 1991 Offete Enterprises, San Mateo, CA. 2. Jia Kun, Prevention and Treatment of Carcinoma in Traditional Chinese Medicine, 1985 The Commercial Press, Hong Kong. 3. Shi Lanling and Shi Peiquan, Experience in Treating Carcinomas with Traditional Chinese Medicine, 1992 Shandong Science and Technology Press, Shandong. 4. Zhang Dai-zhao, The Treatment of Cancer by Integrated Chinese-Western Medicine, 1989 Blue Poppy Press, Boulder, CO. 5. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing

House, Fujian. 6. Groenvold M, et al., Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: a valid comparison? Journal of Clinical Epidemiology 1999; 52(6): 523-530. 7. Fan RL, Zheng SH, and Wu ZS, Study on the relationship between lung cancer at preclinic stage and psycho-social factors: a case control study, Chinese Journal of Blood Diseases 1997; 18(5): 289-292. 8. Cavaljeri EL, et al., Molecular origin of cancer, Proceedings National Academy of Sciences 1997; 94: 10,937-10,942. 9. Pan Mingji, How to Discover Cancer Through Self-Examination, 1992 Fujian Science and Technology Publishing house, Fujian, China. 10. Nesse RM and Williams GC, Why We Get Sick, 1994 Times Books, Random House, New York. 11. Guzman RC, et al., Hormonal prevention of breast cancer: mimicking the protective effect of pregnancy, Proceedings of the National Academy of Sciences USA, 1999; 96(5): 2520-2525. 12. Ader R (editor), Psychoneuroimmunology, 1981 Academic Press, New York. 13. The Burton Goldberg Group, Alternative Medicine: The Definitive Guide, 1993 Future Medicine Publishing Group, Puyallup, WA. 14. Levy S., et al., Correlation of stress factors with sustained depression of natural killer cell activity and predicted prognosis in patients with breast cancer, Journal of Clinical Oncology, 1987; 5(3): 348-353. 15. Ramirez AJ, et al., Stress and relapse of breast cancer, British Medical Journal, 1989; 298: 291-293. 16. Wright JV, Schliesman B, and Robinson L, Comparative measurements of serum estriol, estradiol, and estrone in nonpregnant, premenopausal women: a preliminary investigation, Alternative Medicine Review 1999; 4(4): 266-270. 17. Reed MJ, et al., The role of cytokines and sulphatase inhibitors in regulating estrogen synthesis in breast tumors, Journal of Steroid Biochemistry and Molecular Biology 1995; 53 (1-6): 413-420. 18. Purohlt A, Singh A, and Reed MJ, Regulation of steroid sulphatase and estradiol 17 beta-hydroxysteroid dehydrogenase in breast cancer, Biochemical Society Transactions 1991; 27(2): 523-532. 19. Dantzer R, et al, Cytokines and depression: fortuitous or causative association? Molecular Psychiatry 1999; 4(4): 328-332. 20. Licinio J and Wong ML, The role of inflammatory mediators in the biology of major depression, Molecular Psychiatry 1999; 4(4): 317-327.

APPENDIX 1: Concerns About Attributing Cancer Causation to Emotions Some readers may raise the objection that attributing cancer causation to emotions could place an extra burden on the cancer patient: namely blaming the individual for causing their condition (this point was raised by one of the clinicians at ITM). For each individual cancer patient, blaming their cancer on any particular cause is probably of no value. Whether the cancer is blamed on an environmental chemical introduced by a reckless corporation, or on a high fat diet, on smoking, or on an inherited gene, the treatment of the cancer is not significantly altered; it is not possible to go back and undue the damage. Therefore, to become involved in the matter of placing blame for any individual case is a futile effort. Indeed, no matter what is blamed, the process of placing blame may simply stimulate more emotional distress (e.g., anger and over-thinking) that impairs the healing process. However, discovering possible contributors to cancer, whether emotions or external factors, is helpful for the general population, as it might direct individuals to take measures to minimize their risk. If, as postulated, emotions contribute to cancer formation, then activities that control the emotions (see: Emotions and health) may be among the valuable pursuits in maintaining health. It is also possible that the same practices would be of special interest to those who have been diagnosed with cancer, who were then treated successfully, but remain at risk for recurrence of cancer. Reading the alternative medical literature makes it clear that a large part of the alternative health care movement in the U.S. has focused on the concept that many ills, including cancer, are mainly caused by persons other than the one who suffers from the disease. Therefore, blame is placed on pollutants, food additives (including pesticides) and food processing, stripping of nutrients from the edible plants by modern agriculture practices, radiation from electric power lines and cellular phones, prescription drugs, dentists applying mercury amalgam, and the deceptive statements of the tobacco industry and the food industry (to name a few of the culprits). The role of the individual in properly selecting lifestyle choices that affect health (a selection process that is much helped by learning from those who are wise) are not emphasized except when the blame can be attributed to another party that is also involved. Thus, while having children relatively early is deemed the best natural protection against breast cancer (11), the choice of having children later in life as a major factor in the increasing breast cancer rates is never mentioned by proponents of alternative medicine (as they may endorse this particular lifestyle change from past practice). Instead, birth control pills are blamed (13), perhaps because a pharmaceutical company has manufactured them and a doctor has prescribed them (two external targets of blame). In traditional medical systems, such as Chinese medicine, serious diseases are thought to have several possible contributing factors, but personal practices are deemed especially important in preventing the diseases. Thus, in Jia Kun's outline of cancer prevention activities (2), he includes personal hygiene, proper work and rest, physical exercise, good habits, proper cooking of food, getting physical examinations regularly, and getting treatment for ailments promptly, as well as avoiding emotional disturbance. In addition, he recommends that people should consume stalactite (this is the cave mineral deposit that provides an abundance of trace minerals, though calcium is the dominant component) by putting stalactite into the water supply, making tea with it, or consuming the powder (this is a type of mineral supplementation; today, several minerals, especially calcium and selenium, are thought to have benefits for preventing and treating cancer). When it comes to industrial pollution, he says that: "Harmful gas should not be released into the atmosphere, and planting should be carried out to purify the air," but his longest dissertation is about proper selection and preparation of food. Thus, the concern that a link between emotions and cancer formation could lead to a worsening mental state due to blaming oneself

may simply be a reaction that results from the frequent practice of blaming others for our poor health, a practice that should be modified. No doubt there are several external factors introduced in modern society that contribute to ill health, but the tendency to focus on these influences may result in a particular sensitivity about considering one's personal responsibility for making daily choices that promote good health (see: Promoting health and relaxation during the four seasons). As Pan Mingji relates (9): The external causes of cancer have been all narrated above [included in the preceding pages of his book are the following external causes: contaminated drinking water, moldy food, smoked fish and meat, food polluted by radioactive materials, cigarette smoking, alcohol abuse, chemical food colorings, eating overly hot food, poor posture during eating, work environment contaminated by chemicals], nevertheless, it is the internal cause that takes determinable effect. For example, in coming into contact with the same carcinogen, some people will develop cancer while others will not. Even in areas where cancer occurs at a high rate, only a tiny minority of people die from it while the overwhelming majority of them still live healthy and sound. This illustrates that the occurrence and development of malignant tumor relates closely to the internal factors of the organism. There are a lot of factors which affect the anticancer ability of the organism, but the leading one has to do with whether the spirit, nervous system, and various defenses of the organism are perfect. A lot of evidence proves that those who are optimistic and undertake exercises [in China, this refers mainly to taiji and qigong, along with similar types of practices] tend to have healthy and sound function of the nervous system, strong physiques, and naturally great anticancer ability and immunity. Even if those people come into contact with outside carcinogens, they will not develop cancer. On the contrary, those who have mental injury, who are disheartened, or often have a fear of cancer, and who do not undertake exercises at all or are overtired, whose daily life is irregular and unsanitary, whose spirit and nerve function is disorganized, tend to reduce their defensive ability. As a result, the rate of cancer occurrence among those people is higher. September 1999

ORIENTAL PERSPECTIVES ON CANCER AND ITS TREATMENT by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

CAUSE OF CANCER Modern medicine attributes most cases of cancer to changes in DNA that reduce or eliminate the normal controls over cellular growth, maturation, and programmed cell death. These changes are more likely to occur in people with certain genetic backgrounds (as illustrated by the finding of genes associated with some cases of cancer and familial prevalence of certain cancers) and in persons infected by chronic viruses (e.g., viral hepatitis may lead to liver cancer; HIV may lead to lymphoma). The ultimate cause, regardless of genetic propensity or viruses that may influence the risk of the cancer, is often exposure to carcinogenic chemicals (including those found in nature) and/or to radiation (including natural cosmic and earthly radiation), coupled with a failure of the immune system to eliminate the cancer cells at an early stage in their multiplication. The immunological weakness might arise years after the exposure to chemicals or radiation. In the field of traditional Chinese medicine, which evolved its ideas over many centuries, the genetic propensities and the impact of viruses and radiation could not be known: these are 20th century discoveries. However, the Chinese have understood that something from the environment, some kind of toxin, was a likely contributor to development of the disease. Perhaps more importantly for our current concerns, the experience of Chinese doctors points to emotional contributions to the development of cancer. In particular, depression (as in repressed anger), anxiety (worry, fearfulness, and excess circular thinking), and grief (usually because of death of a loved one) are thought to result in stagnation of circulation. If this circulatory disturbance continues, there may be a local accumulationeventually to become the tumor mass-at the weak point in the body. An underlying weakness in an organ or other body tissue is what allows the problem of stagnancy in circulation to eventually overcome normal patterns of cellular growth. Thus, a tumor, or some other type of excessive cellular activity, occurs. Stagnation and accumulation, as described in this Chinese model, do not always result in malignancy (one may experience a benign lump), but if the center of stagnancy becomes "toxic," it will produce either an abscess (growth of bacterial cells) or a tumor (growth of one type of body cells). Abscesses and tumors occur by different processes, but there is a frequent overlap in the successful Chinese medical approaches to treating bacterial infections that cause abscesses and in treating tumors. Chinese doctors interviewing patients who have unusual swellings find a high frequency of reports of depression, anxiety, grief, and similar emotional states. Although it might be argued that these conditions arose because of the cancer, Chinese doctors are convinced that they existed prior to development of cancer. This conception follows the underlying principles of Chinese physiology, developed over 2,000 years ago. Modern researchers in America have noted a similar relationship between depression and cardiovascular disease, another type of circulatory disorder. Diseases caused by emotional conditions are said to be of internal origin and are distinguished from those diseases of external origin, such as epidemic infections. Depression, anxiety, suppressed anger, and other emotional conditions are traditionally treated in China not with anything like the modern Western technique of psychotherapy, but rather, through reliance on the family and society, and guidance towards restoring for the individual the long-held views on how to live (in ways that help unfold the persons true destiny, overcoming the obstruction that causes emotional stagnation and physical disease). In addition, there are herbal remedies that help relieve the physiological correlates (altered patterns of circulation) to the emotional conditions and some that are believed to address the psychological processes directly. The "toxic" aspect of tumor growth is the aspect that is introduced from the outside. In modern terms, chemicals in the environment (from natural or man-made sources), components of cigarette smoke, and viruses all count as examples of the toxins depicted by traditional Chinese doctors. In the Oriental context, a toxin is anything that transforms a simple, functional or organic abnormality into a difficult-to-control disease. Long before the formal science of epidemiology, Chinese physicians noted that cancers were more prevalent in some geographical areas than others and attributed this to substances in the environment (e.g., in the drinking water) or to unique characteristics of the local diet. We now know that in addition to ingestion of carcinogens, deficiencies of certain nutrients (such as selenium and flavonoids) that affect a cell's carcinogen susceptibility and that are important to the immune system, may have also been behind regional high incidence of cancers.

TREATMENT Cancer has long been treated by Chinese doctors, with herb therapies being the main protocol. The treatments varied according to the preferences of the doctor for certain theories of cancer etiology and resolution, and for certain herbs, as well as according to the cancer site and stage of development. The effectiveness of the treatments was not well-established prior to the introduction of clinical trials. Today, the herbal therapies are most frequently coordinated with Western medical approaches that may include surgery, chemotherapy, and radiation, as deemed suitable for the type of cancer. The herb prescriptions that were given to cancer patients as the sole therapy primarily contain herbs that are said to remove or counteract toxins, remove or shrink accumulations, restore normal circulation, and promote the functions of the internal organs. When Western medical therapies are applied, the toxin-removing and accumulation shrinking therapies become less important, because the Western methods often accomplish the same goal (though it may be the case that using both together will get a better result). As an adjunct to Western medical interventions, Chinese herbs are directed at restoring normal circulation (something that the Western therapies are not designed to do) and protecting the body from damaging effects of those therapies (or treating specific side effects, if they have occurred). To prevent a recurrence of the disease after the therapies have been apparently successful, it is considered important for the person to reduce one's negative emotional influences as well as to strengthen any weak areas of the body so that they are no longer as susceptible to abnormality.

TOXIN-REMOVING THERAPY

An example of an herb used to counteract toxins is sophora root. There are two species used. One is from Sophora flavescens, called kushen by the Chinese, meaning the bitter root of miraculous effect (in comparison to the relatively sweet root of miraculous effect, renshen: ginseng). It contains alkaloids of the matrine series, which, in laboratory mice, have been shown to inhibit the growth of sarcoma-180 (a cancer strain commonly used in experiments). The therapeutic index of the sophora root is 7.8 times higher than a common chemotherapuetic agent called mitomycin C (meaning that it takes 7.8 times as much of the latter to have the same effect). Sophora is used clinically to treat a wide range of ailments, but in terms of its purported "antitoxin" action, it is used to treat dysentery, parasites (trichomoniasis), skin diseases, acute hepatitis, and chronic bronchitis. It is also applied topically with good effect for vaginal trichomonas and for Mycobacterium leprae, the organism that causes leprosy. The other species is Sophora subprostrata, called shandougen by the Chinese, meaning the root of the mountain bean. Sophora is in the legume family and produces bean pods; this species grows in the mountains and also contains matrine series alkaloids. It has similar medical applications. These two species are of particular interest because they inhibit tumors without inhibiting the immune system, a problematic aspect of nearly all chemotherapy agents. To the contrary, experiments show that they can enhance immune functions, including increasing leukocyte (white blood cell) numbers and promotion of the peripheral immune system responses. The toxicity is quite low, and there are only slight adverse responses when the dosage is especially high. Presently, there is no clear evidence that these herbs, when used alone, can cure any human cancers. However, they appear to contribute significantly to the curative effectiveness of complex herb formulas and combination treatments of herbs and Western therapies. There are at least two dozen other herbs that have similar activity (inhibiting cancer, promoting immune functions), with various types of active components; and several such herbs are combined together in the production of a complex formula used in clinical practice. An example of another toxin-removing herb that is often used for cancer is oldenlandia. The Chinese call it baihuasheshecao, describing its white flowers (baihua) and calling it a snake (she) weed (cao), possibly because of early use as a remedy for snake bites. When cancer cells are grown in culture, the addition of oldenlandia extract significantly reduces the cells rapid growth rate. For general use in removing toxins, this herb can be applied successfully in cases of appendicitis, peritonitis (inflammation of the abdominal lining), pelvic inflammatory disease, urinary tract infection, mumps, hepatitis, chronic bronchitis, and many other infectious disorders. The herb is added at high dosage (one to two ounces per day) to herb formulas for treating cancer. It has been used, for example, to treat cervical, breast, and rectal tumors.

RESOLVING ACCUMULATIONS In an effort to remove accumulations (cell masses, such as a tumor), an herb that is often utilized is curcuma, a member of the ginger family. There are two species commonly used in cancer therapy that, like ginger, have a spicy taste. Curcuma aromatica is called yujin by the Chinese, after its affect on stagnation (yu means stagnation; jin refers to the golden color and to its ability to treat the lungs, the organ system associated with the metal element, for which gold is a symbol). It contains aromatic volatile oils that help to remove excessive lipids from the blood, reduce aggregation of platelets (sticking of the blood cells to form masses), and reduce inflammation. In addition, the herb's oily components enhance fibrinolysis (the process that breaks down fibrous proteins, such as those that protect tumors from the immune system), and promote secretion of bile, which helps to clear congestion of the liver, promote digestion of fats, and aid intestinal peristalsis (intestinal movements that help evacuation). Thus, these essential oils help to get rid of many types of accumulation. The other species is Curcuma zedoaria, known by the Chinese name ezhu (the origin of this name is obscure). It likewise contains volatile oils. When the extract is injected into mice that have tumors, it is found that the tumors shrink. It is believed that the enhanced fibrinolysis and other processes stimulated by the volatile oils allow immune system cells to enter the interior of the tumor and consume and destroy the tumor cells. One of the main clinical uses of zedoaria is to treat cervical cancer, with the oil injected into the tumor mass (which is accessible through the vaginal opening). These herbs also have low toxicity. Studies of liver enzymes and of kidney function in patients given large doses of the herb did not show abnormalities. In a few individuals, increased bowel movements may occur. According to Chinese dogma and experience, salty materials help to soften up and dissolve masses that form in the body. One of the popular materials to use for such purposes is oyster shell. These shells contain calcium salts and complex proteins. Calcium has been shown to enhance immune functions; the complex proteins may interact with cell surface receptors and alter the signals that tell cancer cells to continually reproduce. Seaweeds are used similarly: their effects may rely primarily on sulfated polysaccharides rather than calcium for promoting immune system functions. Kelp (called laminaria) and sea tangle (called sargassum), are examples of seaweeds frequently used for softening masses.

CIRCULATION NORMALIZING We know now that a tumor develops its own blood supply system (as a branch from the normal supply), but it is a poorly developed circulation, with the cancer cells surviving with low oxygen: such cells are less susceptible to the effects of radiation than those cells that have adequate levels of oxygen. One method of cancer therapy now being investigated is inhibition of angiogenesis (blood vessel formation), which might be accomplished by various cartilage sources, including that from shark and calf, and from compounds of similar structure found in the sea cucumber. Additionally, the blood vessels of surrounding normal tissues are eliminated or displaced by the tumor, thus weakening the surrounding tissues, and making them more susceptible to replacement by tumor mass. There are many other changes in the blood circulation in those with cancer. According to studies in China, about 90% of cancer patients have abnormal microcirculation patterns (this is circulation through capillary beds) and most cancer patients have high fibrinogen levels in the blood and higher than normal coagulability of blood. Tumors are often surrounded by a fibrin coating that prevents immune cells of the blood stream from entering and destroying the tumor. Since the combination of viscous blood and fibrin coating hinder the penetration of tumors by antineoplastic drugs and by active immune cells, blood-activating herbs (herbs that restore normal blood conditions and circulation patterns) are usually prescribed to cancer patients in order to promote the positive effects of cancer therapies while limiting their negative impacts.

One of the most serious developments for a cancer patient is metastasis from the original site to other body sites, as this process reduces the potential to remove the cancer by surgery or local radiation. For metastatic cancer cells to attach to tissues, so as to develop a new tumor mass, they require the assistance of "sticky" materials from the blood. A group of herbs classified as blood-activating herbs are used to counter all of these problems. Some blood-activating herbs also have direct cancer-inhibiting actions (just as the herbs for removing toxins do) and others promote immune system attack against cancer cells. In addition, blood-activating herbs reduce the tendency to form adhesions and excessive scar tissue following surgery and reduce some of the side effects of chemotherapy, such as hepatitis and pulmonary fibrosis. Curcuma and zedoaria, mentioned above because of their mass-reducing quality, are also categorized as herbs for activating blood circulation. Chinese doctors also often rely on two other herbs: salvia and sparganium. Salvia is known to the Chinese as danshen, meaning the cinnabar-colored herb of miraculous effect. This herb is used more than almost any of the other blood-vitalizing herbs for reducing the stickiness of the blood, and increasing circulation to areas where circulation has become restricted. Chinese doctors prescribe salvia in the treatment and prevention of heart attack, stroke, and peripheral vascular occlusion. Sparganium is known to the Chinese as sanleng, referring to its appearance as a plant made up of straws (leng), of which there are most often three (san). This herb is frequently combined with zedoaria to treat firm lumps (as opposed to the soft lumps such as found in lipomas). In the case of a person undergoing radiation therapy, an herb for promoting blood circulation that is relied on to make the cancer more susceptible to destruction is tien-chi ginseng, known by the Chinese name of sanqi, meaning three and seven (referring to the leaf pattern).

PROTECTION FROM SIDE EFFECTS OF CHEMOTHERAPY For many people, one of the frightening consequences of a diagnosis of cancer is the ordeal of chemotherapy or radiation therapy. Ideally, modern research will lead to less offensive remedies in the future. The dominant chemotherapeutic agents are those that inhibit the reproduction of cells. Since malignant cancer cells reproduce more rapidly than most other cells in the body, the chemotherapuetic agent interferes to a greater extent with the cancer cells than your own, slower growing cells. Any group of cells in the body that need to reproduce rapidly are also inhibited by standard chemotherapy: these include the bone marrow "stem" cells that produce blood cells (especially affecting the white blood cells, thus causing the immune deficiency condition known as leukopenia), the stomach lining cells (causing nausea), and the hair follicles (causing hair loss). It is appropriate to say that the chemotherapeutic agents are poisons that are somewhat selective in which cells they poison. They are usually given for a short time, until a patient's system begins to be inhibited too severely, and then there is a rest period to allow recovery of the immune cells before another dose is administered (in some chemotherapeutic regimens, a low dose of the drug is given regularly). The Chinese interpretation of chemotherapeutic impact is that it defeats the normal defensive and metabolic systems within the body. It is believed that this action can be countered by using certain herbs that enhance the usual body functions. They can protect the body's cells from the effects of chemotherapy, without protecting the cancer cells, because the cancer is not participating harmoniously in the integrated body metabolism that the herbs support. In fact, as described above, one can make the cancer cells even more susceptible to the medical therapies by using the blood-vitalizing herbs as part of the treatment. The immune-enhancing effect of the tonic herbs used to protect against chemotherapy damage is important in helping to defeat the tumor that is weakened by the drugs. A laboratory measure of body damage due to chemotherapy or radiation is decline in the white blood cell count (the individual may experience other effects that are deemed uncomfortable, but not necessarily dangerous). If the white cell (leukocyte) count goes too low as a result of the therapies, the cancer therapy must temporarily halt, because the patient is then at high risk of experiencing a dangerous infection. This halt in therapy is a significant problem because it gives the cancer cells a chance to rejuvenate, especially in an environment in which the body's immune system (which might otherwise help to eliminate cancer cells) is weakened. The main herb used for restoring the immune functions that are inhibited by cancer therapies is astragalus. The Chinese name for this herb, huangqi, refers to the yellow color (huang) of the inner portion of the root, a measure of its quality. The yellow color is conferred by flavonoid components. The main active component for immune system effects are polysaccharides (long chains of sugar molecules). Their influence on the immune system, and on its attack against cancer cells, is shown in illustration #1. This mechanism of action was worked out for a polysaccharide from a medicinal mushroom (the shiitake mushroom that is often used in Oriental cuisine)but the effects are the same as astragalus. The influence of the astragalus polysaccharide was confirmed in tests at the well-known M.D. Anderson Hospital in Houston, Texas during the 1980's. Unfortunately, an immune-enhancing drug was not developed from this work because of the inability to patent a polysaccharide component from plants. But many effective health food products have been generated from the herbal polysaccharides. In Japan, the most widely used natural cancer therapy agents are polysaccharide extracts from medicinal mushrooms. Ganoderma (Japanese: reishi), lentinus (Japanese: shiitake), and coriolus (yielding the commercial product PSK, for polysaccharide krestin) are the main mushrooms used as sources of immune-restoring, cancer-inhibiting polysaccharides. Astragalus is used in China for almost all immune deficiency disorders, and also for most autoimmune disorders, because of its broad-spectrum normalizing effect for the immune system. It helps regulate T-cells, produce interferon (a cellular component that helps fight viruses and cancers), and promote phagocytosis (swallowing up foreign cells or particles by immune system cells). An herb that is used for the purpose of countering blood cell deficiency from cancer therapies is millettia. The Chinese name, jixueteng, means the chicken's blood vine, referring to the blood (xue) red color of the stem. The herb is used extensively for restoring both red and white blood cell counts that are depressed by a variety of causes. Millettia is classified with the herbs for promoting blood circulation, having a property similar to that of salvia-these herbs are frequently combined in the formulas cancer patients receive. Deer antlers are sometimes used in herb medicine formulas for treating bone marrow suppression, because the antler is the fastest regenerating part of any mammal, and it is an extension of bone. The non-ossified inner portion is gelatinous and has been shown to promote blood cell generation. For the nausea associated with chemotherapy, anti-nauseant herbs that have been found useful for other purposes, such as for morning sickness or nausea caused by consumption of contaminated foods, are used. Among the best herbs for this purpose are ginger

root (the same as obtained in the grocery store), a medicinal mushroom called hoelen, which grows on pine trees and contains a pectinlike substance (pectin is usually obtained from apple and other fruit peels), and the bulb-like underground stem (rhizome) of pinellia. The latter is a poisonous herb when collected, but it is processed by Chinese herbalists to remove the toxicity. These herbs reduce nausea, vomiting, and diarrhea. Ginger and hoelen contain substances that bind up components in the stomach (and intestines) that instigate a nausea reaction. Pinellia calms the nerves that affect the stomach and intestines and reduces any inflammation of the lining of these tissues. A combination of pinellia, hoelen, and ginger is used in Japan for nausea and vomiting associated with pregnancy. The herbs are included in numerous remedies for acute digestive disorders caused by eating contaminated foods or because of disturbed digestive functions that arise because of emotional stress, viruses, and liver diseases. In China, such herbs are usually combined with a fermented mixture of wheat and herbs called shen-chu (Chinese shenqu; spirit of fermented grain); it contains digestive enzymes. Numerous technical books have been written about the treatment of cancer and the side effects of cancer therapies. They reveal an extensive knowledge of the subject by Chinese physicians. These books are rarely accessible by the public, as they are meant for specialists in the field. However, individuals who have a diagnosis of cancer can work with practitioners trained in herbal medicine to coordinate a treatment with their oncologist.

QI: A BASIC CONCEPT IN RELATION TO CANCER Qi (pronounced "chee" with emphasis on the "ch"), is a term used by Chinese doctors to describe the source of nutritive substances and metabolic activities in the body. Qi is derived primarily from foods, but some is also present in the body as essential essence at birth and some is acquired through breathing. According to the Chinese concept, the patterns of interaction between the various parts of the body can be charted as a circulation of q i . Acupuncturists, in their study of the medical technique, memorize the main interaction channels-meridians-of the body. By stimulating a point or region of this interaction channel, one can have an influence elsewhere, that is, somewhere along the pathway of qi circulation that might be less accessible to the practitioner (such as deep within the body). This concept helps explain how, for example, an acupuncturist can insert a needle in the hand and have an effect on the intestines. From the Western point of view, the needle causes a release of substances that affect the nervous system and the hormones; the different points cause different effects because they generate more of one or another of the transmitting substances, or because of proximity to a certain part of the nervous system or to certain blood vessels. Depression, anxiety, and grief are examples of emotions associated with impairment of action. A person who is depressed, for example, may be very dissatisfied with the life he or she is leading, but be unable to take any action to change it. The person who suffers from anxiety may have a particular goal in mind, but, upon taking a step towards it, is turned away at the slightest provocation or indication of trouble. The person suffering from grief may feel that there is no point in pursuing any of the usually pleasurable activities as it seems inappropriate to their state of mind. People with anxiety, depression, and grief may complain of lack of energy or vitality. From the Oriental perspective, this is the binding up of qi, disrupting its normal pattern of circulation. A common modern medical treatment for these mind/body conditions is to apply sedatives. At first, it would seem strange to use a sedating agent to treat someone whose actions are impaired and who feels lethargic as a result, but, it often works-at least temporarily. This is because the qi is binding up, and by relaxing (sedating) it, it can unwind and flow more freely. The bound qi is like someone who exercises too vigorously without stretching first and the muscles cramp up so that there is no further motion. The basic energy to move exists, but it has become uncoordinated, bound up, and solid: a sedative (in this case, a muscle relaxant) will reduce the energy to those bound muscles, so that motion can take place again: relaxation leads to motion, not stillness. The qi that becomes bound up by emotion can form a mass that could occur in many areas, depending on which part of the body is susceptible, due either to some previous experience or to an inborn pattern (including genetics). However, qi stagnation is not enough to produce cancer. Breast swelling, one of the signs of qi stagnation, is far from breast tumors, and constipation (another sign of qi stagnation) is far from intestinal cancer. From the qi stagnation, there can occur a build-up of fluids, sometimes an excess growth of cells. Thus, breasts may develop the benign lumps and intestines may develop polyps or local pockets of inflammation. The swelling, which is sometimes palpable, is said by Chinese doctors to correspond to entanglement of qi and an accumulation of phlegm (this is the general term for most substances in the body that have a sticky or mucus-like nature and are not very hard to the touch but are less fluid than water). Still, this is not a tumor. Again, if this condition persists, the blood circulation to the area of accumulation will eventually become disrupted. The capillary beds will have to bend and turn and develop abnormally to work around the swelling. This can cause the soft mass to become more firm. It is said that the blood circulation in the area has stagnated. Instead of coursing through normal tissues, it must slow, and be diverted around areas of accumulation-and thus the stagnant blood accumulates there too. Nonetheless, this is not a tumor, though at this point a lump or mass might be detected by modern medical techniques (if not by simpler methods) and a doctor may be concerned about the nature of the problem. Now, enter the complicating factor of a "toxin." As described previously, the toxin can be a chemical, a virus, or some other influence that transforms ordinary irregularities in the body to more active and dangerous ones. We know now that viruses and chemicals can enter the body at one time and not yield a cancer until much later. Thus, the toxin need not enter after a lump has formed. Rather, it might be present before the lump is formed and only display its effects once the accumulation is there. At the point when the various conditions (qi stagnation, accumulation of fluids, toxin) come together, a tumor does form. Thus, cancer prevention, from the Oriental view, would involve early treatment of depression, anxiety, grief, or other strong emotional factors that bind up qi circulation, avoidance of excessive phlegm substance in the body so that accumulation will not proceed, promotion of blood circulation so that stagnation will be minimized, and elimination of toxins. Once a cancer is diagnosed, the rule of thumb in Western medicine, as well as Oriental medicine, is to allow it no more time to

grow. Thus, modern therapies are initiated very soon after the diagnosis. In most cases, there is no time to try an alternative therapy first to see if it works, and, if not, go on to the more orthodox modern methods. Therefore, most of the time Chinese medical therapy is applied to assist the modern therapies. When the modern therapy is finished, it is a good idea-essential, even-to look again at prevention, because cancer recurrence is quite common.

HERBS COMMONLY USED IN ANTICANCER FORMULAS Examples of Antitoxin Herbs Used in Cancer Therapy Isatis Paris Solanum Wasp's nest Lonicera Prunella Sophora Wikstroemia Oldenlandia Scutellaria Viola Examples of Mass-Reducing Herbs Used in Cancer Therapy Chih-ko Laminaria Curcuma Sargassum Fritillaria Oyster shell Examples of Blood-Vitalizing Herbs Used in Cancer Therapy Pangolin scales Frankincense Sparganium Carthamus Myrrh Zedoaria Curcuma Persica Salvia Examples of Tonic Herbs Used in Cancer Therapy Adenophora Cordyceps Glehnia Licorice Astragalus Coriolus Gynostemma Rehmannia Codonopsis Ganoderma Jujube Ophiopogon May 1997

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ADJUNCT CANCER THERAPY AT THE IMMUNE ENHANCEMENT PROJECT (IEP) CLINIC by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine (ITM), Portland, Oregon The TCM Interpretation People who receive a diagnosis of cancer cannot help but feel that they have been struck by a powerful force; the test results conveyed by a medical expert produce a sense of being injured and weakened; life pathways are suddenly obstructed, and, in some cases, the recipient of such news may become apprehensive of defeat even before embarking on the long journey through cancer therapy. Being informed of having cancer disturbs the spirit, an impact that fits the traditional Chinese medicine (TCM) classification of emotion as pathogenic factor, with anxiety and fear as an initial response. After that, it is not uncommon for anger to arise over inadequacies of diagnosis and prognosis, as well as from learning the limited treatment options; emotional distress may lead to depression. All this distress has a substantial effect on qi, causing it to weaken, stagnate, and to circulate unevenly. The particular manifestation of changes to the body will vary among individuals, but the disruption of circulatory patterns yields common syndromes. In the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (1) the harmful impacts of strong emotions on health, as manifest via the internal organ functions, are summarized: Although emotional factors may impair all five zang organs, they mostly affect the heart, liver, and spleen. Because the heart controls the mind, heart malfunction may cause palpitations, insomnia, dream-disturbed sleep, mental restlessness, laughing and weeping without apparent cause, mania, hysteria, etc. Liver trouble often leads to depression, irascibility, hypochondria pain, sighing, a feeling of obstruction in the throat, menstrual irregularities, and pain due to distention or a lump in the breast; these occur because the liver is responsible for the free flow of qi. The spleen controls the transportation and transformation of nutrients. So, spleen dysfunction gives rise to a poor appetite, distending pain in the stomach, and diarrhea. Emotional activities may both disturb the function of a single organ and that of several organs simultaneously. Pensiveness, for instance, injures both the heart and spleen and leads to the expenditure of heart blood and the impeded transport of nutrients. When anger injures the liver, the spleen is often involved as well, resulting in the disharmony of both. The emotional influences on the organ functions are compounded by physical damage to the body; in the early stages of cancer, the disease itself has not caused much direct physical harm. Yet, the process of arriving at the diagnosis may have already involved various kinds of invasive tests (e.g., biopsy), and if there is a particular tumor site (as opposed to a disseminated disease), initial treatment will often include surgical removal of a mass. Modern surgical techniques are designed to minimize damage, but there is always some level of circulatory disruption at the surgical site; sometimes portions of the body are removed along with the tumor (e.g., mastectomy, colectomy, oophorectomy). Therefore, accompanying the physical injury, the procedure might leave the patient with the feeling of never again fully possessing what was there before, as it is either damaged or missing; the traumatic emotional consequences may be somewhat lessened by knowledge that these surgeries save function and life or, at the least, that they provide hope for such a result. Still the thoughts associated with loss of wholeness are not easily overcome and may lead to melancholy and sleep disturbance. Chemotherapy is the component of cancer treatment that most frequently leads people to seek help from Chinese medicine; unlike the local damage caused by surgery, chemotherapy has broad influences on body functions and overall sense of well-being. There has been good reason to pursue this kind of natural health care assistance. During China’s immediate post-revolutionary period, it was realized that the attempt to use TCM alone as a treatment for cancer was not yielding significant long-term results. Therefore, considerable laboratory and clinical research was undertaken with the aim of utilizing the medical tradition for a different objective: to help people better cope with the adverse effects of chemotherapy and to improve overall outcomes (e.g., increasing the degree of tumor response, survival rate, and total longevity). This work, dominated by herbal medicine, generated promising results by the early 1960s, and the information about this methodology was eventually brought to the Western world, which was just beginning to adopt Chinese medicine by the mid-1970s. The primary uses of Chinese medicine in the West were initially directed to other applications, such as treatment of pain (e.g., arthritis, sciatica, injuries), but by the mid-1990s acupuncture and Chinese herbs became known as resources for cancer patients. In an evaluation of dozens of surveys conducted with cancer patients to determine how many were turning to “alternative and complementary medicine” and from which methods they sought help (2), 81 such surveys from several countries were considered to have useful data related to Chinese medicine. All but three of the surveys were published during 2000-2010 (the last year checked); the other 3 were published in the earlier interval 1995-1999. Chinese medicine was a common means of therapy that the patients utilized, for which acupuncture was by far the most commonlytried technique. The chemicals utilized for cancer treatment are feared for their toxicity and the resulting damaging effects, which often include fatigue, reduced production of blood cells, irritation of the gastro-intestinal tract, and loss of hair. The plan to begin chemotherapy heightens the already existing anxiety and fear arising from the initial diagnosis and any surgical treatment, and the chemicals impair the organs that have been distressed by emotions. Additionally, the impact of the cancer-inhibiting treatments on bone marrow (blood-cell-producing stem cells), which is considered an extension of the kidney system as described by traditional Chinese anatomy and physiology, begins undermining the foundations of the body, namely, the essence stored in the kidney. While cancer that is detected early (stages 1 or 2) may require but one course of chemotherapy lasting a few

months, that same undertaking is only the first of many such protocols when the condition being treated is diagnosed at an advanced stage (stages 3 or 4). In such cases, there will typically be a series of weekly treatments using one or two powerful drugs followed by a change to another series if the first was too difficult to tolerate or if it failed to have the desired effect (either immediately or after a period of temporary success); this process of shifting drugs, each with its unique side effect profile, might continue for years. As a complicating factor, patients who have treatment-resistant tumors are increasingly enrolled in trials of new drugs or new combination therapies which provide hope for a good outcome that was elusive before but also adds the additional worry of being given a placebo treatment at a critical time. Thus, for those with metastatic cancer or suspected metastasis, there is the distress of entering a very uncertain future, with the roller coaster of newly offered hope and dashed hopes. The flow of qi becomes erratic and there is difficulty finding rest day or night; a struggle ensues in the usually simple task of taking in adequate food and then being able to distribute its nutrients. In addition to impairing the functions of the internal organs, chemotherapy may cause lasting damage to peripheral nerves (neuropathy) and brain cells (cognitive impairment); when treating older patients, there is also potential permanent inhibition of the bone marrow, where the temporary drug-induced suppression transforms into a progressive collapse. Radiation is used for some patients to eliminate the last remaining cancer cells at the original cancer site from which the bulk of the tumor was surgically removed; other times radiation serves as an alternative to surgery; and this method is often selected for reducing metastatic growths when they are producing severe symptoms, such as spinal metastases that cause pain. Though the techniques of radiation have improved dramatically in recent years, reducing damage to surrounding tissue with more accurate visualization of the tumor location and with far greater focus of the tumor-killing rays, there are still adverse effects of burning some tissues in the radiation pathway and impairing marrow stem cells and body energy. Both chemotherapy and radiation typically lead to lowered blood status and depletion of qi after any prolonged treatment. Many patients come to the IEP Clinic very soon after receiving their cancer diagnosis (most often, after surgery, and either just before or just after beginning chemotherapy), though others don’t learn about what is offered at the clinic until a later phase in their process of responding to the diagnosis. Indeed, a number of people arrive when last ditch therapies are being pursued, and the patients might not have become aware that they were reaching the end of their journey with a disease resistant to known treatments. In advanced cases, the qi is weakened and the functions of the five zang organs are compromised. Patients present to the IEP practitioners physical and emotional conditions affected by the stage of cancer at time of diagnosis and phase of medical intervention they are in, while being confronted with personal circumstances that affect how they will proceed with treatment. In keeping with the basic principles of traditional Chinese medicine, each patient is treated according to their unique needs, which differ not only between patients but also, for any given person, from one visit to another. Yet, there are aspects of the IEP clinical work that are relatively uniform; the common methods are outlined briefly here because they may help inform and guide other practitioners less familiar with treating cancer patients. Based on the description given above, a basic treatment needs to be supportive, strengthening, and stabilizing for body and mind; such treatment may be categorized as tonifying. There is also need to release stagnation related to emotional impact on qi circulation, to help resolve the accumulations associated with cancer growth (qi entanglement, phlegm-dampness, and blood stasis), and to alleviate the obstructing effects of cancer therapies on qi and blood circulation. Three Therapeutic Modes At the IEP Clinic, there are three basic modes of treatment; the primary one is acupuncture. Acupuncture is expected to produce quick and obvious results that are often felt at the time of treatment and persist to some extent for hours or days thereafter. This treatment method is most easily adjusted in response to patient reports of symptoms of concern. Acupuncture point selection will be a major focus of the following section. Acupuncture is complemented by a form of massage therapy referred to as “Zen Shiatsu.” This is a modern variant of the traditional Japanese pressure massage; it was developed by Shizuto Masunaga (1925-1981) and it is of particular interest in relation to an acupuncture program because the treatment strategy is largely based on meridian therapy (3). The meridian pathways used by the shiatsu practitioners are similar to the Chinese ones, the main difference being an extension of each meridian to range from legs to arms, passing through the associated diagnostic region of the abdomen. The theory of acupuncture treatment holds that needling has, as one of its major functions, the alleviation of obstruction of qi circulation and consequent normalization of qi and blood flow for the treated meridian. The impact of acupuncture at points on one or, as more common, a few meridians treated in a single session is not limited to the freeing up of circulation in those particular meridians; it has a beneficial impact on the entire system. Acupuncture points are frequently selected because of their individual indications rather than strictly on the basis of a meridian diagnosis, yet, in the overall analysis, meridians are a central feature of treatment strategies. Zen Shiatsu reinforces this meridian-opening effect; it is not necessary for the meridians treated by this application of pressure to be the same meridians as those treated by the acupuncturist: the mutual benefits of opening and stabilizing circulation in one meridian upon the functional capabilities of others allows these two similar but distinctive systems of diagnosis and therapy—acupuncture and Zen Shiatsu—to reinforce one another. The third mode is Chinese herbs plus nutritional supplements and diet counseling; these sometimes diverse considerations—involving both Chinese and Western approaches to the analysis and selection of ingredients—are bound together as one modality for purposes of this discussion based on the Chinese concept of the close relationship between administering herbs, especially the mild herbs we are able to use in modern practice, and dietetic treatments. A group of practitioners who have training in both Chinese medicine and naturopathic medicine are available during one portion of the clinic schedule to assist IEP patients in the area of diet and nutrition (as well as related concepts of naturopathic therapies), while Chinese herbs are recommended throughout the program. These three modes of therapy, covering many aspects of adjunctive care, are not comprehensive. One could add,

for example, qigong exercises and other natural health care approaches from the Chinese tradition as well as incorporate health care practices from other cultures (e.g., yoga). The three modes that are provided at IEP fit within the limited availability of physical space, the constraints of practitioner and patient time for participation, and the primary range of expertise at the Institute for Traditional Medicine. The plan described to patients interested in utilizing IEP services is that they will come to the clinic for acupuncture twice per week during the first several weeks of treatment and at those times when chemotherapy or radiation is in progress; the frequency may decline to once per week after sessions of the medical therapy are completed, that is, during periods when there is less physical and emotional distress. Shiatsu services are made available to an extent that allows for treatment every other week, which is almost always provided immediately before or immediately after acupuncture. Typical of supportive shiatsu therapy is pressing along the stomach and spleen meridians, especially the portions at the legs, and along the triple heater (sanjiao) and heart protector (pericardium) meridians that traverse the arms. Acupuncture and shiatsu sessions are just a half hour each; in other settings, the practitioners might spend 45 minutes for an acupuncture visit and an hour for a shiatsu visit, but the shorter treatment duration fits with the concept of offering more frequent and lower cost treatment. Herbal and nutritional supplements are often provided in accordance with a basic model of “supporting normality,” that is, following the “fuzheng” concept developed in China for this purpose, which would typically incorporate huangqi (astragalus) and baizhu (atractylodes) as spleen qi tonics and danggui (tang-kuei) and gouqizi (lycium fruit) as liver blood nourishing agents. If the qi and blood are full, the Chinese doctrine says, then pathological influences will not be able to disrupt normal functions. One of the common concerns is the bone marrow inhibiting effect of chemotherapy and radiation, for which various forms of Shengxue Tang (Decoction for Generating Blood) are utilized. The formulations used in China vary considerably, but two common ingredients are jixueteng (millettia; spatholobus) and huangqi (astragalus); most other components of such formulas are additional blood-vitalizing agents and tonics (for qi, blood, and essence). I reviewed several such blood generating formulas in my 1998 article Countering the Side Effects of Modern Medical Therapies (4) and in my 1999 article Millettia (jixueteng) (5). The clinicians at IEP have reported that this treatment approach seems to be one of the most effective of the commonly prescribed herbal therapies. The primary formula used at IEP when patients convey concerns over blood tests showing marked inhibition of marrow is a tablet comprised of jixueteng, danshen, sangshen, yejiaoteng, huangqi, chuanxiong, shudi, xuduan, and muxiang. Standard nutritional supplements recommended to patients include a broad mixture of minerals and vitamins and a mixture of antioxidants intended to replace the multiplicity of products that are recommended in the literature. These provide a substantial quantity of the substances that are purported to be of low quantity in the blood stream (due to reduced food consumption and/or poor absorption) and in particularly high need in light of the effects of the anti-cancer medical therapies. A naturopathic consultation is offered close to the beginning of the acupuncture series and may be followed up from time to time, with average duration between consultations of about three to four months. At each visit, the patient’s current symptoms, lab test results, drugs, Chinese herbs, nutritional supplements, and daily activities are reviewed. There may be suggestions made for some additional laboratory testing, for undertaking certain diet and exercise strategies, and for supplements not routinely included in the IEP model. Among common recommendations associated with these consultations are eating multiple small meals to manage the problem of reduced appetite, utilizing various protein sources (whether isolates or high-protein foods), taking supplemental fish oil and vitamin D3, using probiotics, taking melatonin for sleep (also used for symptom relief at higher than usual dosage, such as 20 mg/day), and getting basic exercise (even if limited to 20 to 30 minute walks, though more is encouraged when possible). Such direct suggestions are supplemented by referral to specialists who might assist with other methods of addressing unique symptoms or by providing additional treatment programs. To encourage the greatest level of participation in the IEP program components, the cost of treatment is set by a monthly fee that is established on a sliding scale basis, often allowing free treatment, and currently not exceeding $150/month. The cost to the patient is not influenced by frequency of acupuncture, shiatsu, or naturopathic consultation, or by the selection or quantity of prescribed supplements within our basic list. There will be an extra cost for any of the naturopathic recommendations that are outside the standard supplement regimens and patients will have to incur the costs or submit to their insurance the expenses associated with any additional laboratory testing that they pursue in response to suggestions at IEP. Foundational Acupuncture During most visits to the clinic by cancer patients, a model point formulation is utilized, which is modified as appropriate. The acupuncturists at IEP refer to the most commonly selected acupuncture point set with terms such as “cancer support,” “chemo support,” or “immune support,” and the variations in designation are not intended to indicate different concepts. The primary strategy begins with an adaptation of an approach that was utilized by Wang Leting, a TCM practitioner whose work spanned the pre-revolutionary and post-revolutionary period in China; he practiced for 50 years from 1929-1979. An English translation from the 1984 Chinese book that describes his work is Golden Needle Wang Leting, which was published in 1997 (6). Much of Wang’s therapeutic efforts revolved around one particular acupuncture point on the stomach meridian: zusanli (ST-36). He is reported to have said: “For hundreds of diseases, don’t forget zusanli,” and “in treating the root, first treat the stomach” and “if a person is diseased and one does not treat the stomach, on what can they rely for life?” In 1998, I produced an extensive review of zusanli and its uses to encourage better understanding of the factors that lead to its selection as a key part of the treatment (7). Two of Wang’s point formulations serve as inspiration for the foundational acupuncture at IEP. Of particular interest as an adjunct therapy for cancer patients, there was one which Wang Leting described as having an effect like that of the herbal formula Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination). This well-known tonic prescription combines the spleen/stomach formula Sijunzi Tang (Major Four Herbs Combination) with the liver

blood formula Siwu Tang (Tang-kuei Four Combination) plus huangqi (astraglus) and rougui (cinnamon bark). It has been the traditional formula most frequently recommended for support of cancer patients in recent decades, especially utilized for this purpose by Japanese and Taiwanese doctors who select from a set of about two hundred traditional formulations that are covered by national health insurance. In composing the acupuncture point formula, Wang contemplated the actions of the herbs and compared those with the functions of acupuncture points; thus, for example, he drew a parallel between needling of hegu (LI-4) and the role of astragalus because, among other similarities, they both address insufficiency of defensive qi. Wang’s Shiquan Dabu acupuncture formula: zusanli (ST-36) sanyinjiao (SP-6) neiguan (PC-6) guanyuan (CV-4) zhongwan (CV-12) hegu (LI-4) quchi (LI-11) yanglingquan (GB-34) taichong (LV-3) zhangmen (LV-13) Wang also frequently used a formulation which he called Old Ten Needles, the term “old” referring to a traditional style of acupuncture point selection. He worked with certain key points for years and then finalized this particular group around 1966. Wang’s primary application for Old Ten Needles was gastrointestinal weakness and distress, a common concern for the patients at IEP. Wang’s Old Ten Needles: zusanli (ST-36) tianshu (ST-25) neiguan (PC-6) qihai (CV-6) xiawan (CV-10) zhongwan (CV-12) shangwan (CV-13) The first three points of this small formula are treated bilaterally, making 6 of the 10 points, and the next four are along the front centerline, so each has one needle, making four more. By the time this information was relayed in the English language text, many acupuncturists in the U.S. were already familiar with a slightly different set of ten needles that was relayed by Miriam Lee in her 1992 book (8). Lee’s Ten Great Needles: zusanli (ST-36) sanyinjiao (SP-6) hegu (LI-4) quchi (LI -11) lieque (LU-7) All five of these points are treated bilaterally. Like Wang, Lee considered zusanli as a key point and devoted a chapter of her book to using that point alone. Lee had utilized this set of ten needles for a wide variety of disorders, but especially for disorders causing weakness, fatigue, and depression. Other variants of this approach, in which a small group of needles comprise a foundational treatment, have been reported. One of the IEP practitioners had developed his own variant of Lee’s ten needles by replacing quchi (LI-11) with shousanli (LI-10) and replacing lieque (LU-7) with shenmen (HT-7). Through adding and subtracting from these insightful formulations, we have the group of points used at the IEP Clinic for adjunctive cancer therapy, which I now refer to as “New Twenty Needles” (NTN). These points are still “old” in the sense of common traditional points and combinations, but they are here used for a new application—in support of patient’s undergoing medical treatments for cancer—which postdates Wang and Lee’s primary work. Not all these points would be used at one treatment session, but a total of ten to twenty body points (this count including the bilateral needling, but not including any added ear needles) would form the basis of one session. New Twenty Needles (NTN): zusanli (ST-36) tianshu (ST-25) neiguan (PC-6) taichong (LV-3) hegu (LI-4) quchi (LI-11) sanyinjiao (SP-6) taixi (KI-3) qihai (CV-6) zhongwan (CV-12) baihui (GV-20) yintang (Ex-HN-3) The points that differ from those listed by Wang and Lee are baihui (GV-20) and yintang (Ex-HN-3), which are especially used in stabilizing the emotional distress common to our patients, and taixi (KI-3), for tonification therapy

to resist the impairing effect of chemotherapy and radiation on the kidney yin and yang. To better display how these are used, the NTN points can be described in terms of being “primary” or “secondary”, not to distinguish their relative values, but to draw attention to the fact that the primary points are being used two to three times as often as the secondary ones. NTN Primary Points: zusanli (ST-36) sanyinjiao (SP-6) Lower Limbs taichong (LV-3) hegu (LI-4) Upper Limbs quchi (LI-11) baihui (GV-20) Head NTN Secondary Points: taixi (KI-3) Lower Limbs neiguan (PC-6) Upper Limbs qihai (CV-6) zhongwan (CV-12) Torso tianshu (ST-25) yintang (Ex-HN-3) Head Common additions to the above set were the lower limb points yinlingquan (SP-9; substituted for SP-6 or added to it), zhaohai (KI-6; substituted for KI-3), qiuxu (GB-40); upper limb points shousanli (LI-10, frequent substitute for LI-11); shenmen (HT-7; substitute for PC-6 or added to it), lieque (LU-7), waiguan (TB-5); torso points jianjing (GB-21), danzhong (CV-17; also called shanzhong); and head/neck points shenting (GV-24; added to GV-20), fengchi (GB-20), and extra point anmian (near GB-20). In a few instances, two adjacent points on a meridian were needled at the same time, such as LI-10 and LI-11 or GB-20 and GB-21. The additional points mentioned here, though beyond the NTN, belong to the foundational acupuncture treatment group. The acupuncture set selected during a patient visit may involve some alterations to address symptoms that have become severe. Thus, for example, a complaint of women undergoing treatment for hormone-dependent cancers is hot flashes, and if they become more frequent or intense fuliu (KI-7) in conjunction with yinxi (HT-6) would be used; these are points routinely combined with several others that belong to NTN for this symptom in non-cancer patients. In efforts to alleviate foot neuropathy, extra point bafeng (four points on an affected foot) might be used, sometimes adding yongquan (KI-1) or rangu (KI-2). Nonetheless, when these same symptoms are relatively stable—not especially disruptive or not worsening—the foundational acupuncture with NTN is usually sufficient to provide relief without the necessity of needling points deemed specific to those symptoms. Due to the relatively short duration of an acupuncture session, 30 minutes, patients are usually treated on one side of the body, laying face up, without needling of back points (GB-20 is the main exception, but can be treated because of the curvature of the neck). The usual set of foundational points also minimizes the need to remove clothing so long as the patient wears loose clothing that allows exposure below the knee and from the elbow down. For points that are ordinarily needled bilaterally, a patient might instead receive left-sided and right-sided points that differ; this method would most often occur if there were unique symptoms on one side; for example, one arm might have swelling from lymphedema while the other arm remains unaffected. In my article on zusanli, I relayed an immune enhancing protocol that was being evaluated in patients whose primary complaint was pain, based on the pair of zusanli and hegu (LI-4); other pairings I relayed from the Chinese medical literature were zusanli and neiguan (PC-6), reported to be useful for side effects of chemotherapy and radiation such as poor appetite, nausea, vomiting, diarrhea, dizziness, insomnia, and fatigue), and zusanli with sanyinjiao (SP-6) that had been provided to patients undergoing radiation therapy to prevent impairment of white blood cell counts. I pointed out that this set of four points (zusanli, hegu, neiguan, sanyinjiao) were the main ones employed in a study of treating pain due to stomach cancer and the side effects of stomach cancer treatment by chemotherapy. In a more recent study describing treatment of liver cancer patients having postoperative gastroparesis (9), a set of four primary acupuncture points were: zhongwan (CV-12), zusanli (ST-36), neiguan (PC6), and sanyinjiao (SP-6), which is the same set, except hegu is replaced by zhongwan. As can be seen, this fundamental pattern of treatment applies to chemotherapy and to surgery as well as to different cancer types. The general stabilizing effect of the point sets used at IEP is illustrated by similar acupuncture formulas for treating tremor. In the book Case Studies from the Medical Records of Leading Chinese Acupuncture Experts (10), a suggested treatment was: zusanli (ST-36), sanyinjiao (SP-6), hegu (LI-4), taixi (KI-3), taichong (LV-3), shousanli (LI-10), shenmen (HT-7), and fengchi (GB-20), with xuanzhong (GB-39) and yanglingquan (GB-34) included for specific treatment of tremor. Wang Leting had compared the acupuncture point yuanglingquan with rougui (cinnamon bark) in Shiquan Dabu Tang because they both treat upwardly counterflowing qi and both eliminate wind, cold, and damp. The foundational acupuncture set also follows a description I provided in a booklet on treating disturbed spirit (11), which indicated the tendency of Chinese doctors to utilize “five zones” of acupuncture for spirit disorders, typically treating one to four points in each zone: in the area of the head (e.g., GV-20, GV-24, yintang); at the forearm-hand area bilaterally (e.g., LI-10, PC-6, LI-4, HT-7), and on the lower limbs bilaterally beneath the knee (e.g., ST-36, SP-6, KI-3, LV-3). The five zones are treated together to yield a therapy for anxiety, depression, insomnia, easy crying, and other characteristic symptoms of shen disorders. The points zusanli (ST-36), tianshu (ST-25), sanyinjiao (SP-6), taichong (LV-3), quchi (LI-11), neiguan (PC-6), and baihui (GV-20) of NTN are examples of those commonly used in modern Chinese treatments for persistent anxiety and distress. Renzhong (GV-

26; also called shuigou) is often chosen in China for these psychological conditions—in addition to, or rather than, shenting (GV-24) or yintang—though this point is not as acceptable for use in the West. Examples of Chinese medical literature reports on this five zone pattern of treatment include a study of patients with mental depression (12) that relied on needling the main points baihui (GV-20), shenting (GV-24), yintang (Ex-HN-3), renzhong (GV26), anmian (extra point near GB-20), danzhong (CV-17), neiguan (PC-6), daling (PC-7), shenmen (HT-7), and taichong (LV-3) and treatment of “depressive neurosis” with herbs and acupuncture (13) using taiyang (Ex-HN-5), shenting (GV-24), qucha (BL-4), baihui (GV-20), neiguan (PC-6), shenmen (HT-7), sanyinjiao (SP-6), and taichong (LV-3). For the purpose of calming the disturbed spirit, some practitioners at IEP also add ear points, most often turning to variants of the “5NP,” referring to Nogier’s Points (NP) that have since been adopted into the Chinese system. These particular points were initially recommended by Dr. Michael Smith for the National Acupuncture Detoxification Association (NADA) protocol, namely 5NP = sympathetic, shenmen, lung, liver and kidney. A simplified version is more commonly applied at IEP, called “3NP” = shenmen, liver, and kidney. Sometimes, ear point selection varies from these standardized protocols, simplifying to shenmen alone or by substituting a point in the basic set (e.g., heart replacing lung) or adding one or two other points to 3NP. In a recent study of using acupuncture for patients with lung cancer (14), points selected for treatment were: hegu (LI-4), taichong (LV-3), zusanli (ST-36), sanyinjiao (SP-6), lieque (LU-7), and 3NP. This pattern is consistent with that used at IEP. As another example, a protocol for cancer patients monitored for effects on depression and sleep disturbance (15) utilized the points fenglong (ST-40), yinlingquan (SP-9), xuehai (SP-10), sanyinjiao (SP-6), neiguan (PC-6), yintang (Ex-HN-3), baihui (GV-20), sishencong (Ex-HN-1; these are four points surrounding GV20), and ear point shenmen. Except for the shift of zusanli to fenglong and addition of xuehai, this pattern fits reasonably well with what is being done at IEP. Sishencong can serve an alternative to using shenting (GV-24) in treating distress symptoms, and is also sometimes the choice for this purpose at IEP. The New Twenty Needles and commonly used added points serve multiple functions but especially help with the emotional distress associated with cancer diagnosis and treatment, supporting immune functions, alleviating pain, and normalizing the gastrointestinal system. Standard herbal formulas prescribed to the patients will further support one or more functions of the acupuncture treatment. Extraordinary Results: Examples of Treatment Effects The ideal cases where success can be declared are those where the IEP methods of therapy assist patients recently diagnosed with stage 1 or stage 2 cancer get through the course of medical treatment, such as surgery and chemotherapy, with relative ease. Thanks to the three modes of therapy described above, particularly the dramatic effect often experienced from receiving acupuncture, there is an amelioration of anxiety and other emotional distress, they find that the medical and adjunctive interventions—though taking a lot of time—produce a minimum of disruption to capabilities, and they arrive in just a few months to the end result of being evaluated by their oncologist as cancer free or, at least, there is not a recurrence due to undetectable metastatic cells for some years after the initial course of treatment. Quite a few patients have this situation and for them the stabilizing effect of acupuncture and other adjunctive therapies is greatly appreciated. The course of their participation at IEP might involve about 60 acupuncture treatments and about 15 shiatsu sessions, a commitment that could be afforded by some patients attending clinics charging standard rates. However, a sense of success is sometimes more evident in those situations where the patient has advanced cancer and is not expected to be cured of the disease; the patient may not be able to work or can only do so to a limited extent: these are difficult situations where a person suffers greatly in a state of little hope in the absence of such a program of adjunct therapy. For these situations, being able to tolerate the ongoing chemotherapy attempts is a great achievement and maintaining reasonable pain control is welcomed; the ability to function, make difficult medical decisions, and be present to family members accomplishes much in transforming a terrible situation into one which can have many bright moments. Below, ten examples of patients with advanced cancer treated at IEP are described. They came to the program at ages 48-75, which is a typical range for patients at IEP. Most of these patients came to the clinic with stage 3 or stage 4 cancer (one had indeterminate staging with signs of metastatic disease); in all but two of the cases conveyed here the patient died, usually shortly after their last visit to IEP, indicating that they retained activity and mobility until their last few days. Practitioners at the clinic selected these cases as examples of extraordinary results because of the very favorable feedback from the patients and their families (sometimes also their doctors) as well as their impression that individual treatments yielded especially good responses. The patients are not presented here in any particular order; there were seven women and three men in the collection of cases, and this represents the roughly 2:1 ratio of female to male cancer patients treated at the clinic. IEP chart notes present any noteworthy comments made by the patient at each visit as well as the basic details of the treatment administered (e.g., acupuncture points). The records can be used to determine compliance with recommended frequency for acupuncture and shiatsu, the dates when chemotherapy or other medical treatment is initiated or terminated, what symptoms are of primary concern, any reported significant changes in symptoms, the total duration of participation at the clinic, and, in most instances, the cause for completion of the treatment program. 1. Patient TV, a 75-year-old man with terminal cancer. He had gone to the hospital in very serious condition and was diagnosed with stage 4 lung adenocarcinoma (patient was non-smoker) and came to our clinic about seven months later. Chemotherapy caused notable tiredness, weakness, and fatigue. However, his primary complaint was severe chest pain, particularly at the primary tumor site; he also suffered some abdominal pain, and from time to time, felt pain all over his body. He continued to receive chemotherapy during the first several months of his IEP clinic visits. He responded very well to acupuncture, with notable pain reduction. Pain would return, but acupuncture would help control it each time and his appetite improved as well. He received 38 acupuncture treatments, often with electro-acupuncture incorporated for pain control, and 18 shiatsu treatments over the period of six months before he

was no longer able to attend the clinic; he lost ability to walk and sit-up and then went into a coma and died one month after his last visit to IEP. It was found that electro-acupuncture (EA) was especially effective for his pain. An example of EA was hegu (LI-4) to taichong (LV-3) on the left, lingxu (KI-24) to qimen (LV-14) on the right, but the specific point selection for EA varied. Aside from the usual points selected for cancer support, points for chest pain such as lingxu (KI-24) and wuyi (ST-15) were commonly used. The success in this case was the marked pain relief that allowed him a quality of life he would not otherwise have had during his final months. Pain in late stage 4 cancer is often intractable; patients do not like taking high doses of morphine or other powerful pain drugs (this patient had been using oxycodone), as they feel they cannot mentally function at an adequate level. In this case, the impairment of breathing that occurs with any high dose of such pain drugs would compromise breathing capabilities that had already been reduced by the lung tumor and would therefore risk bringing on coma and early death. Despite coming to our clinic with a far advanced cancer condition, he remained stable during the months of his visits. He most likely succumbed to a circulatory shut down because of the widespread cancer, lack of physical activity, and reduced nutritional status associated with low appetite. 2. Patient VI, a 57-year-old woman with terminal liver cancer affecting the bile duct (stage 4), came to the clinic just after diagnosis; he had undergone exploratory surgery and not had yet started chemotherapy. She received treatments at our clinic for 15 months, and then planned on moving into hospice, but died promptly before she could make that transition. Except for the first three months at IEP, she did not get frequent acupuncture as usual for our protocol; in total she received 88 acupuncture treatments and 29 shiatsu treatments. She did well with her chemo treatments, with a relatively low level of side-effects; nonetheless, her hair fell out, she had fatigue and hot flashes and she did miss one scheduled chemo due to low blood counts. Practitioner notes after six months of chemo indicated: “generally tolerating chemo well,” and her tumor responded to the treatment, shrinking by 40%, but radiation was added in an effort to get the tumor under greater control. After nearly a year of chemo, and then with added radiation, the practitioner report indicated that she was “feeling well.” A change in the chemo regimen at that point had obvious deleterious effects, with her reporting notable depletion of energy and developing neuropathy. The most serious development, however, was shoulder pain attributed to a tumor pressing upon a nerve. The pain worsened, extending from shoulder to chest, and she was put on morphine. This last phase of her life included a period between when she was reported as “feeling well” to a couple of months later when she was reported as “doing o.k. and “pretty good;” but, she ceased coming to the clinic at that point and died two months later. This patient was diagnosed at a time when the cancer was advanced and beyond effective treatment. Nonetheless, combining Chinese medicine, chemotherapy, and radiation, she did well with her treatments for over a year, and then suffered a rapid decline due to the fact that the tumor remained and was causing obstruction (pain due to nerve impingement; death likely due to blockage of the liver). Her acupuncture treatment was mainly categorized as “immune support” utilizing the NTN needle set and 3NP as described above. 3. Patient JM, a 48-year-old woman, arrived at our clinic with stage 4 colon cancer. She had already had three surgeries, and several courses of chemotherapy during the year and a half between diagnosis and coming to our clinic for the first time. Surgery included removal of parts of her colon, ovaries, and parts of her liver (this last, just three weeks prior to attending our clinic), and she was pursuing chemotherapy while participating in the IEP Clinic. She had 64 acupuncture treatments, and 16 shiatsu treatments over a period of 10 months. During most of the time at our clinic the practitioners relayed that she was feeling well, and on days when chemo side effects were more prominent (with heartburn, reduced appetite, and nausea), she felt better after getting acupuncture, which was described as “very helpful” for acid reflux and for nausea. A practitioner noted “acupuncture seems to eliminate post-chemo GERD.” She did experience hair loss and fatigue as part of the chemo side effects over time. After completing her course of chemotherapy, she continued to come to the clinic for about 10 weeks; her hair began growing back (the hair loss had disturbed her), and she was gaining strength, but with some fatigue. After completing our program, she came in to report that she was “doing really well.” She continued taking herbal and nutritional formulations that had been previously prescribed. Her tolerance of the chemotherapy-induced symptoms and her quick recovery from its effects (especially given the immediately prior history of surgery and chemotherapy) were remarkable. During much of her time at the clinic she received acupuncture with the basic chemo support concepts. She remains alive today. 4. Patient CR, a 65-year-old woman, had a diagnosis of ovarian cancer the year before coming to the IEP Clinic. She had undergone surgery and was treated with chemotherapy for nearly 11 months; her cancer was at stage 4. She attended the clinic over a period of more than 8 years. After a total of nine years of chemotherapy, her cancer was deemed untreatable, and she was taken off the last regimen; she continued to come to the clinic for a few more treatments and then ceased coming because of sudden deteriorated health. We learned that she passed away two months after her last visit to our clinic; for the prior two months she had been coming only twice per month for acupuncture. During her last years at the clinic, the acupuncture frequency was routinely once per week. She was given general cancer support protocols and was also treated for individual symptoms as they arose; for example, when she tried her last chemotherapy drug she had a reaction of severely reduced appetite and that was the focus of therapies with acupuncture and her medications. Throughout much of her time at the clinic, she did report fatigue or low energy, but on many visits she felt well otherwise, and she was given the general acupuncture treatment described as “maintenance” or “tune up” or “cancer support.” What was remarkable about her case was not only her longevity, but how well she was managing with ongoing chemotherapy for years. For example, 10 months before she died, it was noted in her chart that “her CA-125 was

going up, but she doesn’t have any symptoms.” Five months before her death, she was reported to be “eating well, no pain issues,” and she had no insomnia, normal bowel conditions, but low energy. And in the next month, the practitioner wrote “no complaints today.” One of our practitioners considered that “ part of the reason she did well for years was her personality (not easily rattled) and that her daughter and family (2 granddaughters) lived across the street…She often talked about them in treatments.” What eventually caused her death, most likely, were metastatic tumors in the lungs, which impaired her breathing, along with the final chemo attempt, which appeared to contribute to a downturn without providing any cancer inhibition; those impairments caused her to come to the clinic less frequently the last two months and then cease getting acupuncture for about 6 weeks before she died. 5. Patient OA, a 75-year-old man, had breast cancer diagnosed 8 years earlier, followed by liver cancer, which had been successfully treated 5 years earlier, but then recurred a year before coming to IEP. There were two tumorremoving surgeries (breast and liver) and a later abdominal surgery for bowel blockages. He came to the clinic at a time when his cancer was not showing up on scans (the cancer appeared to be in remission according to his oncologist, and the apparent remission was reported again a few months later), but he was utilizing doxorubicineluting beads, a new type of long-term liver cancer therapy and he eventually received other chemotherapy treatments because his oncologist was sure that the tumor growth would resume if not more aggressively pursued. He had considerable abdominal pain, being treated with morphine. He received 67 acupuncture treatments and 38 shiatsu treatments over 10 months (this is an unusually high number of shiatsu for this period of time, utilized to help address pain symptoms). Acupuncture point selection for this patient was somewhat more varied than for many patients because of the efforts to alleviate certain specific symptoms that arose, but he did frequently receive general “cancer support” treatment as described above. He had a number of symptoms, many of them involving pain and/or spasms at several sites, which would easily vary from one week to the next. Still, this patient reported “feeling well” and “feeling much better with shiatsu and acupuncture” during the first three months; there were intermittent reports of him feeling well two months before his death. Fatigue remained a persistent complaint, but treatment was helping with pains of the middle back, stomach, and head. Chemotherapy was then discontinued, but a tumor was eventually visualized affecting the bile duct, and he had to have a drain put in for the bile to bypass the obstruction. Chemotherapy was not resumed, and it appears the oncologist did not believe further chemotherapy would be of help. The patient, who had been doing reasonably well at his last visit to our clinic, died within four weeks of that visit. Despite his advanced age and years of dealing with cancer, the surgeries, and the chemotherapy, he remained in fairly good health during his time with us; he was known locally as a master musician and he continued performing for six months after his first visit to IEP. He likely succumbed as the result of a blood infection associated with the port that had been used for bile duct drainage. 6. Patient LZ, a 51-year-old woman, was diagnosed with stage 3 ovarian cancer a few weeks before coming to the IEP clinic, having had a debulking surgery for the tumor, and starting chemo just the week before her first acupuncture treatment. She originally received twice per week acupuncture, but later took breaks and would come back for a series of acupuncture sessions over a period of about three years. She then took off about one year and came back toward the end of her life for two treatments; she died two months after the last treatment. She managed remarkably well through a long course of various chemotherapy attempts. She was able to return to work, at least part time and, for a short while, full time, and resumed her active lifestyle (e.g., going skiing). Her utilization of acupuncture was much less than we advised. During her first year, she received 49 acupuncture treatments, a rate of just under once per week (she had started at twice per week, but soon reduced the frequency to once per week), and the second year she had 30 treatments over a period of 9 months, then was absent for about five months following a skiing accident (broke both legs), and then another 32 treatments over a year. Because of the lower acupuncture frequency and taking time off, she probably got much less effect than was possible. It appears she initially was quite drawn to acupuncture therapy and then was less interested in that approach: the first year, she did not receive any shiatsu massage, but for the following years, she arranged to have shiatsu without acupuncture for every other visit. This patient preferred lying in the prone position, so the standard needling received by most patients was usually not administered in her case, and her protocol included several points of the Bladder Meridian and Hua Tuo points and tianzong (SI-11); she might also receive treatment at points of the foundational protocol easily accessible in that position and compatible with the others chosen. She often reported fatigue and low energy from chemotherapy, but the focus of treatment would typically be for pains that arose in different parts of her body. Sometimes, this was from her physical activities; for example, she reported one day that everything was sore from physical activity (swimming, hiking, and golfing) What finally depleted her system, it appears, was non-cancer related surgeries: she had chipped talus bones which were treated by surgery (two separate surgeries, one ankle at a time), and then rectal surgery for hemorrhoids. It was right around the time of these surgeries that she ceased getting acupuncture, retired from her teaching career, and, though we don’t know what happened during this time, she developed leg lymphedema, probably from the series of lower body surgeries, and was not able to continue her passion for physical activity. She lived about half hour drive from the clinic and this lengthy transit, which was time consuming for her, yet something she could do regularly while she was relatively healthy. With her skiing accident (broken legs) and later surgeries she wasn’t able to travel to our clinic. So, her location explained why she didn’t get regular acupuncture when it might have helped for recovery from injury and surgery as well as manage the effects of cancer treatments. 7. Patient LC, a 48-year-old woman, had been diagnosed ovarian cancer just two months before starting treatment at IEP; she already had surgery and had undergone the first two chemotherapy sessions. The surgery revealed extensive cancer in her abdomen (categorized as stage 3c, grade 3), and she had a hysterectomy as well as oophorectomy. She came for acupuncture twice per week initially, but soon transitioned to once per week and occasionally missed a week. She received a total of 68 acupuncture treatments and 48 shiatsu over a period of about 19 months.

Her health during the chemotherapy was remarkably stable; she had persistent complaints of constipation, and did develop some hand neuropathy, but did not experience fatigue and low energy. After completing her first course of chemotherapy, which was just over three months long, she rebounded well and her constipation resolved (it would come back as a symptom later). Despite her basic good health, she developed persistent anxiety and feeling “emotional” overall. Her anxiety was primarily over the cancer diagnosis, and, in fact, about nine months after starting at IEP she received the news that the cancer had returned and that the prognosis was poor. A new chemotherapy was begun, and this produced fatigue and some neuropathy (fingers and toes); she otherwise tolerated it well. After a CAT scan, she was put on another chemo drug, and this was less well tolerated; unfortunately, at this time she came in for acupuncture infrequently, and she died four months after starting that new treatment. Her death did not appear to be due to the new chemotherapy effects, as after the first treatment or two that “hit her hard” she was tolerating it well; for example, she reported no neuropathy at her last visit. Her acupuncture treatments were consistent with others for general support, but because of the substantial abdominal symptoms, she would tend to get needled along Conception Vessel points that were in addition to those used for most other patients. In my interpretation, the turning point for her was a loss of will to live when the cancer tests showed that the disease was progressing. The anxiety that she reported a year and a half earlier—after her first chemotherapy series which resulted in cancer being undetectable—stuck with her and could turn to depression. For one of her chemotherapy series, she was in a research protocol and was convinced she was receiving the placebo. During a later chemotherapy protocol, a practitioner recorded that her mood was low and that she was “scared”; despite this, the same chart record indicates “good quality of life,” and there were other reports of her “doing well.” A later note indicated that she was sad and emotional after having had a liver ultrasound in the morning before her visit to our clinic. At her last visit to the clinic, about 6 weeks before she died, she reported that a recent MRI showed a lesion on the pancreas. While acupuncture helped with emotional distress, she was not getting treatment with sufficient frequency after the first three months. During her last year at the IEP Clinic, she had taken a substantial break for nearly four months, and then returned for treatments only once per week during the final six months. Her tolerance of several courses of chemotherapy was remarkable, and though she seemed increasingly emotionally defeated, she maintained a relatively good health status through her time at IEP, with many chart notes indicating that symptoms had improved. 8. Patient CB, a 58-year-old man, was diagnosed with stage 4 bilateral lung adenocarcinoma two months prior and had his first chemotherapy just before coming to the clinic; he was also scheduled for a series of radiation treatments for tumors on the spine. He received 250 acupuncture treatments at our clinic over a period of 32 months and did not receive shiatsu other than three treatments during the last weeks of his time at IEP. His final visit to us was followed by his transfer to hospice, and then he died a week after entering hospice. He was put on a series of different chemotherapy treatments; one of them, which unfortunately caused apparent allergy reaction with significant itching, did result in shrinkage of the lung tumors (this was about 9 months into the treatments). He also developed persistent shortness of breath and coughing that may have been from the presence of the tumors despite their shrinking, or as a reaction to chemotherapy; this symptom was alleviated to some extent by acupuncture. Unlike most of the other patients described here, because of the focus on the lung symptoms, he less frequently received the foundational acupuncture protocol that was given when lying face up, and tended to receive more points aimed at alleviating breathing problems, with several back points, such as the extra point dingchuan and Bladder Meridian points (e.g., BL-7, BL-12, BL-13, along with frequent use of KI-3). For several session, he would sit up for treatment to make it easier to access all the points at once. He sometimes received needles at the standard points, with frequent addition of chize (LU-5). Overall, he suffered from fatigue, nausea, and shortness of breath, and then with pain. Though he struggled with various side effects of the chemotherapy regimens and radiation treatments, he responded well to acupuncture to keep the symptoms under some control. After about two years, one of the chemotherapies he tried was an experimental one and he was convinced that he received the placebo; regardless, his study participation was suspended because his tumors were growing. Switching then to another chemotherapy, his symptoms stabilized, and his shortness of breath was better. This stability remained for several months, and his CAT scan showed the cancer to be stable as well; his blood lab results also looked good. Unfortunately the tumor at his spine then began growing, so radiation was resumed for that and a tumor in his fibula was also found, which was likewise treated with radiation. A new drug regimen was also tried, since the former drug seemed to be losing its beneficial effects, as demonstrated by the growth of these bone metastases. It was at the time of this transition in medical treatments, with failure of the newly introduced drug to have substantial tumor-shrinking effects, that he began showing deterioration, with worsening lung condition, pleural effusion, loss of muscle mass, and increased pain due to bone cancer; he died a few weeks later, just ten days after his last visit to IEP. The situation that overwhelmed him was the failure to control the tumor growth more so than the cumulative impact of multiple drastic cancer drugs and radiation. Most likely, his lungs became unable to provide sufficient oxygen and even though he was put on oxygen at the hospital, this did not suffice because of his deteriorated physical condition associated with low appetite and insufficient nutrition. 9. Patient LS, a 57-year-old woman, was diagnosed with stage 4 ovarian cancer three months before coming to the clinic; she had surgery and started chemotherapy during the month prior to her first acupuncture session, and was suffering from significant side effects; she was also losing weight. The cancer had spread over several areas, so that even though she had hoped to discontinue chemotherapy, it was deemed a necessary treatment; at one point she underwent chemotherapy for a tumor at her left shoulder. She had 125 acupuncture treatments and 41 shiatsu sessions over a period of 13 months. She was highly symptomatic at every visit: fatigue, nausea, loss of appetite, constipation, poor sleep, heartburn, lung congestion, cough, costal pain, and low back pain. Acupuncture and other therapies helped her manage these

symptoms, but could not overcome them; they kept her functioning and there were occasional reports of her “doing good” or “feeling better emotionally” or that her “back is better.” Specific benefits were suggested: “ear points helping nausea” as well as general ones, such as this comment relayed by a shiatsu practitioner nearly four months into the IEP clinical program: “feels like she is doing well, shiatsu and acupuncture helping a lot.” About two months before her last visit, she seemed to recognize that she had lost the battle with cancer and practitioners frequently charted her as being “teary” and “crying” and having experience of panic and anxiety, being overwhelmed; sadness, and depression. Nonetheless, she kept coming to the clinic regularly until just a few weeks before she died. She came on average twice per week for acupuncture as we had recommended, and though she suffered many symptoms, she had functioned quite well until about three months before her death. In this case, the turning point appeared to be a dramatic loss of control over her situation, where she became highly emotional and somewhat disoriented. The chemotherapy, and, perhaps the cancer itself, may have affected her brain functions, and her situation was not helped by the fact that she developed oral thrush and then needed considerable dental work, including a root canal. This patient had not been healthy prior to her cancer diagnosis, having suffered long-term asthma, sinus allergies, and GERD. She had not given up hope on cancer treatment; even two months before her death, she had been given the option of palliative care (end of life care) or another try at chemotherapy, and she chose the latter. 10. Patient CM had come to our clinic many years ago, following a 1999 diagnosis of breast cancer detected during a routine mammogram at age 62. She had a modified mastectomy at that time. Her cancer was in remission and she came back to the clinic for treatment of other non-cancer related conditions and health maintenance. Then, more than ten years after her first cancer diagnosis, she came to the clinic for adjunctive cancer treatment when she was diagnosed with a recurrence of breast cancer (age 73): she was scheduled at that time for a full mastectomy and then chemotherapy. There were findings of cancer cells in the lymph nodes an partial evidence of metastatic sites. For the next 27 months, she came for acupuncture 95 times, but especially tried to arrange to have shiatsu, which she had 65 times. She completed the program in good health; after that, she left on a trip overseas for five weeks and on her return dropped into IEP for just a couple of follow-up treatments. She is alive today at age 76. Her chemotherapy resulted in fatigue and neuropathy, but these had largely resolved once those treatments ended (some permanent peripheral neuropathy as evident), with her main complaints being various aches and pains, many of them from physical activities she undertook rather than the consequences of cancer treatment. Typical of her favorable reports was a practitioner note indicating: “Doing well, energy better, and walking 2 miles consistently.” This report was six weeks after a course of side effect laden chemotherapy had been completed. While recovery from its side effects is to be expected even without intervention, her recovery was remarkably fast: she was beginning to feel notably better just two weeks after the last chemo treatment. Notes reporting her doing very well are found intermittently throughout the years of treatment. The basis for her good outcomes include limited aggressiveness of the cancer she had, with a long period of remission after the first treatment, and the fact that she was able to remain physically active. She followed the treatment schedule suggested at our clinic, and pursued several naturopathic recommendations, and she underwent regular testing by her oncologist, taking the medications and supplements prescribed by her doctors. These factors likely contributed to her remaining in overall good health despite suffering somewhat from the immediate reactions to chemotherapy. References 1. Huang Yarong, compiler, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, volume 2, 1996 New World Press, Beijing.

2. Carmady B and Smith CA, Use of Chinese medicine by cancer patients: a review of surveys. Chinese Medicine 2011; 6:22. 3. Dharmananda S, Zen Shiatsu: The Legacy of Shizuto Masunaga, ITM online articles, 2002: http://www.itmonline.org/arts/shiatsu.htm

4. Dharmananda S, Countering the Side-effects of Modern Medical Therapies with Chinese Herbs, ITM online articles, 1998: http://www.itmonline.org/arts/sidefx.htm

5. Dharmananda S. Millettia (jixueteng), ITM online articles, 1999: http://www.itmonline.org/arts/millettia.htm. 6. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1997 Blue Poppy Press, Boulder, CO 7. Dharmananda S. Zusanli: Stomach-36, 1998 ITM online articles: http://www.itmonline.org/arts/zusanli.htm 8. Lee M, Insights of a Senior Acupuncturist, 1992 Blue Poppy Press, Boulder, CO. 9. Sun BM, et.al., Acupuncture versus metoclopramide in treatment of postoperative gastroparesis syndrome in abdominal surgical patients: a randomized controlled trial, Journal of Chinese Integrative Medicine. 2010; 8(7):641-644.

10. Zhu B, Wang HC, Case Studies from the Medical Records of Leading Chinese Acupuncture Experts, 2010 Singing Dragon, Philadelphia, PA.

11. Dharmananda S, Towards a Spirit at Peace, 2005 ITM Publications, Portland, OR; also available at ITM online articles: http://www.itmonline.org/shen/index.htm

12. He, QY et.al. A controlled study on treatment of mental depression by acupuncture plus TCM medication, Journal of Traditional Chinese Medicine 2007; 27(3): 166-169.

13. Zhao JH and Sang P, Clinical observation on acupuncture treatment of depressive neurosis in 30 cases, Journal of Traditional Chinese Medicine 2006; 26(3): 191-192.

14. Kasymjanova G, et.al. The potential role for acupuncture in treating symptoms in patients with lung cancer: an observational longitudinal study, Current Oncology 2013; 20(3):152-157

15. Feng Yu, et.al. Clinical research of acupuncture on malignant tumor patients for improving depression and sleep quality, Journal of Traditional Chinese Medicine 2011; 31(3): 199-202.

September 2013

TREATMENT OF CARDIOVASCULAR DISEASES WITH CHINESE HERBS Congestive Heart Failure and Other Cardiovascular Disorders of Aging by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

In the practice of modern medicine, it is recognized that high blood pressure, atherosclerosis, easy blood clotting, and heart enlargement can lead to catastrophic events such as heart attack and stroke, which are the principal causes of death in persons over 40 years of age. Therefore, a major campaign has been launched to get all adults in this age range tested for cardiovascular disease risk factors and to have them treated by drug therapies when there is increased risk. As a result of such efforts, millions of adults are taking one or more of the drugs to lower blood pressure, lower cholesterol, and/or to reduce platelet aggregation. The prescribed regimen must be adjusted for individual needs by modulating the drug dosage and selecting from a collection of possible drugs to yield the desired response while keeping serious side effects to a minimum. Among the side effects commonly reported are fatigue and lowered libido from some antihypertensive drugs and liver damage from cholesterol reducers. Anticoagulant therapies carry the risk of bleeding episodes and cause considerable worry about interactions with drugs, herbs, vitamins, and even ordinary foods. In addition to regular use of the drugs, patients with elevated risk are also asked to participate in a program of cardiovascular preventive health care including a lower fat diet and increased exercise. Once a person has been started on a drug therapy, it becomes more difficult to recommend an herb therapy that might also be of assistance largely because of fears that the herbs will interact with the drugs, disturbing the careful balance that has been attained. Further, there are concerns that too little is known about the herb actions, so that doctors and patients wonder whether or not the herbs might do more harm than good. In evaluations of drug innovations, the calcium channel blockers that had been recommended as an improvement on earlier therapies turned out to be no better overall, and actually appeared to increase risk of heart attacks (18). The possibility that herbs might do little, or might even worsen certain outcomes, can be raised. Still, a growing collection of promising research reports about herbs leads many people to seek out appropriate supplements. While the use of herbs may be contraindicated or limited when an elderly patient is taking multiple drugs, there are many others who are being tested for cardiovascular risk factors while still relatively young and healthy: that is, when herb therapy might be a reasonable option, at least to try before starting a drug regimen. In addition, some drug therapies, especially single agents used to lower single risk factors, might be augmented with herbs without imposing a significant new risk if the herbs are selected carefully. As an example, a single blood-pressure lowering drug might be augmented with herb therapy so long as regular monitoring of blood pressure shows that it remains under control. While a potent anticoagulant such as Warfarin (coumadin) is thought to be subject to significant herb-drug interactions (including herbs such as salvia, ginseng, and tang-kuei), low dose aspirin (85 mg/day) used as an anticoagulant may be better suited to mixing with herbs. After all, low dose aspirin is little different from administering willow bark or meadowsweet (herbs that contain aspirin-like active ingredients) in an herbal formulation. Following is a brief overview of a few key herbs used for cardiovascular diseases associated with aging. The purpose of this article is not to provide extensive details of the treatment methods, but to illustrate the tendency of modern Chinese clinical reports to refer repeatedly to certain herbs that contain a relatively limited range of active components. The dominant herbs are qi tonics, of which the ones relied upon most consistently are ginseng and astragalus. A few years ago, Chinese doctors and researchers had focused on treating cardiovascular disease by the method of clearing phlegm-obstruction of the orifices. This method is slowly being downplayed in favor of the tonic preparations and use of mild blood vitalizing herbs, notably salvia. The change is timely, as many of the ingredients that were used in the orifice opening therapies have since been deemed toxic or endangered (see Appendix 1 for an example).

COMMONLY USED HERBS AND THEIR ACTIVE COMPONENTS There are two groups of non-toxic constituents frequently found in herbs employed for cardiovascular diseases: flavonoids and triterpenes. These substances can be ingested in quantities of several hundred milligrams per day and appear to be safe for long-term administration. They are present in some foods and in numerous herbs that are considered non-toxic. Flavonoids are the main active components of two herbs widely used and promoted in Europe for improving circulation: gingko leaf (see: Ginkgo) and crataegus, commonly called hawthorn fruit (17). Both these herbs are used in China, though their application to treatment of cardiovascular disease is relatively new. In traditional Chinese medicine, the ginkgo tree was primarily used as a source of ginkgo nuts, which are used for the treatment of asthma; crataegus is primarily used in traditional Chinese medicine for aiding digestion. Flavonoids are also the active ingredients associated with cardiovascular benefits in red grapes, soybeans, and green tea (which contains polyphenols, a condensed flavonoid). In China, considerable research has been carried out with pueraria flavonoids for cardiovascular health (see: Pueraria flavonoids). There is growing evidence that regular ingestion of flavonoids can reduce the incidence of cardiovascular disease, perhaps by reducing blood pressure, blood coagulation, and blood fats Triterpenes are the main active components of ginseng, which has been promoted as an aid to treatment of cardiovascular diseases in modern times; traditionally, it was used mainly in formulas to benefit digestion. Triterpenes have also been identified as an active ingredient in the popular new herbs from China, gynostemma and rhodiola, as well as in ganoderma, a rare herb famous in ancient times that was reintroduced after cultivation methods were developed. All three of these herbs have been the subject of research related to potential beneficial cardiovascular effects. The ginseng saponins (triterpene glycosides) are believed to be the primary active components in Shengmai San (Pulse Generating Powder) used in China for recovery from heart attacks (see: Shengmai San). The triterpenes lower blood lipids and enhance oxygen utilization and may have cardiac protective effects, such as reducing free radical damage.

SAMPLE THERAPIES Several reports in Chinese medical journals detail evaluation of patients with coronary heart diseases who have been treated with Chinese herbs. In the following summary, the main purpose is to illustrate the herbs selected for treatment of patients, rather than to

elaborate the claimed benefits of the treatment. Repeated reliance on certain herbs or on herbs with similar active components suggests that there is general agreement among Chinese physicians that these methods of therapy are useful. In a review of the traditional Chinese medicine (TCM) approach to congestive heart failure, Liang Donghui and Zhang Min specified that one should pay attention to the following principles, paraphrased from their article (5): 1. Consider both the Western medical information and TCM diagnostic approach to determine the right therapy, and be flexible in selection of herbs in order to respond to the complete information. 2. While focusing the main part of treatment on care for the heart, other organs might be affected as well and should not be ignored. 3. Tonification therapy is important both for those who have obvious deficiency disease, and for those who show some secondary excess signs (e.g., fluid accumulation, blood stasis, phlegm turbidity). 4. Vitalizing blood circulation is important because blood stasis is a common result of heart failure. They mentioned certain herbs and base formulas (to be modified as needed) that had been used in clinical trials, with the qi tonics astragalus, ginseng, and atractylodes being most prominent, and supported by the blood vitalizers salvia, leonurus, red peony, curcuma, and notoginseng. Formulas mentioned included Zhen Wu Tang , a formula with atractylodes and aconite; Shengmai San, a formula with ginseng and ophiopogon; and Shen Fu Tang, comprised of ginseng and aconite. An example of the use of the herbs and modifications of the formulas is the anti-myocardial infarction mixture made with the qi tonics astragalus, codonopsis, and polygonatum (huangjing) and the blood vitalizers salvia, red peony, and curcuma (15). Additional herbs were described in the article as adjunctive agents, such as using alisma to alleviate edematous swelling due to heart failure) and aconite to treat coldness and to strengthen the heart contractions. For ginseng, either red ginseng or American ginseng might be selected, depending on the presentation of symptoms (e.g., use American ginseng when yin deficiency is present), while notoginseng is sometimes selected to combine qi tonic and blood vitalizing properties. All these ginseng plants have similar active components. Shen Mai injection, a combination of ginseng and ophiopogon (similar to Shengmai San, but without schizandra) was used in treatment of congestive heart failure (8) and Shen Fu injection, the combination of ginseng and aconite, has been used in the treatment of heart damage due to viral myocarditis (16). The combination of ginseng, astragalus, and tang-kuei, called Yiqi Huoxue injection, has been used for coronary heart disease (7, 15). Ganoderma, which contains ganoderic acids that are similar in structure and effect to ginsenosides, has been used as a therapy for coronary heart disease and hyperlipemia (13). Ganoderma is also an ingredient, along with notoginseng and salvia, in a tranquilizing formula, Qingxin Anshen Fang, designed to treat coronary heart disease with premature beat (1). By contrast, a stimulating formula, Huo Dou Wan , was administered for treatment of sick sinus syndrome; the pill is made with astragalus, codonopsis, epimedium, curculigo, ma-huang, and salvia (4). The general approach is to use qi tonics supplemented by a few herbs that address constitutional factors (e.g., use aconite for yang deficiency; ophiopogon for yin deficiency; salvia or other herbs for blood stasis). Zhu Boqing and his colleagues at the Huashen Hospital of the Shanghai Medical College explained a basis for primary reliance on qi tonics, even in patients with blood stasis syndrome (2). They had treated patients with chronic congestive heart failure of various causes with the combination of astragalus and codonopsis. This combination was considered cardiotonic and suitable for patients with both qi deficiency and blood stasis, the latter condition responding to qi tonics according to the traditional principle: "if the qi is set in motion through the use of the tonics, then the blood circulation will proceed normally." They recognized that it was common to use salvia to vitalize blood circulation, but considered that the qi tonics were the key to the therapy in these patients. The treatments were administered either as an intravenous drip (11) or an oral preparation; for oral administration, as would be suitable outside of China, the dosage of 10-15 grams of each herb. A course of therapy would be 2-4 weeks, which could then be repeated. Zhu Boqing wrote a followup report on Chinese herbs for various cardiac disorders in which he focused on the value of astragalus, codonopsis, salvia, and aconite, and concluded that (9): Salvia can effectively improve myocardial ischemia and abnormal hemorrheological parameters in patients with coronary heart disease. Astragalus can significantly enhance cardiac systolic function in patients with heart failure. It also has a positive iontropic effect [increases cardiac contractility]. Astragalus and salvia exhibit a synergistic effect for the improvement of symptoms and cardiac performance, and hemorrheology in patients with heart failure of the qi deficiency and blood stasis type. Aconite can effectively improve sinus-node function and cardiac performance in asthenic patients with sick sinus syndrome, especially those of the yang deficiency type. Codonopsis was not included in his summary, but was mentioned in combination with astragalus, as in his former study report. These key herbs have been used in a variety of combinations. Aconite with salvia was used in one study for treatment of heart failure, in which Zhen Wu Tang (an aconite-containing prescription) was combined with both salvia and carthamus; another study of heart failure was carried out with Zhen Wu Tang plus astragalus and cinnamon (10). The combination of astragalus and salvia (30 grams each, as a daily dose in decoction form) was another treatment administered for heart failure (3). The essential herbs for treating cardiovascular diseases have all been reviewed in recent years. Thus, for example, a review of pharmacological studies of astragalus in relation to the cardiovascular system indicated that it had protective effects against myocardial ischemia and reperfusion injury, on free radical injury, on platelet sticking, and on myocardial viral infection (6). A review of ginseng (12) described the same benefits as those listed for astragalus, except for the effect against myocardial viral infection (the herb is, nonetheless, used to aid recovery from such infections). A review of ganoderma indicated that it could have a positive iontropic effect, and protect against myocaridal ischemia (13). Salvia is reported to facilitate circulation by improving capillary bed circulation, dilating peripheral blood vessels, reducing excessive platelet aggregation, inhibiting vascular smooth muscle cell proliferation, and having a positive iontropic effect (14).

REFERENCES 1. Jia Yuhua, et al., 107 middle-aged and senile cases of coronary heart disease with ventricular premature beat treated by Qing Xin An Shen Fang, Journal of Traditional Chinese Medicine 2001; 21(4): 247-251.

2. Zhu Boqing, et al., Research on the theory of correlation between qi and blood: the use of qi nourishing herbs in treating patients with heart failure and qi deficiency and blood stasis type, Journal of Integrated Traditional and Western Medicine 1986; 6(2): 75-77. 3. Wu Liushen, Treatment of heart failure with astragalus decocted later, Shanxi Journal of TCM Reports, 1986; 1(1): 35. 4. Zhao Zhongyin, et al., Treatment of sick sinus syndrome with Chinese herbs, Journal of Traditional Chinese Medicine 1990; 31(2): 37-38. 5. Liang Donghui and Zhang Min, The thinking on TCM differential treatment of congestive heart failure, Journal of Traditional Chinese Medicine; 2000; 20(1): 44-47. 6. Han Ling and Chen Keji, Advances in experimental pharmacological studies of effects of astragalus on the cardiovascular system, Chinese Journal of Integrated Traditional and Western Medicine 2001; 7(2): 146-151. 7. Liao Jiazhen, Clinical and experimental studies of coronary heart disease treated with Yiqi Huoxue injection, Journal of Traditional Chinese Medicine 1989; 9(3): 193-198. 8. Liu Zhihong, et al., Observation on the effect of Shen Mai Injection in treating patients of congestive heart failure, Chinese Journal of Integrated Traditional and Western Medicine 2000; 6(2): 119-121. 9. Zhu Boqing, Effects of traditional Chinese herbs on myocaridal ischemia, heart failure, and sick sinus syndrome, International Journal of Oriental Medicine 1993; 18(1): 1-10. 10. Wang Junning and Liu Gengsheng, Pharmacological research and clinical application of Vitality Combination (Zhen Wu Tang), International Journal of Oriental Medicine 2001; 26 (1): 52-56. 11. Liao Jiazhen, et al., Pharmacological effects of codonopsis-astragalus injection in the treatment of coronary heart disease patients, Journal of Traditional Chinese Medicine 1988; 8(1): 1-8. 12. Chen Xiu, Panax ginseng and ginsenosides, in Zhou Jinhuang and Liu Ganzhong (editors), Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing, pp. 91-99. 13. Lin Zhibin, Pharmacological effects and clinical applications of Ganoderma lucidum, in Zhou Jinhuang and Liu Ganzhong (editors), Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing; pp.133-140. 14. Li Lianda, Liu Ganzhong and Sun Hong, Drugs for activating blood circulation to remove blood stasis, in Zhou Jinhuang and Liu Ganzhong (editors), Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing; pp. 197-210. 15. Liao Jiazhen, The principles of traditional Chinese medicine in the treatment of coronary heart disease, in Zhou Jinhuang and Liu Ganzhong (editors), Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing; pp: 245-260. 16. Sheng Yong and Li Chunmei, Observation on clinical effects of Shen Fu injection and vitamin C for the treatment of acute virus myocarditis, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 22(2): 138-139. 17. Schmidt U, et al., Efficacy of the hawthorn preparation LI32 in 78 patients with chronic congestive heart failure, Phytomedicine 1994; 1: 17-24. 18. Opie LH and Schall R, Evidence-based evaluation of calcium channel blockers for hypertension: equality of mortality and cariovascular risk relative to conventional therapy, Journal of the American College of Cardiology 2002; 39(2): 315-322.

APPENDIX 1: Guanxin Suhe Wan: Effective Medicine or Deadly Poison? There are two English language journals of Chinese medicine published in China that are distributed in the West: the Journal of Traditional Chinese Medicine and the Chinese Journal of Integrated Traditional and Western Medicine . In a recent issue of the latter journal (December 2000), there appeared a brief summary of the famous Chinese patent remedy Guanxin Suhe Wan (a similar summary had appeared earlier in the Journal of Traditional Chinese Medicine). This formula was developed by the Shanghai Huashan Hospital and the Shanghai First Traditional Pharmaceutical Factory. It has appeared in the 1988 and 1995 editions of the Pharmacopoeia of the People's Republic of China. The formula is as follows: Styrax (aka storax; suhexiang) Borneol (synthetic; rengong bingpian) Frankincense (processed; ruxiang) Sandalwood (white sandalwood; baitanxiang) Birthwort (aristolochia root; qingmuxiang)

50 mg 105 mg 105 mg 210 mg 210 mg

The herbs are powdered, mixed with honey, and made into pills, with 680 mg of herbs per pill; the weight of the finished pill is 900-1,000 mg, including the honey. The dosage is one pill each time, 1-3 times per day. The pill is chewed, sucked, and then swallowed. Its uses are: for treating coronary heat disease, angina pectoris, and stuffiness in the chest. It is contraindicated during pregnancy. This formula is a simplification of a prescription of the Taiping Huimin Hejiju Fang (1110 A.D.) called Suhexiang Wan (Styrax Pills). That formula has 10 additional ingredients, including the now banned substances rhino horn and musk, the mercuric compound cinnabar, and a collection of aromatic and spicy herbs such as clove, aquilaria, and cyperus. Suhexiang Wan is still produced as a patent

medicine in China, with all the original ingredients listed. In a modern book on patents (Zhongguo Jiben Chenyao, 1988), cinnabar is included in the formulation for Guanxin Suhe Wan as well. Guanxin Suhe Wan has been produced by several factories; the article in the Chinese Journal of Integrated Traditional and Western Medicine mentions it as a product of factories in the following cities: Hebei, Shijiazhuang, Huhehot, Shenyang, Changchun, Harbin, Shanghai, Nanjing, Hebei, Jinan, Henan, Wuhan, Guangzhou, and Xian. Two products became commonly distributed in the U.S.: the Shanghai product in the form of pills (30 pills per bottle) and a Tianjin product in the form of capsules (40 capsules per bottle). According to the labeling of the Tianjin product, birthwort is replaced by oroxylum (muhudie), but this may be a labeling error. Most of the patents that have arrived in the U.S. go to California and its numerous Chinese herb shops concentrated in Los Angeles and San Francisco. The U.S. FDA and the California FDA (the Food and Drug Branch of the Health Department), have numerous objections to the product. In addition to serious concerns about labeling that would indicate treatment of any disease condition (especially such a potentially dangerous one as cardiovascular disease marked by the symptom of angina pectoris), the California FDA considers two of the five ingredients to be toxic. Borneol is listed by the California FDA as a cardiac toxin. Borneol occurs naturally in some approved herbal materials, such as cardamon seed, so this component (in its natural form) should be permissible in herbal products up to a certain level, not more than about 2%. In Guanxin Suhe Wan, borneol is present as 15% of the herbal formulation, and about 11% of the entire pill (when made as a honey pill) and it is synthetic borneol. All aristolochia materials are currently restricted for any use by the U.S. FDA, since they contain aristolochic acid, a carcinogenic agent that might cause renal failure with prolonged use. There are no indications for duration of use or any limitations on duration of use of this formula in any of the Chinese literature. In America, patients with angina pectoris and other coronary heart diseases are usually prescribed drugs that must be taken for life; thus, it would be reasonable for practitioners prescribing the herbs to consider long-term administration. In a test evaluation of several patent formulas found in Chinese herb shops, the California FDA checked Guanxin Suhe Wan manufactured in Guangzhou. It was found to contain no mercury (a marker compound for cinnabar), but it had 74 ppm of arsenic, which is usually contributed by realgar. Currently, a major effort is being made in the U.S., and California in particular, to reduce exposure to arsenic by removing naturally-occurring arsenic from community water supplies. The combination of borneol, aristolochic acid, and arsenic (in at least one of the versions), makes this product appear, from the FDA perspective, to be a deadly poison. Nowhere in the articles alluded to above is there any discussion or mention of toxicity or any cautions about use other than the contraindication during pregnancy. In Clinical Handbook of Chinese Prepared Medicines (1989), there is an additional contraindication which reads: "Do not use this formula if the coronary artery disease is caused by blood stasis, which will be indicated by such symptoms as fixed, stabbing, strong, sharp pain that is possibly worse at night, or heart palpitations, accompanied by a dark purple tongue and a deep and choppy pulse. In such cases, Dan Shen Pian is the formula of choice." Dan Shen Pian is reported to contain just salvia (danshen) and borneol. Although it is unclear why Guanxin Suhe Wan would be contraindicated in cases of blood stasis, the formula design is not aimed at treatment of blood stasis cases, but for regulating the flow of qi and resolving obstruction due to "turbid phlegm." The symptoms that would indicate use of the formula include stuffiness and numbness rather than sharp-stabbing pain. Clearly, there is a complete divergence of views regarding this formula from the perspective of Chinese doctors versus that of the California FDA. The pharmacological effects of the formula, as described in the above-referenced journal article are: "improve the cardiovascular function; dilate coronary artery; increase the coronary blood flow; inhibit platelet aggregation and thrombosis; and promote the repairing of heart muscle necrosis." These are all highly desirable actions for persons suffering from chronic cardiovascular disease. However, from the FDA point of view, the product is a poisonous and carcinogenic preparation, which may be contaminated by toxic metals, labeled with illegal indications for use (because it is not a registered drug), and presenting a potential for adverse interactions with drugs, particularly if the pills effectively reduce platelet aggregation and, thereby, overemphasize the effect of anticoagulants commonly prescribed to these patients.

March 2002

ORIENTAL PERSPECTIVES ON CARDIOVASCULAR DISEASES AND THEIR TREATMENT by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Cardiovascular diseases encompass an immense category of disorders, because many things can go wrong with the heart and blood vessels. Nonetheless, it is a rather common classification term for the primary cause of death in the U.S. and in most countries. Cardiovascular diseases often involve accumulation (plaques in the arteries) and stagnated circulation (platelet stickiness, clots of blood, and restricted passage of blood through the arteries either by hypertensive constriction or plaques). The other major cause of death in the U.S., cancer, also involves accumulation (more rapid, with tumors rather than plaques) and increased stickiness of the blood. It is well-known that major contributors to cardiovascular disease are diet (especially from a high fat and low fiber diet) and stress (especially low-exercise emotional tension). Persons who move from a part of the world with low incidence of cardiovascular disease to a part of the world with high incidence of this category of disease soon experience the higher risk themselves. The Oriental view of cardiovascular diseases and their causes is influenced by certain circumstances in the Chinese culture which led to very low incidence of such diseases until quite recently. Modernization has thrust the hearts and vessels of the Chinese people into a condition not much different than their Western counterparts who have been suffering from cardiovascular problems for the past century. Unlike the West, and until very recently, the Chinese diet was free of dairy products (which have been uniformly high in fat, until the recent introduction of fat-reduced products) and was generally low in all sources of fats, especially low in animal fats. Obesity was rare, and most people labored, which provides exercise, and cardiovascular disease was therefore very rare. Cardiovascular disease is now a major topic of concern among Oriental doctors: not only because the people are exposed to more of the same disease-causing dietary and life style factors. Also, Chinese researchers have made a concerted effort to interest Westerners in their medical techniques, by focusing on this highly publicized health problem of the West. Although many significant details about cardiovascular diseases have been elucidated by modern research efforts, an easilyunderstood designation for these problems is "poor circulation." Much of the work done in China with traditional methods of herbal prescribing has focused on the use of herbs that are said to promote normal circulation. To treat poor circulation, there are two primary considerations. First, the blood flow can be sluggish because the vessels are contracted and/or the blood is sticky-there are herbs that simultaneously address both these conditions. Second, the blood flow can be restricted by the presence of excess fats, either circulating in the blood or attached to the vessel walls (plaques). Fat is considered by Chinese doctors to be in the same category as phlegm, because it is a thick soft, material.

VITALIZING BLOOD CIRCULATION The dominant herb in modern therapies for cardiovascular disease in China is salvia. This is the root of a Chinese "sage" plant, Salvia miltiorrhiza, of which the root is used. The Chinese name for it, danshen, indicates the color of the root, like the mineral cinnabar (a purplish red color), and the term shen suggests that it has an extraordinary effect (this is the same term used to describe sophora roots-kushen-which are used in cancer therapy and to treat infections). It has been shown that salvia helps to reduce platelet aggregation (sticking of blood cells that can form artery-blocking clots), reduces the tension in the arteries (thus causing them to dilate, or open wider to allow blood cells to pass), and promotes the cardiac action (thus better pumping of the blood). The active components are a group of quinones, compounds of structure similar to a nutrient factor widely used in treating cardiovascular diseases-coenzyme Q10 (ubiquinone; so-named because it is ubiquitous, everywhere). Two other herbs are especially noteworthy in regard to cardiac circulation. First, there is peony root. There are two species. One is called white peony, the Chinese name being baishao (bai = white; shao = peony), and the other is called wild peony or red peony, named chishao (chi = red; the color designations do not refer to the flower colors but to the relative colors of the root materials that are used for making the medicines). Like salvia, the peony species reduce platelet aggregation and relax blood vessels, causing dilation and easier flow of blood (stress reaction causes the muscles surrounding the blood vessels to tighten, causing the pressure of the blood within the vessels to increase; this reaction is mediated by chemical messengers that are released under certain conditions). The white peony has a moderate taste that can be easily manipulated by other ingredients in a blend; it has been used in ancient Chinese cooking to make a sauce and in modern Chinese manufacturing to produce "Shaolin cola," a beverage tasting remarkably like the American cola drinks but having the purported advantage of promoting heart health. The other herb of special interest is carthamus, honghua (hong = red: it is more commonly used to designate red than chi; hua = flower) which is known in the West (where the seeds are used as a food and a source of cooking oil) as safflower. The flower promotes the circulation of blood, helps reduce blood lipids, and breaks up blood clots. According to Chinese doctrine, the motive force behind the blood circulation is the essential energy called qi (see the article Oriental perspectives on cancer for more about this concept). That is, if the qi is weak, the blood circulation can not be vigorous. Therefore, when the blood circulation is impaired, Chinese doctors try to overcome this by "loosening up" the blood, with the herbs just described, and by invigorating its circulation, using herbs that strengthen the qi. The two main herbs for this latter purpose include astragalus, well-known for its ability to enhance immune functions, and codonopsis, a root known to the Chinese as dangshen (dang refers to the original source of the herb in China, Shang Dang, and shen is the same term used in describing salvia and sophora; it has the meaning of being an herb of extraordinary effects).

Codonopsis is a substitute herb for the rarer and more costly ginseng, which may be used when it is available and afforded. Ginseng is known as renshen, or the herb of extraordinary effect that has the essence of man (ren = man; as in the generic meaning, human). The effect of qi tonic herbs are enhanced by using a small amount of licorice, which is itself a qi tonic.

HERB COLOR AND ACTION To take a short detour, it may be of interest here to point out that Chinese doctors have asserted that there is an association with herb color and its particular actions. For example, several herbs with a reddish coloration-salvia, peony, and carthamus-promote the normal functions of the heart and invigorate the circulation of blood. The primary organ system for generating qi is called the spleen system, and herbs that have a yellowish color (ginseng, codonopsis, astragalus, licorice) promote the function of the system and boost the qi. While the association of herb color and herbal effect is certainly not universal (there are as many exceptions as cases that follow the rule), it is remarkable to see a collection of herbs that addresses each of the organ systems recognized by Chinese doctors and to observe the tendency of a certain color of the herbs to be dominant. Ginseng can be processed with other herbs to transform its color to red; it then becomes a superior treatment for disorders of the heart, yet it retains its essential nature as a tonic for the spleen system.

DETECTING THE NEED FOR QI TONICS Chinese doctors can detect the problem of insufficient qi by feeling the pulse at the wrist (in such cases, it will feel quite weak compared to that of a healthy person), and by certain symptoms, such as general weakness (the weak pulse reflects this broader symptom) or becoming easily fatigued. In addition, it is common for the tongue of a person with qi deficiency to take on a bloated appearance, and one will see indentations along the edge where it has pressed against the teeth. If as a result of using the blood circulating herb the blood becomes less sticky, and the vessels are less tightly constricted, and if through the use of qi tonic herbs the movement within the vessels is invigorated, then the person will no longer suffer from poor circulation-unless there is obstruction of the circulation by accumulated fatty masses.

LOWERING FATS The Chinese term "tan" (pronounced as tann) refers to thick fluids; in the medical field, the term is applied to mucus, fat, and substances of similar nature. A portion of this material is absolutely necessary for health, but it is also possible for too much to accumulate, in which case, it contributes to diseases and symptoms. The translated term is "phlegm," though this may not convey its meaning very well. The ancient Chinese had developed a concept that "tan" spreads through the body as a fine mist, but under various pathological influences, the mist could obstruct the blood vessels and the "orifice of the heart," which is the connection between the physical body and the mind, the spiritual center. Today, we know that people with cardiovascular disease are susceptible to brain circulation problems, including stroke, poor memory, and dementia, and we also know that the outer membrane of the brain and nerve cells-a thick fatty material-is critical to proper function of the central nervous system. Modern medicine, which generally places the mind in the realm of the brain, has not yet elucidated the relationship of mind and the physical body. According to the Chinese concept, the effect of the "tan" mist occurring in excess is not only to obstruct the circulation of blood, but also to derange the normal functions of the mind. Hence, in modern terms, the "tan" disturbs the brain and central nervous system. The fatty mist can arise from a few sources. First and foremost, there are fatty substances in the diet. If not completely digested, utilized, and eliminated, these can lead to harmful fat in the circulatory system and dispersed throughout the body. The digestion of these fats depends on the complete degradation of food by the stomach before it is sent to the small intestine, and then by the influence of bile secreted by the gallbladder. Bile forms complexes with the fats to make them easily assimilable. Persons with disorders of stomach or gallbladder functions may fail to properly process the fats, leading to the "tan" mist. Two of the most favored substances for resolving the mist are of animal origin. There is the highly aromatic secretion of the musk deer, which we call musk and the Chinese call shexiang (she = strong, xiang = fragrance). It is the same material used in perfumes (since it is secreted by the male deer to attract the female, it is especially used in fragrances for men). There is not a large supply of this natural material, so synthetic replacements have been developed, mainly the chemical muscone, which is used both in perfumery and medicine. According to some laboratory and clinical trials of medicines, the synthetic compound works about the same as the original. The powerful aromatic nature of the musk is deemed to be penetrating-it can thus enter the thickened fluid and help it dissolve. Musk also opens the vessels. It is shown to stimulate the nervous system, relax the blood vessels, and improve the circulation. The other substance commonly favored is the gallstone of the water buffalo, or ox gallstone, which is called by the Chinese niuhuang (niu = ox, huang = yellow; the color of pure ox bile is yellow). The gallstones are more prevalent in oxen in Africa than in China, so many are imported from there, but the gallstones formed in American cattle are the brightest yellow and thus bring the highest price (African gallstones tend to be black). Still, there aren't many gallstones found in ox, so two methods have been developed to get more. Just like oysters are seeded to produce pearls, ox gallbladders can be seeded to produce stones (material must be injected into the gallbladder). Easier still, simple bile from ox gallbladders is mixed with various minerals to produce "man-made ox gallstone," (rengong niuhuang; ren = man, gong = to make) and this is currently used in producing most of the medicines in China that include ox gallstone. The material is quite valuable, and there have been news articles in the Chinese press about the arrests of people involved in faking the fake ox gallstone. The bile acids in the ox gallstone promote the functions of the gallbladder of those who ingest it, and the minerals also contribute to aiding the digestion of the fats that have caused a problem. These two aromatic substances were originally used to treat the mist of the heart orifice that connects to the mind: utilized in therapies for coma and for extreme mental disease. Modern doctors have expanded the use of these substances to treat the obstruction of the blood carrying vessels. For example, a prepared formula Niuhuang Jiangya Wan (jiang = to lower, ya = blood pressure, wan = pills), is a modern preparation made with musk and ox gallstone, which won an award in China for its beneficial effects on cardiovascular patients. There are also some plants that yield mist-resolving materials. One of the most fragrant plant substances is a camphorous crystal, called Borneo camphor, or borneol (named for its original source: the island of Borneo). Today, it is obtained from several plants; the Chinese call it bingpian (bing = ice, pian = slice; referring to its appearance, like a flat slice of ice). Its aromatic quality measures up well

to that of musk and its influences are similar. Aromatic resins from various Styrax trees, also give rise to medicines for this purpose. One of the resins is a substance commonly used in the West, because it acts as a preservative, known as benzoin. The other, simply called styrax, is very high in a fragrant derivative of cinnamic acid-related to the spicy component of cinnamon. The Chinese name for styrax is suhexiang (su = from Vietnam, he = closed, xiang = fragrant); it is so-named because this fragrant material from Vietnam is used to treat severe obstruction or closure of the orifice. Two other herbs are frequently relied on for relieving obstruction. One of these is called acorus. There are two species. Acorus gramineus is the more commonly used; it contains an essential oil rich in asarone, a very penetrating fragrant compound. The other is Acorus calamus, an herb that has been used by the American Indians to treat digestive disorders. This latter herb is somewhat toxic, and is usually not taken internally. These varieties are distinguished in their naming, the former is shichangpu (shi = stone) and the latter is shuichangpu (shui = water), making reference to the environment in which the plants grow (pu refers to the long narrow leaves like those used for weaving into mats). The other herb, usually combined with acorus in modern Chinese prescriptions, is called polygala. The Chinese name for it, yuanzhi, indicates that it benefits the mind (yuan = greater, zhi = memory), increasing wisdom. When properly combined with other ingredients, these herbs for controlling the phlegm-mist are used for neurologic disorders that include fainting, loss of sensory acuity, paralysis, and convulsion. They may also address problems of severe mental distress such as deep depression and mania, or for mental deterioration associated with aging, such as loss of memory (Alzheimer's disease), Parkinson's disease, and confusion.

HYPERTENSION As was already mentioned, salvia and peony can relax the muscles surrounding the blood vessels, allowing the vessels to expand, and thereby lowering blood pressure. However, the primary role for these herbs in most cardiovascular formulas is to enhance the ability of blood cells to more easily traverse the primary vessels by reducing their stickiness. Chinese doctors have discovered some other herbs that are especially effective at lowering the pressure within vessels via an antispasmodic action affecting the vessel muscles. It should be noted that hypertension is difficult to detect without use of the blood pressure cuff, which was unavailable to Chinese doctors prior to this century. Therefore, treatment of hypertension by Chinese medicine is a relatively new area of interest. There are two fundamental types of hypertension. The most common, called essential hypertension, is a stress reaction which causes the vessels to contract, thus increasing the pressure within them, just as one can build up pressure in a water hose by squeezing it into a smaller diameter. This type of hypertension tends to be quite variable. Blood pressure builds up further during especially stressful times, and goes down somewhat during times of calmness. It has been shown that meditation, biofeedback, massage, and other relaxation methods help with this type of hypertensive problem. Persons who experience the stress reactions chronically may eventually develop hypertension that only moderately remits during periods of relative relaxation (e.g., when on vacation). According to traditional Chinese medical thought, muscular tension, such as that which contracts the arteries, is a response to an internal phenomenon known poetically as "wind." It takes on this name for a number of reasons, but especially because wind can come up suddenly and it is erratic, as are certain disease symptoms, and because a person who is exposed to windy weather (without adequate protective clothing) will feel their muscles tighten up. Since the external wind (an environmental phenomenon) causes variable symptoms and muscular contraction, internal forces (e.g., emotions, stress reactions to events, etc.) that cause variable symptoms and muscular contraction are called "internal wind." Just as the wind gusts, the variable hypertension being considered here is surges at times of stress.

NAMING INTERNAL PHENOMENA Describing internal processes with the same terms as environmental phenomena is an important part of Chinese medical thinking. According to the most ancient ideas, the human body is no more and no less than an integral part of the environment in which it exists. Though we have a boundary of skin separating the inside from the outside, in fact, the working of the inner body and the working of the outer world is the same and the influence of the environment on the body is continual. In ancient China, it was also thought that the actions of mankind could influence the environment. Since man's representative (from the Chinese perspective) was the Emperor, the actions of the Emperor were thought to determine, among other things, the weather, the fertility of the land, and the occurrence of earthquakes. If the environment became especially hostile, it would be taken as a sign that the Emperor had lost his mandate from heaven, was internally in turmoil, and would be replaced during the course of subsequent events.

HERBS FOR INTERNAL WIND Herbs that calm the internal wind are those that relax muscular spasms and convulsions. Since it is possible for tightening of muscles to proceed so far that one can not move (known as tonic paralysis), some cases of paralysis are also treated by these herbs. There are two key plant materials for inhibiting internal wind. One is the hooked vine called uncaria, which the Chinese call gouteng (gou = hook, teng = vine). The sharp, curled hooks have long been deemed the most effective part, and it has been said that using them is like being able to hook tension and pain within the body and carry it out. Modern research confirms that the amount of the active component, an alkaloid called ryncophylline, is most concentrated in these hooks. The herb is traditionally used to treat nervousness and convulsions, and the isolated active component has been shown to do the same. It strongly lowers blood pressure that is due to vascular tension. The other herb is obtained from the rhizome (rhizomes are the storage portion of plants, potatoes are a typical example, and they usually are high in starch), of gastrodia, which the Chinese call tianma (tian = heavenly, ma = hemp). Like uncaria, it was used traditionally to treat erratic conditions such as headache, dizziness, and convulsions. There is an interesting story about this plant. When its hypotensive (blood pressure lowering) properties were discovered several years ago, the herb became quite popular. The availability of the plant was limited, however, driving the price very high. Vigorous attempts to cultivate it in order to get adequate supplies were all unsuccessful. After long research, however, it was discovered that this plant only grows if it is cultured together with a symbiotic fungus, Armillaria. In such symbiotic relations, the plant provides essential nutrients to the fungus and the fungus provides essential nutrients to the plant. It thus became possible to cultivate gastrodia by combining the two. Further research showed that the active component for "calming internal wind" was, in fact, a component of the fungus. Therefore, one could grow the fungus in batch culture (a laboratory

method in which a nutrient broth and temperature control can yield huge amounts in a relatively short time) and make it into tablets for medicinal purposes. This material is called mihuanjun (mi = dense, huan = ring, jun = mushroom; referring to the dense ring of mushroom mycelia that grows on the culture medium). Gastrodia and armillaria are now used as remedies for hypertension, alone or in complex formulas; armillaria is the more potent. These materials increase coronary and cerebral blood flow by reducing vascular resistance; they are used for treating vascular headaches as well.

ANIMALS AND HERBAL MEDICINE Several animal substances are used to treat hypertension. Before describing these, it is worth pausing here and describing the role of animal medicines in the realm of Chinese herbalism. The term we use, "Chinese herbs," is a translation of the Chinese zhongyiyao. The word is comprised of three parts, zhong, comes from zhongguo, meaning central country, the name for China. Yi refers to the practice of medicine. For example, Western medicine is called xiyi (xi = Western). Yao refers to medicinal materials, the medicines themselves. Thus, "Chinese herbs" means materials used in the practice of Chinese medicine. There is no reference to any limitation of the source of materials, as might be conveyed by the term "herb" in English. In an attempt to make "herbs" seem more fitted to modern medicine, Western herbalists have called them phytomedicines (phyto = from plants) or other designations which suggest a plant nature, because most modern Western herbalists develop their art from an enthusiasm for plants. This is quite different than the situation in China. Among the medicinal materials used by Chinese doctors over the centuries are those of plant, mineral, and animal origin. About 20% of the materials listed in Chinese medical books, whether an ancient reference from 2,000 years ago, or a modern one published last year, are derived from animals. Further, it is explained by Chinese doctors that since animals have a nature which is like that of humans, they are especially helpful in treating human-type problems: that is, problems which involve the muscles, nerves, and mind (as opposed to universal biological problems, such as infection, reactions to cold or hot weather, or physical injury). Two such substances mentioned already are ox gallstone and musk.

ANIMAL SOURCES OF TREATMENT FOR INTERNAL WIND In the case of treatments for internal wind, there are two groups of animal substances used. One group is comprised of small creatures (Chinese: chong) that contain inhibitors of the nervous system. The method corresponds, very roughly, to the Western medical treatments using beta blockers (there are two nerve transmission systems labeled alpha and beta, these drugs block transmission of the beta system; a side-effect of such drugs is to lower other tension responses in the body, reducing sexual tension and overall sense of liveliness). Scorpions, centipedes, and earthworms all contain nervous system inhibitors. Scorpions and centipedes have toxic components, which injected into the body (by the insect or any other means) is quite dangerous, but when taken orally is safe. Earthworms contain substances that are non-toxic, and produce the blood pressure lowering effect through an indirect inhibition of the nervous system agitation that causes the hypertension. An advantage of these herbal compounds is that they do not produce the undesired side-effects of beta blockers. The other animal substances are those rich in mineral components, especially calcium, which has a spasm-relieving action if the person being treated has low levels of calcium. Nutritional studies have shown that many Americans, perhaps the majority, have some degree of calcium deficiency, and this deficiency tends to worsen with age. It is a public health problem due to a combination of inadequate ingestion of the mineral coupled with poor absorption. Of the calcium sources used by Chinese doctors for treating hypertension, the most frequently relied upon item is haliotis, the shell of the abalone. The Chinese name for this material, shijueming, means the stone that brings brightness, and this is because another effect of using it is to clarify vision (an extract of haliotis, or some of the other sea materials rich in calcium, applied to the eyes of those suffering from cataracts will help to reduce the opacity of the cataracts). Sea shells are rich sources of calcium carbonates; oyster shell is often used as a nutritional resource and a Chinese medicine. In a similar way, the shells of turtles and tortoises, which are rich in both calcium carbonate and calcium phosphate, are used in some treatments for hypertension. It is likely that the tough proteins in the shells of these animals also contribute some of the hypotensive effect. Another calcium-rich material used by Chinese doctors is called dragon bone. It is actually the fossilized remains of various animals found in vast pits in certain parts of China. Like other fossils, they contain mostly calcium carbonate. The second type of hypertension is one in which there is relatively little reduction of pressure accomplished through relaxation. One of the main causes of this type of hypertension is a failure of the kidney to remove water from the blood vessels, and the condition is called renal hypertension (renal = kidney). Even if the muscles surrounding the blood vessels are quite relaxed, the pressure within the vessels doesn't go down because the fluid content is too high. Diuretic drugs are often tried in such cases, but they often function for only a short time, until the body gets used to their presence, and then the hypertension returns. From the Oriental viewpoint, there are several considerations that lead to developing a therapy for kidney problems. First, the kidneys are clearly failing to do their job of passing water to the bladder. Applying diuretic drugs will usually produce only a temporary benefit because they do not resolve the specific problem: poor blood circulation through the kidneys. Therefore, the Chinese medical treatment is to improve the overall kidney function and to enhance the circulation through the kidneys. Treating the kidneys has a different meaning in the West and in the Orient. Western physicians focus their attention on the paired small organs that have been carefully analyzed and defined through microscopic and biochemical methods. Chinese physicians have been dealing with "kidney problems" for many centuries and they've done so without the assistance of any detailed analysis of the physical tissues. They have described a kidney system which is defined by functional attributes. It is much broader than that defined by the modern analysis. As an example, the kidney is seen as extending from the small tissues in the lower back to include the spinal cord and brain, the reproductive organs, and the bone marrow. As a result, the functions of the kidney described by Chinese doctors extend far beyond those defined by modern medicine. Treatments for this broad kidney system are described differently than for the narrower "Western kidney." Describing the Oriental kidney system and the treatments for it in Western terms is one of the major undertakings of researchers in China. While much progress has been made, there is still much more work to be done and the implications may have a strong impact on the future of medical practice, both East and West. For purposes of this section, the issue can be limited to a brief discussion of a treatment for the kidney system that was first described nearly two thousand years ago and is still used today. In an ancient text Prescriptions from the Golden Cabinet (Jin Gui Yao

Lue), there is a formula called Ba Wei Di Huang Wan , meaning the Eight Ingredients Rehmannia Pill (rehmannia is the leading herb in the formulation of eight ingredients, usually prepared as a pill). This formula is so central to the practice of traditional Chinese medicine that it is also called "Golden Book Pill" (the main formula from the book called Golden Cabinet). In this ancient book about difficultto-treat diseases, the Rehmannia Pill is described as having several applications, including "weakness and fatigue, lower back pain, and limited urination, water stagnancy that has to be eliminated through urination, and shift of the bladder that makes the patient incapable of urinating." This formulation is not a simple diuretic. In fact, in the same book, it is described also as a treatment for frequent urge to urinate or frequent urination. It is a formula designed to restore the normal functions of the kidney system. The herb rehmannia is a heavy, rich tasting root, used in the majority of formulations, old and new, for treating the kidney system. By combining the Golden Book Pill with herbs for invigorating the circulation of blood (e.g., salvia, red peony), one can begin to treat the renal hypertension. This type of disorder, which develops over a long period of time and is quite serious, must be treated for a long time in order to get some results. Even successful treatment with herbs may not be able to fully restore normal blood pressure, but it can help the individual lower the risks associated with constant very high blood pressure. Fortunately, gastrodia and amallaria have been found useful in treating renal hypertension as well as the vascular tension described above.

ANOTHER CARDIAC PROBLEM: THE COLD HEART A heart which is exhausted, like a locomotive engine which has gone cold, leaves the blood circulation to the forces of gravity and osmosis. Water leaks from the vessels and causes edema, especially swelling of the legs; moisture may penetrate the lungs, to cause difficult breathing (cardiac asthma). In response to this type of disorder, Chinese doctors try to fire-up the heart using herbs that are said to have a strong heating quality. One of the main ones for this purpose is aconite, which the Chinese call fuzi, referring to the fact that it is the branch root (the son, zi, of the main root) of the plant that is collected for this application. Aconite is extremely toxic in its raw state. Even two grams of the raw root can produce life-threatening reactions. Raw aconite is used extensively in China, mainly for treating arthritis pain, and it is the primary cause of side-effects and death from using orally ingested medicinal herbs in that country (serious side effects of herb use are relatively rare and are mostly the result of allergic reaction to herbs given by injection, but there are a few toxic materials employed which can be dangerous if used without adequate precaution). The active components, alkaloids of the aconitine series, can stop the breathing at moderate dosage. However, Chinese herbalists learned more than 2,000 years ago to process the root to make it essentially non-toxic. The processing, which includes soaking the herb in water or vinegar or other solution to remove some of the components, and cooking it in a broth of herbs to oxidize the remaining alkaloids, produces a safe and effective remedy. The processed aconite can be used in quantities of up to 12 grams (dry weight) per daily dose by oral ingestion. It is also used in some Chinese hospitals, by intravenous drip, to treat cardiac insufficiency. When making herbal formulas, aconite is often combined with ginger (the same material used today as a spice in cooking). The sun dried ginger root has a more warming impact on the body metabolism than the fresh ginger roots. Additional warming effects are obtained by using the bark of cinnamon, rich in the spicy cinnamaldehyde. These warming herbs, aconite, dry ginger, and cinnamon bark, are used to recapture, restore, and invigorate the fundamental energy of the body, called yang. This is one half of the duo of yin and yang, which is a critical concept underlying most of Chinese medical doctrine. In simplistic terms, the yang aspect of the body is the unbridled activity; while the yin aspect of the body is the cooling, calming, fluid counterbalance to the activity. As a model, if one considers an engine, the igniting fuel is the yang which provides the entire energy of movement; the lubricating oil and cooling water are the yin that prevent the engine from overheating and grinding to a halt. Both are necessary to keep going. With aging, the human body begins to lose some of its total yin and yang, which is the cause of lower overall activity of the individual organs and the body as a whole, and also the cause of the drying and withering of the body tissues and fluids. Depending on many factors, the yin or the yang may be relatively more depleted with age. The "cold heart" is an example of extreme depletion of yang. The herb mentioned in the previous section, rehmannia, is an example of one which nourishes the yin. The Golden Book Pill (also known as the Rehmannia Eight Formula) includes a high dose of rehmannia, with a small dose of cinnamon bark and aconite, which reinforce the yang. These three herbs together help to restore the depleted yin and yang. The formula is thus thought of as an antiaging prescription because it corrects the depletion of yin and yang that naturally occurs with aging and that is accelerated by various habits, by environmental influences, and by diseases. Cardiovascular diseases are an example of problems associated with aging. In fact, modern studies indicate that virtually everyone experiences cardiovascular disease if they live past the age of 50. In China, it is recommended that people who wish to live long and healthy lives undertake certain practices after the age of 50: this includes daily ingestion of Rehmannia Eight Formula or one of the many prescriptions that have a similar nature. Another formula for cold conditions is called Aconite Combination (it was formulated by the same physician who developed the Rehmannia Eight Formula). It is made of five herbs, three of them mentioned already in this article: aconite, ginseng, and peony; the other two herbs have the property of alleviating edema. There are many variants of this formula and each of them may be considered in the treatment of coronary insufficiency in persons who experience chilliness due to weakening of the yang.

OTHER CARDIOVASCULAR PROBLEMS It is beyond the scope of this article to deal with every cardiovascular disorder. Among the many problems that are medically encountered are irregularities in the heart rate (e.g., tachycardia and bradycardia), valvular problems (e.g., mitrial valve prolapse), blockage of the vessels in the legs (e.g., peripheral arterial occlusion, deep vein thrombosis), and Reynaud's syndrome (an autoimmune disease that causes very poor circulation to the fingers and toes). Each disorder is analyzed by a complete examination of symptoms and signs, and then treated according to the imbalance of yin and yang, the presence or absence of internal wind, by regulating the circulation of blood, and other procedures, most of them already described here.

HERBS COMMONLY USED IN TREATING CARDIOVASCULAR DISORDERS

Herbs That "Vitalize Blood Circulation": Salvia Persica Red peony Cnidium Carthamus Crataegus Herbs That "Tonify The Qi": Astragalus Ginseng Codonopsis Licorice Herbs That Clear The Accumulated "Phlegm-Mist": Musk Styrax Ox gallstone Acorus Borneol Polygala Herbs That Calm "Internal Wind" (Relieve Spasms): Uncaria Haliotis Armillaria Tortoise shell Earthworm Turtle shell Scorpion Oyster shell Centipede Dragon bone Gastrodia Herbs That "Warm The Yang" (Stimulate The Weak Heart): Aconite Dry ginger Cinnamon bark (or twig) Herbs That "Nourish The Yin": Rehmannia Ophiopogon

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CATARACTS Prevention and Treatment-with Reference to Chinese Medicine by Subhuti Dharmananda, Institute for Traditional Medicine, Portland, Oregon

Cataract is the term for clouding of the lens of the eye; if the cloudiness is sufficient to inhibit transmission of images to the retina, then vision is partly or fully obstructed. Mild cloudiness, the most common condition associated with cataracts, does not need surgical intervention for correction, but can often be compensated for by using corrective lenses; more severe cloudiness is usually treated by surgery, removing the original lens and replacing with an artificial lens. Cataract surgery is part of ancient medical arts; it was one of the earliest of surgical procedures, even in the Orient, traced back over 2,000 years. It is likely that the reliance on surgery had the effect of limiting efforts to develop non-surgical treatment methods; similarly, it is likely that non-surgical methods that had been tried were relatively unsatisfactory, making surgery seem an appropriate alternative. Therefore, when examining suggested non-surgical treatments, one should be careful about expectations for dramatic effects on vision. Further, when reviewing treatment options, cataracts should be differentiated from "nebulae" which are described as clouding the vision but refer to films that form on the surface of the eye (cornea). Cataracts occur most often in the elderly-sometimes referred to as senile cataracts which affect 25% of those over the age of 65. They are especially common in those with diabetes. Some drug therapies induce cataract formation. Nearly 1.5 million cataract surgeries are performed in the U.S. each year.

UNDERSTANDING THE CAUSE OF CATARACTS AND PROGRESSION OF CATARACTS The lens of the eye is a small oval structure consisting of a thin, clear capsule enveloping a fluid protein. The protein is clear and colorless at birth, but over the years it discolors and clouds gradually. It first yellows, then turns brown, and finally, cloudy. Often, it is not diagnosed until the fluid becomes so cloudy that it interferes with vision, but, in fact, the process is usually gradual (rapid development may be induced by elevation of blood sugar or use of some drugs). A cataract is not a growth, nor is it a film over the eye. Initially, the cataract changes the focusing power of the eye-by dispersing the light that passes through it-so that a change of corrective lenses can satisfactorily improve vision. However, clarity will gradually decline if the condition progresses so that vision becomes increasingly difficult despite the best possible corrective lenses; this is when surgery is recommended.

In a normal eye (left) the lens is clear, allowing light to focus properly on the retina. When a cataract occurs (right), the lens becomes clouded, causing light rays to scatter. The discoloration and clouding of the lens protein fluid arises from a number of processes. One is cross-linking of the proteins, which converts them to thicker, darker colored materials. Cross-linking of proteins is caused by exposure to UV light, by oxidative chemical reactions, and by addition of glucose to the proteins (glycosylation) that promotes cross-linking. Therefore, using good quality UV-blocking sunglasses to protect the eyes, having an antioxidant-rich diet (and avoiding smoking, which increases oxidation reactions), taking additional antioxidants, and keeping blood sugar well-regulated can all help slow the development of cataracts. Topical application of antioxidants has been tried in many countries as a means of preventing further development of cataracts and even reversing them; these methods are rarely used in the U.S. in routine ophthalmology care. In addition to protein cross-linking, breakdown of the normal proteins of the lens may also occur, especially if calcium levels in the lens increase (the cause of such change in calcium is not yet established). A calcium-activated protease can break down the proteins into smaller units, rearranging the protein matrix and scattering the incoming light. Enzyme inhibitors are considered potentially useful in preventing and treating cataracts: inhibitors of aldose reductase may slow cataract formation in diabetics by preventing glycosylation of the proteins and protease inhibitors may prevent the breakdown of the lens protein. Such inhibitors have been derived from herbs and developed as new drugs. As examples of herbs of potential use, salvia and licorice are potent inhibitors of aldose reductase; the flavonoids from pueraria and scute also serve this function (1). It is difficult to reverse the clouding of the lens that has already occurred, but there may be mechanisms within the lens that help restore the protein fluid so that if the destructive processes cease, some degree of improvement may occur. Efforts should be made to begin prevention measures early: as soon as cataracts can be detected (during routine eye exams) and even sooner where risk factors can be identified (high exposure to UV light; diabetes). The previously-mentioned preventive practices-sunglasses, good diet, not smoking, taking antioxidants, regulating blood sugar-should be standard for people over the age of 40. Wearing sunglasses to protect the eyes can also slow development of floaters; other therapies, such as relying on antioxidants, may similarly be useful for restraining formation of floaters, which also involve changes in the protein fluid (in the central portion of the eye ball; see: Floaters and their treatment with Chinese herbs). Below, some herb formulas will be mentioned as potentially helpful for preventing and treating cataracts; many of the ingredients are used in "anti-aging" formulations and could be taken regularly as part of a program of preventive health care that might help preserve vision.

RECENT CHINESE EXPERIENCE TREATING CATARACTS It is estimated (by Pro Ro Nata, Inc., a consulting firm) that traditional Chinese medicine products for eye disorders accounted for 41 million dollars (U.S.) of business in 2002, with 80% sold over the counter in pharmacies, the rest prescribed at hospitals and clinics. Cataracts are a major target of therapy, with 40% of the ophthalmic drug market (including non-TCM therapies). Unfortunately, little is known about the success rate for these treatments. Both internal and topical therapies are used.

CHINESE HERBAL RECOMMENDATIONS FOR CATARACTS In the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (2), there is a chapter on diseases of the lens. Three basic formulations (well-known traditional prescriptions) are recommended for senile cataract on the basis of differential diagnosis of syndromes, as follows (the number of grams used for a daily dose of decoction is indicated in parentheses after the common names of the herbs): Liver/Kidney Deficiency

Spleen Qi Deficiency

Qi Ju Dihuang Tang Rehmannia (24) Cornus (12) Dioscorea (12) Alisma (9) Hoelen (9) Moutan (9) Lycium (9) Chrysanthemum (9)

Yiqi Congming Tang Vitex (12) Phellodendron (9) Peony (9) Astragalus (6) Ginseng (6) Baked Licorice (3) Pueraria (3)

Yin Deficiency and Damp Heat Ganlu Yin Eriobotrya (24) Asparagus (12) Ophiopogon (12) Rehmannia (9) Rehmannia, raw (9) Dendrobium (9) Scute (9) Ching-hao (9) Licorice (6)

According to the text: "Medication [referring to these herb therapies] may be effective in the incipient stage [of cataract]; when there is notable opacity of the lens, medication will not work, and so surgical treatment should be considered." In the book Traditional Chinese Treatment for Senile Diseases (3), the etiology of cataracts is described as based in deficiency, leading to inadequate nourishment of the eyes. It is evident from the wording of the text that its contents are derived primarily from the same sources as that used for the above-mentioned Encyclopedia. The three formulas described above are listed (with slight variation on the dosage of individual ingredients), along with two other formulas for additional diagnostic categories: Liver/Kidney Yin Deficiency Buyin Bushen Tang Rehmannia (24) Black sesame (12) Cassia seed (12) Morus fruit (12) Lycium (12) Tang-kuei (10) Dioscorea (10) Alisma (10) Hoelen (10) Moutan (10) Schizandra (10)

Liver Deficiency and Spleen Damp Siwu Tang + Erchen Tang Rehmannia (18) Tang-kuei (10) Peony (10) Cnidium (10) Citrus (10) Pinellia (10) Plantago (10) Licorice (10)

Both texts also mention the use of eye drops, two items being listed are Phacolysin and Catalin. Catalin is a brand name for the drug pirenoxine sodium (see illustration and explanation below), which is probably the most widely-used eye drop for early stage cataracts, with more than 50 years of use and distribution in 40 countries. It is produced by 20 manufacturers in China; the brand Catalin is made in Japan. Phacolysin (also called Phacolin) is a complex anti-oxidant (see structure diagram left); it has been used both topically and internally as a therapy for eye disorders.

In addition to Pirenoxine eye drops, the main OTC cataract products in China include Zhangyanming Tablets (there are several of these, including Zhangyan Mingmu Pian, Neizhang Yanming Pian, etc.; they are tonics for kidney and liver with herbs for nourishing the eyes and promoting circulation) and Shihu Yeguang Wan (produced by many factories; the item entering the U.S. is called Dendrobium Night Sight Pills). These products are indicated for early and mid-stage cataracts, as well as for nebulae. In Japan, Rehmannia Eight Formula (Bawei Dihuang Wan, also called Jingui Shenqi Wan ) is recommended for treatment of several disorders of aging, including diabetes and cataracts. The modified version, Achyranthes, Plantago, and Rehmannia Formula (Rehmannia Eight Formula with achyranthes, niuxi, and plantago seed, cheqian, added, called Niu Che Shenqi Wan; in Japan, called Goshajinkigan) is especially used for complications of diabetes, such as diabetic neuropathy and cataracts. The formula appears to be effective for reducing corneal sensitivity in diabetes patients, indicating an influence on the eye (4).

A CASE OF SUCCESSFUL CATARACT TREATMENT IN A DIABETIC WOMAN In an article from Japan, published in the American Journal of Chinese Medicine (5), three physicians report on a successful case of cataract treatment with a traditional herb formula. This involved a 68-year-old woman with diabetes having a cataract in one eye. The cataract had been present for more than four years at the time of treatment with the herb formula. She was given Achyranthes, Plantago, and Rehmannia Formula. She had been taking Catalin eye drops and Tathion eye drops (glutathione eye drops, another antioxidant strategy), with only slight effect, but when she began taking the herb formula, her vision began to rapidly improve within 10 days, and continued to improve over three months of therapy. The affected eye then remained in improved condition thereafter, with continued use of the herbs (dried extract granules, 7.5 grams per day).

ILLUSTRATIONS OF TOPICAL PREPARATIONS FOR CATARACT Sample of pirenoxine eyedrops (a modified phenoxazine carboxylic acid, see structure diagram, right) for cataract; this is labeled Catalin (in Japan); it is also sold as Clarvisan, Clarvisor, and under other names; a Chinese version is called Baineiting.

N-acetylcarnosine, is an antioxidant provided as an eye drop; the pictured product is called Can-C; carnosine is also sold as Bright Eyes and NuEyes, and under other names. Carnosine is a dipeptide (alaninehistidine) researched mainly in Russia as a treatment for cataracts. In one study (6), it was claimed that after 6 months, 89% of all eyes treated with the drops had an improvement of glare sensitivity; 41% had improvement of the transmissivity of the lens, and 90% of the eyes showed improvement in visual acuity. The improvements were said to be retained during two years of follow-up with continued use of the eye drops. Carnosine may specifically inhibit glycosylation of the lens proteins.

A Swiss product called Quinax (dihydroazapentacen or azapentacene polysulfonate) is used as a treatment for cataracts. According to one research report from Poland (7): "An observation of (on average) 5 years duration showed that systematic application of the drug prevents the development of early senile cataract and distinctly slows down the progress of the condition in the group of patients without the risk factors. Non systematic application of the compound also slows down the progress of the condition in the group of early cataract. The drug was ineffective in patients with an advanced diabetic cataract."

REFERENCES 1. Zhang JQ and Zhou YP, Inhibition of aldose reductase from rat lens by some Chinese herbs and their components, Journal of Chinese Herb Drugs 1989; 14(9): 557-559, 576. 2. Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 17: Ophthalmology, 1994 Higher Education Press, Beijing. 3. Hou Jinglun and Geng Xiu'e (chief editors), Traditional Chinese Treatment for Senile Diseases, 1997 Academy Press, Beijing. 4. Yasunori Nagaki, et al., Effects of Goshajinkigan on corneal sensitivity, superficial punctate keratopathy and tear secretion in patients with insulin-dependent diabetes mellitus, American Journal of Chinese Medicine 2003; 31 (1): 103-109. 5. Yoshie Usuki, et al., Successful treatment of a senile diabetic woman with cataract with Goshajinkigan, American Journal of Chinese Medicine 1991; 19 (3-4): 259-263. 6. Babizhayev MA, et al., N-Acetylcarnosine, a natural histidine-containing dipeptide, as a potent ophthalmic drug in treatment of human cataracts, Peptides 2001; 22(6): 979-994. 7. Stankiewicz A, et al., Evaluation of the effectiveness of Quinax in the prevention of the development of senile cataract, Clinical Ophthalmology 1990; 92(3-4): 52-54.

January 2004

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Five Zone Acupuncture and Six Actions Herb Prescribing: Countering the Adverse Effects of Cancer Chemotherapy by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine (ITM), Portland, Oregon

Offering traditional Chinese medicine (TCM) as an adjunct to modern cancer therapies, with the primary aim of countering the adverse effects of those modern therapies and secondarily to improve long-term outcomes, represents a relatively new application of TCM. Experience with this medical specialty at one of the Institute for Traditional Medicine facilities was outlined in my 2013 report Adjunct Cancer Therapy at the Immune Enhancement Project (IEP) Clinic (1). In that document, which focused attention on the acupuncture aspect of the therapeutic program, I referred to the five zones method and here elaborate that approach to acupuncture point selection (part I). The main focus of the remainder of the current paper is introducing what I refer to as Six Actions Herb Prescribing, relaying experience gained in China and at the IEP Clinic in relation to design of herb formulations for cancer patients (part II)+.

I. Wǔqū Fāngfǎ (五区⽅法): Five Zones Method The five zones method reflects a practice of many acupuncturists that had not been formally described by acupuncturists. I presented this method, without giving it a name, in an article on mind/brain disorders produced in 2000 (2), saying: “In this article, the use of standard body acupuncture for mind and brain disorders is discussed. It will be seen that only a limited number of points, on just a few of the acupuncture channels, are repeatedly relied upon to treat a variety of these disorders. This may reflect the unique effectiveness of at least some of these acupuncture points which appear to be grouped around the head, forearms, and lower legs.” I then expanded upon these acupuncture treatment strategies in my book on treating shen [spirit] disorders (3), for which I mentioned this grouping of acupuncture points in both the acupuncture section and concluding remarks. I further pointed to this method in a brief update for the acupuncture section of that book published the following year (4), providing a more recent example of its use for treating depression in post-stroke patients. It was not until 2012 that I designated this point selection approach as the five zones method, having previously referred only to needling the “three parts of the body,” for which two parts have bilateral needling, hence, a total of five zones. The name for the method was publicly revealed in 2013 at the 25th Anniversary Pacific College Symposium. In giving this brief overview of the developments, I want to make clear that I did not devise the method I am describing, but reported on acupuncture point selections that were being widely used in modern TCM, and then gave a definition to the acupuncture formulations by noting the range of points utilized, and, finally, provided this designation. While the method has its greatest number of applications in treating mind/brain disorders, it is by no means limited to that area of therapy as will be described below. The five zones include the bilateral “transportation districts,” from elbow to hand and from knee to foot, that incorporate the five types of peripheral transportation (shu) points: jing, ying, shu, jing he, translated as: well, spring, stream, river, sea, representing the gradually enlarging flow through the channels. With Wuqu Fangfa, the points to be needled within these zones need not be only the transportation points, but should normally include at least one bilateral pair of the transportation points for arms and one pair for legs in the total point set, examples being forearm points shenmen (HT-7), waiguan (TB-5), hegu (LI-4), quchi (LI-11), and lower leg points yinlingquan (SP-9), taichong (LV-3), taixi (KI-3), zusanli (ST-36). The combination of hegu (LI-4) and taichong (LV-3), known as siguan (four gates), is commonly selected to calm psychological and physical distress; as another example, shenmen (HT-7), taixi (KI-3) and zusanli (ST-36) are often chosen in the treatment of organic brain disorders. With this method, points are also selected in the zone of head and back of the neck—the fifth zone—primarily along the centerline, the GV vessel ranging from dazhui (GV-14) through renzhong (GV-26; also called shuigou) and including the extra point yintang between GV-24 and GV-25. Starting at dazhui (GV-14), the back of the head points are selected for strengthening yang and for treating disorders that physically affect the brain. Reaching the top of the head, needling regulates the yang and alleviates disorders that affect the function of the brain, such as insomnia. Moving to the front of the head, treated points drain excess and calm agitation. Points along either side of the center line may be used additionally, such as sishencong (EX-HN-1), fengqi (GB-20), or anmian. The inclusion of centerline head points with the more commonly selected points at all the extremities (bilateral upper and lower limbs) produces effects that are notable; I have described the effects as a “stabilizing pattern.” In essence, the four peripheral transportation zones help the clear yang to ascend to the head and the head points of the fifth zone help the yang to return to the lower body, so that the mind is calm and focused and the body has a more firm and controlled foundation. Wuqu Fangfa does not preclude use of points at other locations of the body, but does require these five zones to be needled as a substantial portion of the treatment strategy. The most common additions for general use are the waist area points: at the front of the body from guanyuang (CV-4) to zhongwan (CV-12) and alongside this channel, such as tianshu (ST-25); and at the back from yaoyangguan (GV-3) to jizhong (GV-6), mainly relying on shu points of the adjacent bladder channel from dachangshu (BL-25) to pishu (BL-20), as well as points on the outer bladder channel of that region, such as zhishi (BL-52). When specific symptoms suggest use of points elsewhere, they are selected accordingly as secondary points. Ashi points and modern ear acupuncture points (which are not head points

of Wuqu) might make another addition, but attention to the five zones should not be lost. Because needling of these zones is often recommended by acupuncturists without making reference to the presence of a particular methodology as I am defining here, practitioners reading about the treatment of symptoms and diseases may not gain a valuable insight into this five zone strategy that can be purposefully employed. For example Dr. Li Zhang, trained at Beijing University of Chinese Medicine, described treatments for anxiety (5) with four syndrome categories using points that fit the Wuqu method. This table displays the recommended points, with head/neck, arm, and leg points separated into columns for easy visualization of the five zones. Pattern Heart/Spleen Deficiency Liver Qi Stagnation Affecting Spleen Kidney Qi Deficiency Lung Qi Deficiency

Head/Neck sishencong sishencong, yintang, taiyang sishencong, yintang, shengting sishencong, yintang

Arms shaohai, shenmen, daling waiguan, yemen chize, neiguan quchi, kongzui, lieque

Legs yinlingquan, fenglong, sanyinjiao yinlingquan, zusanli, ligou, taichong jiaoxin, taixi, shenmai, kunlun zusanli, xiajuxu, fenglong, neiting

Others danzhong, zhongwan, qihai qimen, xuehai, daimai guanyuan, zhongli yutang

The most frequent references to point selection consistent with the five zone method of therapy is to be found in the book Case Studies from the Medical Records of Leading Chinese Acupuncture Experts (6). Though the book was compiled in 2009 and published in 2011, it predominantly presents case reports from before the year 2000, some going back to the 1960s. The advisor for this book and the largest contributor of case studies to its collection is a leading acupuncture professor, one of China’s designated “great masters of TCM,” Cheng Xinnong (1921-present). Even more so than the others whose cases were offered, he used the five zones treatment pattern frequently and for a diverse array of disorders. Cheng is best known internationally for his book Chinese Acupuncture and Moxibustion (7) chosen in China and the west as a college text for acupuncture studies. He noted that for the use of distal points (emphasis added): “Among the points of the fourteen meridians, those located on the limbs, especially below the elbow and knee joints, are effective not only for local disorders but also for disorders of the remote zang-fu organs and tissues on the course of their pertaining meridians.” In the collection of case studies, it is noted that: “The head is the place where all the yang channels meet, and clean yang qi of the six fu organs and the essence of the five zang organs all flow upward to it.” The conceptual framework for the five zone method is essentially laid out in these two statements, but the parts needed to be joined together: peripheral points from elbow to fingers and from knees to toes, and the points in the region of the head and neck. From an examination of published acupuncture strategies that do not incorporate the five zones, such as those that dominate the extensive list of recommendations in Therapeutics of Acupuncture and Moxibustion (8), it is evident that the forearm and lower leg points are often selected, but head points not included. The deficiency in choosing head points was a concern expressed by the developers of scalp acupuncture (9), who focused on what were designated as shu points on the scalp, placing particular reliance on the “zone” of central line of the governing vessel and adjacent to it. Scalp acupuncture was often accompanied by needling shu points on the extremities, such as quchi (LI-11), hegu (LI-4), waiguan (TB-5), neiguan (PC-6), sanyinjiao (SP-6), and taichong (LV-3) for stroke patients. Needling the points of the governing channel removes obstruction in the flow of the yang qi and essence and thereby aids the return of these pure essences to the rest of the body, so that the head points will be important for treating symptoms that arise locally, such as headache, dizziness, facial paralysis, sinus congestion, and eye disorders, as well as for treating syndromes affecting the rest of the body, which may be due to dysfunctions of the brain (e.g., epilepsy, post-stroke, and restlessness) or because of disrupted circulation of qi, blood, and yang downward, as in acute lumbar pain due to invasion of wind. The situations that may call for use of Wuqu Fangfa can be contrasted to those where other methods would be more appropriate. Although the outline presented here represents broad generalizations, the division illustrates that Wuqu Fangfa has many applications but is not a likely first choice for other medical concerns: Indications for Five Zone Method

Other Methods Usually More Appropriate

Disorders affecting the head

Localized disorders, but not the head or along GV vessel

Dysfunctions, injuries, diseases of the brain

Disorders affecting primarily the fu organs

Emotional distress and mental imbalances

Disorders that do not disturb the mental activities

Peripheral nervous system dysfunction

Endocrine dysfunction

Disorders affecting several parts of the body

Disorders primarily affecting a single zang organ

Imbalances in yang qi circulation

Imbalances of yin essence

The “other methods” include simple needling with two or three points locally or, for more complex patterns,

leaving out one area of the five defined zones: for example, no points of the head/neck zone, or no forearm points, or no lower leg points; there will usually be more attention to torso points. In the case of adverse effects of chemotherapy and radiation, because these medical interventions affect several parts of the body, cause an imbalance of yang qi circulation (often affecting appetite and sleep as a result), are accompanied by emotional distress, adversely alter brain activity (the condition sometimes referred to as “chemo brain”) and sometimes the peripheral nervous system (neuropathy), the five zone method fits well for this application. For easy reference, I present here a summary of the five zones method as applies to the treatment of cancer patients at the IEP Clinic, relying on our foundational group of points, the new twenty needles and their associated points (1): New Twenty Needles Points: zusanli (ST-36) sanyinjiao (SP-6) taixi (KI-3) taichong (LV-3) hegu (LI-4) quchi (LI-11) neiguan (PC-6) baihui (GV-20) yintang (Ex-HN-3) qihai (CV-6) zhongwan (CV-12) tianshu (ST-25)

Lower Limbs Upper Limbs Head Torso Example of Five Zones Method

Common additions to the above set were the lower limb points yinlingquan (SP-9; substituted for SP-6 or added to it), zhaohai (KI-6; substituted for KI-3), qiuxu (GB-40); upper limb points shousanli (LI-10, frequent substitute for LI-11); shenmen (HT-7; substitute for PC-6 or added to it), lieque (LU-7), waiguan (TB-5); torso points jianjing (GB-21), danzhong (CV-17; also called shanzhong); and head/neck points shenting (GV-24; added to GV-20), fengchi (GB-20), and extra point anmian (near GB-20). In a few instances, two adjacent points on a meridian were needled at the same time, such as LI-10 and LI-11 or GB-20 and GB-21. For calming the disturbed spirit, some practitioners at IEP also add ear points.

II. Six Actions Herb Therapy Introduction to the Reasons for Changing Herbal Strategies The subject of counteracting adverse effects of cancer therapies with herbs has been approached by many Chinese physicians. The reason for offering this particular presentation about six actions is to raise the concern that the initial focal point for thinking about and addressing this problem may be inadequate, while remaining largely unchallenged. I am willing to make this suggestion because I have experienced other areas of Chinese medicine applied to modern medical concerns where the original way of analyzing the disorder relied too heavily on ancient concepts that were more suited to the experience with notably different disease conditions, even though symptoms were similar. There are instances where Chinese physicians have come to this same conclusion, so I am not treading upon entirely new territory. As an example, multiple sclerosis is a disease that was relatively rare in earlier centuries (appearing in the late 19th century) and virtually non-existent in China until quite recently. One of its common manifestations is a progressive difficulty with moving the legs and feet, which then causes withering of the leg muscles because they are less used. These signs of the disease turned attention of modern TCM doctors to the ancient literature, as is the common method of determining how to proceed from the traditional-style pathology and therapeutics to the modern case. They sought formerly encountered diseases that caused weakening of the muscles, particularly of the legs, with withering of the muscle mass, a condition known as weizheng (flaccidity syndrome). The texts, starting with the preferred reference point, the Neijing Suwen, depicted a heat syndrome that caused damage through one or more of a number of possible mechanisms. The dominant thought was that heat so damaged the yin that it could no longer sustain the flesh, and the muscles would wither. Treatment strategies for such conditions—restoring yin and cleansing deficiency heat that remained after the initiating disorder—had been developed in ancient times and were then suggested by modern practitioners of TCM for patients with MS (10) However, upon seeing numerous American MS patients at the IEP clinic, it became evident that neither a feverish disease nor other fire syndrome was associated with onset of MS, that yin deficiency was rarely seen as a predominant disease manifestation, and that yin nourishing herbs were of value but had only limited effect on the current status of the disability or its progression. By contrast, it was observed that stagnation syndromes were more prevalent. Along similar lines, a Chinese physician, Cheng Yongde, who saw many patients with ALS, considered that the application of ancient doctrines was steering treatment in the wrong direction, working with one of the traditional views of weizheng. I wrote about his considerations in an article on ALS (11): Cheng Yongde noted that in the past Chinese physicians mainly relied on the ancient doctrine of the

Niejing Suwen (ca. 100 A.D.) in treating diseases where the muscles atrophy. The basic approach they take when encountering a disease that causes the muscles to weaken and atrophy is to direct treatment at enhancing the function of the stomach/spleen system, rooted in the concept that the spleen governs the muscles. By treating the associated meridians (e.g., yangming meridian), the muscles would be nourished and invigorated. Cheng believes, instead, that ALS is due to a blockage of the governing vessel, leaving it unable to regulate the qi and blood flowing to the viscera; then, the limbs are not adequately nourished by the flow of qi and blood. Therefore, using acupuncture to unblock the governing vessel is the key to therapy. The lesson to be gained from these and other such examples is that when we encounter new disease conditions, the first analysis made through the process of applying standard TCM principles may need revision as experience and understanding of the new disorder grows; the determination serving as a starting point may represent only one aspect of the disease process, possibly not the central one Even if some success is attained initially, it may be only a partial result compared to what is potentially to be achieved. I chose these two examples because they represent cases where tonification therapies—to replenish damaged yin on the one hand, and to restore function of the spleen and its generation of qi and blood to nourish the muscles on the other—did not quite fit the patient presentations. In the case of countering the side-effects of chemotherapy and radiation, the early clinical work on this subject was done in China at a time when there were only a few chemotherapy drugs and when radiation beams were quite crudely applied (the beam was relatively wide and could only be approximately aimed at the internal mass). The effects of treatment were drastic and were also largely uncontrolled by any of the palliative medications that were available. Of particular note was the frequent occurrence of oral ulcerations and skin irritation from chemotherapy and substantial burning of the skin (and everything in the path) of the radiation beam. It is not surprising, then, that in an English language publication based on this early work (12) it was reported that “According to Traditional Chinese Medicine, radiation and chemotherapy are regarded as an extrinsic external stimulus which manifest in the form of heated toxin. It invades the body as an external evil damaging and destroying the normal physiology….” At the outset, each particular manifestation of this destructive effect was treated by modifications of well-known traditional formulas, thus, for example: a modified Xuanfuhua Daizheshi Tang (Inula and Hematite Combination) for treating nausea and vomiting; a modified Guipi Tang (Ginseng and Longan Combination) for low blood counts; or modified Baitouweng Tang (Pulsatilla Combination) for burning and inflammation affecting the bowels. However, not long afterward it was realized that one could address the fundamental impact of the medical treatments by relying on a basic formula suited to most patients that might then be modified if necessary to address the most severe manifestations in the individual. Such modification would either be attained by adding herbs for the specific concern or by providing a second formulation to address the condition. The dominant treatment method for countering side effects of cancer chemotherapy has been tonification, and this comes in response to the evident debility caused by the interventions and the apparent inability of some organs to function, such as the spleen (in relation to the digestive system disturbances) and the kidney (in relation to the blood system deficiencies). Defensive activity would be impaired (as revealed by serious infections) and the hair would fall out (indicating blood deficiency). Because of the interpretation that “heat toxin” damaged the yin and substantially weakened the spleen, nourishing yin (with moistening herbs like maimendong and herbs that benefit the hair, like nüzhenzi) and tonifying qi (with herbs that bolster weiqi, such as huangqi, and that protect spleen functions, with soothing herbs like qianshi and shanyao) became the prominent methods. By examining formulas that the modern TCM doctors were prescribing for their patients, certain herbs drew the attention of laboratory researchers. For example huangqi (astragalus) and nüzhenzi (ligustrum) were announced as being beneficial for cancer patients at a 1983 Chinese conference (MD Anderson Cancer Center in Houston cosponsored the Chinese conference and provide the site for research on these two herbs). A pair of related publications suggested that each of these herbs could have the effect of restoring immune functions in the patients, as illustrated by study of blood drawn from them and compared to that from a control group of non-cancer patients. While there is no doubt that cancer patients undergoing modern medical therapies suffer from deficiency syndromes, some of the modern drugs give less evidence of heat toxin and yin deficiency than was seen in the past. The circumstances surrounding cancer diagnosis and treatment as well as physiological effects of cancer treatment also point to the presence of stagnation syndromes, not just deficiency. The presence of stagnation was originally observed only in passing, for example that radiation and chemotherapy causes (12, emphasis added): “imbalance of yin and yang, obstruction of the circulation of qi and blood, disturbance of the function of the organs…” In one of the most extensive texts about providing herbal support for cancer patients undergoing chemotherapy (13), a section was devoted to the problem of blood stasis, indicating its importance. Nonetheless, little further commentary was provided throughout the rest of the book and the formulas routinely incorporated only one herb, jixueteng (millettia) that might have been classified as being used for this purpose. Therefore, the emphasis and aim of this article will be to make a broader analysis of the situation and suggest a more comprehensive way of treatment. Why Six Actions? Since ancient times, scholars of Chinese medicine have frequently presented their medical concepts, diagnostics, and therapeutics by enumeration of a small number of divisions: three essences, four diagnostic methods, five elements, six climatic factors, seven emotional factors, eight types of herbal therapy. When establishing these defined categories in order to concisely sum up the complexities of nature and of human health and disease and to provide an easy reference for memorization and description, subtle gradations—complex and intermediate conditions—could become lost. Such losses are particularly acute during a student’s study of these classifications, because a novice can easily accept the simplicity they convey as being not so much a useful tool for interchange of information and ideas, but a profound key to an absolute reality of nature. The important subtleties that are not immediately obvious from the classification systems can be brought back into the discussion, and especially so when describing multiple therapeutic actions of an individual herbs or particular circumstances that affect a patient. Still, it is necessary to

intentionally and sometimes laboriously pursue the actual complexities rather than taking the easier path of turning to the few restrictive categories. Otherwise the fallback route of black and white divisions will overshadow reality, clouding observations and limiting effective actions. When it comes to herbal therapies, the most fundamental influence driving the original development of its categories was—and remains—the concept of yin and yang. In the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (14), where the early history of Chinese medicine theories is being reviewed and brought forward to the modern times, it is noted that: In the final analysis, a disease is the result of a breakdown in the equilibrium of the body’s yin and yang….Thus, a cardinal principle of treatment is to reconcile the two aspects….just as Basic Questions says, “The yin and yang should be carefully observed and adjusted.” ….Since the theory of yin/yang underlies the differentiation of syndromes, all pathological changes may be summarized as disturbances of yin and yang. Any disorders of the exterior and interior, of descending and ascending of qi, all syndromes of heat and cold, excess and deficiency, any disharmony between the ying and wei systems, and all disturbances of the qi and blood, are expressions of the disharmony between yin and yang. Broadly speaking, the following treatment methods are used to balance yin and yang: relieving exterior syndromes and eliminating interior syndromes; sending up the lucid yang and bringing down wastes; clearing away the heat and warming the cold; reinforcing the deficient in deficiency syndromes and reducing the excess is excess syndromes; harmonizing the nutrient and defensive systems; and adjusting the qi and blood. This last listing of methods provides subdivisions of yin and yang that depict paired opposites of bodily conditions, such as deficiency and excess; cold and heat; internal causation and external causation of disorders; internal manifestation and external manifestation of symptoms and signs. This set of four pairs gave rise to the standard “eight methods [strategies] of therapy” used in herbalism. The eight features of an ailment to be addressed by herbs were elucidated by Gou Congshi in the Bencao Yanyi , published around 1119 A.D. He provided some fairly limiting category descriptions, which point to the general principles involved allowing for broader applications, writing that (15): There are eight important points in the treatment of illness...The first is deficiency, signified by the five signs: fine pulse, cold skin, shortness of breath, polyuria and diarrhea, low appetite for food and drink. The second is excess, this is signified by the five signs: full pulse, hot skin, bloated abdomen, urinary retention and constipation, depression. The third is cold, that is, cold in the internal organs [zangfu]. The fourth is heat, that is, heat in the internal organs. The fifth is superficial evil, signifying that the disease did not originate with a disturbance of the normal qi in the organs. The sixth is internal evil, that is, the illness did not arise from external causes. The seventh is interior; this signifies that the disease is not located in the body surface [skin and muscles]. The eighth is the exterior; this signifies that the illness is not located in the interior portion of the body [internal organs, bones]. And, the basic yin/yang division later yielded the three other pairs: “sending up the lucid yang and bringing down wastes; harmonizing the nutrient and defensive systems; and adjusting the qi and blood.” As the systematic application of herbology grew more complex over the subsequent centuries, the number of categories of treatment also grew so that in most modern listings of herbs the various medicinal materials are divided into about two dozen standard categories. In addition to the above mentioned categories there are such groupings as herbs to: resolve phlegm, sedate internal wind, open the orifices, sedate the spirit, and astringe discharge. The number six frequently has been used in Chinese medicine categorization, such as the six environmental influences, the six disease stages (of the Shanghan Lun), and the six pairs of zang and fu (with five sets corresponding to the five elements, and the fire element divided into two). It is not a matter of six being a magical number to which the medical scholars tried to fit many of their concepts, rather, it is a number of categories that is sufficiently large to account for many phenomena, yet small enough that the divisions can be remembered and worked with. As will become evident, the six actions herb therapy comprise about the largest number of therapeutic effects that can be utilized at once without formulations becoming diffuse and cumbersome. The “Six Actions Herb Prescribing” that is described here does not represent a proposal for a new categorization of the herb actions; rather, these are strategies selected as a particular subset of the roughly two dozen groupings routinely used in modern TCM. To incorporate the important herbs into these groups, some adjustments are made as to how a few of the herbs might be best categorized for the current purpose. As an example, chaihu (bupleurum) is categorized in modern Materia Medica with the herbs for resolving the surface (the cooling subgroup), but this herb is probably more often used in regulating the flow of qi—influencing the liver’s controlling mechanism and helping to raise clear qi—so it is placed in what follows with qi regulating herbs. The six actions chosen for inclusion here are contained within the yin/yang summary that was given in the Advanced Textbook (14) as quoted above, with a focus on “adjusting qi and blood.” The six actions come from expansion of the pairing of qi and blood, namely: qi and blood to be nourished; qi and blood to be circulated; clear qi to be raised up to the brain; and blood to be generated from marrow (the brain and marrow being two extensions of the kidney organ system). My selection of these therapeutic approaches was arrived at through recognition that the actions are both theoretically of benefit in countering the side effects of chemotherapy for cancer and they are being utilized frequently at the IEP Clinic because practitioners are seeing these as appropriate to the cancer patients. Experience at IEP is of potential value because the circumstances in China differed from those encountered here and the changes in modern medical treatment are progressing rapidly with new drugs, new drug delivery methods, and improved palliative care. In contrast to the continued reliance on tonification therapy relayed in modern literature, it is proposed here that all six action of herbs are likely of value in treating cancer patients and that most of them

should be combined into a single treatment, either within a single formulation, or through the combining of two or more base formulas. This article will focus attention on chemotherapy, but the principles of treatment for countering adverse effects of radiation therapy are quite similar. An Orientation to Chemotherapy The term chemotherapy could be applied to any drug; the term was originally utilized by the German chemist Paul Ehrlich when he was working on drugs to treat infections: he coined it for any use of chemicals (chemo-) given to treat disease (therapy). In the realm of cancer treatment, chemotherapy is most often used to describe drugs that directly inhibit the reproduction of cancer cells (e.g., 5-FU, taxol, platinum drugs), but it can also be used to depict other strategies, such as drugs that block estrogens from stimulating cancer cells (e.g. Tamoxifen, Aromatase Inhibitors), which typically involve a notably different (and often milder) set of adverse reactions. The subject of concern in this article is the former group of drugs that powerfully inhibit the metabolism and reproduction of cancer cells, often leading to cell death (apoptosis). A characteristic of their common side effect profiles is that they tend to also inhibit the metabolic activity and reproduction of other non-cancer cells, having particularly strong impact on rapidly reproducing cells. Chemotherapy drugs are selected, developed, and approved for use by virtue of their specificity for inhibiting cancer cells, yet none of the current widely used agents are sufficiently specific that they don’t produce to a lesser extent the same type of inhibitory impact on non-cancer cells. Inhibitory effects include bone marrow suppression, impaired turn-over of gastro-intestinal cells, and reduced mitochondrial activity. While active cancer cells (those that are reproducing) will die as a result of the treatment, with shrinking of tumor masses, non-cancer cells are more likely to be functionally inhibited but with relatively limited die-off, so that recovery of their functions can take place during the days after treatment is withdrawn. Sometimes adverse effects will persist, especially in the case of neurological damage to peripheral nerves, but for most patients the production of blood cells and intestinal cells returns to normal or near normal. TCM Interpretation of Chemotherapy Adverse Effects In the early development of Chinese medicine some herbs were suggested to have the capability to counteract toxicity of plant drugs, and I reviewed these in the introduction to the subject of countering side effects of modern drug therapies (16). The best known of the group is licorice, and there are two prominent sets of herb materials that are related to it: 1) those from the same family as licorice (Leguminosae) also used for this purpose, including shandougen (Sophora subprostrata), baibiandou (dolichos), dandouchi (soja; processed soybeans), and chixiaodou (phaseolus); and 2) very sweet tasting items, such as dazao (jujube) and fengmi (honey). Eating legumes (beans, Chinese: dou) as part of the diet for cancer patients is best for getting an adequate dose of these food-herbs for this counter-toxicity approach, rather than adding ingredients to already complex herb formulas, but shandougen, though attributed some sweet taste, is predominantly very bitter, so this ingredient or its concentrated extract, would be used in formulations that could be swallowed directly without tasting (e.g., tablet). The primary approach to chemotherapy adverse effects requires an analysis of the bodily imbalances that are to be rectified. From the TCM perspective, the ability of the body to regenerate day to day is primarily a function of the qi and blood and so the inhibition of cellular reproduction by chemotherapy points to imposed deficiencies of qi and blood. The Advanced Textbook (14) lists five functions of qi, designated as: promoting, warming, defensive, controlling, and activity. Qi and blood function as a pair, and in virtually all the ancient medical literature of China, the phrase “qi and blood” was the basis for what we today often simply depict as qi. The nature and role of blood in TCM is somewhat less clearly defined than qi, but one of the Neijing Suwen quotations is often utilized to give a sense of the function of blood: “When the liver receives blood, the vision is normal; when the feet receive blood, they are able to walk; when the palms receive blood, they are able to hold things; and when the fingers receive blood, they are able to grasp.” Once the first dose or two of chemotherapy works its way through the populations of existing cells to impact their activity and reproduction (about ten days), the physical changes come on very rapidly. From the first day of obvious symptoms, their severity increase day by day, either until a plateau is reached or some corrective measures are put in place, with palliative drugs, for example. This rapid change in the body’s ability to promote its replenishment, control its functions, and be active in transformation of food essences, with lethargy as one of the signs of the drug actions illustrates the impairment of qi and blood. The defensive action of qi is today interpreted in terms of immune responses, so herbs that tonify qi and herbs that are said to enhance immune responses may be gathered together under the same grouping. Below is presented a table of herbs that tonify qi, adding to the standard list eleuthero and gynostemma and medicinal mushrooms (a few of which are described in a separate table); additionally, two antitoxin herbs that were used in China as anticancer medicinals but are now often designated as functioning through immune enhancing activity are included in a separate table in this section.

Herbs that Tonify Qi Common Name, Pinyin, Sources

Additional Properties

Comments

Astragalus huangqi Astragalus membranaceus

increases and raises clear qi and yang, controls sweating

Frequently used for persons debilitated by disease with weakened immune functions, poor digestion, and spontaneous sweating.

Atractylodes baizhu Atractylodes macrocephala

dries dampness, harmonizes stomach and spleen

Especially used in cases of weakened digestion and diarrhea and for those who easily get infections.

Codonopsis dangshen Codonopsis pilosula

increases fluids

Frequently used as a substitute for ginseng; it lacks the yang invigorating action.

Eleuthero ciwujia Eleutherococcus senticosus

benefits kidney; warm

Developed as health product in Russia during 1970s, adopted by China for same use, as a ginseng-substitute.

Medicinal Mushroom*

benefits lungs, sweet

Ginseng renshen Panax ginseng

In modern times, these herbs are increasingly used for immune-enhancing properties.

tonifies kidney and lung, pacifies spirit, invigorates, raises yang

Useful in virtually all deficiency syndromes; especially used with spirit agitation.

Gynostemma jiaogulan Gynostemma pentaphyllum

benefits lung; cool

A Chinese folk remedy for lung diseases, popularized in the 1990s, after it was found to contain some active ingredients of ginseng.

Jujube dazao (or hongzao) Zizyphus jujuba

pacifies spirit, harmonizes actions of herbs, protects stomach

Used as an aid to reduce harshness, protect the stomach, and harmonize the action of ingredients.

Licorice gancao Glycyrrhiza uralensis

moistens lungs, harmonizes actions of herbs, counters toxicity

Often prepared by honey-frying to enhance tonic effects; used in small amounts in numerous formulas to harmonize ingredients.

*Examples of Mushrooms used to Boost Immune Functions Cordyceps dongchongxiacao Cordyceps sinensis

controls cough and dyspnea

Mainly used for chronic asthma associated with kidney deficiency; recently adopted as immune enhancing agent.

Coriolus yunzhi Coriolus versicolor

dispels moisture; warm

Developed as a source of immune-enhancing polysaccharides in Japan during 1970s, adopted by China for same purpose.

Ganoderma* lingzhi Ganoderma lucidum

nourishes all internal organs, removes toxin, vitalizes blood

Designated as a sedative, this herb is mainly used now for immune-enhancing and blood-circulating properties.

Anti-Toxin Herbs that Enhance Immune Functions Common Name, Pinyin, Sources

Additional or Dominant Properties

Comments

Oldenlandia baihuasheshecao Oldenlandia diffusa

antitumor effects

Modern applications are mainly for cancer patients; it is an herb of low toxicity with reputation for inhibiting tumor growth.

Scutellaria banzhilian Scutellaria barbata

antitumor effects

Modern applications of this herb are as an addition to oldenlandia in the treatment of tumors.

Herbs that Nourish Blood Tang-kuei danggui Angelica sinensis

vitalizes blood, moves qi, moistens intestines, regulates menstruation

This is the most widely used blood nourishing herb.

Lycium gouqizi Lycium barbarum

nourishes yin, aids vision, benefits marrow

Especially used for the combination of kidneyand liver-deficiency syndrome and for eye disorders.

Peony (white peony) baishao Paeonia alba

cools blood, vitalizes blood, astringes liver yin, alleviates spasms and pain

Peony is extensively used for a variety of applications; red peony (chishao) is used when blood vitalizing is the main concern.

Ho-shou-wu heshouwu Polygonum multiflorum

nourishes yin

Ho-shou-wu is mostly used when there is kidney and liver deficiency; it is almost always used in formulas for the hair.

Rehmannia shou dihuang Rehmannia glutinosa

nourishes yin, benefits marrow

Extensively used in cases of kidney deficiency, and almost always used when for kidney/liver deficiency.

Smoothing the Flow of Qi, Enlivening the Circulation of Blood Deficiency of qi will itself cause some disturbance in the flow of qi through the body. However, a substantial impact on the quality of qi circulation comes from emotional distress that is in this case associated with cancer diagnosis and response to the difficult experience of medical treatments that often become increasingly traumatic. In the book

Prevention and Treatment of Carcinoma with Traditional Chinese Medicine (17), it is noted that: The mental state of the patient plays an important role in the course of treatment….Generally speaking, cancer patients are in low spirits and full of worries….Vexation, hesitation, grief, fear, nervousness, depression and low spirit should be relieved so as to prevent poor appetite. While the author believed that the mental state of the patient would be addressed primarily by the actions and words of family, friends, and medical staff, these conditions persist to a certain extent and influence the body. As one major consequence, qi circulation can stagnate, thus worsening drug-induced fatigue, lowering appetite, and altering ability to make decisions. Further, while qi deficiency is a reasonable means of representing what happens to the person as a result of the chemotherapy impact on cellular activities, the transporting action of the spleen and the qi smoothing action of the liver are also inhibited by chemotherapy, so that there is a direct effect on qi circulation that requires attention. Both qi deficiency and disturbances in qi circulation impair the free flowing of blood, as does the decline in physical activity that results from fatigue. In the book Cancer Treatment with Fu Zheng Pei Ben Principle by Pan Mingji (13), Pan indicates that blood stasis is a problem even before cancer is diagnosed, before any treatment with surgery, chemotherapy, or radiation. He says: TCM believes the mechanism of cancer is related to blood stasis….The fact that cancer patients reveal a state of hyper-coagulation has been gradually accepted….90% of cancer cases reveal, by fingertip volume pulse wave and microcirculation of the nail fold, that arterial capillaries are spasmodic and narrow, with decreased or even missing capillary loops. Some may reveal blood corpuscle congestion and blood flow is intermittently interrupted. Tissue damage due to surgery or radiation therapy will cause more severe blood stasis in the affected area. With regard to chemotherapy, Pan notes that blood vitalizing herbs are important to the comprehensive treatment, including the long-term success of the medical therapies: Usually, the side effects of chemotherapy can be greatly ameliorated when coordinated with Fu Zheng Pei Ben prescriptions and [herbs] which activate blood circulation and relieve blood stasis, thereby also increasing the blood flowing in cancer tissue. It is very helpful when the concentration of chemicals, immune remedies, and immune lymphocytes increase in the cancer tissues, as the therapeutic effect is then also greatly increased. Along similar lines, it is thought that the impact of radiation therapy is improved by vitalizing blood circulation, because one of the mechanisms of radiation is to introduce high concentrations of reactive (ionized) oxygen to kill the cancer cells, such that if the cells are at the same time better able to get oxygen from the blood the effect will be enhanced. Additionally, quick access of immune substances from the blood will help kill the damaged cells and break them down. Pan referred to this in a later text (18), saying: The main function of this medicine [herbs for removing blood stasis] is to ameliorate damage to microcirculation and add to the flow of blood and oxygen in tumor tissue. It is desirable to bring the anticarcinogen [drug] into the tumor to help the chemotherapy drugs. One of the reasons why radiotherapy fails is the lack of oxygen in cancer cells. The medicine for removing blood stasis can increase the quantity of oxygen in cancer cell and heighten their sensitivity to radiation. Limited circulation reduces the ability of the severely damaged cancer cells to die, while good circulation may help the less damaged normal cells recover more quickly. The concern for improving circulation to tumor cells differs from efforts to halt tumor-stimulated growth of a circulatory system for a tumor mass, for which the drugs that inhibit the generation of new vessels (angiogenesis inhibitors) are directed. The tumor needs a blood supply to survive at all, but it is able to utilize a restricted one quite effectively and especially the restrictions prevent cancer treatments from having their full effects. Western practitioners of Chinese medicine raised the concern that activating blood circulation might promote metastasis of cancer cells. However, metastasis in many cancers is a normal process that is very difficult to alter, and the Chinese concept is that the primary cause for concern is not the temporary circulation of the cells, but the adherence of them to other tissues, an adherence that is needed to allow for new tumor growth. The herbs used for promoting blood circulation are understood to reduce this adherence and thus inhibit metastatic growths from occurring. While the formerly mentioned methods of tonify qi and nourishing blood are a good means of improving qi circulation, additional efforts may be needed. Below are some of the herbs classified as regulating qi, with a separated section to display the large number of ingredients that are various types of citrus fruits. It is important to note, however, that herbs in other categories may also regulate qi as a secondary property, such as chuanxiong (cnidium), so that one can formulate concisely by relying on those ingredients.

Herbs that Regulate Qi Common Name, Pinyin, Sources Areca seed binglangzi Areca catechu

Additional or Dominant Properties dispels moisture accumulation, breaks up accumulations

Comments Primarily used for abdominal swelling associated with water accumulation. Areca peel (dafupi) is sometimes used instead.

Bupleurum chaihu Bupleurum chinense

raises yang qi, resolves surface, cooling

Used for dredging qi from liver constraint; especially valued for disorders that combine internal syndromes with external syndromes.

Citrus Group (see separate table)

resolves phlegm-damp

Several members of the citrus family are used to regulate qi; they are grouped together in a table displaying some of their slight differences.

Cyperus xiangfuzi Cyperus rotundus

alleviates pain, regulates menstruation

Analgesic for headaches and abdominal pains and alleviates stagnation-caused menstrual irregularities; overcomes mild depression.

Lindera wuyao Lindera strychnifolia

alleviates pain, warms the kidney

Mainly used for lower abdominal pain associated with cold kidney; has properties similar to cinnamon twig (guizhi).

Melia chuanlianzi Melia toosendan

alleviates pain

Mainly used for pain in the chest and upper abdomen (liver area).

Saussurea muxiang Saussurea lappa or Jurinea souliei

alleviates pain, controls diarrhea, sedative

Used for mainly for abdominal disorders that include diarrhea.

Citrus Group of Qi Regulating Herbs Common Name, Pinyin, Sources

Additional or Dominant Properties

Comments

Chih-ko zhiqiao Citrus aurantium

resolves phlegm, disperses accumulations

Used for food stagnancy, epigastric aching, and lung congestion.

Chih-shih zhishi Citrus aurantium

purges gallbladder to produce mild laxative effect, clears heat and phlegm

Used for abdominal stagnation with constipation and for lung congestion.

Blue citrus qingpi Citrus reticulata

resolves phlegm

Mainly used for lung disorders with phlegm accumulation and for dispersing soft swellings.

Citrus chenpi Citrus noblis

strengthens spleen, dries moisture and phlegm

The most widely used qi-regulating herb; it is also used in treatment of most phlegm disorders, combined with pinellia.

Aurantium jupi Citrus reticulata

lowers up-rushing qi, relieves stagnation in the chest

Used for nausea, vomiting, hiccough, and coughing.

Fu-shou fushougan Citrus medica

alleviates pain, controls vomiting

Used for digestive distress with abdominal pain and distention.



The herbs that vitalize blood circulation are emphasized as important by TCM cancer specialists but often do not appear in the formulations, with the primary exception of jixueteng (millettia or spatholobus, see illustration below, the stem is used). This herb is chosen because of its dual use for nourishing and vitalizing blood circulation; it came into the cancer adjunct formulas early on and has been retained.



Herbs that VITALIZE BLOOD Common Name, Pinyin, Sources

Additional or Dominant Properties

Comments

Carthamus honghua Carthamus tinctorius

regulates menstruation, alleviates pain of injuries

Combined with persica in treatments of blood stasis causing pain.

Cnidium chuanxiong Ligusticum chuanxiong

dispels wind, regulates qi, controls pain, nourishes blood controls pain, regulates qi

It is the main herb used for headache pain; used in most formulas for qi and blood staganation and in many formulas for nourishing blood. Mainly used for abdominal pain syndromes, including menstrual pain.

Curcuma yujin Curcuma aromatica Millettia jixueteng Spatholobus suberectus

regulates qi, disperses accumulations

Myrrh moyao Commiphora sp.

controls pain, disperses swellings, promotes tissue regeneration controls pain, relaxes muscles, reduces bleeding

Mainly used in cases of qi and blood stagnation with accumulation, including treatment of phlegm masses and other lumps. Modern applications are mainly for anemia and promoting microcirculation; traditionally used for numbness of the legs in the elderly. Used mainly for injuries (along with frankincense, ruxiang) and for swellings, such as abscesses.

Corydalis yanhusuo Corydalis ambigua

Frankincense (or mastic) ruxiang Boswellia carterii Red peony chishao Paeonia obovata Persica taoren Prunus persica Salvia danshen Salvia miltiorrhiza

nourishes blood, alleviates numbness, relaxes tendons

clears heat, cools blood

Mainly used in treatment of injuries, usually combined with myrrh (moyao), considered useful for peripheral neuropathy. Especially used for blood stasis syndrome with blood heat.

moistens the intestines

Often used for abdominal blood stasis accompanied by constipation; combined with carthamus (honghua) for blood stasis disorders. cools blood, nourishes blood, Primarily used for cardiovascular disorders and for sedative liver fibrosis; also useful as a sedative.

Sparganium (or Scirpus) sanleng Sparganium stoloniferum

regulates qi, disperses mass

Vaccaria wangbuliuxing Vaccaria pramidata Zedoaria ezhu Curcuma zedoaria

regulates menstruation, disperses swelling regulates qi, disperses mass, benefits stomach functions

Mainly used for hard masses (blood stasis type), especially those in the abdomen; usually combined with Zedoaria (ezhu). Primarily used for swelling in the lower abdomen, particularly for women’s disorders. Mainly used for hard masses, in combination with Sparganium (sanleng); also for digestive disturbance with distention.

Raising Clear Qi and Yang Raising of clear qi primarily refers to extracting the nutritive essences from food and raising them to the upper body so that they can then be distributed (by lung and heart) to all the organs. Raising of the clear yang refers mainly to bringing both nutrients and yang qi to the head so that the brain and mind can function properly; the yang will then be distributed downward from the top of the body. However, the references to raising clear (“lucid”) qi and yang are not firmly distinguished and depending on the author and the emphasis placed on the different functions, these terms may be used interchangeably and so it is perhaps best to refer to them together as an entity. In the book Essentials of Chinese Medicine (19), there is this explanation of raising of the clear: This is a characteristic function of the spleen, and refers to both raising clear qi upward and stabilizing the internal organs in their original locations [i.e., counteracting prolapse]. Controlling the raising up of the Clear: Here, the “clear” means the nutrients that are extracted from drink and food, and raising the clear means propelling them upward and distributing them. After food and drink have been digested by the stomach, the spleen extracts the nutrients and, though its function of raising the clear, delivers them upward to the heart and lung, and thence to the entire body. If this function of the spleen is normal, all the internal viscera and tissues will obtain enough nutrients and function well. If it is abnormal, there may appear such symptoms as dizziness, blurred vision, and fatigue. If clear yang fails to ascend, the clear and the turbid may remain intermixed and sink downward. This may be manifested by such symptoms as spermatorrhea, vaginal discharge, abdominal distention, and diarrhea. The separation of clear and turbid is an important subdivision of the raising of the clear; “intermixing” of clear and turbid, when their separation is incomplete, can lead to a variety of abdominal problems and discharges from the lower body. In his essay, Heaven Above, Earth Below, Cheng Lok-Kwan provides this elucidation (20):

The distinction between clear yang and turbid yin is very important in Chinese medicine. Turbid means thick, or dense. Turbid does not mean dirty or bad. The head is heaven: it is the highest part of the body. It is the most yang part of the body, hence, it should be filled with clear yang. If it is, the brain and senses will function well. The person will be able to perceive the world and communicate clearly, and respond appropriately. If it is not, then we think either a blockage prevented the clear yang from rising, or that the body is unable to descend the turbid yin. Either way, the head is now filled with turbid yin. The senses will be clouded, the head will feel heavy, and the person will not be able to think or speak clearly. Here, the concept of raising clear yang is associated with bringing nourishment (which is as aspect of the qi) to the brain. For raising clear qi and yang, the primary principle is to strengthen the spleen, particularly with herbs that contribute an upward movement, so that huangqi (astragalus) and renshen (ginseng) are key items. However, to assure separation of clear and turbid, herbs that promote the digestive functions of the stomach are utilized: they help to generate a clear qi and to aid the downward movement to the “thick” digestive materials. Of greatest importance are shenqu (shen-chu), maiya (malt), and jineijin (gallus) and the aromatic herbs sharen (cardamom), muxiang (saussurea), and yizhiren (alpinia). To help make sure the channels of flow are clear and open, orifice opening herbs are used, such as shichangpu (acorus) and yuanzhi (polygala). As an adjunct to these different types of herbs, those that help filter excess dampness are utilized: they improve spleen function, aid the separation of clear and turbid, and promote fluid movement to the kidney system. The primary ingredients relied upon are baizhu (atractylodes) and fuling (hoelen). Some herbs were already described in the tables above.

Additional Herbs to Help Raising Clear Qi and Yang Common Name, Pinyin, Sources

Additional or Dominant Properties

Comments

Acorus shichangpu Acorus gramineus

sedative, warms meridians, invigorates digestion

This is the most widely used herb for orifice opening; it is included in many sedative formulas and has a mild action.

Alpinia yizhiren Alpinia oxyphylla

supplements spleen, strengthens stomach

Mainly used for abdominal pain due to cold; also for poor appetite; action is similar to cardamom (sharen).

Cardamom sharen Amomum villosum

alleviates stagnation of food

Alleviates stomach pain, loss of appetite, nausea, diarrhea, and fullness after eating.

Crataegus shanzha Crataegus pinnatifida

helps digestion of meat and fats, resolves phlegm

This herb has modern uses of promoting blood circulation; traditionally used to promote digestion of thick foods.

Gallus jineijin Chicken gizzard lining

controls diarrhea

This material is thought to help break down masses and is used in treatment of concretions (stones) and tumors.

Hoelen (or Poria) fuling Poria cocos

strengthens spleen, calms spirit

The most widely used herb for filtering fluids, it is very mild yet highly effective, especially in decoction form.

Malt maiya Hordeum vulgare

regulates qi

Used as a mild agent to harmonize liver and spleen, regulating the flow of qi while promoting the stomach’s digestive function.

Shen-chu shenqu Medicated wheat

strengthens spleen, controls diarrhea, resolves surface congestion

This is the most widely used digestive aid; it is also suited to treatment of acute ailments, such as summer heat syndrome.

Oryza guya Oryza sativa

harmonizes stomach and spleen, strengthens spleen

Sprouted rice is used as a tonic and also a stomach protectant when administering fire-purging herbs, such as gypsum (shigao).

resolves phlegm

Often selected for insomnia, poor memory, and confusion associated with “phlegm mist affecting the heart orifices.”

Polygala yuanzhi Polygala tenuifolia

Benefitting the Marrow One of the cell lines highly sensitive to the effects of chemotherapy and radiation are the stem cells that produce red and white blood cells and platelets (thrombocytes) located in the marrow. The decline in production of new blood cells is one of the major reasons for halting a chemotherapy sequence, because of increased susceptibility to infection (as a result of low WBC) and debilitating fatigue (result of low RBC). Some protection of the marrow function is attained by utilizing hormones that stimulate the production of blood cells (e.g., Epogen and Neupogen); it is anticipated that some protective action can be attained with herbs such as lurong (deer antler), shudi (rehmannia), and gouqizi) lycium fruit. While the marrow of Chinese medicine has this overlapping connection to the marrow we understand by modern medicine that produces these blood cell lines, the marrow of Chinese medicine also extends to the brain. Therefore, nourishing the marrow along with raising the pure qi and yang, is important in maintaining good cognitive function, memory, and mental focus, according to the Chinese medicine system. Some of the herbs for benefiting marrow were already included in descriptions of blood nourishing herbs.

Additional Herbs for Benefiting Marrow Common Name, Pinyin, Sources

Additional or Dominant Properties

Comments

Deer antler lurong Cervus nippon Cistanche roucongrong Cistanche salsa Cuscuta tusizi Cuscuta chinensis Dipsacus xuduan Dipsacus asper Morinda bajitian Morinda officinalis Psoralea buguzhi Psoralea corylifolia Tortoise shell guiban Chinemys reevesii Turtle Shell biejia Trionychidae species

nourishes blood, invigorates yang

Frequently used in cases of weakness with a combination of yin, yang, and blood deficiency; the gelatin nourishes blood.

moistens intestines

Mostly used for impotence and infertility; useful in cases of constipation due to abdominal cold and blood deficiency.

astringent, clears vision

Widely used in kidney-tonic formulas due to its mild nature. Used in eye formulas based on treating kidney/liver deficiency.

vitalizes blood

Mainly used in cases of wounds and bone fractures; also for female reproductive disorders.

dispels chill, invigorates yang

Mainly used when yang deficiency manifests in chilliness and cold-caused pain.

dispels chill, nourishes blood

Used in cases of coldness due to yang deficiency; also used in treating bone marrow deficiency.

lowers yang, cools blood, nourishes blood, stops bleeding

Frequently used for deficiency of yin and blood with yang agitation or bleeding, with modern use for aplastic anemia.

softens lumps, disperses accumulations

Used for abdominal masses; combined with tortoise shell (guiban) in treatment of yin and blood deficiency with sweating.

Providing the Herbal Formulations In China, the majority of the reported work done with cancer patients has been through administration of high dose decoctions. The decoction form allows for adjustment of ingredients according to patient presentation. This form also allows for a high level of active constituents, since a quantity of one to two cups of tea can maintain in soluble form the extractable content of about 100-200 grams of dried crude herbs. The decoctions are prepared for the patients when they are in hospital, and that service is often continued by the hospital pharmacy for out-patients. Many western patients (though certainly not all) reject the decoction form due to the lengthy cooking procedure, the smell of the herbs while being prepared, and the taste of the decoction when consumed. The use of dried decoctions to make “instant” teas removes these first two barriers, but usually imposes a significant cost, and few practitioners or patients realize that the conversion from 100-200 grams of dried herbs in decoctions corresponds to about 20-40 grams of dried decoctions (made as 5:1 extracts). By switching to culturally acceptable forms, such as pills, capsules, and tablets, the quantity of herb materials that can reasonably be ingested is greatly reduced, while the cost may remain relatively high. Some herbs are successfully used in their powdered form in somewhat modest quantity, and some extracts that can be put into pill form are more concentrated than the dried decoctions used to make tea. Therefore, with some careful design, herbal materials in these more acceptable forms may be utilized, but with the understanding that a significant number of “units” must be consumed to have the desired impact, that is, to have more than a placebo effect or greater than a barely perceptible outcome. Transitioning from Tonic Formulation The attempt to counteract the adverse effects of chemotherapy came to be known as Fu Zheng treatment, meaning to “support normality.” The concept was that adverse influences, whether those described in ancient times (often as evil qi, xieqi) or of modern times (such as side effects of powerful drugs) were resisted by the person’s normal qi, which could be strengthened by tonic herbs. Later, this basic concept was broadened to what Pan Mingji had described as Fu Zheng Pei Ben, where the latter term means to strengthen the root, referring to supplementing the depleted foundation of qi, blood, and essence (jing). In his 1988 book describing that approach (13), Pan presented a generalized prescription based on his clinical work with cancer patients undergoing chemotherapy which he dubbed Yiqi Buxue Jianpi Tang (yiqi is a term used to indicate strengthening the qi and raising the clear qi; buxue is to nourish the blood; and jianpi is to strengthen the spleen). His formula was a very high dose decoction as follows:

Yiqi Buxue Jianpi Tang Chinese Name huangqi dangshen baizhu fuling gancao shudi gouqizi heshouwu huangjing nüzhenzi beishashen maimendong

Common Name astragalus codonopsis atractylodes hoelen licorice rehmannia lycium ho-shou-wu polygonatum ligustrum glehnia ophiopogon

Dosage 15-30 15-18 12 12 4.5 15 12 12 10 15 10 10

Relevant Action tonify qi, strengthen spleen tonify qi, strengthen spleen tonify qi; strengthen spleen improve spleen function tonify qi; strengthen spleen nourish blood nourish blood nourish blood tonify qi nourish yin nourish yin nourish yin

jixueteng

millettia

24

nourish blood

qianshi shanyao

euryale dioscorea

12 12

strengthen spleen strengthen spleen

The decoction of about 200 grams of herbs could be further modified to address specific symptoms, mainly by adding more herbs, though some of the standard ingredients might be removed as well (he did not indicate which might be removed, but gave lists of potential additions). Dangshen (codonopsis) was being used as a substitute for renshen (ginseng). Although renshen was the preferred ingredient, this prescription was written at the time when the herb was mainly reserved for manufactured products and for export, not allowed for most hospital prescriptions. The effects of tonifying qi and strengthening the spleen, and of nourishing blood and yin are each supported by several herbs of Pan’s basic formula, but in light of the six herb actions, it is weak in the areas of circulating qi and blood, and only slightly directed at benefitting marrow. Use of this particular formulation in the west turned out to be problematic for a number of reasons, most of them described above in terms of the decoction form of the herbs. The instant tea (dried decoctions) that were available for use appeared more attractive, and formula selection came from Japan. In Japan, the practice of Chinese herbal medicine called Kampo, has been based on selecting formulas from a group of prescriptions that had been selected by experts in the early 1950s and then relied upon continuously since then. The problem of countering side effects of chemotherapy was raised in the 1980s, and the primary formula selected for that purpose was Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination). At that time, and until recently, the Kampo formulas were provided to the west mainly through Taiwan rather than Japan, and this particular formula was well-known. It tonifies qi and strengthens the spleen with the ingredients of Si Junzi Tang (Major Four Herbs Combination) and nourishes and vitalizes blood with the ingredients of Si Wu Tang (Tang-kuei Four Combination), and also aids the uplifting of clear qi with huangqi (astragalus). A number of its ingredients are considered important for enhancing immune functions, including renshen, huangqi, baizhu, and gancao. The formula is relatively weak in the areas of promoting circulation of qi (danggui and chuanxiong have some effect), and it is also deficient in nourishing the marrow. Chinese doctors also considered this formula for the same applications, but made various modifications to better suit their understanding of the needs. As an example (21), the base formula was modified by adding jixueteng (millettia), huangjing (polygonatum), gouqizi (lycium fruit), heshouwu (ho-shou-wu), shanzhuyu (cornus), lianzi (lotus seed), and shanyao (dioscorea), which primarily increased the tonification effects and more closely approximated Pan’s recommended formula; it was stronger in benefiting marrow than Shiquan Dabu Tang alone. Early Efforts at ITM At the end of the 1980s, as Pan’s Fu Zheng Pei Ben book became available, concerns regarding cancer therapies remained strongly focused on immunosuppression. This was a decade before approval of the drug neuopogen for helping stimulate production of white blood cells (WBC), when a break in the chemotherapy regimen was common; allowing for growth and metastasis of cancer cells, making them resistant to further treatment. An early effort at countering the immunosuppression was an ITM formula in tablet form designated Astragalus 10+ (Huang Qi Da Bu Pian). The name reflects a key ingredient for enhancing immune functions, and portrays the development of the formulation, which began in 1986 as “Astragalus Eight Herb Formula” was then expanded to Astragalus Ten Herb Formula, and finally to the twelve herb version (hence the “+”) first described in 1988. It includes the eight herbs that were subject of considerable research efforts following up on the “adaptogen” model, as mentioned above, and eventually adding others which were consistent with the concept of Fu Zheng Pei Ben therapy. Using renshen (ginseng) rather than dangshen (codonopsis), Astragalus 10+ includes ingredients of Pan Mingji’s prescription: (maimendong) ophiopogon, nüzhenzi (ligustrum), heshouwu (ho-shou-wu), baizhu (atractylodes), and huangqi (astragalus). It additionally provides the adaptogens ciwujia (eleuthero) and wuweizi (schizandra), and these other ingredients: lingzhi (ganoderma; reflecting the growing interest in medicinal mushrooms for cancer patients), roucongrong (cistanche; pursuing the idea of nourishing kidney yin and yang to enhance marrow function), and shangshen (morus fruit, which nourishes yin and blood while improving marrow, having a function similar to gouqizi). The formula can be properly described as a combination of tonic herbs, with principles of action being to tonify qi, raise clear qi and yang, nourish blood, and benefit marrow. In relation to six herb actions, the formulation is weak in the areas of regulating qi circulation and vitalizing blood (lingzhi was considered a blood vitalizing herb). The number of tablets to take was rather large to help approach a useful dosage, though one could not come close to the massive dosage of Pan’s decoctions. An effort to get a decoction format was also made. The concept behind it was to suggest turning to this form of administration for patients recently diagnosed and about to start or just starting chemotherapy, before the most severe symptoms had set in. The patient would have a chance to get used to making and drinking decoctions without the presence of nausea, and the result of using the formula would hopefully reduce the severity of the reactions, permitting continued use of the decoction for some time. The usual recommendation, provided in advance of offering the first batch of crude herbs, was to plan on using the decoctions for about three weeks then follow-up with tablets if desired. The crude herbs were provided in packets that were ready to cook as a tea, and labeled Astragalus/Oldenlandia Mixture. The intent of the formula was illustrated in the name, with astragalus already well-known for qi tonifying and immune enhancing effects and with baihuasheshecao (oldenlandia) being one of China’s “anticancer” herbs. This herb is almost always used in combination with banzhilian (scutellaria) for cancer patients, and its activity was increasingly attributed to immune-related functions rather than any direct inhibition of cancer cell growth. Given the concerns about development of chemotherapy induced nausea that could inhibit use of this form of the herbs, digestion-promoting, stomach-calming ingredients were included: yizhiren (alpinia), sharen (cardamom), and

shenqu (shen-chu). To help assure the continued distribution of “clear qi,” jiegeng (platycodon) was included to resolve phlegm and stagnation in the chest. The choice of yizhiren and sharen was made to also aid the circulation of qi, as these spicy agents would disperse stagnation. Further, based on the concept that qi and blood deficiency were early adverse effects of chemotherapy, huangqi in this formula was paired with the blood nourishing agents shudi (rehmannia) and biejia (turtle shell). Since qi and blood deficiency engendered impairment of blood circulation, jixueteng (millettia) and danshen (salvia) were also used. The combination of shudi and biejia for nourishing kidney yin with danshen and jiexueteng for microcirculation were expected to help protect bone marrow. This formulation was thus an early representation of the six actions approach that this article has described. A new tablet formula was then composed, to be one of the potential alternatives to Astragalus 10+, which made use of an herb gaining interest by Chinese physicians working with cancer patients: jiaogulan (gynostemma). This herb was not one of the mainline TCM ingredients, but was known from folk medicine. Researchers discovered that its active components were similar to, and in some cases the same as, those of ginseng. Based on traditional uses, it also has some of the properties attributed to jiegeng (platycodon). The following formula, called Gynostemma Tablets (Fu Zheng Kang Ai Pian), was made for patients with concern about low bone marrow function (22): jiaogulan Gynostemma huangqi Astragalus baizhu Atractylodes baihuasheshecao Oldenlandia gouqizi Lycium heshouwu Ho-shou-wu danggui Tang-kuei buguzhi Psoralea tusizi Cuscuta The emphasis is on tonifying qi and raising clear qi (huangqi, jiaogulan, baizhu) and nourishing blood and yin (danggui, heshouwu, gouqizi), but two herbs are included for benefiting marrow, buguzhi (psoralea) and tusizi (cuscuta), and these two were selected because they were being used in China for conditions of low production of blood cells, such as in cases of aplastic anemia as well as for leukopenia secondary to cancer chemotherapy. This formula returns to the focus on tonification therapy, but was intended to be combined with another formula, such as one for regulating qi and vitalizing blood, and this is because it lacks the other methods of therapy that have been identified as of importance for these cases. Further investigation of Chinese prescriptions for bone marrow deficiencies led to design of a second formula, called Millettia 9 (Ji Xue Teng Pian) that could be combined with one of the above combinations (Astragalus 10+ or Gynostemma Tablets or the Astragalus/Oldenlandia Decoction) providing an emphasis on blood vitalizing to restore microcirculation to the marrow (22): jixueteng danshen sangshen yejiaoteng huangqi chuanxiong shudi xuduan muxiang

Millettia Salvia Morus fruit Polygonum stem Astragalus Cnidium Rehmannia Dipsacus Saussurea

This formula is derived from blood-nourishing prescriptions described in Chinese medicine publications for bone marrow depression. As an example, if one combined Gynostemma Tablets with Millettia 9, the formula closely approximates Jixueteng Yijing Tang (23; Millettia Raise the Marrow Decoction), which likewise includes jixueteng, danshen, huangqi, and shudi from Millettia 9 and gouqizi, huangqi, heshouwu, buguzhi, tusizi, and danggui from Gynostemma Tablets, the only other ingredients in Jixueteng Yijing base formula are ejiao (gelatin), nüzhenzi (ligustrum), and hanliancao (eclipta). In these formulas, jixueteng (millettia) and danshen (salvia) are of particular interest because Chinese doctors consider these to have both vitalizing and nourishing properties, which is also true of chuanxiong (cnidium). Yejiaoteng (polygonum stem) is the stem of heshouwu, sharing in its blood nourishing properties. Muxiang regulates qi circulation, but also helps raise clear qi. Xuduan with shudi benefit both the yang and yin of the kidney to nourish marrow; xuduan (dipsacus) has the secondary effect of vitalizing blood circulation. A combination of Gynostemma Tablets and Millettia 9 will contribute to all six methods of therapy, with perhaps a weakness in the area of raising clear qi, though that is addressed with huangqi (astragalus) and baizhu (atractylodes); regulating qi circulation is also somewhat limited, accomplished in part with chuanxiong (cnidium) and primarily with muxiang (saussurea). Still, the Chinese concept that nourishing the blood of the liver allows it to better circulate qi definitely applies here, and there is considerable focus of these formulas in nourishing blood. This pair of formulas used together is one which practitioners at IEP have considered especially effective.

The difficulty encountered is delivering these six therapeutic methods with a relatively small number of herbs, so additional formulation work is underway. Normally, two to three herbs are to be employed for each therapeutic action, relying especially on herbs that provide more than one of those actions. Each of these two formulas has 9 herbs, and there are 17 different herbs (though heshouwu and yejiaoteng could be deemed a single herbal material, so 16); this is comparable to Pan’s base formula of 15 herbs. To consolidate multiple formulas into one concise prescription that incorporates all six herb actions is accomplished by selecting only those herbs that are most critical to the desired effects. A previous presentation of six actions herb prescribing came about by combining three TCM formulas for helping patients with multiple sclerosis and other autoimmune disorders. After successful treatment, or as a result of natural disease variations, when the patient is in a relatively stable condition, a formula can be utilized to help maintain that condition. In 1998, the formula called Remission Pills (San Fang Ding Ji Pian; San Fang refers to three formulas) was introduced by ITM for these cases. It involved the combination of Xiao Chaihu Tang (Minor Bupleurum Combination) to tonify qi, raise clear qi, and regulate qi circulation, Tao Hong Siwu Tang (Tang-kuei Four Combination with taoren and honghua) to nourish blood and vitalize blood, and Liuwei Dihuang Wan (Rehmannia Six Formula) to benefit kidney. Because of the different application, the sixth action did not focus as much on the marrow aspect of the kidney as would formulas for cancer patients. The formula has 18 ingredients. An investigation of herb prescribing at the IEP Clinic shows that certain formulations aside from the usual ones for counteracting adverse chemotherapy effects are used with some frequency. Some are given only once or intermittently for particular situations that arise, such as using a prescription for common cold or influenza or a combination suited for an acute injury. The most commonly used prescription for general use, often given for an extended time, is a tablet called Bupleurum 12 (Tiao He Pian; the name refers to its harmonizing intent). This is a “constitutional” formula that addresses general imbalances rather than a specific symptom or disease. Bupleurum 12 is especially useful for regulating qi and raising qi and yang, the two areas where a combination such as Gynostemma Tablets and Millettia 9 are somewhat weak. Although I do not advise combining three formulas at once to get the desired actions (but prefer to design alternative formulas that provide the desired therapeutic actions with fewer herbs), it is worthwhile to see how the herbs in these three frequently used formulas at IEP Clinic serve to address the six herb actions: Action Tonify qi Regulate qi Raise clear qi Nourish blood Vitalize blood Benefit marrow

Herbs with Primary Use in the Category huangqi, renshen, jiaogulan, gancao chaihu, zhishi, muxiang fuling, banxia, ganjiang danggui, baishao, shudi, heshouwu, gouqizi, sangshen, yejiaoteng jixueteng, danshen, chuanxiong, buguzhi, tusizi, xuduan

Herbs with Secondary Use baizhu danggui, chuanxiong huangqi, baizhu, renshen, chaihu jixueteng, danshen, chuanxiong xuduan, baishao, danggui shudi, goujizi

In working toward developing more concise formulations, a starting point is the key herbs that generate the desired actions. Some of the herbs described in this article are clearly central to the treatment strategy for aiding cancer patients suffering from side effects of their medical therapies, including huangqi (astragalus), jixueteng (millettia), shudi (rehmannia), baizhu (atractylodes), and danggui (tang-kuei). The other formula ingredients are best chosen to extend the properties of those herbs, and in this case, attention to marrow benefiting herbs is distinctly needed. Of the six herb actions, the regulation of qi has been the weakest aspect of this area of formula development and it is my hope that this deficiency will be recognized by the explanations provided here and rectified in the future. While some specific herbal combinations that are used at the IEP Clinic have been described here, the same approach can be utilized with other formulations, so these serve only as examples for explanation. Most importantly, the six herb action prescribing method provides a foundation for designing an effective treatment.

References 1. Dharmananda S, Adjunct Cancer Therapy at the Immune Enhancement Project (IEP) Clinic. 2013 Institute for Traditional Medicine, Portland, OR. 2. Dharmananda S, Acupuncture and Herbs for Mind/Brain Disorders (part I: Acupuncture). 2000 Institute for Traditional Medicine, Portland, OR. 3. Dharmananda S, Towards a Spirit at Peace. 2005 Institute for Traditional Medicine, Portland, OR. 4. Dharmananda S, Acupuncture for Shen Disorders Update, 2006 Institute for Traditional Medicine, Portland, OR. 5. Zhang L, Generalized Anxiety Disorder and Acupuncture Treatment. Acupuncture.com 2010: 8 (7). 6. Zhu B, Wang HC, Case Studies from the Medical Records of Leading Chinese Acupuncture Experts, 2010 Singing Dragon, Philadelphia, PA. 7. Cheng XN (chief editor), Chinese Acupuncture and Moxibustion. 1987 (revised 1999; third edition 2010) Foreign Languages Press, Beijing. 8. Xu XG (chief editor), Therapeutics of Acupuncture and Moxibustion (vol 6. of The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine). 1989 Higher Education Press, Beijing. 9. Dharmananda S and Vickers E, Synopsis of Scalp Acupuncture. 2000 Institute for Traditional Medicine, Portland, OR. 10. Dharmananda S, Chinese Herbal Treatment for Multiple Sclerosis and Other Flaccidity Syndromes, Including Myasthenia Gravis and Amyotrophic Lateral Sclerosis. 1996 Institute for Traditional Medicine, Portland, OR. 11. Dharmananda S, Treatment of ALS with Chinese Medicine. 2003 Institute for Traditional Medicine, Portland, OR. 12. Cheung CS, Kaw UA, Treatment of Toxic Effects Resulting from Radiation and Chemotherapy by Traditional Chinese Medicine. 1980 Traditional Chinese Medicine Publisher, San Francisco, CA. 13. Pan Mingji (compiler). Cancer Treatment with Fu Zheng Pei Ben Principle. 1987/1988 Fujian Science and Technology Publishing House, Fuzhou 14. State Administration of TCM and Pharmacy, Advanced Textbook of Traditional Chinese Medicine and Pharmacology (v. 1). 1991 New World Press. Beijing. 15. Dharmananda S, Enumerating the Methods of Therapy. 1997 Institute for Traditional Medicine, Portland, OR. 16. Dharmananda S, Counteracting the Side Effects of Modern Medical Therapies with Chinese Herbs. 1998 Institute for Traditional Medicine, Portland, OR. 17. Kun J. Prevention and Treatment of Carcinoma with Traditional Chinese Medicine. 1983/1985 Commercial Press, Hong Kong. 18. Pan Mingji (compiler). How to Discover Cancer through Self Examination. 1990 Fujian Science and Technology Publishing House, Fuzhou. 19. Liu L and Liu ZW, Essentials of Chinese Medicine (v 2). 2010 Springe-Verlag, London 20. Cheng LK, Heaven Above, Earth Below. 2011 http://lok-kwan.com/2011/08/21/heaven-above-earthbelow/ 21. Wang YR, Influence of Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination) on immune functions after radio- and chemotherapies in tumor patients. Hubei Journal of Traditional Chinese Medicine 1997; 19(5): 21–22. 22. Dharmananda S. A Bag of Pearls. 2004 Institute for Traditional Medicine, Portland, OR 23. Dharmananda S, Millettia (jixeuteng). 1999 Institute for Traditional Medicine, Portland, OR. February 2014



VIRAL MYOCARDITIS: Coxsackie Virus Infections by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Coxsackie refers to a collection of closely related viruses classified among the enteroviruses, namely those that cause infection after being taken in orally with contaminated food or water and then multiply in the intestines (entero = intestinal). The coxsackie viruses were named after the town Coxsackie, New York. A strain of this virus was discovered there during the investigation of an epidemic that occurred in 1948 alongside a polio epidemic (polio being another enterovirus). The coxsackie viruses are divided into two major subgroups, labeled A and B. There are 23 known coxsackie A viruses that usually cause only enteric diseases, and 6 known coxsackie B viruses, which are the ones of greatest concern because of their ability to cause serious diseases beyond the intestinal tract. Coxsackie B3 has been found to be one of the main causes of certain debilitating or life-threatening diseases, such as viral myocarditis. The coxsackie virus apparently produces few or no symptoms in most instances, but it can cause a commonly occurring intestinal disease, with abdominal distress and diarrhea. Even when symptomatic, the resulting disease is usually a relatively mild one, which might be referred to as "intestinal flu." It most often occurs in late summer or early autumn and is consistent with what the Chinese call "summer heat syndrome," which usually manifests as an intestinal disorder accompanied by muscle aches and/or headaches, and fever. Rarely, the coxsackie virus can cause a more severe disease. It has been suggested that most people experience coxsackie infections at some time, and they are particularly prevalent in infants and young children, and, to a lesser extent, adolescents, with first onset related largely to the hygienic conditions (lack thereof) in which the child lives. The disease symptoms appear between 2 and 10 days after exposure, and are gone within a few days, similar to the experience of the common cold or influenza, but with intestinal symptoms. It is thought that a partial immunity to coxsackie viruses develops in most children exposed to it, so that symptomatic disease is rare or even milder for adults. In some cases, however, the virus escapes the intestinal tract to cause serious disease. In children, coxsackie may go on to produce viral meningitis and it has been proposed, on the basis of epidemiological evidence, that coxsackie and other enteroviruses (such as ECHO) may be among the causes of childhood insulin-dependent diabetes. In adults, viral myocarditis and dilated cardiomyopathy can occur if the virus infects the heart muscle. Coxsackie B viruses are estimated to be responsible for at least 50% of the cases of infectioncaused heart diseases. For reasons yet unknown, the cardiac disease caused by this virus mainly occurs in middle-aged men, with onset occurring, on average, around age 42. The cardiac disease becomes apparent about two weeks after exposure to the virus. The early symptoms of the coxsackie-induced cardiac myopathy include some generalized viral symptoms-fever, fatigue, malaisewith the addition of chest pains. As the virus enters the heart cells, the immune system attacks and damages both infected and normal heart cells; the affected individual feels severe fatigue when there is significant impairment of heart function. In most cases, the disease is resolved spontaneously without any treatment, though some permanent heart damage may have occurred. But, in about 20% of the cases, there can be progressive disease or recurrence of symptoms; the heart damage can be extensive, causing arrhythmias, weakened left ventricular functions, and, in the worst cases, heart failure requiring heart transplantation. In these severe cases, cardiac disease progression persists after the virus is long gone: the immune system continues to damage the heart. Effective medical therapies have yet to be worked out for viral myocarditis; one approach is to administer anti-inflammatory or immunosuppressive drugs during the early stage of the disease to impair the immune attack and resulting inflammatory response that damages the heart. Patients are usually told to rest, as the damaged heart does not withstand the demands for vigorous activity.

CHINESE HERBAL THERAPIES AND OTHER MEASURES Coxsackie infections are recognized as health problems in modern China, contributing to the high rates of childhood intestinal disease, meningitis, and, for adults, myocarditis. These infections are the subject of some research into the potential value of Chinese herbs. The main strategies are to inhibit viruses with the heat clearing herbs, of which sophora root (kushen) appears to be the most promising agent, and to bolster the resistance to the disease and limit its damaging effects to the heart with qi tonics, for which astragalus (huangqi) and ginseng (renshen) appear particularly valuable. At the Shanghai Second Medical University (13, 15), it was reported that animal studies showed prolonged survival of mice with coxsackie-induced myocarditis when given sophora root. On that basis, the affiliated Renji Hospital began using sophora for treating this condition in humans (14, 19), using the injection form of the extract. It was claimed that coxsackie B virus RNA clearance (evaluated by PCR test) was dose dependent and that all 76 patients treated in the study group had relief of arrhythmia. Further, there were improvements in ejection fraction, stroke volume, cardiac output, and cardiac index, while left ventricular mass and its index were decreased significantly. The anti-coxsackie antibodies returned to normal titer after five months of therapy. Sophora has also been administered in the treatment of heart arrhythmias from various causes, so it may provide direct symptomatic relief, as well as its antiviral activity, in yielding the observed effects. A coordinating group for sophora research at the Beijing Medical University has reported on sophora's rapid effects for tachycardia (13). In a recent rat study at the Shanghai Second Medical University (2), sophora root was found to inhibit Coxsackie B3 replication in myocardial cells. The herb and its alkaloid components (matrine and oxymatrine) appear to have broad antiviral effects, with inhibition of hepatitis B in mice (20), hepatitis C both in vitro (16) and in clinical trials (17), and significant inhibition of respiratory syncytial virus in vitro (18). According to the book Antiviral Compounds from Plants (3), flavones may have an inhibitory effect on coxsackie viruses; in particular, a flavone isolated from Agastache rugosa (huoxiang) was said to be effective, though it needed to be used in very high dosage if given for systemic infection (e.g., cardiac infection) due to poor absorption from the intestines. Agastache is one of the key herbs for treating summer heat syndrome (especially in the formula Huoxiang Zhengqi San); the condition is sometimes referred to as "common cold in summer," though most cases are intestinal diseases that from contaminated food and water. Until recently, China had no refrigeration and limited food sterilization, leading to a high level of intestinal diseases during the warm months. Sophora also contains

flavone components, mainly isoflavones. One of the qi tonic herbs that has been researched for coxsackie-induced cardiomyopathy is astragalus. The work has been done by a team at the Shanghai Medical College and its associated hospitals. Studies with mice have suggested that astragalus protects the heart muscle (4, 5) and even inhibits the viral activity (6, 7). In one of the early mouse studies (8), the combination of the heart nutrients taurine (an amino acid) and coenzyme Q10 with the Chinese herb astragalus was said to reduce the mortality due to coxsackie B3 viral myocarditis. The active ingredients in astragalus include flavonoids and saponins. Clinical evaluations of astragalus-based therapies have also begun, but on a small scale. Kang Er Xin number 1 is a recipe used to treat viral myocarditis (9). It consists of lonicera, astragalus, and ophiopogon. The formula is designed to clear away heat and toxin, supplement qi, and nourish yin. A clinical study with 26 patients was carried out with this formula in a cross-over design using coenzyme Q10 as the control treatment, and monitoring left ventricular function. Treatment time was two weeks, with favorable results on heart function and its related symptoms in which the herb therapy was deemed superior to coenzyme Q10. An experimental study in support of the clinical trial showed that the formula inactivated coxsackie B3 in vitro, protected the heart cells in mice (preventing attack by coxsackie B3), and promoted interferon production. The cardiac formula Shengmai San, comprised of ginseng, schizandra, and ophiopogon, has been reported to be helpful in recovering heart function in patients with viral myocarditis and dilated cardiomyopathy (10, 11). Like sophora, ginseng is well known as a treatment for arrhythmia, but its active constituents differ: ginseng saponins are the effective component. A preparation for heart arrhythmia due to cardiomyopathy made at the Shanghai Penta Ocean Medical and Health Care Food Company is Fufang Sishenyin Chongji (Modified Formulation of Four Shen Drink in Granules) made with ginseng (renshen), salvia (danshen), adenophora (shashen), and sophora (kushen). The herbs are extracted and combined with sugar granules to make an instant tea, to be consumed three times per day. Salvia is frequently used in the treatment of cardiovascular diseases. Minor Bupleurum Combination (Xiao Chaihu Tang) has been evaluated in animal models of coxsackie-induced myocarditis (22, 23) with findings suggesting that the herbs regulate T-lymphocyte subsets and antibodies involved in the attack against the cardiac cells, speed clearance of the virus, and protect the heart. This formula includes ginseng, jujube, and bupleurum with saponin components, and scute with flavonoids; licorice contains both types of compounds. The formula is commonly used in treatment of viral hepatitis. Scute (Scutellaria baicalensis; see Figure 1) has been shown to inhibit influenza, HIV, and respiratory syncytial in vitro. The preparation Xinkang Shui (Heart Protecting Oral Liquid) was developed as a heart protectant that has been used for treating adriamycin cardiotoxicity (24). It has further been tested in laboratory animals for cardiac protection against both coxsackie B virus (25) and ischemic myocardial damage (26), and applied clinically for treating arrhythmias (27). The formula (not fully revealed) includes astragalus, ginseng and scute (in common with Minor Bupleurum Combination), raw rehmannia, and taraxacum.

SUGGESTED THERAPIES The development of clinical knowledge in this field is relatively limited; only tentative recommendations can be made. Of the herbs mentioned, sophora is the most studied as a broad spectrum anti-infection agent and antiarrhythmic that might be a reasonable component of therapy during the time when the virus is active. Scute (huangqin) may also be an additional useful antiviral. Astragalus and ginseng are valued as heart protective agents; they are widely used in China, and appear to have direct application to myocarditis based on pharmacology studies and limited clinical evaluations. Taurine and coenzyme Q10 are among the best known of the heart protective agents in the West, so their use could be recommended, especially in light of their negligible toxicity (in addition to taurine, the amino acid carnitine is a heart protectant). Preliminary tests show that taurine transport into heart cells is inhibited by coxsackie B3 infection (21).

THE ANTIVIRAL HERBS A brief summary of in vitro findings published in Modern Study and Application of Materia Medica (1), lists hu-chang, belamcanda, isatis leaf, loranthus, and osmunda (Osmunda japonica, a fern mainly used in Japanese cuisine) as effective agents for coxsackie virus. Of these, isatis and hu-chang are used extensively as antiviral agents. Isatis leaf (daqingye) is obtained primarily from Isatis indigotica (see Figure 2), but also from Polygonum tinctorium, and Baphicacanthus cusia, each of these herbs being from a different plant family. They all have in common the ingredients indican and indirubin. Isatis was shown to inhibit several viruses in vitro, including encephalitis B, mumps, and influenza. It has been used clinically in treatment of many epidemic disorders; measles, hepatitis, and herpes simplex, in addition to the three previously mentioned. Qingdai, an extract of the leaves of the same plants that are used or isatis leaf, contains 5-8% indigo. It is indicated for the treatment of various epidemic diseases, including those that cause chest pain (6). Hu-chang is obtained from Polygonum cuspidatum (see Figure 3), which contains a number of anthraquinones, such as emodin, physcion, and chrysophanol, and the stilbene derivative resveratrol (this compound is an ingredient in red grapes that is thought to be responsible for some of the health benefits of red wine). In vitro studies showed that the herb extract could inhibit several viruses including influenza, herpes simplex, adenovirus, polio, coxsackie A and B, EHCO, and encephalitis B. Isatis leaf, hu-chang, and sophora (for more information about the latter; see the START article: Sophora) are all used in the treatment of viral hepatitis in China; in addition, they are all used in formulas for treatment of sore throat due to various infections.

REFERENCES 1. Dong Zhilin and Yu Shufang, Modern Study and Application of Materia Medica, 1990 China Ocean Press, Beijing. 2. Chen SX, et al., Effect of Sophora flavescens on cultured beating myocardial cells of coxsackie B3 virus infected newborn rat, Chinese Journal of Infectious Diseases, 2000; 14(2): 137-140. 3. Hudson JB, Antiviral Compounds from Plants, 1990 CRC Press, Boca Raton, FL. 4. Rui T, et al., Effect of Astragalus membranaceus on electrophysiological activities of acute experimental coxsackie B3 viral myocarditis, Journal of Chinese Medical Science, 1993; 8(4): 203-206. 5. Rui T, Yang YZ, and Zhou TS, Effect of Astragalus membranaceus on electrophysiological activities of acute experimental coxsackie B3 viral myocarditis in mice, Chinese Journal of Integrated Traditional and Western Medicine 1994; 14(5): 292-

294. 6. Peng TQ, Yang YZ, and Kandolf R, Effect and mechanism of Astragalus membranaceus on coxsackie B3 virus RNA in mice, Chinese Journal of Integrated Traditional and Western Medicine 1994; 14(11): 664-666. 7. Peng T, Yang YZ, Riesemann H, Kandolf R, The inhibitory effect of Astragalus membranaceus on coxsackie B3 virus RNA replication, Journal of Chinese Medical Science, 1995; 10(3): 146-150. 8. Xiong D, Yang Y, and Su Y, Experimental study on treatment of myocarditis in mice by integrated traditional Chinese and Western medicine, Chinese Journal of Integrated Traditional and Western Medicine 1998; 18(8): 480-482. 9. Yan HJ, Clinical and experimental study of the effect of kang er xin-1 on viral myocarditis, Chinese Journal of Modern Developments 1991; 11(8): 468-70, 452. 10. Chen S, Chang P, and Wang C, Therapeutic effect of yupingfeng san and shengmai yin on coxsackie B viral myocarditis, Chinese Journal of Integrated Traditional and Western Medicine 1990; 10 (1):20-21. 11. Jiang Jian, Fang Jing, and Luo Decheng, Effects of shengmai yin on left ventricular performance and exercise tolerance in patients with dilated cardiomyopathy, Chinese Journal of Cardiology, 1988; 16(1): 65-67, 125. 12. Zhu Youping, Chinese Materia Medica: Chemistry, Pharmacology, and Applications, 1998 Harwood Academic Publishers, Amsterdam. 13. Niu Kuizhi, Pharmacology and clinical application of sophora flavescentis, International Journal of Oriental Medicine 1997; 22(1): 75-81. 14. Li D, Wang PQ, and Zhang NS, Research progress and clinical application of matrine type alkaloids, Chinese Traditional and Herbal Drugs, 1996; 27: 308. 15. Yuan WL, et al., Effect of astragalus membranaceus on electric activities of cultured rat beating heart cells infected with coxsackie B2 virus, Chinese Medical Journal 1990; 103(3): 177-182. 16. Chen Y, et al., The inhibitory effect of oxymatrine on hepatitis C virus in vitro, Chinese Journal of Liver Diseases 2001; 9 (supplement): 12-14. 17. Li Jiqiang, et al., A preliminary study on therapeutic effect of oxymatrine in treating patients with chronic hepatitis C, Chinese Journal of Integrated Traditional and Western Medicine, 1998; 18(4): 227-229. 18. Ma SC, et al., Antiviral Chinese medicinal herbs against respiratory syncytial virus, Journal of Ethnopharmacology, 2002; 79 (2): 205-211. 19. Chen SX, Mei SW, and Wang PQ, Therapeutic effect of kangke injection on viral myocarditis and its anticoxsackie virus mechanism, Chinese Journal of Integrated Traditional and Western Medicine 1997; 17(4); 207-209. 20. Xiao SC, et al., Inhibition of hepatitis B virus by oxymatrine in vivo, World Journal of Gastroenterology 2001; 7(1): 49-52. 21. Su Y, et al., Taurine influx in cultured rat cardiomyocytes and changes after CVB3 infection, Chinese Medicine Science Journal 1997; 12 (3): 159-163. 22. Wang X, et al., Minor Bupleurum Decoction in treatment of viral myocarditis models, Journal of Chinese Medicinal Herbs 1997; 22(11): 684-686. 23. Wang X, Liu F, and Wei K, Myocardial protection and immunoregulation of Minor Bupleurum Decoction and its decomposed preparations on coxsackie B3 viral myocarditis in mice, Chinese Journal of Integrated Traditional and Western Medicine 2000; 20(8): 599-602. 24. Lin Hongsheng and Xu Chengqiu, Therapeutic effects of xinkang oral liquid on cardiac toxicity caused by adriamycin, Journal of Traditional Chinese Medicine 1994; 35(12): 735-736. 25. Zhao H, Wan S, and Xu X, Experimental study of preventive effect of xinkang oral liquid on acute viral myocarditis in mice, Journal of Infectious and Toxic Diseases 2001; 15(2): 139-142. 26. He X, Cui J, and Li Y, Study on the protective effect of xinkang oral liquid on the isoproterenol-induced ischemic myocardial damage in rats, Chinese Herbs 2001; 24(10): 739-740. 27. Zhou Wenquan, Clinical and experimental research on xinkang oral liquid in treating arrhythmia, [complete journal citation unavailable].

March 2002

Figure 1: Scutellaria baicalensis.

Figure 2:Isatis indigotica.

Figure 3:Polygonum cuspidatum.

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TREATMENT OF INTERSTITIAL CYSTITIS WITH CHINESE MEDICINE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Interstitial cystitis (IC) appears to be a relatively new disorder. First reports of IC emerged during the early 20th century, but it did not become a subject of medical investigation until the number of cases markedly increased during the 1970s. IC is almost exclusively a disorder suffered by women, who are estimated to make up 90% or more of the total cases. The number of people affected by IC is unknown; it has been suggested that most cases still go undiagnosed, but there are about 100,000 diagnosed cases at any given time (precise statistics are not available), and it has been claimed that this may be only 20% of the actual cases. The median age of symptom onset is 40, with only 25% of patients under the age of 30, most of those in their late 20s. The nature of IC is not fully known. It is diagnosed tentatively by certain characteristic findings and by elimination of other disorders-mainly bacterial infections-from the list of possible alternative diagnostic categories (see Table 1). IC is suggested by reports of urinary bladder symptoms such as urinary urgency, frequency, and bladder pain, all of which can be caused by bladder infections, but urine tests show no evidence of infection or other obvious pathology, and antibiotics fail to resolve the symptoms. Further investigation by cytoscope (device for viewing the inside of the bladder, Figure 1) show only pinpoint submucosal hemorrhages (glomerulations) that become evident after distention of the bladder; there may be reduced bladder capacity, and there may be some ulceration (at one point, the disorder was distinguished as ulcerative or non-ulcerative IC, but this distinction is not deemed important). Pain symptoms are reported to worsen during menstruation. For most IC sufferers, the disorder may begin as an ordinary bladder infection, but it fails to resolve fully even after the usually-successful treatments for infections, and can progress in severity, so that the symptoms are extreme and debilitating (1,2). Table 1. Diagnostics for Interstitial Cystitis Diagnostic Component

Findings

Symptoms reported

urination urgency and frequency, pelvic pain, painful intercourse, flare-ups and remissions

Conditions often accompanying

migraine, vulvadynia, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome

Possible triggers for symptom exacerbation

dietary components (e.g., alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, high-acid foods, artificial sweeteners), allergens, sexual activity

Physical examination

bladder neck tenderness on bimanual examination

Cytoscope findings

Hunner's ulcerations or glomerulations (mainly seen with hydrodistention), scarring; rule out cancerous lesions and other diseases.

Urine tests

rule out bacterial infections; may find mast cells

Other tests to rule out alternative diagnosis

check for infections of the genitals or prostate; check for history of bladder damage due to radiation therapy or chemical agents (e.g., cyclophosphamide)

Figure 1: Cytoscope. Practitioners of Chinese medicine who receive patient reports of characteristic symptoms, triggers of exacerbation, and accompanying syndromes, should refer the patient to a urologist for confirming diagnosis by manual and cytoscope exams as well as blood tests (see Table 1). A particular characteristic of this disorder is pain that occurs as the bladder begins to fill, with significant alleviation on voiding; as a result of this pattern, IC suffers may void dozens of times in one day. A possible scenario for cause of IC is an autoimmune response that develops in susceptible individuals as a result of an earlier infection, perhaps by bacterial strains that have become more prevalent in recent decades. With this proposal, one imagines endothelial bladder cells-with altered membranes making them appear to the immune system as cells to be eliminated-are attacked, resulting in inflammation with degradation of the bladder mucosa. Alternatively, IC may be one localized manifestation of a systemic autoimmune disorder, one that started elsewhere in the body and which causes other pain syndromes. This scenario could apply, since many people with IC also suffer multiple pain syndromes, including other equally mysterious conditions, such as fibromyalgia or vulvadynia. The experience of flare-ups and remissions of the disorder that is often reported is consistent with experience of many autoimmune disorders.

However, in only some cases are mast cells, characteristic of autoimmune processes, found in the urine of people with IC, leaving the mechanism of the disease obscure. IC research has been hampered by the difficulty in defining the syndrome more precisely and by the difficulty of getting sufficient numbers of cases at one site where studies could then be conducted. Certain therapies are available, but it is difficult for urologists to offer a prognosis for their patients due to lack of sufficient data on responses. Instead, different approaches are tried to see if one appears to work. A therapy that has been in use for IC for 25 years is dimethyl sulfoxide (DMSO), an anti-inflammatory agent, that is instilled directly into the bladder. The first oral drug approved by the FDA (in 1996) for IC is pentosan polysulfate sodium (tradename: Elmiron). Its effects are limited; clinical trials showed a success rate in alleviating symptoms at 38%, and the duration of therapy until some symptom relief is noted may be as long as 2-4 months, while decrease of urinary frequency may require up to six months of therapy. Though its mechanism of action is unknown, it is thought that it slowly repairs the bladder mucosa. The drug has a low incidence of adverse effects, but it can rarely cause liver damage and has been known to cause reversible hair loss in some users. Due to their limited satisfactory treatment options, patients with IC often seek out alternative therapies to find relief from their syndrome and hope for a possible cure. Practitioners of Chinese medicine, confronted with this disorder will find that most Chinese texts refer only to syndromes corresponding to infections, passing of stones, and obstruction of urination (uroschesis). For example, most of the textbook descriptions involve discharge of blood with the urine, which is not characteristic of IC. Medical reports from China do not include IC as a specific target of treatment. Until recently, China has lacked the equipment, such as cytoscope, to make a diagnosis, and it remains unclear whether this disorder is at all common in China. This article briefly explores potential Chinese herbal therapies and acupuncture for IC.

BASIS FOR SELECTING HERB THERAPIES While Chinese medicine has a long history of application to numerous diseases, during recent decades, it has been applied to conditions never before experienced in its history. As examples, Chinese medicine has been applied to treating the side effects of modern cancer therapies, treating new diseases such as hepatitis C and HIV infection, and treating diseases that rarely occur in China, such as multiple sclerosis. The method for selecting herb therapies for conditions and diseases that are new or rare is to examine earlier therapies for diseases that have similar presentations, and to take into consideration modern diagnostic data in order to focus on certain therapeutic principles. In the case of IC, the symptoms of urinary urgency, urinary frequency, and bladder pain are not different from those of some other bladder disorders, such as urinary tract infections. Therefore, herbal formulas that have been successful for bladder infections are tried for IC. Unlike antibiotic therapies, which are known to have no impact on IC, the Chinese herb therapies may have therapeutic functions that differ from merely inhibiting the bacterial activity. Most of the herbs utilized for the bladder syndromes are aimed at alleviating a condition defined as "damp heat of the lower burner (jiao)." These herbs have the properties of clearing heat and draining or drying dampness. The herbs are selected for having a primary action on the genito-urinary system. The source of the damp heat may be local (as occurs when there are bacteria introduced into the bladder through the urethra) or secondary to heat of the heart (usually indicated by emotional distress) or small intestine (often suggested by abdominal distress after eating). The severity of pain, and its persistence, in IC indicates to Chinese doctors that a blood stasis syndrome is involved. Herbs that vitalize blood are frequently employed for lower abdominal pain syndromes and have been utilized for conditions such as uterine fibroids, endometriosis, and other causes of persisting abdominal pain. The herbs have the properties of invigorating circulation of blood and breaking down static blood. The cytoscopic finding of hemorrhagic spots is consistent with a Chinese syndrome of blood stasis. Hemorrhage is sometimes considered to be a sequel to blood stasis, following the concept that the blood must "move around" the static blood and may, thereby, escape the vessels. Hemorrhage is also considered a secondary effect of a heat syndrome, especially heat in the blood, but since the hemorrhagic spots are apparently due to distention and not spontaneously occurring, and since they do not lead to actual discharge of any significant amount of blood, this sign is not necessarily to be associated with heat. In fact, many patients with IC report experiencing a dominance of cold-type symptoms aside from the bladder problem itself. The finding of hemorrhagic spots may lead to incorporating into a formula one or more herbs that restrain bleeding, especially herbs that have a dual function of vitalizing blood and restraining bleeding (e.g., san-chi and typha). One cannot know if such considerations will result in successful therapy, but they can be a basis for applying traditional Chinese medicine principles and experience to the treatment of the new disorder. Informal reports of use of Chinese herbs to treat IC have been relayed by practitioners in America from time to time, and the formulas utilized tend to follow the therapies recommended in China for urinary tract infections.

HERBS OF POTENTIAL VALUE Chinese herb books that make reference to treatment of urinary bladder syndromes usually give special attention to a traditional formula of the Taiping Huimin Hejiju Fang (ca. 1100 A.D.): Bazheng San (Eight Herb Rectifying Powder). This formula treats painful urination due to damp heat of the lower burner. Unlike IC, the disorder that it was designed to treat involves other signs of heat syndromes, such as dark, turbid, and scanty urine, and accompanying heat signs, such as rapid pulse and yellow tongue coating, and other damp signs, such as slippery pulse and greasy tongue coating. Still, these differences are instructive, in that they help point to the more localized nature of IC, without the requirement of finding systemic heat and damp symptoms. When produced as a powder, equal proportions of the eight ingredients may be used: Bazheng San Plantago seed (cheqianzi) Dianthus (qumai) Polygonum (bianxu) Akebia (mutong) Talc (huashi) Gardenia (zhizi)

Rhubarb (dahuang) Licorice (gancao) The 8-herb powder is taken in doses of 6-9 grams each time, or it can be decocted first in somewhat higher dose and consumed as a drink. It is traditionally taken with 1.5-3.0 grams of juncus (dengxincao) . A few other herbs are included in similar formulations or sometimes simply added to this one, primarily pyrrosia (shiwei) and abutilon (dongkuizi); these herbs are particularly used when there are urinary stones, but not exclusively for that purpose. In some of the ancient formulas, mirabilitum (mangxiao) or pharbitis (qianniuzi) are used in place of rhubarb, where all serve a role of promoting a laxative effect to clear stagnation, accumulation, and heat in the lower warmer. Rhubarb can be fried with a little wheat flour to reduce its purgative effect while retaining its ability to vitalize blood circulation and clear damp heat. In Western practice of Chinese herbal medicine, special cautions have been raised about using akebia ( mutong), to avoid the commonly used species Aristolochia manshuriensis, and rely, instead of Akebia trifoliata, Akebia quinata, or Clematis armandi. For abdominal pain due to blood stasis, commonly used herbs include: pteropus (weilingzhi) with typha (puhuang), myrrh (moyao) with frankincense (ruxiang), and corydalis (yanhusuo). A therapy widely used for endometriosis includes succinum (amber; hupo) with rhubarb as a treatment for persistent abdominal pain (turtle shell is included in the formulations to resolve the endometrial cysts, which is not a concern with IC). In proposing any formulation for IC, reference to commonly used treatments is helpful, and herbs may be included or excluded based on their applicability to the specific presentation of IC compared to the disorders treated by the other herbs. The base remedy might be Bazheng San plus herbs for blood stasis, as mentioned above. Gardenia might be removed if there is no systemic heat syndrome (and knowing that there is no bladder infection); akebia might be replaced by pyrrosia and abutilon to avoid concerns about undesired herb substitution. A sample formulation would be: IC Formula Plantago seed (cheqianzi) Dianthus (qumai) Polygonum (bianxu) Pyrrosia (shiwei) Abutilon (dongkuizi) Talc (huashi) Rhubarb (dahuang) Licorice (gancao) Juncus (dengxincao) Pteropus (weilingzhi) Typha (puhuang) Myrrh (moyao) Frankincense (ruxiang) Corydalis (yanhusuo) These herbs could be provided in the form of decoction or dried decoction, with san-chi (sanqi; tien-chi ginseng) powder and succinum powder provided separately (these herbs are usually not decocted, and are instead given as powder or tableted powder). In total, there are 14 herbs in the decoction plus two herb powders, and the size of this formulation is not unlike those often given to patients with chronic diseases. The aim of the formula is to reduce inflammation, open the natural flow of urine, reduce pain, and aid healing. Its nature is very bitter and slightly cold (the cold herbs are plantago seed, dianthus, abutilon, talc, rhubarb, and juncus; polygonum, pyrrosia, licorice, myrrh, and typha are neutral; pteropus, frankincense, and corydalis are warm). A formula that has been presented for use in treating IC in the U.S. was developed by Ching-yao Shi about 10 years ago, based on combining gardenia and rhubarb of Bazhen San with kidney tonic herbs: rehmannia, dioscorea, hoelen, and cornus of Liuwei Dihuang Wa n (Rehmannia Six Formula) and curculigo, morinda, and anemarrhena of Erxian Tang (Two Immortals Decoction). The tea formulation is: Gardenia (zhizi) Rhubarb (dahuang) Rehmannia (shudi) Dioscorea (shanyao) Hoelen (fuling) Cornus (shanzhuyu) Cuscuta (tusizi) Curculigo (xianmao) Morinda (bajitian) Anemarrhena (zhimu) Her theoretical basis for the formulation, which is claimed to provide relief to many patients (significant improvement to just over half of them in an uncontrolled evaluation), is that IC occurs when the kidney qi is weak, hence the emphasis on kidney tonification therapy. The herbs gardenia, rehmannia, and cornus have iridoid glycosides as major active components; these have been shown to produce anti-inflammatory effects.

ACUPUNCTURE THERAPY Perhaps to a greater extent than with herbs, acupuncture therapy is not specific to the disease being treated but is suited to treating the manifestations, which may be similar for different diseases. Acupuncture is especially effective for prompt alleviation of acute symptoms of the disease. Training in acupuncture therapy includes learning of certain points that can treat pain in the lower abdomen, as well as selection of

meridians for therapy aimed at alleviating bladder disorders. Among the commonly recommended points are those on the urinary bladder channel and the governing (du; GV) and conception (ren; CV) channels, with emphasis on local points (those in the region of the bladder). Examples are CV-3 (zhongji), CV-4 (guanyuan), and CV-6 (qihai); GV-4 (mingmen); and BL points (running from BL-22 to BL-35 on the inner channel, and BL-51 to BL-54 on the outer channel). Distal points are utilized to regulate overall circulation of qi and blood to affect the bladder region; in particular, SP-9 (yinlingquan) is needled to promote free urination. In a study of acupuncture and moxibustion for female urethral syndrome (3), the authors indicated that the basis of the disease being treated was persistent urinary tract infection that was resistant to treatment by antibiotics. The symptoms included frequent urination, urgency, dysuria, abdominal distention and bearing-down pain. Cytoscopy did not reveal evident lesions. The condition is consistent with IC, but the patient group may also have included those with what is commonly called "overactive bladder" or "irritable bladder." The authors selected two groups of points: Group 1 (patient lying face up)

Group 2 (patient lying face down)

CV-6 (qihai)

GV-4 (mingmen)

CV-4 (guanyuan)

BL-23 (shenshu)

KI-12 (dahe)

BL-24 (qihaishu)

K-11 (henggu)

BL-22 (sanjiaoshu)

KI-3 (taixi)

BL-29 (zhonglushu)

ST-28 (shuidao)

BL-35 (huiyang)

SP-6 (sanyinjiao)

BL-39 (weiyang)

For patients with damp heat syndrome, SP-9 (yinlinguqan) and KI-8 (jiaoxin) could be added to either group. The points CV-6 and GV-4 were treated by acupuncture and moxibustion, the other points were treated by acupuncture only, using the tonification procedure for manipulating the needles at all points. For each treatment, points from one group would be selected, and then the other group, alternating point groups from one treatment to the next. Only 3-4 points would be treated each day, selected from the above groups. Long needles were used to treat BL-35 and BL-29 to get a needling sensation that would radiate to the lower abdomen and perineum. Moxibustion was performed by burning three cones on a medicinal herb cake through which the acupuncture needle was first inserted to reach the acupoint. Acupuncture was administered every other day, with ten treatments making a course of therapy, and patients were treated for one to two courses (hence, about 1-2 months total duration of treatment based on three treatments per week). The authors of the study claimed that for a group of 128 patients treated by acupuncture, just over 50% of the patients had remarkable improvement in the characteristic symptoms. On average, the frequency of urination (both day time and night time) was reduced by about half in the acupuncture group. A control group of 52 patients, who did not receive acupuncture, but did receive a low dose of an herbal patent medicine formula in tablets, displayed only minor improvements that were neither statistically or clinically significant. As part of the study, the researchers evaluated the urination flow rate, intrabladder pressure, and urethral pressure. They determined, based on the observations and measurements, that high urethral pressure was a feature of the disorder being treated in most of the women. The authors described their understanding of the syndrome and the effect of acupuncture: The cause of elevation of the urethreal pressure is not yet clear. Some specialists consider that elevation of the urethral pressure in patients with urethral syndrome may be related to the increase of excitability of pudendal nerves innervating the urethra and sympathetic nerves. This excitability of nerves induces spasm of the external sphincter of the urethra, the smooth muscle of the bladder neck, and pelvic floor muscles (also innervated by pudendal nerves), resulting in elevation of uretrhal pressure, increase of urethral resistance and disorder in urination. Based on the previous studies, it can be seen that the nerves under the acupoints chosen in this study all enter the spinal segments of L1 to L5, corresponding to nerves innervating the urethra. Hence, when stimulating these points by acupuncture and moxibustion, especially deep puncture of huiyang (BL-35) and zhonglushu (BL-29), the tip of the needle can reach directly the nerves nearby in the pelvic cavity, resulting in afferent impulses spreading to the urination center to inhibit related neurons excessively excited, relax the urethral sphincter and pelvic floor muscles, and lower the urethral resistance. In essence, the symptoms are alleviated because pressure in the bladder and urethra is reduced by an action of the acupuncture needles on blocking excessive nerve impulses. This specific mechanism may or may not be entirely relevant to IC. However, if the acupuncture treatment can adjust the nerve impulses to the bladder, it may be possible to alleviate some of the sense of urgency that occurs with small amounts of urine in the bladder and it may also reduce some of the inflammatory processes that occur in the bladder lining.

The two points of specific concern, BL-35 and BL-29, had been used previously by the authors to treat urinary disturbances that were complications of diabetes. These two points were also the focus of a recent article on their physiology, with examples of clinical applications of treating urethral syndrome, prostate pain, and sciatica (4). The author, Chen Yuelai, states (text edited slightly for clarity): Both huiyang and zhonglushu are acupoints of the bladder meridian of foot-taiyang located in the sacral region. These two points are often used in combination to treat urinary dysfunction, and their regulatory effects are very satisfactory. Huiyang can be detected at 0.5 cun lateral to the coccyx, which is the crossing spot of the bladder meridian and the d u meridian [governing vessel]. It functions to warm yang, promote diuresis, and improve the micturating function of the urinary bladder. Zhonglushu is 1.5 cun lateral to the du meridian at the level of the third posterior sacral foramen. It is used for regulating the lower jiao, strengthening the waist and kidney, and regulating the flow of qi to promote diuresis. Their stratified anatomy is: skin, subcutaneous tissue, greatest gluteal muscle [gluteus maximus]. The nerves distributed from shallow to deep in these point areas are the middle clunial nerve, inferior gluteal nerve, pelvic nerve, and branches of the pudendal nerve. Among them, the pelvic nerve plexus is distributed in the pelvic organs, such as the urinary bladder, urethra, prostate gland, womb, vagina, and rectum. During excitement or inhibition, the nerves will release corresponding transmitters and induce either contraction or relaxation of the smooth muscles of these organs. If there is a disturbance in contraction or relaxation due to diseases of the nerve itself or due to the impact of other factors, the functional disorders of the organs involved may occur. When there is functional disturbance of the nerves that control the smooth muscles of the urethra and urinary bladder, the functional disturbance of the sphincter muscle of the urethra and detrusor urinae [the muscle whose function is to expel the urine] may occur, resulting in frequent or urgent micturition, enuresis, and dysuria. The author then gives a case example of urethral syndrome that seems consistent with IC, though it may simply present similar symptoms. The woman, aged 38, had suffered from urinary urgency and frequent micturition for three years. This had started with a urinary tract infection that had improved after treatment of antibiotics, but then the symptoms returned and became more severe and persisted. The patient was treated with acupuncture, using huiyang and zhonglushu as main points along with BL-32 (ciliao), BL-33 (zhongliao), and BL-40 (weizhong). The needling method and its results were described as follows: In needling huiyang, oblique insertion of 3-4 cun was performed with the needle tip pointed toward the pubic symphysis, and in needling zhonglushu, oblique insertion of about 3 cun alongside the margin of the sacral bone was performed. The needling sensations were made to transit to the lower abdomen. Repeated lifting and thrusting were carried out to strengthen the needling sensation. After the arrival of qi, the manipulation of reinforcement was performed by twirling the needles. For the rest of the points, the needling depth was about 1.5 cun and the manipulation of reinforcement was also performed, with the needles retained for 20-30 minutes. The treatment was given once every other day and ten treatment sessions made up one therapeutic course. After two courses, the patients felt that her urgent and frequent micturition was remarkably improved and other symptoms were relieved greatly....Then, five more treatment sessions were given before all of the symptoms disappeared. A follow-up two months later found no relapse at all. Thus, a course of 25 treatments was used (during a period of about two months) to resolve this disorder. In a prior report, huiyang had been used as a single point for treatment of postpartum inhibited urination (5). This condition is due to prolonged compression of the perineal nerve by the head of the fetus. Since this nerve originates from the sacral nerve plexus under the huiyang point and innervates the urethra and sphincter of the bladder, needling of this point was usually able to restore normal urinary control. Such control over urination is not a significant focus for treating IC, as the problem of urgency and frequent micturition is likely the result of the irritation of the nerves within the bladder. However, the apparent ability of acupuncture therapy-at points affecting the nerves that enter the bladder and urethra-to resolve functional disorders suggests that this type of therapy may prove of benefit to sufferers of IC. Further, if the mechanism of action for acupuncture involves regulating the pelvic nerves that affect not only the bladder, but also the genitals, it is possible that these treatments will also alleviate accompanying symptoms of vulvadynia. A therapy developed in 1981 called sacral nerve root stimulation has been evaluated for treatment of interstitial cystitis (6, 7), and has been applied as a treatment for other lower abdominal disorders, including regulating bowel function and alleviating vulvadynia and vulvar vestibulitis (8), with positive results. There is likely a similarity in the effects of treating huiyang and zhonglushu by acupuncture and by this particular nerve stimulation technique, giving further support to the concept that regulating the nerves by physical stimulus can alleviate the disease symptoms.

REFERENCES 1. Metts JF, Interstitial cystitis: urgency and frequency syndrome, 2001 American Family Physician, 64: 1199-206, 1212-1214. 2. National Kidney and Urologic Diseases Clearing House, Interstitial cystitis, 2002 NIH Publication Number 02-3220, Bethesda, MD (http://www.niddk.nih.gov/health/urolog/pubs/cystitis/cystitis.htm). 3. Zheng Huitian, et al., Study on acupuncture and moxibustion therapy for female urethral syndrome, Journal of Traditional Chinese Medicine 1998; 18(2): 122-127. 4. Chen Yuelai, The anatomical physiology and clinical application of the points huiyang and zhonglushu, Journal of Traditional Chinese Medicine 2002; 22(3): 180-182. 5. Li Ling, Zhoug Jifang, and Shi Xipeng, 103 cases of postpartum uroschesis treated by acupuncture at huiyang point, Journal of Traditional Chinese Medicine 1996; 16(3): 198-200. 6. Maher CF, et al., Percutaneous sacral nerve root neuromodulation for intractabale interstitial cystitis, Journal of Urology 2001; 165(3): 884-886. 7. Comiter CV, Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study , Journal of Urology 2003; 169(4): 1369-1373. 8. Pettit PD, Thompson JR, and Chen AH, Sacral neuromodulation: new applications in the treatment of female pelvic floor dysfunction, Current Opinions in Obstetrics and Gynecology 2002; 14(5): 521-525.

May 2003

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DEGENERATIVE DISEASES Interpretation and Treatment with Chinese Medicine by Subhuti Dharmananda, Institute for Traditional Medicine, Portland, Oregon

The term "degenerative diseases" has been loosely applied to numerous severe health problems, but the primary medical use of this designation is for describing progressive diseases of the central nervous system-the brain and spinal cord. In the central nervous system (CNS), under ordinary circumstances, the nerve cells do not regenerate. These CNS neurons differ from most of the other cells of the body that break down and are then replaced. The central nerves also differ from peripheral nerves which, under usual circumstances, are able to regenerate when injured. Among the better known neurodegenerative diseases are Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS).

THE CENTRAL NERVOUS SYSTEM The spinal cord is the soft nerve material in the core of the hard spinal vertebrae, and this cord is seen by the traditional Chinese system as a type of "marrow." The kidneys, as the only organ near the base of the spinal column and located on either side of it, are understood to be the spine's origin, since all body components are depicted as derivatives of the viscera. Hence the spinal cord, and its blossoming into the complex brain at the top, is considered an outgrowth of the kidney likened to the marrow of the bones. The kidney system is the storehouse of the prenatal and postnatal essence (jing), the basis of the life gate, and the controller of the underlying fire and water (yang and yin) of the body, working as a regulator in harmony with the heart. The description we get from the traditional Chinese medical (TCM) system doesn't correlate readily with what is known about the body from modern medical investigations, which clearly distinguish the nature of bone marrow, nerves, and kidneys, but the Chinese description can be viewed a functional one that helps describe the nature of the body as a whole. The utility of the TCM depiction of the central nervous system depends on whether or not the remedies devised on the basis of that description actually help the patients. For us to know whether these remedies are helpful, we would ideally have viable clinical evidence. The type of evidence available to us is somewhat limited, mostly as a result of the poor quality of evaluations and reporting by the Chinese physicians rather than a lack of clinical experience treating such conditions. As a result, we are able to observe what the Chinese doctors do, while recognizing that the recommended therapies still need to be proven effective.

CAUSE OF DEGENERATION It is recognized in the Chinese medical system that degeneration occurs spontaneously to a certain extent with aging, and these agerelated changes then serve as a model for interpreting degeneration from other causes. Specifically, the prenatal essence has been "used up" through the aging process, while the ability to supply postnatal essence declines, partly because of weakening of the zangfu functions, most notably that of the stomach/spleen which is responsible for deriving the essential elements from foods to produce qi, blood, and essence. With aging, it is common to have a lower appetite, thus to eat less, and therefore to have less essence to store in the kidneys. Also, with aging, the mobility of the body slows, and that includes both the overall physical activity (e.g., ability to walk and get exercise) as well as the internal processes (ability to circulate qi, blood, and moisture). With this sluggish circulation, there can be accumulation of materials in the body, particularly static blood and phlegm (dried fluids), which further obstruct the circulation, damage the organ functions, and inhibit replenishment of the essence. All or some of these processes may be triggered earlier in life that they would appear otherwise by certain mechanisms, such as injuries, pathogenic organisms (e.g., viruses), and genetic disorders (in TCM: a derangement or short supply of the prenatal essence). Within the comprehensive Chinese system of interpreting disease causation are the climatic influences (e.g., cold, damp, wind, etc.), but these are mainly seen in modern Chinese work as triggers for initiating a disease or exacerbating a mild condition, while the other factors just described are considered the fundamental causes (i.e., deficiency and stagnation; the latter is considered a type of excess syndrome). According to the traditional Chinese understanding of aging, over time the yin essence of the kidney and liver declines, and this leads to the most common signs of old age, such as drying of body fluids, fragility of body structures, graying of the hair, wrinkling of the skin, loosening of the teeth, and withering of the flesh. The basic text of Chinese medical theory, Neijing Suwen (ca. 100 A.D.), says that "One who is over 40 years of age will have his yin half-reduced." In ancient descriptions of trembling of hands, shaking of the head, and stiffening of the muscles (characteristics of Parkinson's disease), it is mentioned that these symptoms are a manifestation of wind that arise from deficiency of yin and blood of the liver organ system. The Neijing says: "All kinds of wind and dizziness are associated with the liver; all kinds of sudden stiffness are associated with wind." In order for the blood and yin of the liver to be full (thus preventing internal wind from arising), the kidney essence must be adequate, since it serves as the primary source of the liver yin. The decline of both kidney and liver function has a common origin in the decline of yin during the aging process. Modern medical investigations of the central nervous system can often reveal the specific site of degeneration, and yield some details about the biochemical processes involved. In some instances, one or more contributing causative factors have been determined, but for most of the neurodegenerative diseases, it appears that there are multiple causative factors merging together to initiate or accelerate the disease process. The Chinese descriptions of the disease provide some suggestions for help through means available now, used for either preventing the disease or bringing it under control (especially if treated early enough). The modern medical descriptions may also provide some limited preventive strategies and a few drugs for alleviating the symptoms at the early stage, but they generally provide little satisfactory results at present, partly because any modern preventive or treatment strategy now under development must undergo extensive evaluation before a claim for efficacy is made. By contrast, with the traditional Chinese system, the strategy to be employed is based on the underlying theories rather than conclusive evidence.

TREATMENT STRATEGIES OVERVIEW Chinese medical treatments using herbal formulations for neurodegenerative disorders generally rely on four components: 1. Nourish the kidney as the primary means of nourishing the central nervous system that is suffering degeneration, helping it

to resist further deterioration. The approach is to treat kidney and marrow, and since most treatments for the kidney immediately benefit the liver (according to the Chinese doctrine), the nourishing herbs to be used are usually said to benefit the kidney/liver. Many of the symptoms of neurodegenerative diseases are understood as manifestations of internal wind, reflecting the deficiency of the liver system. The herbs may be said to nourish yin or strengthen yang, or do both, so long as the integrity of the yin is maintained. 2. Invigorate other organ systems, particularly stomach/spleen, to aid in nourishing the kidney; the heart system might be treated to help regulate the "ministerial fire" that influences kidney conditions. 3. Clear away existing accumulations and prevent further accumulation by promoting circulation of qi, blood, and moisture, with focus on the problems of blood stasis and accumulation of "phlegm-mist" obstructing the meridians. 4. Treat the symptomatic manifestation of the disease, such as alleviating wind to calm tremors. It is understood that when the kidney and liver are adequately nourished, the wind symptoms will be alleviated, but supplementing deficiency can be a long-term process and herbs that might immediately quell wind are used initially. Acupuncture therapies may be utilized to accomplish the same objectives as described here for the herb formulations; in addition, acupuncture may be applied locally (over the head or along the spine) in an effort to invigorate the affected part of the nervous system. Thus, points along the governing vessel and in close proximity on either side of it (e.g., Hua Tuo points and Bladder Meridian points), are often part of the treatment. Another aspect of acupuncture therapy is to treat the deficiencies and stagnation through body points that are particularly suited to those purposes (e.g., zusanli for deficiency and hegu for stagnation).

HERBAL THERAPIES Although numerous ingredients have been used by Chinese doctors to make the formulas given to patients with neurodegenerative diseases, in fact there are only about 50 ingredients that are routinely relied upon; these are outlined below as tonics, blood-vitalizing herbs, herbs for resolving phlegm and phlegm-mist, and herbs for calming internal wind. Some ingredients which are no longer available for use, because of concerns about toxicity or endangered species status of the sources, have not been included here.

Tonics Common Name, Pinyin, Sources

Relevant Primary and Secondary Properties

Astragalus huangqi Astragalus membranaceus

tonifies qi, increases and raises yang, benefits stomach/spleen

Frequently used for persons debilitated by disease with weakened immune functions, poor digestion, and spontaneous sweating.

Atractylodes baizhu Atractylodes macrocephala

tonifies qi, harmonizes stomach and spleen, dries damp

Especially used in cases of weakened digestion and diarrhea, but also for general debility.

Cistanche roucongrong Cistanche salsa

tonifies yang, nourishes blood and essence, moistens intestines

Considered a balanced yang tonic because of its moistening properties. Often used for impotence and infertility; useful in cases of constipation due to blood deficiency.

Codonopsis dangshen Codonopsis pilosula

tonifies qi, benefits spleen, increases fluids

Frequently used as a substitute for ginseng; it lacks the yang invigorating action but is less costly.

Cordyceps dongchongxiacao Cordyceps sinensis

tonifies yang, replenishes essence, controls cough and dyspnea

Mainly used for kidney deficiency or kidney/lung weakness; recently adopted as an immune enhancing agent.

Cornus shanzhuyu Cornus officinalis

nourishes liver and kidney, astringes essence

This is the most commonly used astringent for kidney tonic formulas; it also nourishes yin and blood and benefits the liver.

Cuscuta tusizi Cuscuta chinensis

tonifies yang, benefits yin, astringes essence, clears vision

Widely used in kidney-tonic formulas due to its mild nature. Used in vision formulas based on treating kidney/liver deficiency.

Deer antler lurong Cervus nippon

tonifies yang, nourishes blood, benefits marrow

Frequently used in cases of weakness with a combination of yin, yang, and blood deficiencies; the gelatin nourishes blood and yin.

Dioscorea shanyao Dioscorea batatas

tonifies qi, nourishes kidney, nourishes spleen yin

Commonly used for spleen deficiency with diarrhea and for kidney deficiency syndromes, especially those involving yin deficiency.

Dipsacus xuduan Dipsacus asper

tonifies yang, vitalizes blood

Used for yang deficiency with blood stasis due to aging; also a common remedy for bone weakness and injured bones.

Epimedium yinyanghuo Epimedium sagittatum

tonifies yang, dispels wind-damp

Especially used for hormonal disorders, including impotence and menopause; also for arthralgia affecting the lower body.

Comments

Eucommia duzhong Eucommia ulmoides

tonifies yang and benefits yin, strengthens muscles, tendons, and bones

Frequently used due to its mild nature, it is mainly employed for weakness and pain in the lower body; also lowers blood pressure.

Ginseng renshen Panax ginseng

tonifies qi, invigorates kidney and lung, pacifies spirit, invigorates yang

Useful in virtually all deficiency syndromes; especially used with spirit agitation. High doses are used to invigorate yang.

Ho-shou-wu heshouwu Polygonum multiflorum

nourishes blood and yin; used for essence deficiency and aging disorders

Ho-shou-wu is commonly used when there is combined kidney and liver deficiency; it is almost always used in formulas for the hair.

Hoelen (or Poria) fuling Poria cocos

strengthens spleen, dispels damp, calms spirit

Commonly combined with atractylodes and other qi tonics to improve stomach/spleen function and dissipate stagnant moisture.

Licorice gancao Glycyrrhiza uralensis

harmonizes actions of herbs, invigorates stomach/spleen functions

Processing (honey-fried; baked) is used to enhance its tonic effects; small amounts of licorice are said to harmonize ingredients.

Ligustrum Nuzhenzi Ligustrum lucidium

nourishes yin and blood; replenishes essence

Used for kidney/liver deficiency with dizziness, palpitation, and insomnia. Modern usage: immune enhancing effects.

Lycium (fruit) gouqizi Lycium barbarum

Especially used for the combination of kidneynourishes blood and yin, aids vision and liver-deficiency syndrome, for general essence deficiency, and for eye disorders.

Peony (or white peony) baishao Paeonia alba

nourishes, cools, and vitalizes Peony is extensively used for nourishing the blood, astringes liver yin, alleviates liver; red peony (chishao) is used when blood spasms vitalizing is the main concern.

Polygonatum huangjing Polygonatum sibiricum

tonifies qi, nourishes essence, moistens dryness

Used in some kidney-deficiency syndromes; considered to be like cooked rehmannia but with qi tonic rather than blood tonic effects.

Rehmannia (cooked) shudihuang Rehmannia glutinosa

nourishes blood and yin

Used for most cases of kidney deficiency. The related herb scrophularia is sometimes combined with rehmannia to reinforce the effects.

Tang-kuei danggui Angelica sinensis

nourishes blood, vitalizes blood, moistens intestines

This is the most widely used blood nourishing herb; it also invigorates circulation and helps prevent wind from invading the meridians.

nourishes yin and blood, lowers yang, cools blood, stops bleeding

Frequently used for deficiency of yin and blood with yang agitation or bleeding; the gelatin portion is sometimes isolated for this purpose. Used along with deer antler (or antler gelatin) to nourish essence.

Tortoise shell guiban Chinemys reevesii

Blood-Vitalizers Common Name, Pinyin, Sources

Relevant Primary and Secondary Properties

Comments

Achyranthes niuxi, huainiuxi Achyranthes bidentata

nourishes blood, vitalizes blood, dispels wind-damp

Used to harmonize with yang tonic herbs, such as eucommia to nourish kidney essence; a directing herb to move blood from upper to lower body. For blood stasis, cyathula (chuanniuxi) is sometimes used instead.

Carthamus honghua Carthamus tinctorius

vitalize blood, alleviates pain

Most often it is combined with persica in treatments of blood stasis, especially when the stasis is causing pain.

Cnidium chuanxiong Ligusticum chuanxiong

vitalizes and nourishes blood, It is used in most formulas for blood stasis and dispels wind, regulates qi, controls in many formulas for nourishing blood; it is pain especially used for headache and dizziness.

Corydalis yanhusuo Corydalis ambigua

vitalizes blood, regulates qi, controls pain

Curcuma yujin Curcuma aromatica

regulates qi, vitalizes blood Mainly used in cases of stagnation with disperses accumulations (especially accumulation, including treatment of phlegm phlegm) obstructing meridians or forming masses.

Millettia jixueteng Spatholobus suberectus

vitalizes and nourishes blood, alleviates numbness, relaxes tendons

Mainly used for abdominal pain, especially with peony and licorice to alleviate spastic pain, including pain in the limbs.

Modern applications are mainly for patients with anemia; traditionally used for numbness and spasm of the legs in the elderly.

Red peony chishao Paeonia obovata

vitalizes blood, cools blood

Especially used for blood stasis syndrome with blood heat, often combined with salvia and/or moutan.

Persica taoren Prunus persica

vitalizes blood, moistens the intestines

Often used for abdominal blood stasis accompanied by constipation; combined with carthamus for many blood stasis disorders.

Salvia danshen Salvia miltiorrhiza

vitalizes, cools, and nourishes blood, sedative

Primarily used for cardiovascular disorders and for liver fibrosis, but increasingly used for all blood stasis syndromes, especially those associated with aging, autoimmunity, and progressive diseases.

Sparganium (or Scirpus) sanleng Sparganium stoloniferum

vitalizes blood, regulates qi, disperses mass

Mainly used for hard masses (blood stasis type), especially those in the abdomen; usually combined with zedoaria.

Zedoaria ezhu Curcuma zedoaria

vitalizes blood, regulates qi, disperses mass, benefits stomach functions

Mainly used for hard masses, in combination with sparganium; also for digestive disturbance with distention.

Dispel Phlegm and Phlegm-Mist Common Name, Pinyin, Sources

Relevant Primary and Secondary Properties

Comments

Acorus shichangpu Acorus gramineus

A primary herb for resolving blockages of opens orifices blocked by phlegmmeridians and heart vessels; it is included in mist, sedative, warms meridians many sedative and brain tonic formulas.

Arisaema tiannanxing Arisaema consanguineum

resolves phlegm, disperses accumulations

This herb is most often used in cases of CNS disorders (e.g., mental disturbance, stroke, epilepsy) due to phlegm obstruction.

Bamboo zhuru Phyllostachys nigra

resolves phlegm, calms irritability

This herb is commonly used in treating mental disorders, particularly when there is a heat syndrome; also lowers uprising stomach qi.

Magnolia bark houpu Magnolia officinalis

resolves dampness and phlegm accumulation, disperses qi

Used in cases of abdominal distention, fullness in the chest, anxiety, neurosis, and depression; helps to rapidly dissipate damp

Pinellia banxia Pinellia ternata

resolves phlegm, lowers stomach qi, promotes digestion

The most commonly used phlegm dispelling herb, its mild nature allows it to be used freely in both warming and cooling formulas.

Calm Internal Wind Common Name, Pinyin, Sources

Relevant Primary and Secondary Properties

Antelope horn lingyangjiao Saiga tatarica

calms wind, calms fright, cleans toxin

It is often used as a substitute for the rare rhino horn; sometimes used as an antipyretic for viral infections; turtle shell may be used as substitute.

Centipede wugong Scolopendra subspinipes

calms wind, removes toxin

Mainly used for convulsions and spasms, usually along with scorpion. It functions as an inhibitor of excess neurological activity.

Earthworm dilong Pheretima asiatica

calms wind, clears meridians, clears heat

Earthworm is said to open blockages in the meridians; it is used in cases of phlegm-mist obstruction.

Gastrodia tianma Gastrodia elata

calms wind, analgesic

Used for headaches, hypertension, brain disorders, and spasms; gastrodia mushroom, having the same properties, is a substitute.

Scorpion quanxie Bruthus martensi

calms wind, controls pain, disperses accumulations

Mainly used for convulsions and spasms, usually combined with centipede; it is especially used when there is pain.

Silkworm baijiangcan Bombyx mori

calms wind, resolves phlegm, disperses accumulations

It is used for wind-phlegm disorder, with tonic paralysis or convulsion. A fungus infecting the silkworm is the active component.

Uncaria gouteng Uncaria rhynchophylla

clams wind, clears heat

This herb is used in remedies for epilepsy, convulsions, and hypertension; may also be used for calming nervousness.

Comments

EXAMPLE OF COMPREHENSIVE ANALYSIS: PARKINSON'S DISEASE The disorder that was to become known as Parkinson's disease was first described as shaking palsy in 1817 by a London physician named James Parkinson. It is now known to involve progressive degeneration of neurons in a region of the brain that controls movement. This degeneration creates a shortage of dopamine, which is the immediate cause of the movement dysfunctions that characterize the disease: administration of l-dopa (a precursor to dopamine, which is converted in brain cells to dopamine) has considerable beneficial effects in many patients with Parkinson's disease (the Ayurvedic herb, Mucuna pruriens, is a natural source of ldopa and has also been used to treat the disease). In most cases, the first symptom of Parkinson's disease is tremor (trembling or shaking) of a limb, especially when the body is at rest (reminiscent of restless legs syndrome). The tremor often begins on one side of the body, frequently in one hand. As the disease progresses, both sides of the body may be involved and shaking of the head may also occur. Other common symptoms include slow movement, difficulty in initiating movement, rigid limbs, a shuffling gait, a stooped posture, and reduced facial expressions. In about a third of the cases, the disease also causes or is associated with depression, personality changes, dementia, sleep disturbances, speech impairments, and/or sexual difficulties. Parkinson's disease is associated with aging: it affects about 6% of those over the age of 65 (average age of onset is about 60), affecting more men than women. Causes of Parkinson's disease are not fully known, but there are genetic factors involved in susceptibility and there may be contributions from a variety of habitual activities. Coffee consumption, for example, appears to help protect against getting this disease. There is no known cure for Parkinson's disease. Many patients are only mildly affected and need no treatment for several years after the initial diagnosis. When symptoms grow severe, doctors usually prescribe levodopa (l-dopa), which helps replenish the brain's dopamine. Sometimes doctors prescribe other drugs that affect dopamine levels in the brain (e.g., drugs that inhibit the breakdown of dopamine). In patients who are very severely affected, surgery and various experimental procedures may be attempted. None of the current therapies have long-term success.

CHINESE MEDICINE The characteristic symptoms of Parkinson's have appeared in ancient Chinese medical texts, which described a syndrome of trembling of the hands and shaking of the head. The disorder and its basis has been subjected to considerable analysis over the centuries. Syndromes in which elderly patients suffer from spontaneous shaking, or from other muscular manifestations of disease, such as paralysis or tonic spasm, are thought to be the result of yin deficiency of the kidney and liver leading to generation of "internal wind." Genetic propensity to suffer from Parkinson's disease corresponds to inherited defects in the kidney essence. Susceptibility of the liver to deficiency and generation of wind may occur as the result of diseases that damage the liver, from excessive use of alcohol and drugs that can damage the liver, or from a long history of behaviors that are unhealthy (having the effect of damaging yin and essence). The result is disordered flow of qi. As described in the Compendium of Medicine: "The upgoing qi in the channels and collaterals does not keep its proper position, thus causing the head to shake and the limbs to tremble." The mental disturbances that also arise in some Parkinson's patients may be attributed, from the perspective of traditional Chinese medicine, to a failure of the kidney to nourish the brain as well as from stagnation of phlegm that may obstruct the pathways for flow of qi and blood. In addition to genetic factors related to this decline in kidney essence, there may also be weakening of the kidney by exposure to cold, by excessive fear, by excessive sexual activity, and by consuming foods, drugs, or other substances that harm the kidney and especially those that deplete kidney yin. Also, physical injuries and surgeries can disrupt the normal interconnection of the internal organs and result in depletion of yin of the kidney and liver. In a recent review article about Parkinson's treatment with TCM (1), the authors noted the following commentaries by Chinese physicians on causation: The disease has various causes and complicated pathogenesis. Zhu holds that insufficiency of the liver and kidney and failing of the brain, spinal cord, and tendons to be nourished are the basic pathogeneses of the disease, and stagnation of phlegm in the collaterals is an important pathological link in the development and changes in the condition. Wang considers that the disease is caused mostly by gradual loss of the kidney essence due to old age and infirmity, or various poisoning factors caused by trauma….The pathogenesis is deficiency in origin and excess in superficiality; deficiency in origin manifests in deficiency of qi and blood, and insufficiency of liver and kidney; and excess in superficiality manifests as endogenous wind, stasis of blood, and phlegm-heat….Zhou, et al., consider the important pathological factors of this disease mainly deficiency of liver and kidney, wind stirring inside, accumulation of phlegm and blood stasis, a disease with coexistence of deficiency and excess…. This interpretation of causation, as well as the symptoms and signs associated with Parkinson's disease, leads directly to a therapeutic regimen: nourish the kidney and liver, with focus on nourishing yin, disperse accumulated phlegm and blood stasis, and sedate internal wind. For the tonification component, one of the most commonly used formulations-especially for treating yin deficiency with aging-is Rehmannia Six Formula (Liuwei Dihuang Wan ), with its key tonic herbs rehmannia and cornus for liver and kidney, and dioscorea and hoelen for spleen and kidney. It might be modified with additional tonics for kidney and liver (typically, lycium fruit and ho-shou-wu would be recommended). Yang deficiency often exists with the syndrome; it especially appears as the disease progresses, and the person's ability to move declines, and their metabolism weakens. That problem might be addressed by herbs that gently strengthen yang while still benefiting yin, such as cistanche and cuscuta. Zuogui Wan, a well-known formula for nourishing kidney essence, primarily nourishes yin, but also gently assists yang (it is comprised of rehmannia, cornus, dioscorea, cuscuta, lycium, tortoise shell, deer antler, and achyranthes). There are several wind-inhibiting substances recommended by Chinese herbalists. The main plant-based remedy is gastrodia tuber (uncaria is sometimes combined with it), while most of the substances given for this purpose are of animal origin, including scorpion, centipede, earthworm, antelope horn, and silkworm. The persistence and progression of the disease may be attributable to "phlegm obstruction of the channels." This substance in the meridians and blood vessels "fixes" the wind so that the symptoms worsen and also persist over a long period of time. Otherwise, wind syndromes tend to come and go. Herbs used to resolve this problem of phlegm

obstruction include arisaema, pinellia, and acorus (these are botanically related); silkworm and gastrodia are considered helpful for both calming wind and clearing phlegm obstruction. Curcuma (yujin), an herb often used for vitalizing blood circulation, is used in modern Chinese practice for dispersing stagnant obstructive phlegm.

CLINICAL REPORTS OF HERB THERAPY FOR PARKINSON'S A report (2) on treatment of 40 cases of Parkinson's syndrome involved 31 male and 9 female patients, aged 54-80 years (mean 69 years), with cases classified as being severe (3 patients), moderate (27 patients), or mild (10 patients). All patients were considered to have deficiency of kidney and liver yin with stirring up of internal wind. In addition, 3/4 of the patients were described as having phlegm in the channels. Of the remaining 10 patients, rather than this phlegm obstruction syndrome, 6 were said to have deficiency of qi and blood and 4 were said to have deficiency of yang. A basic prescription was developed for treatment: ho-shou-wu (20g), lycium (12g), cistanche (12g), gastrodia (15g), uncaria (18g), cnidium (15g), and acorus (10g). This collection of herbs would be modified according to symptoms, adding 2-6 herbs (yielding a total of about 120 grams of herbs per daily dose). After decocting the herbs, the resulting tea was divided into three portions, to be taken one portion each time, three times per day. Treatment time was three months, with the patients taking the decoction daily while discontinuing Western medications. According to the authors of the report, 5 of the patients were "markedly improved" by the treatment and 15 additional cases were improved, while the remaining 10 only had slight changes. Improvement was evaluated on the basis of scores for symptoms characteristic of Parkinson's disease, including tremor, rigidity, hypokinesis, gait disturbance, and mask-like face. They suggested that acupuncture, moxibustion, and scalp-needling might be helpful additions to the treatment. Many patients with Parkinson's also suffer from atherosclerosis, and there is some thought that this problem contributes to more rapid degeneration of the neurons, perhaps as a direct result of insufficient blood flow, or as a development from inflammatory processes that contribute to both atherosclerosis and to neuron degeneration. In a study of patients with atherosclerosis and Parkinsonism, 60 cases were treated with the same herb formula described above, by the same research group (3). In this case, there were 42 male and 18 female patients; aged 61-78 years (mean 67 years). In this group, it was reported that 7 of the patients were markedly improved, and 24 were improved, 15 were slightly improved, while the remaining 14 failed to respond to treatment. In another study of the effects of Chinese herbal medicine (4), 700 cases of treatments of Parkinson's patients at a hospital were reviewed; 50 of them, involving prolonged therapy, were analyzed. The case reports were concerning 32 men and 18 women. The patients were divided into three categories by the traditional method of differentiation and were treated with herbs accordingly. Because these were case studies, rather than administration of a specific prescription, commonly used herbs were mentioned. For yin deficiency of kidney and liver, the main herbs were: rehmannia (raw and cooked), ho-shou-wu, cornus, tortoise shell, scrophularia. For qi stagnation and blood stasis type, the main herbs were: salvia, red peony, carthamus, persica, cnidium, achyranthes, tang-kuei, eupolyphaga (zhechong), and pangolin scale (chuanshanjia) For deficiency of qi and blood, the main herbs were: ginseng, astragalus, atractylodes, tang-kuei, rehmannia, licorice, peony, salvia, schizandra, and ligustrum. The formulas would be modified according to specific symptoms, for example, to address continuous trembling, use antelope horn, uncaria, and gastrodia; additional wind-sedating substances might also be used for this purpose. The herbs were prepared in the form of decoction, which was given in two doses per day. Most of the patients took the decoctions daily for three months. Many of the patients were using standard Western medicines at the start of the treatment and, according to the authors, several were able to reduce their dosage or discontinue these medicines during or after treatment with the decoctions. The authors reported that of the 50 patients analyzed, the treatment was markedly effective in 15 cases, and somewhat effective in 24 cases, the remainder (11 cases) did not respond to therapy significantly. Information from other Chinese clinical work was reported at the International Congress on Traditional Medicine held in Beijing (April 22-24, 2000). Limited details were provided in the abstracts, indicating that most of the patients given these herb therapies showed improvement. Treatment time, when reported, was 6-12 weeks, and the herbs might be given in capsules or decoctions. No side effects of the herb therapies were noted. As with the studies reported above, the methodology employed does not meet current standards for reliably demonstrating effectiveness. Following are summarized from three reports. Clinical study on treatment of Parkinson's disease with Wengan Zhichan Jiaonang, by Gai Guozhong, et al. 32 cases of Parkinson's disease were randomly divided into a treatment group and a control group (16 patients each). The treatment group received Wengan Zhichan Jiaonang (Warming the Liver to Control Vibration Capsule), which included the following herbs: astragalus, ginseng, ho-shou-wu, dipsacus, magnolia bark, ligustrum, and cnidium (incomplete list). The herb extracts were encapsulated (500 mg per capsule), with administration of 4 capsules, three times daily. The control group received l-dopa and carbidopa. According to the authors, the results for the two groups, in terms of Parkinson's symptoms, were the same, but the herb-taking group had improvement of other symptoms associated with deficiency syndrome. Clinical observation on treatment of Parkinson's disease with Xiaochan Tang, by Ding Hongzhan A new formula for alleviating wind-paralysis, Xiaochan Tang, was evaluated; it is a decoction made with silkworm, scorpion, centipede, uncaria, and aconite; patients were also given powder of antelope horn. This basic formula was then modified with addition of numerous herbs for the patients according to their diagnostic category as follows: for yin deficiency of kidney and liver: add rehmannia, dioscorea, cornus, peony, tortoise shell, ligustrum, and achyranthes; for deficiency of qi and blood: add ginseng, hoelen, atractylodes, licorice, rehmannia, tang-kuei, peony, and additional cnidium (these are the ingredients of the traditional formula Bazhen Tang); for heated phlegm, add bamboo sap (zhuli), arisaema, and chih-shih; or for blood stasis, add cnidium, tang-kuei, red peony, and cyathula. All the herbs were used in heavy dosage, typically 9-15 grams in decoction (except the scorpion and centipede, about 6 grams each).

All the herbs were used in heavy dosage, typically 9-15 grams in decoction (except the scorpion and centipede, about 6 grams each). The herbs were given once daily for 25-60 days (average 42 days). Some degree of improvement was noted in 86% of patients, though only 13% showed marked improvement with the 6 week average treatment. Clinical effect of Zhenchanshu capsule on 21 cases of Parkinson's syndrome by Feng Guangkui Zhenchanshu was made as a capsule containing herb extracts, taken 4-6 capsules each time, three times daily, for three months to patients who had limited response to levodopa. The ingredients were not listed. It was stated that 86% of patients showed some degree of improvement, with 10% showing complete resolution of symptoms. The authors said that this herb therapy was better for early and intermediate cases and that it performed better for tremor and rigidity but not very effectively for difficult limb movement.

ACUPUNCTURE THERAPY In a review of Parkinson's disease treatment (1), it was noted that "The use of acupoints on the head is extremely important… moxibustion should be used as the main method with acupuncture as assistance." The main points recommended for moxibustion were baihui (GV-20) and dazhui (GV-14) in the head region; plus tender points at the shoulder and upper back, plus certain body points: tanzhong (CV-17), zhongwan (CV-12), tianshu (ST-25), along with zusanli (ST-36) or sanyinjiao (SP-6). These suggestions, sometimes using acupuncture rather than moxibustion, have been followed in some clinical work reported recently, mentioned in the review article (1) and the following reports. For example, in a study (5) of acupuncture therapy administered to 29 patients with Parkinson's, the patients were treated every other day for three months while the standard drugs were used as per usual practice; a control group taking Western drugs alone (24 patients) was also monitored. Two sets of acupuncture points served as the basis of therapy, and they were administered alternately: 1. sishencong (EX-HN-1; four points surrounding GV-20), quchi (LI-11), waiguan (TB-5), yanglingquan (GB-34), zusanli (ST-36), and fenglong (ST-40). 2. baihui (GV-20), benshen (GB-13), fengchi (GB-20), hegu (LI-4), sanyinjiao (SP-6), and taichong (LV-3). Electro-stimulation was administered to sishencong, benshen, and fengchi for 15 minutes, using a frequency of 180 cycles/minute, with the intensity adjusted to the tolerance limit for the patient. To avoid reduction of sensitivity to the stimulus over the course of the treatment, a continuous wave was used initially, but then followed by a "disperse-dense" wave. The other points were needled with the conventional manual method of stimulation. Needle retention was 40 minutes. Additional acupuncture points would be used for treating specific symptoms, so that, with most points being bilateral, about 12-16 needles were used in each session. The authors reported that there was a significant improvement in symptoms for those treated with acupuncture, while for patients treated with drugs alone, there was a worsening of symptoms. Further, the patients treated by acupuncture ended up using a lower total dosage of drugs after the three months of treatment, while those using only the drugs retained their original drug dosage. A follow-up study (6) was conducted by the same group, focusing on the sishencong points, with a comparison group treated with four points on the limbs (arms and legs). According to the report, acupuncture increased the cerebral blood flow velocity, which was taken as a sign of improved circulation to the affected parts of the brain, and the sishencong points had a more notable effect on the brain circulation. Another report on acupuncture (7) also focused on acupuncture near the point baihui (GV-20). In this case, acupuncture was performed along the scalp from qianding (GV-21) to baihui (GV-20), using the standard techniques of scalp acupuncture. Needles were inserted at a small distance to either side of the governing vessel (central line), in parallel groups with a total of 12 needles used. After manual manipulation using a rapid twirling maneuver, the inner needles (closest to the center line) were attached to electrodes of an electro-stimulation device (with disperse-compact alternating wave form) and stimulated for 40 minutes at the highest intensity the patient would accept. Treatment was administered every other day for ten consecutive treatments over a three week period; this was repeated each month for three months. In addition, yamen (GV-15), fengchi (GB-20), and other points at the neck would be treated by standard acupuncture. It was noted that there were some responses immediately after treatment, with calming of tremor in 2/3 of the patients. Among 24 patients that completed three months of therapy, 6 were said to show marked improvement, and the other 18 moderately improved (some other patients discontinued the treatments).

APPENDIX. Two Formulations Suitable for Neurodegenerative Diseases Developed by the Author Cord Tablets (Seven Forests brand tablets, 700 mg) serves as a tonic for the Chinese diagnostic category of kidney essence deficiency syndrome: longgu

Dragon bone

14% tusizi

lurong guiban duzhong xuduan

Deer antler Tortoise shell Eucommia Dipsacus

14% shudi 14% huangqi 14% baizhu 10%

Cuscuta

10%

Rehmannia Astragalus Atractylodes

10% 7% 7%

This formulation focuses on the pairing of deer antler and tortoise shell to nourish the essence. These ingredients are described as have these actions: "deer antler supplements kidney yang, opens the governing vessel, strengthens sinew and bone, boosts marrow, and nourishes blood; tortoise shell enriches yin and blood and supplements the liver and kidney to invigorate the root." Dragon bone secures and astringes the kidney essence, and directs the action of the formula to the spine. Eucommia, dipsacus, and cuscuta assist antler in nourishing the kidney and strengthening the root. Rehmannia, along with tortoise shell, harmonizes the yang tonics, aiding in nourishing yin, blood, and essence. Tortoise shell and dragon bone prevent yang from rising to cause agitation. Astragalus and atractylodes promote the spleen's function of absorbing essences from food to nourish the kidney essence. Disorders to be addressed include: Degenerative nerve disorders (e.g., ALS, MS, Parkinson's Disease) Degenerative spinal disc and osteoporosis

Loss of control over urination Impotence and loss of libido Cord Tablets shares herbs and characteristics with the traditional formula You Gui Wan (Restore the Right Kidney Pill), which has deer antler, rehmannia, cuscuta, and eucommia in common. It was described, by Bensky and Gamble in Formulations and Strategies, as "one of the best formulas for treating kidney yang deficiency with insufficiency of essence and blood." This revised version maintains these benefits. A formulation for ALS reported in the Chinese literature was comprised of antler and tortoise shell gelatins, rehmannia, tiger bone, dipsacus, cuscuta, eucommia, atractylodes, licorice, (with astragalus added for a later prescription), eucommia, achyranthes, tang-kuei, peony, phellodendron, anemarrhena, and citrus. In Cord Tablets, tiger bone is replaced by dragon bone and the herbs for deficiency fire (phellodendron and anemarrhena) have been left out (Zhi Bai Di Huang Wan could be administered along with this formula). Stabilizing Tablets (Seven Forests brand tablets, 750 mg) was designed for the treatment of destabilizing conditions (with loss of motor and/or sensory controls) that most often arise with aging and involve more rapid than normal decline in liver and kidney yin and essence. Gouqizi Tianma

Lycium Gastrodia (m)

14% roucongrong Cistanche 10% dongchongxiacao Cordyceps

heshouwu danshen shanzhuyu

Ho-shou-wu Salvia Cornus

10% baijiangcan 10% shichangpu 10% chuanxiong

Silkworm Acorus Cnidium

10% 9% 9% 9% 9%

This formulation focuses on the pairing of gastrodia and batryticated silkworm to inhibit wind, particularly the syndrome of windphlegm; these ingredients are described as have these actions: "gastrodia extinguishes wind, dispels phlegm, and checks spasm; silkworm dispels wind and resolves spasm, disperses phlegm, and dissipates binding." Lycium fruit, ho-shou-wu, cornus, cordyceps, and cistanche nourish the liver and kidney, supplementing the yin, blood, and essence, while gently tonifying yang. Salvia, acorus, and cnidium enliven the circulation of blood to overcome some of the damaging effects of chronic disease, aging, and lack of healthy exercise. Disorders that may be addressed by a formula such as this include: Parkinson's disease Spastic conditions associated with multiple sclerosis and other neurodegenerative diseases Unsteady gait due to poor circulation and weakness Spasms and convulsions associated with late onset epilepsy Mental confusion, dizziness, tinnitus, and blurred vision The tonic portion of Stabilizing Tablets shares herbs and characteristics with the traditional formula Huan Shao Dan (Youth Restoring Pellet), which has lycium fruit, cistanche, cornus, and acorus in common. Although the other herbs in Stabilizing Tablets differ, they contribute to several actions intended for the Huan Shao Dan formula, which is described by Ellis in Notes from South Mountain this way: "greatly supplements root qi, [it treats] abstraction, confusion, and clouding of the essence-spirit, congealed or stagnant qi and blood, inability to taste food and drink, thin body, fatigue, diminished sight and hearing loss." The added wind-calming herbs in Stabilizing Tablets contribute to the treatment of shaking, spasm, convulsion, and unsteadiness. In a review of Parkinson's disease treatment, one of the formulas suggested was the "Powder for Checking Tremor and Stopping Spasm," comprised of ho-shouwu, salvia, earthworm, gastrodia, cistanche, and other ingredients; another formula mentioned contains lycium fruit, cnidium, uncaria, ho-shou-wu, astragalus, atractylodes, gastrodia, and other ingredients. These approaches are similar to the ones expressed in Stabilizing Tablets.

REFERENCES 1. He Jiancheng, et al., Present situation and prospects of TCM treatment of Parkinson's disease, Journal of Traditional Chinese Medicine 2004; 24(4): 308-314. 2. Chen Jianzong, et al., Traditional Chinese medicine treatment of Parkinson's syndrome-a report of 40 cases, Journal of Traditional Chinese Medicine 2003; 23(3): 168-169. 3. Chen Jianzong, et al., 60 cases of atherosclerotic Parkinsonism syndrome treated by supplementing liver and kidney method, Shaanxi Journal of Traditional Chinese Medicine 1999; 20 (1): 19. 4. Li Genghe, Clinical observation on Parkinson's disease treated by integration of traditional Chinese and Western medicine, Journal of Traditional Chinese Medicine 1995; 15(3): 163-169. 5. Zhuang Xiaolan and Wang Lingling, Acupuncture treatment of Parkinson's disease-a report of 29 cases, Journal of Traditional Chinese Medicine 2000; 20(4): 263-267. 6. Wang Lingling, et al., Influence of acupuncture on brain blood flowing state in Parkinson's patients, Chinese Acupuncture and Moxibustion 1999; (2): 115-116. 7. Xi Guifang, et al., Impact of electrostimulation at scalp points on tremor-myeloectropotential in Parkinson's disease patients, Shanghai Journal of Acupuncture and Moxibustion 1996; 15(3); 5-6.

August 2005

EVALUATION OF DHEA LEVELS IN MULTIPLE SCLEROSIS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Dehydroepiandrosterone (DHEA) is an androgenic steroidal hormone produced by the adrenal gland. Its specific physiological functions, other than serving as a precursor to other steroid hormones (such as testosterone), are not yet established. It is possible that DHEA plays an important role in physical development during puberty. The amount of circulating DHEA in the blood varies considerably with age and sex. DHEA levels begin to increase several years prior to puberty (at about age 7) and reach their maximum level at around ages 20–25. In young adults, plasma DHEA levels are about 10 times higher than plasma cortisol levels. With aging, cortisol levels remain about the same, while DHEA declines; at age 50, it is typically only about half the peak level, and by age 75 it declines to about 10% the peak level. Low levels of DHEA in adults have been found to correlate with increased incidence of cardiovascular disease, breast and endometrial cancer, Alzheimer’s Disease, and progression of HIV disease. DHEA levels have been found to decline during illness, with major depressive disorders, and with prolonged stress. Laboratory animal studies suggest that DHEA regulates immune functions (influences production of interleukin-2 and regulates cellular immune responses); has antidiabetic, antiatherosclerotic, and antiobesity effects; protects against autoimmune nephritis, and inhibits neoplasms. Relatively little is currently known about potential clinical benefits of administering DHEA, especially over a prolonged period. Dr. Samuel Yen (University of California, San Diego), who first reported on the correlation of DHEA and cardiovascular disease, has since administered DHEA to elderly patients and reported that it increases mobility, reduces joint discomfort, and improves sleep. Preliminary work with systemic lupus erythematosus (SLE) patients showed low baseline levels of DHEA and symptom improvement with DHEA administration; a phase III trial of a synthetic DHEA for treatment of lupus has been approved and is now enrolling participants. Based on these findings, one might hypothesize that persons with multiple sclerosis have low DHEA levels. As with autoimmune nephritis and SLE, they suffer from an autoimmune disorder; they also tend to suffer from stress and depression, and they have frequent illnesses. Persons with MS who have low DHEA levels might experience benefits from normalizing those levels, since restricted mobility and poor sleep are common complaints. In a preliminary 1990 study by Roberts and Faubile (1), persons with MS were found to have low DHEA levels which were improved by DHEA administration. It was also noted that the majority of these patients had discernible improvement, after DHEA administration, in their quality of life, including increased energy levels, better dexterity, greater limb strength, decreased sensations of numbness, and an increase in libido. In a non-randomized 1990 study by Calabrese (2), it was concluded that DHEA administration helped to improve fatigue symptoms in those with MS. Orally administered DHEA is reported to be readily absorbed, and is converted by the liver to DHEA sulfate (DHEA-S), which is the form usually monitored. DHEA-S must be desulfinated again in order to become physiologically active. The daily adrenal production of DHEA is roughly 30 mg, and typical blood levels of DHEA-S for healthy middle-age female adults are on the order of 150–200 mg/dl (for males, about 200–400 mg/dl). Currently, DHEA and/or DHEA-S testing is usually not suggested by neurologists working with MS patients; in fact, it is rarely recommended by other physicians. The cost of testing is somewhat high (about $90/test for each component). DHEA supplementation is sometimes recommended to patients by naturopathic physicians, but it is rarely recommended by medical doctors. DHEA is currently available as a non-prescription oral supplement in the U.S. This unusual status arises because DHEA is not currently used as a drug: it is a natural component of the body (a derivative of cholesterol), it is found in foods, and demand for it has been generated on the basis of studies conducted during the past 30 years suggesting anti-aging effects and other benefits. Unfortunately, products on the market are of varying quality, from pharmaceutical grade DHEA to herbal extracts claimed, incorrectly, to contain “natural DHEA.” Common recommendations for taking supplemental DHEA, found in the popular literature that cites its potential benefits, is 25–50 mg daily (sometimes higher; with some sources recommending 50–150 mg/day). DHEA has been utilized as an experimental viral inhibitor for persons with HIV infection at doses of 600 mg/day or higher. While DHEA appears to be generally safe for short-term use, it may cause general androgenic responses (which can be more easily noted in females) and little is known about the impact of long-term administration of the very high levels that have been suggested by some proponents. Further, there is concern that large doses of DHEA may increase testosterone levels in men with testosterone-dependent prostate cancers. Therefore, it is important to learn more about the effects of DHEA administration on circulating DHEA levels.

METHODS For this preliminary evaluation, 7 female patients with multiple sclerosis and 1 male patient with an MS-like disorder (originally diagnosed as MS) were selected from participants of the MS treatment at the ITM clinic (Lovejoy facility; see separate report for details). Selection was based on the following criteria: 1. Not currently or recently taking DHEA as a supplement. 2. A regular ITM program participant for at least 9 months. 3. Willing and able to cooperate with study (including three blood draws). No health parameters were considered in the selection process. The first two criteria eliminated about one-third the potential participants (we required 9 month participation time to assure compliance and to eliminate variables associated with program start-up; some patients were prescribed DHEA at our clinic prior to the study), and most of the others were eliminated by the third criteria. All but one of the MS patients had a relapsing/remitting type of disease; average participation time in our program was 23 months. An initial blood draw was taken to determine baseline DHEA-S levels. Since the laboratory reference range for DHEA-S levels vary

by age and sex (example: female, age 56, reference range 26–200 mg/dl; male, age 34, reference range 120–520 mg/dl), a single comparison scale was developed for this study. The scale was set as follows: 1. The laboratories highest normal DHEA-S level for the patient age and sex was set at 100. 2. The lowest normal DHEA-S level for the patient was set as 0. 3. The measured value was then adjusted to the scale as follows: [Measured value–lowest normal value]/[Highest normal value–lowest normal value] Using this method, a scale value of 50 represents the middle of the laboratory reference range for the patient. A negative reading means the patient’s DHEA-S level was below the lowest value given for the reference range. After obtaining the baseline value for DHEA-S, patients were instructed to take encapsulated DHEA at a dosage of 15 mg/day, one time per day (morning). The one male patient was instructed to use 30 mg/day (one time per day), based on usual higher DHEA levels in males than females. A retest of DHEA-S levels was scheduled for approximately six weeks after DHEA dosing began. For the second test, patients were instructed to skip their morning dose of DHEA, get the blood draw, and then take their daily dose. In that way, the DHEA-S level would reflect the combination of underlying DHEA production and the remainder of the previous dose, somewhat more than 24 hours after it was taken. DHEA laboratory testing (conducted by Rhein Consulting Laboratories, in Portland) and prescription of DHEA (obtained from Diosynth in Holland via Flanders Pharmacy, a compounding pharmacy, in Portland) was managed by Edythe Vickers, N.D., L.Ac.

RESULTS The baseline values of DHEA, both laboratory reported values and using our 100 point scale, were as follows: I.D. mg/dl scale value Patient 1: 59.4 6.4 Patient 2: 111.0 29.3 Patient 3: 40.5 –2.0 Patient 4: 62.5 –14.3 [male] Patient 5: 140.0 51.9 Patient 6: 32.9 0.4 Patient 7: 77.8 22.0 Patient 8: 33.7 4.4 Average: 69.7 12.3 Since the average scale value for a random selection of healthy individuals is expected to be about 50, these values reveal low levels of DHEA. For the retest at six weeks, 2 patients (with results described below under the heading Pharmacokinetics) did not comply properly with the retest protocol. Of the 6 who did comply, the initial and retest data, converted to our 100 point scale, is as follows: I.D. baseline 6 weeks change Patient 1: 6.4 28.4 +22.0 Patient 3: –2.0 62.2 +64.2 Patient 4: –14.3 11.3 +25.6 [male; took 30 mg/day] Patient 5: 51.9 79.3 +27.4 Patient 7: 22.0 52.0 +30.0 Patient 8: 4.4 19.7 +15.3 Average: 11.4 42.2 +30.8 This data indicates that DHEA is absorbed from the gastrointestinal tract, and that some of it remains in the blood for at least the 24 hours after the last oral dose. Patient 3 had taken a course of prednisone in the interval between the two tests, not for treatment of MS, but for bronchial inflammation, and this may have affected the outcome (hers was the only unusual change, notably greater than the others). On follow-up questioning, she did not report a deviation from the protocol of getting a blood draw in the morning after skipping the morning DHEA dose. During the two weeks prior to the second test, this patient showed a sign of possible excess androgen (chin acne), though it is not possible to directly attribute the symptom to this particular combination of steroid interventions.

PHARMACOKINETICS One patient took her morning dose of DHEA the day of the second test (about four hours between oral dosing and the blood draw). Her DHEA-S baseline value was 40.5 mg/dl (on our scale, 29.5), but her retest value was 394 mg/dl (on our scale, 155), demonstrating that the DHEA is readily absorbed and reaches relatively high values in the blood within four hours after administration. In fact, 15 mg of DHEA distributed in 5 liters of blood would yield a level of 300 mg/dl, which corresponds closely to the change in DHEA-S level observed in this individual. As observed from the other participants, who took morning doses of DHEA regularly but did not take it the day of the second blood draw, about one day after the DHEA level in the blood reaches its peak value (due to exogenous supply) the amount declines to a level that is in the normal range. In our group, the result of ingesting 15 mg was that the average DHEA level a day after administration was still somewhat below the mid-point of the normal range. To give an idea of the clearance of exogenous DHEA, for patient #7, as a representative example, the initial DHEA-S level was 78 mg/dl, and the retest value was 140 mg/dl; an increase of 62 mg/dl. If her blood level soon after DHEA ingestion was about 300 mg/dl higher than her baseline value (15 mg in 5 liters of blood), then 80% of the extra DHEA was eliminated in somewhat more than 24 hours. This corresponds, roughly, to a DHEA-S serum half-life of about 12 hours.

One patient did not take her morning dose of DHEA for the two days prior to the test. Her DHEA level at the second test was almost identical to the baseline level (32.9 mg/dl versus 32.6 mg/dl for the second test), indicating that the orally consumed DHEA was completely removed by that time. Further, there was no evidence of decline in her usual DHEA production level as a result of six weeks of daily ingestion of 15 mg.

DISCUSSION As an interpretation of this limited preliminary data, the following tentative conclusions might be drawn: 1. Patients with MS tend to have low DHEA levels, generally falling in the lower part of the laboratory’s reference range (7 of 8 patients tested), and sometimes below the normal range (2 of 8 patients tested). This is consistent with other reports that DHEA levels are low in persons with SLE, MS, and with illness in general. The measured levels also suggest that the medical therapies that had been offered to the patients at our clinical facility up to this time (for at least nine months), including nutritional supplements, Chinese herbs, and acupuncture, do not raise DHEA levels substantially. 2. Orally administered DHEA is readily absorbed in patients with MS. At about four hours after ingestion, the DHEA-S level measured in one patient corresponded to full absorption of the DHEA dose. In order to maintain DHEA levels roughly within the normal range for a middle aged adult, a single daily dose of DHEA should not exceed about 10 mg in women (adding about 200 mg/dl to the baseline at its peak) or 20 mg in men (adding about 400 mg/dl to the baseline at its peak). Recommendations in the popular literature often exceed these amounts. 3. The supplemental DHEA remains in the bloodstream for more than 24 hours, its level decreasing over time. The extra DHEA is cleared from the system within about two days. In order to maintain levels in the upper part of the reference range for the individual, dosing two or three times per day, or using time-released DHEA, appears necessary. 4. It is possible that other exogenous steroids influence DHEA levels. In one patient who undertook a course of prednisone therapy for bronchial inflammation, the DHEA levels measured on the second test were considerably raised compared to the other participants. This study does not establish whether or not supplemental DHEA will have a health benefit for persons with multiple sclerosis, due to the short period of administration. However, DHEA is believed to have several potentially beneficial effects, including immune regulation and antiviral activity; as a steroid hormone, it can reduce inflammation. Earlier investigations, though informal, have suggested a benefit of DHEA for those with MS. Our small study further confirms the proposal that persons with autoimmune disorders, and MS in particular, tend to have low DHEA-S levels. Other participants in our MS program have been administered DHEA in the past after finding low DHEA-S levels (data not presented). It is possible that the wide range of DHEA-S values reported in the laboratory reference range includes many low values from patients who suffer from various chronic diseases or who have higher risk for serious diseases. Thus, the desirable level of DHEA may actually be in the upper half of the laboratory’s reference range. Considering what is known about DHEA, normalization of levels in these patients would not be expected to cause adverse reactions. The next step in this ongoing study, based on these initial findings, is to adjust the dosage schedule from 15 mg one time per day to 7.5 mg each time, two times per day. In this way, the DHEA levels are expected to be more constant and maintained closer to the desired range. If full absorption occurs, a 7.5 mg single dose should raise the DHEA levels in most patients to the upper part of the reference range, while the twice per day dosing will help maintain the desired higher levels in the blood throughout the day and night. The dosage that is being administered is about half that normally produced by a healthy middle-aged adult, so that any potential problems of excessive levels of this substance can be avoided. Further testing will reveal the actual DHEA-S levels attained by this amended protocol. If additional testing confirms the findings of the current preliminary study, our clinic will plan to treat most enrolled MS patients with this modest dose of DHEA over a period of six months or longer in an attempt to determine possible clinical benefits. Since DHEA could easily be subjected to a randomized placebo controlled study, it is further proposed that major MS clinics with adequate patient populations consider conducting a careful evaluation of the clinical effects. In this way, if there are any substantial benefits, patients are more likely to receive this therapy.

REFERENCES 1. Roberts E and Fauble TJ, Oral DHEA in multiple sclerosis: results of a phase one, open study , in The Biologic Role of DHEA by Kalimi, M. and Regelson, W., Editors. New York: Walter De Gruyter, 1990, pp. 81–93. 2. Calabrese VP, et al., DHEA in multiple sclerosis: positive effects on the fatigue syndrome in a non-randomized study , in The Biologic Role of DHEA by Kalimi, M. and Regelson, W., Editors. New York: Walter De Gruyter, 1990, pp. 95–100. Funding for this study was received from the McKenzie River Gathering Foundation (Eugene and Portland, Oregon), the National Multiple Sclerosis Foundation (Fort Lauderdale, Florida), and the Institute for Traditional Medicine (Portland). Rhein Consulting Laboratories provided discounted DHEA-S tests and Flanders Pharmacy provided discounted encapsulated DHEA.

September 1997

INTERNET JOURNAL OF THE INSTITUTE FOR TRADITIONAL MEDICINE AND PREVENTIVE HEALTH CARE TREATMENT OF DIABETES WITH CHINESE HERBS AND ACUPUNCTURE

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Web Posting Date: January 2003 Key medical terms: diabetes mellitus, NIDDM (type 2 diabetes, non-insulin dependent) Key Chinese medical references: deficiency and impairment of qi, yin, and yang Chinese herbs: alisma, anemarrhena, astragalus, atractylodes, dioscorea, ginseng, ho-shou-wu, hoelen, lycium, platycodon, polygonatum, pueraria, rehmannia, salvia, scrophularia, trichosanthes Chinese formulas: Baihu Jia Renshen Tang, Liuwei Dihuang Wan, Bawei Dihuang Wan, Maimendong Yinzi, Fangfeng Tongsheng San, Yu Quan Wan, Xiao Ke Wan SUMMARY: Diabetes is out of control in the U.S., with incidence rates as high as 15-20% in some population groups (e.g., the elderly, blacks, Hispanics, and Native Americans), and with substantial increases in all age and racial groups in the past few years. Chinese medicine, relying mainly on herb formulas, but also on acupuncture, has been utilized extensively in East Asia to reduce blood sugar in persons with diabetes, especially those with the most common type (non-insulin dependent diabetes mellitus, NIDDM). Based on extensive laboratory and clinical evaluations, about 20 herbs have emerged as primary candidates for treatment. These herbs have been utilized in a small number of traditional formulations for centuries, both for treating obvious diabetes and for other disorders that produce similar symptoms. Acupuncturists have identified about 20 points on the body that appear to be effective in lowering blood sugar; typically, a dozen of these points are selected for treatment at one time. Although more clinical research needs to be done to demonstrate the level of effectiveness of the herbs and acupuncture, these methods of therapy are currently available in many locations in the Western cultures as a result of the increasing acceptance of Chinese medicine during the past three decades. This article outlines the history and development of Chinese approaches to diabetes and reveals the currently accepted concepts. A second article will present treatment for secondary effects of diabetes, such as impairment of circulation and resulting damage to the eyes, peripheral neuropathy, and increased risk of heart attack.

TREATMENT OF DIABETES WITH CHINESE HERBS AND ACUPUNCTURE I. Lowering Blood Sugar by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Diabetes is a major health problem worldwide, but particularly in America. It is estimated that about 2.1% of the world's population has diabetes, but the disease is out of control in America. In the U.S., current estimates are that over 6% of the adult population has the disease, 99% of them with the type 2 diabetes mellitus (late onset or non-insulin-dependent: NIDDM). Type 2 diabetes usually appears around the age of 50 or later, though it can occur during teen years in some cases of obesity. The incidence rate becomes quite high among elderly Americans (20% for those over the age of 65) and in groups with genetic or other predispositions including blacks (14%), hispanics (15%), and Native Americans (19%). Furthermore, the overall incidence of diabetes is growing, apparently because of increased rates of obesity.

CDC data on prevalence of diabetes across the United States in 1994 (left) and in 2000 (right). The rise in diabetes rates is striking. In the year 2000, no states had less than 4% of the population with diabetes, and only 10 states had under 5%. Despite the major medical advances in rapid and easy monitoring of blood sugar and treatment

with drugs, diabetes remains a serious problem. Blood sugar regulation that can be attained by standard methods, particularly when patients are not fully compliant with all medical recommendations, is often not adequate to avoid common secondary effects of diabetes, including cardiovascular diseases, degenerative eye conditions, limb numbness and pain, skin ulceration, and kidney failure. Thus, investigating other avenues for aiding the treatment of diabetes and its secondary consequences is an important undertaking. Although the incidence of diabetes is far lower in China than in the U.S., predictions are that China and the rest of southeast Asia will rapidly become the world's main site of diabetes cases (by the year 2025) due to the combined high population and change in lifestyle as the countries modernize. The disease has been known since ancient times and it has been a subject of considerable laboratory and clinical research in the Orient. So, the methods of Chinese medicine will no doubt play an important role in the coming years in the population of East Asia. Chinese medical treatment of diabetes includes herbal prescriptions, acupuncture, and dietary recommendations. There is not a single established treatment for diabetes, so it is necessary to review the traditional medical ideas about diabetes and the research that has been conducted to date to give guidance in using these medical therapies. This part of the two-part series focuses on treatments to lower blood sugar; part II focuses on treatment of secondary manifestations of diabetes. Practitioners of Chinese medicine in the U.S. and other Western countries often have more time to spend consulting with their patients than do medical doctors. This extra time gives an opportunity for exploring with the patient the key roles of exercise and dietary control in limiting the impact of diabetes and preventing its development with aging for those who do not currently have the disease. While acupuncture and herbs are an important option for these patients, it is clear from the evidence that exists that as much or more can be accomplished through changes in behavior. It is necessary for practitioners to keep current with information about dietary advice, as some concepts that were common just a few years ago have turned out to be incorrect or misleading, and are replaced by new approaches backed by recent research.

BRIEF HISTORY OF CHINESE MEDICINE AND DIABETES Chinese medicine owes its current stature to the long history of its practice, dating back more than 2,000 years in a form similar to that utilized today. Chinese physicians appear to have had a reasonably good understanding of diabetes since ancient times. In one of the oldest books about Chinese medical theory, the Huangdi Neijing (1), compiled around 100 B.C., the condition known a s xiaoke is mentioned. This is translated today as diabetes or diabetic exhaustion. The literal translation of the term is emaciation-thirst, referring to the disease manifestation when it has gone untreated: namely, one loses body weight despite eating normally, and thirst is persistent. According to this ancient text, the syndrome arises from consuming too much fatty, sweet, or rich food. It is said that it typically occurs among wealthy people: "you ask them to refrain from a rich diet, advice which they may resist." The description fits that of non-insulin-dependent diabetes mellitus. Two of the traditional herbal formulas most frequently used in modern China and Japan for the treatment of diabetes were described in the book Jingui Yaolue (2), which is about miscellaneous diseases, written around 220 A.D. The text described symptoms characteristic of uncontrolled diabetes, including thirst, frequent urination, and loss of body weight. One of the formulas is Rehmannia Eight Formula (Bawei Dihuang Wan; also called Jingui Shenqi Wan ), originally indicated for persons who showed weakness, fatigue, and copious urine excreted soon after drinking water; in some cases, this may have been diabetes as we know it today. The other formula is Ginseng and Gypsum Combination (Baihu Jia Renshen Tang); it was indicated originally for severe thirst and fatigue and is considered ideal for diabetes of recent onset. In 752 A.D., the distinguished physician Wang Tao mentioned that diabetes was indicated by sweet urine and he recommended the consumption of pork pancreas as a treatment, implying that the pancreas was the organ involved in the disease (3). Further, he suggested that the urine of diabetes patients should be tested daily (by tasting for sweetness) to determine the progress of the disease and its treatment. Liu Wansu (ca. 1120-1200 A.D.) propounded the theory that diseases are usually caused by heat in the body, which should be countered by herbs that had a cold nature (4). One of his published formulas for diabetes, Ophiopogon and Trichosanthes Combination (Mainendong Yinzi), is traditionally described as clearing heat and nourishing yin. It is comprised almost entirely of herbs that have been shown by modern research to lower blood sugar. Another of his formulas, Siler and Platycodon Formula (Fangfeng Tongsheng San), is recommended by many Japanese doctors for treatment of obesity and accompanying type 2 diabetic syndrome (5). By the latter half of the 20th century, there were about 200 standard prescriptions recorded as suitable for treating diabetes (6). The majority of these may be viewed as combinations that rely primarily on about two dozen anti-diabetic ingredients (see Table, page 4) plus a small number of auxiliary herbs. These other herbs are understood to have complementary properties (assist the function of the main herbs) or are aimed at treating a specific manifestation of the disease. The main traditional prescriptions brought forward include Rehmannia Eight Formula and its simplified version Rehmannia Six Formula; Ginseng and Gypsum Combination, and Ophiopogon and Trichosanthes Combination.

A theory has arisen as to how diabetes progresses (7, 41). The disease begins with a deficiency of yin. This seems contradictory to the appearance of the patient, who often shows obese constitution and low metabolism, signs that would correspond to excess of yin and deficiency of yang. However, the patients with early stage of diabetes actually have a hyperactive metabolism that does not provide useful energy. Hence, the food nutrients are not successfully utilized; hunger persists, sugar pours out in the urine, thirst develops, and there may be easy sweating. This yin deficiency then generates heat that becomes pathological and then parches the yin. The imbalance of yin and yang eventually degrades and inhibits the qi, so that qi and yin deficiency co-exist. At this point, secondary effects, such as blood stasis and damp-heat, manifest, causing many serious symptoms (29). Without proper nourishment of qi and yin, yang eventually becomes impaired, and the patient, now with advanced disease, has a combined deficiency of qi, yin, and yang.

MODERN HISTORY OF EVALUATING HERBS AND FORMULAS The research on diabetes treatment has been ongoing for several decades, yet remains in the developmental stages due to the complexity of the task at hand. Initial laboratory animal studies of blood-sugar lowering effects of herbs were conducted in China, Korea, and Japan during the period 1927-1952 (6, 13). Several commonly used herbs were shown to lower blood sugar, including yin nourishing rehmannia, scrophularia, ho-shou-wu, and yu-chu; qi tonifying ginseng, atractylodes, and polygonatum (haungjing, which also nourishes yin); and heat clearing herbs, such as phellodendron, coptis, lycium bark, lonicera, and alisma. This hypoglycemic effect occurred when the herbs were used to treat blood sugar increases induced by epinephrine, which acts as a stress hormone. Since the 1960s, a much invigorated program of diabetes research arose. New laboratory evaluations were made possible by the finding that the toxic chemical alloxan selectively destroys the beta cells of the pancreas. Thus, mice, rabbits, or other laboratory animals treated with this compound suffer from a diabetic syndrome quite similar to that of a person who has insulindependent diabetes (type I, early onset). Dr. S. Nagayoshi was able to report that Rehmannia Eight Formula reduced blood sugar in alloxan-treated rabbits in a 1960 journal report (6). Comparing the herbal effects in normal laboratory animals with those in alloxan-treated animals provides some indication of the mechanisms by which the herbs affect blood glucose levels; further information is obtained when using the same herbs to treat animals affected by epinephrine. Progress has been made with studies of a genetic strain of mice-first described in 1979-that gain weight unusually and begin developing a type 2 diabetes after about 10 weeks of growth. These mice were used in a study of the hypoglycemic role of ginseng and its active constituents in the traditional formula Ginseng and Gypsum Combination (24). Perhaps the most extensive laboratory investigation of Chinese herbs for diabetes has been carried out by Huang Ray-Ling and his coworkers at the National Research Institute of Chinese Medicine in Taiwan (16). Dr. Huang tested a variety of herb extracts in both alloxan-treated mice and normal mice, in order to compare the impacts of the herbs with or without insulin involvement. To obtain more significant results, blood sugar responses were monitored at different times after administration of herbs, in glucose tolerance tests, and with differing dosages of the herb materials. Herbs that showed significant hypoglycemic action in both alloxan-treated and untreated mice included some that were not commonly used in traditional formulas, such as red atractylodes (cangzhu), cyperus, and phaseolus (mung bean). Herbs that showed a substantial hypoglycemic effect in alloxan-treated mice but little effect in normal mice, however, matched the pattern of traditional herb therapy; they include rehmannia, scrophularia, astragalus, coix, moutan, lycium bark, lycium fruit, trichosanthes root, alisma, and asparagus root. Traditional herb formulas that had significant hypoglycemic activity by these tests included Rehmannia Six Formula (Liuwei Dihuang Tang ), Rehmannia Eight Formula (Bawei Dihuang Tang ), and Ginseng and Gypsum Combination (Baihu Jia Renshen Tang). The dosages of herbs administered to the mice to obtain the significant hypoglycemic action ranged from 1.25 to 5.0 grams/kg. These dosages are quite high, and it is difficult to translate the effects seen in these diabetes models with these herb dosages to human requirements, but human dosages would be expected to be at the high end of the range normally recommended for treatment of other diseases based on these figures. A summary of Chinese laboratory research on hypoglycemic agents, reported in the books Modern Study and Application of Materia Medica (30) and Pharmacology and Applications of Chinese Materia Medica (13) yielded the following listing of herbs. Only the commonly used items are included here; there were also a small number of additional herbs that showed positive effect but are not included repeatedly in prescriptions mentioned in the published clinical trials. Note that most of the materials are roots and rhizomes and many of the herbs contain saponins or their aglycones, triterpenoids. Common Name Pinyin Name Alisma zexie

Botanical Name Plant Part Alisma plantago-aquatica rhizome

Comments in Rehmannia Six and Rehmannia Eight Formula; contains triterpenes

Anemarrhena zhimu

Anemarrhena asphodeloides rhizome

in Ginseng and Gypsum Combination and Ophiopogon and Trichosanthes Combination; contains saponins that have hypoglycemic action

Astragalus huangqi

Astragalus membranaceus root

contains flavonoids and saponins

Atractylodes baizhu

Atractylodes macrocephala rhizome

contains essential oils; action of decoction is slow: 2-5 hours

Atractylodes, red cangzhu

Atractylodes lancea rhizome

contains essential oils; gradual decrease in blood sugar for alloxan treated rabbits

Dioscorea shanyao

Dioscorea batatas rhizome

in Rehmannia Six and Rehmannia 8 Formula; contains saponins

Ginseng renshen

Panax ginseng root

in Ginseng and Gypsum Combination and Ophiopogon and Trichosanthes Combination; contains saponins

Ho-shou-wu heshouwu

Polygonum multiflorum root

treats peripheral neuropathy; contains anthraquinones

Hoelen fuling

Poria cocos mushroom

in Rehmannia Six and Rehmannia Eight Formula and in Ophiopogon and Trichosanthes Combination

Lycium bark digupi

Lycium chinense bark

slow and lasting action in reducing blood sugar

Lycium gouqizi

Lycium chinense fruit

produces sustained decrease in blood glucose; increases tolerance to carbohydrates

Platycodon jiegeng

Platycodon grandifolium root

contains saponins; reduces blood glucose in normal and alloxantreated animals

Polygonatum huangjing

Polygonatum sibiricum root

inhibits epinephrine-induced hyperglycemia

Pueraria gegen

Pueraria lobata root

in Ophiopogon and Trichosanthes Combination; contains flavonoids

Rehmannia dihuang

Rehmannia glutinosa root

in Rehmannia Six and Rehmannia 8 Formula and Ophiopogon and Trichosanthes Combination

Salvia danshen

Salvia miltiorrhiza Root

shows prolonged hypoglycemic effect; contains quinines

Scrophularia xuanshen

Scrophularia ningpoensis Root

action is weaker than rehmannia

Trichosanthes tianhuafen

Trichosanthes kirilowii root

in Ophiopogon and Trichosanthes Combination

Yu-chu yuzhu

Polygonatum officinale rhizome

contains glycosides; reduces blood sugar in alloxan-treated rats

CLINICAL APPLICATIONS Clinical trials of Chinese herbs for diabetes have been conducted with increasing frequency over the past thirty years. At the 9th Symposium of Oriental Medicine in 1975, Dr. Takahide Kuwaki reported on partial success in treating 15 diabetes patients with traditional herb formulas; nine of the patients treated (duration of using herbs ranged from 2 to 36 months) showed notable improvements (6). In Beijing, a Diabetes Unit was established in 1975 at the Department of Traditional Chinese Medicine at the Capital Hospital; a summary of their recommendations has been published in America, giving an opportunity for Western practitioners to provide similar treatments to their patients (14). In Changchun, the Kuancheng Institute of Diabetes was established; in 1989 researchers there published results of a highly successful clinical trial of herbs used for treating diabetic ketonuria, in which 28 of 33 patients showed marked improvements after consuming a complex formula comprised almost entirely of herbs that individually have hypoglycemic actions (15). These Chinese clinics, and other facilities in China and Japan, have provided herbal treatments to thousands of patients with diabetes, and the results have often been monitored and reported. Examples of clinical recommendations and evaluative trials for the treatment of diabetes are presented in the book Modern Clinic Necessities for Traditional Chinese Medicine (17). The

formulas that had been shown to have hypoglycemic effects in the animal studies, Rehmannia Six Formula and Ginseng and Gypsum Combination, were recommended to treat those who have normal insulin secretion but suffer from diabetes (this would be type 2, or insulin-independent diabetes). These formulas are for the common qi and yin deficiency syndrome found in early stage of clinical symptoms. A traditional variation of Rehmannia Six Formula was also suggested, made by adding anemarrhena and phellodendron (to form Zhi Bai Dihuang Wan). Reducing Sugar Tablet A ( Jiang Tang Jia Pian ), comprised of astragalus, polygonatum, trichosanthes root, pseudostellaria, and rehmannia, was recommended for those with low levels of insulin, but who are still capable of producing insulin. The herbs were administered as extracts in tablet form, with 2.3 grams raw material per tablet, 6 tablets each time, three times daily, for a total dose of over 40 grams per day (raw materials equivalent). The effects were said to be enhancing sugar tolerance and elevating the level of serum insulin. In the treatment of 405 cases of diabetes with this preparation at the Guanganmen Hospital, 76.5% of the patients had improved sugar tolerance. Among those patients who most closely fit the therapeutic pattern of the herbs-those with qi and yin deficiency-the effective rate was slightly higher, 81%. Rehmannia Eight Formula was recommended for those patients who produced little or no insulin. This is for patients with advanced disease, representing a deficiency of yin and yang (the cinnamon bark and aconite added to Rehmannia Six Formula to produce Rehmannia Eight Formula are said to restore yang). In laboratory animal studies, use of this formula resulted in reduction of water demand (thirst), blood sugar, and sugar spill into the urine. Jade Spring Pill (Yu Quan Wan ), a patent formula from China, is recommended for diabetes treatment in the dosage of 50 grams per day (the original form was large honey pills of about 6 grams each), for at least one month. In laboratory animal studies, this formula was shown to increase glycogen in liver cells. The Sichuan Province United Pharmaceutical Manufactory, developed a second generation of Jade Spring Pills comprised of pueraria, trichosanthes root, rehmannia, licorice, schizandra, and other herbs not mentioned on the label. These pills are indicated in the package labeling for the "ill function of the islets of Langerhans." The relatively small pills are packed into small bottles with a total of 6 grams each, and 20 bottles are packed in one box, accompanied by instructions to take one bottle each time, four times daily (the box is a five day supply at 24 grams/day). Compared to the first generation, it is said on the package insert, the new product had been clinically proved to have an improved rate of cure and that the dose had been reduced. Jade Spring Pill is useful for the early stage of diabetes, when yin deficiency and dryness dominate. In a recent clinical evaluation of a Chinese herb formula for diabetes, Jade Spring Pills, used for the control group, was reported to be effective in reducing blood sugar for 79% of cases treated (33). Several clinical trials have been reported in Chinese medical journals with brief English summaries appearing in Abstracts of Chinese Medicine (a Hong Kong publication produced from 1986-1996). A representative report is one that originally appeared in the Journal of the Zhejiang Traditional Chinese Medical College in 1989 (18). Patients were treated with a decoction containing astragalus, codonopsis, rehmannia, gypsum, salvia, persica, carthamus, red atractylodes, anemarrhena, and tang-kuei. This combination of qi and yin tonics plus blood vitalizing herbs is appropriate to treating patients with a middle stage disease showing some secondary symptoms. Modifications of the formula would also be made for the specific symptoms. The patients showed a variety of secondary manifestations of the disease, including nephropathy, peripheral neuropathy, dermatological disorders, retinitis, and liver cirrhosis. Among 19 non-insulin dependent cases treated, fasting blood glucose levels decreased from the pretreatment range of 160-300 mg% to 80110 mg%. One patient with insulin-dependent diabetes showed a decline in fasting blood sugar from 500 mg% before treatment to readings of 110-200 mg% after treatment. Generally, it was found that blood glucose decreased after 1-2 weeks of treatment and became steady after one month, and the blood glucose changes were followed by symptomatic improvements. A new patent formulation developed by the Chengdu University of Traditional Chinese Medicine and Pharmacology is made comprised of Gui Shao Dihuang Wan (Rehmannia Six Formula with tang-kuei and red peony) with added morus leaf, litchi seed, and coptis. The latter three herbs were recently demonstrated to be effective in lowering blood sugar (34, 35, 36).

DIFFERENTIAL THERAPY Although certain herbs have been identified as having hypoglycemic activity, Chinese physicians prefer using them in a formulation that addresses differential diagnosis rather than relying solely on herbs proven effective in laboratory tests. As an example of how the herbs are used in this context, the following is the strategy outlined by Lu Renhe in the treatment of 865 elderly patients with diabetes (41); the large number of patients allowed highly differentiated diagnostic categories. He first divided the disease into five stages, representing a progression from simple yin deficiency to complete break down of the body systems (note that "impairment" is more severe than deficiency, in that it involves active degradation):

I. Yin deficiency; preclinical stage. II. Yin deficiency produces internal heat; early clinical manifestation III. Impairment of both qi and yin; early stage of complications IV. Impairment of qi, yin, and yang; stage of intermediate complications V. Failure of qi, yin, and yang; stage of advanced complications The first four stages were subdivided into a total of 16 syndromes based on the organ systems affected and types of disorders generated by the basic pattern. Within each of these subcategories, the patients could further be grouped according to the severity of manifestation, but this did not influence the choice of herbs to use in treatment. For each pattern, a base formula of 8-12 herbs was presented (see Table below). Among the herbs used in the formulas listed in this table, there is frequent reference to a few that are known as hypoglycemic agents. These are (number of formulas that include each herb in parentheses): pueraria (12) rehmannia (8) trichosanthes (7) scrophularia (7) salvia (7) polygonatum (6) ho-shou-wu (6) ophiopogon (6) Aside from these herbs, some herbs were used with less frequency, but commonly relied upon for certain syndromes: coptis to clear heat achyranthes to vitalize blood circulation hoelen to remove dampness rhubarb to purge the intestines In the case of rhubarb-containing formulas, the rhubarb would be included only so long as constipation remains a problem; after that, it could be removed. Differential Treatment of Diabetes by Stage and Syndrome Stage; Syndrome (# of patients)

Principle of Treatment

Main Herbs

I. Yin deficiency causing hyperactive yang (9)

nourish yin, check exuberance rehmannia (raw), ho-shou-wu, of yang ophiopogon, pueraria, trichosanthes, haliotis, mother of pearl, coptis, achyranthes

I. Deficiency of yin with exuberance of liver (11)

replenish liver yin

II. Retained heat in the stomach and intestines (70)

dispel evil heat from the gypsum, calcite, chih-shih, stomach and intestine, protect adenophora, yu-chu, qi and yin rehmannia (raw), pueraria, trichosanthes, coptis, rhubarb

II. Stagnant qi of the liver transforming to heat (65)

disperse stagnancy of qi of the bupleurum, peony, red peony, liver and remove evil heat chih-ko, chih-shih, magnolia, pueraria, trichosanthes, coptis, scrophularia, rhubarb

II. Deficiency of spleen with accumulation of dampness and heat (50)

invigorate the function of the spleen, resolve dampness, assisted by removal of heat and diuresis

II. Retained heat in the lung forming toxic heat (20)

clear heat in the lung, remove adenophora, ophiopogon, toxin scute, morus bark, lonicera, forsythia, scrophularia, hoshou-wu, pueraria, trichosanthes, chin-chiu

rehmannia (raw), scrophularia, ophiopogon, peony, ho-shou-wu, pueraria, trichosanthes, licorice, salvia

red atractylodes, phellodendron, achyranthes, coix, polyporus, hoelen, magnolia, citrus, capillaris, pueraria, trichosanthes

III. Unrelieved dryness and reinforce the kidney, heat leading to impairment of replenish qi, overcome qi and yin of the kidney (80) dryness, invigorate blood circulation

polygonatum, rehmannia (raw), ho-shou-wu, scrophularia, pueraria, trichosanthes, salvia, achyranthes

III. Impairment of qi and yin causing lack of nourishment to the channels and conduits (90)

polygonatum, rehmannia (raw), ho-shou-wu, pueraria, red peony, salvia, dipsacus, chaenomeles, achyranthes, chin-chiu

reinforce the kidney, replenish qi, invigorate blood circulation, strengthen the pulse to restore flow of qi

III. Impairment of qi and yin reinforce qi, invigorate the astragalus, atractylodes, siler, damaging the spleen and lung spleen, replenish the qi of the morus bark, adenophora, (80) lung ophiopogon, scrophularia, persica, apricot seed, pueraria, chih-shih III. Impairment of qi and yin damaging the heart and spleen (50)

reinforce the kidney and replenish qi of spleen and heart

polygonatum, pseudostellaria, ophiopogon, schizandra, rehmannia (raw), coix, hoelen, salvia

III. Impairment of qi and yin resulting from persistent dampness (60)

regulate the center to resolve dampness, protecting the qi and yin

platycodon, atractylodes, magnolia, hoelen, citrus, pinellia, codonopsis, pueraria, coptis, capillaris, scrophularia, rhubarb

III. Impairment of qi and yin replenish qi, nourish yin, pseudostellaria, polygonatum, causing stagnancy in the liver remove stagnancy of the liver, scrophularia, rehmannia with blood stasis (65) resolve blood stasis (raw), bupleurum, peony, chih-ko, salvia, persica, polygonum fruit, schizandra, crataegus IV. Impairment of yin, yang, regulate and replenish yin and polygonatum, tang-kuei, and qi leading to stagnation of yang and activate the blood cibotium, dipsacus, phlegm and qi (50) chaenomeles, rehmannia (raw), red peony, clematis, gleditsia, centipede, pueraria, trichosanthes IV. Impairment of yin, yang, and qi causing lack of nourishment for the pectoral energy and sinews (30)

reinforce the qi, replenish the kidney, invigorate the yang, strengthen the sinews

American ginseng, deer antler gelatin, tortoise shell gelatin, pipefish, seahorse, cardamom, aquilaria

IV. Impairment of yin, yang, and qi causing lack of nourishment to the tendons and muscles (30)

reinforce qi, invigorate the spleen, nourish the liver and kidney

Astragalus, tang-kuei, pseudostellaria, atractylodes, polyporus, hoelen, salvia, cnidium, lycium, epimeidum, ophiopogon, pueraria, chaenomeles

IV. Impairment of yin, yang, and qi causing lack of nourishment to the stomach and intestines (40)

regulate and reinforce qi, move the bowels

polygonatum, tang-kuei, scrophulari, ho-shou-wu, peony, licorice, chih-shih, salvia, schizandra, cistanche

V. Failure of yin, yang, and qi attempt emergency treatment (85)

address specific manifestations of failure

DOSAGE AND FORM OF ADMINISTRATION The dosage of herbs applied to treatment of diabetes is often quite high. As revealed by the experience with Reducing Sugar Tablet A and Jade Spring Pills, a formula that is considered highly effective must be taken in dosages of about 12-24 grams per day even when presented as a highly condensed extract (made from about 40-80 grams of crude herbs) in convenient form. This apparent requirement is reflected in several books that recommend herbs in decoction form. In the book Clinical Experiences (19), a number of different decoctions are suggested. The dosages of the formulas range from that of an "experiential prescription" containing three herbs (astragalus, rehmannia, and dioscorea, 30 grams each in decoction) at a total dose of 90 grams per day, to a dozen herbs in each of three formulas for yin deficiency syndrome (each prescription contains rehmannia, ophiopogon, and scrophularia), with about 120-150 grams for one day. There is also presented in this book a modified Rehmannia Eight Formula for advanced cases showing yang

deficiency, with about 170 gram per day dosage. Added to Rehmannia Eight Formula are the antidiabetes herbs trichosanthes root, pueraria, salvia, and atractylodes. Regarding efficacy, it is stated that the early-onset type of diabetes responds poorly, but the insulin-independent type with slow onset responds favorably. In the book 100 Famous and Effective Prescriptions of Ancient and Modern Times (20), the Decoction for Diabetes (Yi Tang Tang ) is mentioned. It contains rehmannia, trichosanthes root, dioscorea, gypsum, ophiopogon, dendrobium, and seven other herbs. Taken as a decoction, the standard formula is made with 226 grams of herbs for a daily dose. This formula is usually prescribed with additional herbs to address specific symptoms, so that the total daily dosage often reaches 250 grams. In a study with 215 diabetic patients, it was reported that 62 cases were relieved of thirst, overeating, polyuria, and sugar in the urine; the fasting blood glucose declined to below 130 mg%. Additionally, 88 others had some degree of improvement (total effective rate: 70%). In the book Integrating Chinese and Western Medicine (21), four herb formulas are described: each of the formulas, a two day supply of herbs, is made with over 250 grams of herb materials (thus, over 125 grams/day). All four formulas contain twelve to thirteen herbs, and they all include pueraria, rehmannia, and salvia. Nothing is said directly about the degree of effectiveness of the formulas, but the text ends with the comment that certain pills "are also very effective," citing Rehmannia Six Formula, Jade Spring Pills, and Diabetes Pills (Xiao Ke Wan). I n A Clinical Guide to Chinese Herbs and Formulas (22), three formulas for diabetes are presented. The formulas are comprised of typical hypoglycemic herbs as mentioned above, and the dosage is usually 10-15 grams of each major ingredient, with 6-7 major ingredients, and a total dosage of about 100 grams per day. The formulas can be modified for specific symptoms, which might add about 10 to 30 grams of herbs. The large amount of raw materials apparently needed for treating diabetes may be a reflection of the need to consume several hundred milligrams of mixed non-toxic active components (e.g., flavonoids, saponins, alkaloids, iridoids, anthraquinones) derived from herbs to attain substantial physiological improvements within a typical treatment period of three months or less. It is expected that most of the anti-diabetic active constituents are present at a level of approximately 2% (or less) of the dried herb material. Decoctions that have 90-150 grams of materials (or more), might yield only about 2 grams of hypoglycemic constituents, perhaps an average of 250 mg of each chemical type. Condensing the active components will yield dried materials that must be taken at a level that is often still regarded as inconvenient by many. For example, dried decoctions (manufactured mainly in Taiwan and Japan) of mixed herbs typically yield a product that is about a 5:1 concentration factor (500 grams of raw materials yields 100 grams of finished product). Such materials are available in the West and often packaged in units of 100 grams. To obtain the equivalent of a dosage of 100 grams of crude herbs in decoction, one would consume about 20 grams of the dried extracts (a one day dose), and a bottle of herbs would be a 5 day supply. This is similar to the dosing for the second generation Jade Spring Pills described above, made of condensed extracts. Attempts have been made to isolate active constituents, as one way of making treatment more convenient, but one then loses several of the purported advantages of whole herbs and formulas. One item of current interest is the alkaloid berberine, which has many therapeutic uses, including treatment of hyperglycemia. Rats treated with alloxan and with berberine were less likely to show blood glucose rise and pathological change in the beta cells. Insulin-independent diabetes patients treated with 300-500 mg of berberine daily for one to three months (along with dietary control), showed definite reduction of blood sugar (23). Berberine is an active component of coptis and phellodendron, used in several diabetes prescriptions. A flavonoid-rich fraction isolated from guava leaves was extracted, made into tablets with 400 mg of the concentrate in each, and administered at a dosage of 6-12 tablets each time, three times daily (total daily dose is 7.2-14.4 grams), to produce hypoglycemic action (17). Flavonoids are active components of many herbs, though not necessarily the key components of most anti-diabetes herbs. Ginseng and its saponins have been studied in alloxan-treated, genetically diabetic, and normal mice (24), revealing a hypoglycemic effect; ginseng saponins also stimulate the production of insulin. In elderly patients with hyperglycemia, the saponins reduced serum glucose (25). Ginseng saponins are typically provided in tablets of 50 mg each, with a dose of 1-2 tablets each time, two to three times per day. Other saponins, such as those in platycodon and the Indian herb gymnemma, have been shown to lower blood sugar, and the dosing appears to be in a range of about 300 mg/day or more. Still, an article in the Journal of Traditional Chinese Medicine (26) suggests that a condensed blend of herbs can be prescribed in moderate dosage. This article described treatment of 102 cases of non-insulin-dependent diabetes, using the Gan Lu Xiao Ke capsule, with rehmannia, codonopsis, astragalus, ophiopogon, asparagus, scrophularia, cornus, tang-kuei, hoelen, alisma, and cuscuta. Patients were treated with the herbs for three months. The group average blood glucose level fell from an initial value of 200 mg% to 154 mg%. The dosage of material in the capsules was only 5.4

grams per day. However, the results were also modest (30% were markedly improved, 57% were improved, but the average blood sugar remained quite high), and patients would receive additional herbs to treat specific symptoms: those herbs, adding to the total dosage, might also contribute to the hypoglycemic action. Another example, was a report about treatment of persons with vascular complications of insulin-independent diabetes (e.g., coronary heart disease, vascular disease of the lower extremities, stroke, retinopathy, etc.). They were treated with a sugar-reducing, pulse-invigorating formula. Unfortunately, the ingredients were not specified other than astragalus and rehmannia; the formula is said to tonify qi, nourish blood, and vitalize blood. The herbs were simply powdered and given in capsules, at a dosage of 2-3 grams each time, three times daily (29). The treatment time was three months, and if the treatment was deemed effective, it would then be continued. Improvements in blood parameters were noted in 82% of the cases that fit the pattern of qi and yin deficiency (which the formula mainly addressed), but only about 63% for other cases (yin deficiency with fire, or yin and yang deficiency; the more advanced cases). Fasting blood sugar was maintained below 150 mg% for 77% of those treated. Further investigation is necessary to determine the minimum formula size (number of ingredients) and the proper dosage of those ingredients, as well as the best form (powdered herbs, extracts, or a combination) to get the desired effects. The use of nutritional supplements (9) and Oriental dietetic practices (10) might add to the benefits of herbal medicine prescriptions, a factor that has not yet been the subject of study.

COMBINING DIABETES DRUGS WITH HERBS There is no evidence that diabetes drugs and Chinese herb therapies are incompatible, but there is a concern that when combining the two, the blood sugar may decline too far. If the herbs are added gradually over a few days with continued monitoring of blood sugar, this problem can be avoided. When herbs successfully contribute to lowering blood sugar, drug dosage may be reduced under a physician's instructions. While Chinese literature sometimes mentions, in passing, the use of Chinese herbs along with modern drugs, specific strategies for combining the two are not commonly presented. A report on integrated Chinese and Western treatment of diabetes was published in 1987 (27). For insulindependent diabetics, a formula made with codonopsis, astragalus, atractylodes, rehmannia, ophiopogon, and lycium fruit was given (the formula tonifies qi and nourishes yin). For those with non-insulin-dependent type, they were treated with the same mixture either alone or with tolbutamide or glyburide. The herbs, prepared in liquid form, were given twice daily for three months. It was reported that the herbs exhibited a hypoglycemic effect and synergized with insulin and other drugs. For the group of 53 patients treated, the average fasting blood glucose at the beginning was 177 and at the end of the three months was 135. In another clinical trial (18), a group of 10 patients was identified who had responded poorly to Western drugs and also failed to respond to Chinese herbs. They were then given both the herbs and drugs concurrently. Significant improvements were observed in eight of the ten patients. Further, ginseng is reported to reduce the dosage of insulin needed by patients and to prolong the action of a dose of insulin (13).

ACUPUNCTURE FOR DIABETES Acupuncture therapy is a common approach to treating diabetes in China. Many Americans assume that acupuncture is only suitable for treating pain, perhaps because the initial introduction of acupuncture was mainly for this application. Indeed, the general opinion here appears to be that acupuncture ought to be used mainly for treating chronic back pain. Therefore, relatively few people have turned to acupuncture for treating the disease. Increasingly, people with pain and other health problems for which acupuncture is selected also have diabetes. A report in the 1994 Journal of Traditional Chinese Medicine (37) serves as a model of Chinese research on acupuncture. The researchers recruited 60 patients with diabetes and divided them randomly into two groups: the acupuncture group (38 patients) and the control group (22 patients); the two groups were found to be well matched for symptoms and laboratory results (blood and urine tests). Both groups followed a regulated diet during the study, but one group received acupuncture. Electrical stimulation of the needles was used (this method replaces twirling the needle by hand and provides a pulsating stimulus that can be continued for the entire treatment period). Acupuncture was administered once a day for 30 days. The main acupuncture points used were quchi (LI-11), sanyinjiao (SP-6), zusanli (ST-36), and yishu (special diabetes point located at 1.5 cun lateral to the lower border of the spinous process of the 8th thoracic vertebra). Supplemental points include yuji (LU-10), guanyuan (CV-4), and baihui (GV-20). For the control group, a well-known herbal pill, Xiaoke Wan or Diabetes Pill, was administered. This pill had been the subject of earlier study and the level of effectiveness was already established. The patients were not using diabetes drugs during the trial except for 8 patients who required insulin injections. To evaluate the effects of treatment, three levels of responses were defined. Patients who experienced markedly effective results were those who had their initial symptoms essentially disappear by the end of the one month treatment and their fasting blood-sugar levels had dropped

below 130 (or the blood sugar two hours after a meal would be below 150). Further, the 24-hour, urine-sugar content was reduced by 30% or more at the end of treatment compared to beginning of treatment. These patients were not "cured" of diabetes but they showed very evident improvements. For those deemed effectively treated (not markedly effective), symptoms were improved but not gone, and fasting blood-sugar levels dropped to below 150 (or two hours after meals below 180), and the 24-hour, urinary-sugar excretion declined by at least 10% from initial values (but not up to 30%). If these standards could not be met, then the treatment was deemed ineffective. All but two of the patients showed declines in blood sugar and urinary sugar excretion and improvements in symptoms. More than one-third of the patients had marked improvement. For the 38 participants in the acupuncture group, there were 25 cases rated markedly effective and 10 cases rated effective: nearly 2/3 of the patients treated showed marked improvement and only three patients failed to respond. Further, it was reported that the patients receiving acupuncture experienced a statistically significant decline in cholesterol, triglycerides, and beta-lipoproteins. The drop in triglycerides was most substantial, with a decline from an average value of 151 at the start to 117 one month later (a decline of more than 20%). There were significant improvements in "nail-fold microcirculation," which is a measurement of blood circulation through capillary beds (poor circulation through these beds is one reason persons with diabetes suffer from skin ulceration), which has also been observed in other diabetes studies (11, 12). Among those who were using insulin, the amount needed after the 30 days of acupuncture declined in six of the eight individuals; in two of those cases, the insulin could be stopped altogether. The objective of the study was to show the benefits of acupuncture, using a common patent pill for the control group. Among the 22 participants who took the diabetes pill, there were 8 cases rated as markedly effective and 12 cases as effective (2 ineffective). In both the acupuncture and herb pill groups, most patients responded well. The authors of the study concluded: "the therapeutic effects of acupuncture on diabetes are similar to those of the diabetes pills, however, acupuncture excels in the prevention of complications, especially cardiovascular diseases." In another study, the acupoint sanyinjiao (SP-6) was used as the primary treatment, with adjunctive points according to syndrome differentiation for 30 patients with diabetes (38). Among the common adjunct points were feishu (BL-13) plus sanjiaoshu (BL-22) for thirst and dryness of the mouth; zusanli (ST-36) for hunger; and taixi (KI-3) plus shenshu (BL-23) for polyuria. Treatment was administered once daily for 12 days as a course of treatment, then a 2-3 day break before starting another course. Needle retention was for 30 minutes following getting the qi sensation. The author noted that the effectiveness of treatment (evaluated as reduction of blood sugar to normal or near normal) was better for younger patients than for older patients and that it generally took 2-3 courses of treatment to get optimal results. He pointed out that diabetes may be due to a combination of deficiency syndrome of qi and yin complexed with blood stasis: "Sanyinjiao is the crossing point of the liver channel, spleen channel, and kidney channel, which has the actions of supplementing qi, nourishing yin, and removing blood stasis. Acupuncture of sanyinjiao can therefore regulate the level of blood sugar in the body." Differentiation of the disease manifestation with corresponding acupuncture for each syndrome was reported by Liu Zhicheng and Sun Fengmin of the Nanjing College of Traditional Chinese Medicine (39). Their treatment patterns are summarized in the table below: Syndrome (Number of Patients) Dry heat in the lung and stomach (33)

Principle of Treatment clear away heat, moisten and promote production of body fluids

Main Points (Body Points) feishu (BL-13), weishu (BL21), neiting (ST-44), zusanli (ST-36)

Dry intestines and impairment nourish yin, irrigate the of body fluids (13) intestines

quchi (LI-11), fenglong (ST40), zhigou (TB-6), zhaohai (KI-6)

Damp-heat of spleen and stomach (7)

clear away heat, resolve damp, activate the stomach, strengthen the spleen

zhongwan (CV-12), zusanli (ST-36), tianshu (ST-25), neiguan (PC-6)

Stagnation of liver qi (10)

relieve the depressed liver, regulate circulation of qi, promote blood circulation, remove stasis

taichong (LV-3), quguan (LV-8), ganshu (BL-18), xuehai (SP-10)

Deficiency of spleen qi and kidney qi (4)

invigorate the spleen and replenish qi

pishu (BL-20), weishu (BL21), zhongwan (CV-12), zusanli (ST-36)

Deficiency of liver and kidney yin (6)

nourish liver and kidney

taichong (LV-3), taixi (KI-3), shenshu (BL-23), guanyuan (CV-4)

Deficiency of spleen yang (6) warm and invigorate the spleen and kidney

mingmen (GV-4), guanyuan (CV-4), zusanli (ST-36), yinlingquan (SP-9)

Deficiency of lung qi and spleen qi (5)

feishu (BL-13), pishu (BL20), taibai (SP-3), taiyuan (LU-9)

warm the spleen and nourish the lung to replenish qi

The authors concluded that the best results were attained in younger patients and those with milder disease manifestation. In a review article on acupuncture treatment of diabetes (40), Hu Hui, of the Dongzhimen Hospital of the Beijing TCM University, observed that points are usually selected among back s h u points (e.g., the bladder meridian points), front mu points (e.g., the conception vessel points), and limb points (e.g., spleen, stomach, kidney, and liver points). He listed the most commonly used points as: feishu, pishu, shenshu, zusaanli, sanyinjiao, guanyuan, taixi, zhongwan, geshu, yishu, quchi, hegu, shenmen, diji, neiguan, xuangzhong, fuliu, jinjin, yuye, and chengjiang.

APPLYING THE ACUPUNCTURE TECHNIQUES HERE In the U.S., it is uncommon for people to receive acupuncture therapy every day, as is the method used in the clinical studies reported in the Chinese medical journals. Instead, one may undertake a course of therapy with acupuncture once or twice per week. Needless to say, the impact of the intermittent treatment is not as great as with daily acupuncture. However, through the combination of the less frequent acupuncture and the daily ingestion of herbs, one might reasonably expect to accomplish results comparable to those reported in China where the majority of patients get some degree of blood sugar normalization and relief of symptoms. Best results are expected for younger individuals and those who have had diabetes for only a few years. Most acupuncturists in the U.S. have not been called upon to treat many patients with diabetes, mainly because of the misconception that acupuncture is not suitable for that disorder. Nonetheless, acupuncturists are in a position to provide expert treatment because the points to be needled are also used (in various other combinations) for treating other disorders. For example, the acupuncture point zusanli (called Stomach-36; located on the lower leg) is one of the most commonly used points for chronic diseases and is used especially when the disease is obviously affected by dietary factors. All of the acupuncture points listed above have been used in the U.S. and other countries. The needling techniques reported for the diabetes treatments are also essentially the same as used world-wide, without requiring special additional training.

REFERENCES 1. Maoshing Ni, The Yellow Emperor's Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA. 2. Hong-Yen Hsu and Su-Yen Wang (translators), Chin Kuei You Lueh, 1983 Oriental Healing Arts Institute, Long Beach, CA. 3. Hong-Yen Hsu and Peacher WG, Chen's History of Chinese Medical Science, 1978 Oriental Healing Arts Institute, Long Beach, CA. 4. Xie Zhufan and Huang Xiokai (eds.), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong. 5. Hong-Yen Hsu and Chau-Shin Hsu, Commonly Used Chinese Herb Formulas with Illustrations, 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA. 6. Hong-Yen Hsu, Chinese herb therapy for diabetes mellitus, Bulletin of the Oriental Healing Arts Institute 1978; 3(1): 12-17. 7. Chen DC, et al., Clinical and experimental studies in treating diabetes mellitus by acupuncture, 1994 Journal of Traditional Chinese Medicine; 14(3): 163-166. 8. Clayman CB (ed.), AMA Encyclopedia of Medicine, 1989 Random House, New York. 9. Werbach, MR, Nutritional Influences on Illness, 1993 Third Line Press, Tarzana, CA. 10. Lu He, Chinese System of Food Cures, 1986 Sterling Publishing Co. Inc., New York. 11. Guo SS, et al., Changes in tongue color and whole blood viscosity in diabetics treated with Yiqi Yangyin Huoxue Fang, Journal of traditional Chinese Medicine 1989; 30(2): 9798. 12. Han DW and Xu RL, Progress in the research of blood activation and hemostasis removal, Abstracts of Chinese Medicine 1988; 2(4): 466-483. 13. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore. 14. Zhu KY, Guo SS, Liang XC, Diabetes mellitus treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1983; 1: 24-30. 15. Li Yucai, et al., Treatment of 33 cases of diabetic ketonuria with Jiang Tong Tang, New Journal of Traditional Chinese Medicine 1989; 21(2): 20-22.

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December 2002

ACCESS: Seven Forests herb formulas are available only by prescription from a licensed health care professional. You can find a practitioner who can prescribe Chinese herbs here Further information links: CDC site for diabetes information and other helpful links: http://www.cdc.gov/diabetes/faqs.htm For more information about Liuwei Dihuang Wan, see the article: Rehmannia Six Formula. To provide your comments [no medical consultations can be offered], e-mail: [email protected]

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TREATMENT OF CHRONIC DIARRHEA WITH CHINESE HERBS AND ORIENTAL DIET THERAPY by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Diarrhea refers to a condition of frequent bowel movements, involving mushy, loose, or watery stool. The disorder can be subdivided into broad categories of acute diarrhea and chronic diarrhea. Acute cases can be induced by eating foods that cause a gastro-intestinal reaction resulting in about one day of diarrhea; alternatively, it can occur as a result of the activity of pathogenic organisms contaminating food and/or beverages, which may cause symptoms lasting anywhere from a day (with certain bacteria) to ten days (with other bacteria or viruses). With protozoal and other organisms that remain in the intestines, a persisting, cyclically recurring problem may last for many weeks. The infections and parasites may die off spontaneously, or may survive without causing continued symptoms, but the persisting cases of diarrhea usually require, and often respond to, therapies that inhibit or destroy the offending organisms. Acute intestinal disorders may also occur secondary to certain non-intestinal diseases, including flare-up of chronic liver or gallbladder disease. Chronic diarrhea may be initiated by an acute disorder that, by some means, becomes self-reinforcing so that it does not clear up over time. Lasting for months or years, modern medical tests may show no obvious infections of the intestinal tract nor imperfections in the structure of the intestinal lining; by contrast, when part of the bowel is surgically removed or has been damaged by a disease, chronic diarrhea can be attributed to those specific causes. The condition of recurrent diarrhea is becoming more common as a consequence of the high rates of diabetes; the elevated blood sugar can trigger the reaction. There is elevated risk of developing hemorrhoids with frequent bowel movements, so this can be a secondary manifestation of the intestinal disorder. Drugs that reduce intestinal motility may provide temporary relief, but the bowel problem usually returns when the drugs are discontinued (and, sometimes, continues to occur even with regular use of the drugs). In some cases, chronic diarrhea is accompanied by fecal incontinence, which is a different disorder: the anal muscles are unable to retain closure. When the two disorders combine, as occurs with some chronic diseases and with the deterioration of aging, the result is very distressing and debilitating for the person who suffers from it. Chronic diarrhea, because of its weakening effects, may eventually lead to incontinence. Chronic diarrhea is differentiated from other diseases that may include bouts of diarrhea, such as irritable bowel syndrome (often characterized by constipation interrupted by temporary diarrhea induced by dietary, emotional, or other factors) and ulcerative colitis or Crohn’s disease (in which there is a marked pathology of the intestinal wall associated with autoimmune processes, and worsened by nervous system hyperactivity). These disorders are discussed elsewhere (see: Irritable bowel syndrome; Jian Pi Ling and treatment of ulcerative colitis). Two abnormal processes are of primary concern: Insufficient absorption of water from the colon, and, sometimes, insufficient breakdown and absorption of other food substances, such as fats and complex carbohydrates from the small intestine; Excessive intestinal peristalsis, which moves the fecal material through the intestines more rapidly than usual, reducing time for absorption of fluids and nutrients and passing the material to the rectum in a relatively short time (a few hours). Chinese medicines may beneficially impact both these processes. ORIENTAL VIEW Normally, the purified qi derived from food and drink is transported upward by the spleen to the lung, while the leftover food matter is passed to the intestines for further separation and eventual elimination of the waste materials. The fundamental cause of persisting diarrhea, according to the ancient Chinese medical texts, is the descent of clear splenic qi. If significant additional dampness is also retained with the descending clear qi, then the condition will be more severe. Why does the spleen qi descend rather than ascend? There are three traditionally recognized causes. According to Jingyue Chuan Shu (A Complete Collection of Jingyue’s Works , 1624 A.D.): “Diarrhea is the result of an improper diet, seasonal pathogenic factors, and retained cold [that occurs] after eating raw or cold food (1).” These may be explained as follows: 1. Improper diet (see the section on Oriental diet therapy below), including overeating, not chewing food adequately, irregular meal schedules, or eating the wrong types of foods according to constitutional and disease status indications, disturbs the function of the spleen and then also burdens the intestines with foods that are difficult to separate. It is a case of overwhelming the normal functions of the spleen; 2. Cold foods impair the spleen by overly chilling it (warmth aids the rise of qi, coldness its descent) and raw foods may contain large amounts of indigestible fiber and, more importantly, live pathogens, all of which can contribute to rapid intestinal transit. The “cold spleen” is functionally restricted; 3. Seasonal pathogenic factors, especially dampness and the heat/damp combination that was often experienced in the summer (see The six qi and six yin), overwhelm the spleen’s natural function of separating and dispersing moisture; summer heat syndrome refers primarily to the result of consuming contaminated foods and drinks rather than to the time of year or the temperate conditions, which is when the contamination most

often occurred. With these possible initiating causes of diarrhea, the persisting case is seen to arise primarily because of spleen yang and kidney yang deficiency syndromes. The spleen yang is unable to distribute the qi upward, so the qi descends with the turbid food residues. The kidney yang is unable to warm and invigorate the spleen, so recovery of normal function of the spleen and regularity of the bowel conditions cannot easily occur. The pathogenic organisms are not eliminated because the qi—lacking the vigor of spleen and kidney yang—can not fight them. Diarrhea experienced over an extended period of time further weakens the yang, because of its repeated downward draining of qi, thus perpetuating the symptom. Yang deficiency is often experienced by the elderly and by those who have suffered chronic diarrhea for a very long time, but can occur at any age. In a clinical report on chronic diarrhea in children (2), the role of spleen yang deficiency in those cases is emphasized: Chronic protracted diarrhea in children is mainly caused by improper feeding, infantile dyspepsia, insufficiency in physical constitution, debility, as well as improper treatment of acute diarrhea. Exhaustion of qi and injury to yang often follow long-lasting diarrhea, and hence the theory “persistent diarrhea will injure the spleen yang.” When the spleen yang is impaired, water and food will be unable to be digested, metabolized, transformed, and transported. These will, in turn, induce accumulation of water and turbidity, and disorder in the ascending and descending functions. As a result, diarrhea becomes protracted and difficult to cure. The crux of the disease is the insufficiency of the spleen yang, therefore, the key point in the treatment of the disease is to warm up and invigorate the spleen yang and restore the normal function of transformation and transportation of the spleen. In a report on the spleen/stomach system of Chinese medicine and how it affects intestinal functions (3), it was noted that: Lack of, or poor, ascending circulation [of the spleen qi] is due to irregular meals and improper food intake, emotional trauma and mental or physical exhaustion. Any of these factors damages the spleen yang qi, resulting in dysfunction of splenic circulation and transformation, and weak ascending power. Accompanying signs are manifested in chronic gastritis, chronic enteritis, dysfunction of the stomach and intestines, chronic hepatic or biliary tract diseases, malnutrition, and general degeneration and weakness or ptosis of internal organs. The inability of the spleen to perform healthy circulation is due to poor ascension of the spleen yang qi and may be manifested as deficiency and weakness of spleen qi, as dormant spleen yang, or as sinking of the central qi....The kidney yang is also known as the fire of life gate [mingmen]. It has a propulsive action in the digestive function of the spleen and stomach. If there is an insufficiency of the life gate fire, the digestive function of the spleen and stomach is reduced, with accompanying signs of spleen and kidney yang deficiency complex, such as edema, cold abdominal pain, prolonged diarrhea, early morning diarrhea, or stool with undigested food particles may occur. In the widely used text Formulas and Strategies (4), there is described an “abandoned disorder” from the loss of fluids that occurs through chronic diarrhea, which involves a cycle of debilitating effects: In such cases, the spleen qi has become deficient and the intestines have lost their stability and capacity to absorb. This results in unremitting diarrhea to the point of incontinence....Long term diarrhea not only leads to deficiency of the spleen qi and yang, but also invariably involves the kidneys. This aggravates the diarrhea, which further injures the spleen and kidneys, which in turns worsens the diarrhea, and so on in a vicious circle. Even when initiated by a pathogenic organism, this debilitating cycle could only be partially rectified by removing the offending organism through drug therapy: the spleen and kidney would still be severely weakened. When drug therapies aimed at eliminating parasites and other organisms that cause diarrhea are ineffective, it may be that any microorganisms that participated in the early stages of diarrheal disease are now gone, but the weakness persists. The description in Formulas and Strategies continues: When the spleen and kidneys are deficient and cold, there is fatigue and lethargy as well as mild, persistent abdominal pain that responds favorably to local pressure or warmth. When the spleen is weak, the appetite declines, food intake is reduced, and the complexion becomes wan. Kidney yang deficiency is further expressed in the sore lower back and lack of strength in the legs. The pale tongue with a white coating, and the slow, thin pulse are indicative of deficiency yang of the spleen and kidneys. In another section of the book, it is also stated that “Chronic diarrhea depletes the fluids, which exhausts the yin and blood.” Thus, an overwhelming debility of yin, blood, and yang may eventually arise. Chinese Herbal Treatments The fundamental principles of treatment involve warming the spleen and kidney yang, dispersing the excessive dampness, and astringing the discharge (stabilizing the intestines). An example of a formula recommended for chronic diarrhea is Zhenren Yangzang Tang . The formula consists of ginseng (or codonopsis), atractylodes, cinnamon bark, nutmeg, terminalia, papaver, peony, tang-kuei, saussurea, and licorice. For patients with extreme cold condition, aconite and dry ginger are added to the herb formula. Since papaver (poppy capsule) is not available for use in the West, the patient would take a drug substitute, such as opium tincture or loperamide. When taking the formula, in order to obtain desired results, one should not consume “alcohol, wheat, cold or raw foods, fish, and greasy foods.” These restrictions illustrate the importance of linking diet therapy with herbal therapy.

In presenting the famous herb formula Sishen Wan (Psoralea and Nutmeg Formula), there is this preliminary discussion of diarrhea associated with spleen and kidney deficiency in Formulas and Strategies: When the yang of the spleen and kidneys is deficient, there is a lack of interest in food; and because the deficient spleen yang is unable to cook or decompose the food, what is eaten is not digested....When the yang is deficient, the spirit cannot become fully animated. This lack of animation is manifested as fatigue, lethargy, and a dispirited demeanor. The formula is comprised of psoralea, evodia, nutmeg, and schizandra; the first two ingredients being quite warming, and the latter two being astringents. The pills made from these herbs, ground to powder, are prepared with dry ginger and jujube. Aconite and cinnamon bark can be added when the diarrhea and cold conditions are extreme: “When the spleen and kidneys are warmed and the large intestine is stabilized, the transformation and transportation of foodstuffs will resume, and the diarrhea will cease.” An alternative formulation relies on psoralea and nutmeg combined with fennel and saussurea. Saussurea is used in some of the diarrhea formulas “because of its specific ability to alleviate tenesmus [intestinal cramping]. It also prevents the astringent, binding properties of the other herbs from causing stagnation.” Shen Ling Baizhu San (Ginseng and Atractylodes Formula), a well-known formula for spleen qi deficiency and diarrhea, is described in Formulas and Strategies as indicated for “loose stools or diarrhea, reduced appetite, weakness of the extremities, weight loss, distention and a stifling sensation in the chest and epigastrum, pallid and wan complexion.” The formula contains ginseng, atractylodes, hoelen, licorice, coix, dolichos, dioscorea, lotus seed, platycodon, and cardamom. Using modern research methods, it was shown that a formula similar to Ginseng and Atractylodes Formula, called Qinggong Baxian Gao (Qing Court Eight Immortals Paste), promotes the absorption of fats and complex sugars, compounds that, when malabsorbed, contribute to diarrhea. In laboratory animal experiments, this herb formula helped heal intestinal ulceration and restored vigorous growth of the duodenal mucosa with just two weeks daily treatment. Among its ingredients are ginseng, hoelen, lotus seed, coix, and dioscorea. Zhao Lichen and Chen Fang (5), in an article on food therapy for diarrhea, mention the following general treatment principles: use fragrant herbs to dissolve the turbidity [especially for summer-heat type disorder] clear heat and promote the removal of wetness [especially for damp-heat type of disorder] support the spleen and restrict the liver [especially for liver qi stagnation affecting the spleen] warm the kidney and strengthen the spleen [especially for chronic diarrhea] use astringent measures for consolidating the intestines and arresting diarrhea [for all types of diarrhea] They have recommended some sample food therapies, mentioned below, but these principles can be utilized to formulate an herbal prescription. For example, the following combination (to be made as a decoction or granule mixture) is a means to possibly halt the persisting diarrhea: Codonopsis (dangshen) Atractylodes (baizhu) Coix (yiyiren) Lotus seed (lianzi) Dioscorea (shanyao) Psoralea (buguzhi) Nutmeg (roudoukou) Terminalia (hezi) Peony (baishao) Saussurea (muxiang) Licorice (gancao)

14% 10% 10% 9% 9% 9% 9% 8% 8% 8% 6%

The ingredients have multiple actions on the spleen and intestines. Atractylodes, nutmeg, and saussurea are fragrant herbs that help resolve turbidity; coix and peony are cooling herbs that reduce heat in the intestines; codonopsis, atractylodes, and licorice support the spleen; psoralea warms the kidney; nutmeg, terminallia, dioscorea, and lotus seed are astringents. The dosage is 2 teaspoons (about 6 grams) of granules each time, three times per day (or, in decoction form, about 120 grams of crude herbs made into tea and consumed in 2–3 doses per day). The patient may also take drugs (e.g., Imodium) in the initial phase of treatment to assure control over the symptoms. SAMPLE CLINICAL TRIALS Li Fandong reported on the Chinese medical analysis and treatment of 108 middle-aged and elderly patients suffering from chronic diarrhea who did not reveal any intestinal infection upon stool culturing (6). According to the report, 42 of the cases could be classified primarily as belonging to the spleen/cold deficiency cold type, while 66 cases could be classified primarily as belonging to the kidney yang deficiency type (spleen yang deficiency was also present); the average age of the latter group was 5 years older than the former (61.3 years vs. 56.2 years). The basic treatment was a modified Fu Gui Lizhong Tang, with the following formulation: Aconite (fuzi) Ginseng (renshen) Atractylodes (baizhu)

30 grams 15 grams 15 grams

Cinnamon bark (rougui)

30 grams

Dry ginger (ganjiang) Licorice (gancao)

10 grams 10 grams

The dose of aconite and cinnamon bark were doubled for the kidney yang deficiency type. The herbs were decocted, administered in two divided doses per day, and patients were treated for 6 weeks. According to the reporting physician: Most of the cured cases had their abdominal pain beginning to be reduced after one week of treatment; three weeks later, defecation frequency decreased. One patient of the kidney yang deficiency type presented a slight burning sensation in the stomach after initiating therapy, but after continuing daily use of the formula for one week, that symptom was eliminated, and no other ill effects of treatment were noted. There were 78 patients said to be cured of their diarrhea with no relapse six months afterward and 18 patients who had reduced diarrhea symptoms, but continued to have more frequent than normal bowel movements. In a clinical report on treatment of intermittent diarrhea associated with diabetes, Weng Jianxin recommended a basic formula that he considered useful both for regulating blood sugar and reducing diarrhea (7): Codonopsis (dangshen) Dioscorea (shanyao) Atractylodes (baizhu) Coptis (huanglian) Pomegranite leaf (shiliuye) Psoralea (bughuzhi) Nutmeg (roudoukou) Astragalus (huangqi) Terminalia (hezi)

15 grams 30 grams 10 grams 5 grams 10 grams 10 grams 10 grams 20 grams 10 grams

The formula could be modified for other health problems that coexisted with the diabetes. The treatment time was one month, using this formula as a decoction daily; 40 patients were so treated, average age of 65 and average duration of diarrhea was three months. For 70% of the patients, they were able to have just one formed stool per day, and the effects persisted for six months during follow-up after ceasing use of the decoction. DIET THERAPY According to the Chinese concepts, certain foods are to be avoided, others to be sought out (8). The ones to be avoided include those with high fiber (e.g., celery); those which are greasy (e.g., pork); those that are cold (e.g., chilled drinks, ice cream); those that are slippery or mucilaginous in quality (e.g., most fish, soft fruits); those that increase dampness (e.g., alcohol); and those that contain wheat (e.g., bread, cake, etc.). Recommended foods include those items that are bland and easy to digest (e.g., rice, millet); those that are warming (e.g., things cooked with ginger or ginger tea); and those that are astringent (e.g., lotus seeds). Eating habits can also contribute to chronic diarrhea. For example, patients with chronic diarrhea sometimes note the passage of undigested foods in the stool. This is interpreted as weakness of the digestive system, but is, in fact, most often a sign that the food has not been chewed adequately, leaving identifiable pieces of food to pass through the gastro-intestinal system. Inadequate chewing reduces the digestibility of all foods, and may result in increased peristalsis as the intestines react to the presence of large food particles and fermenting food materials that would otherwise have been digested first. Excessive eating also can contribute to chronic diarrhea. Large meals are poorly digested and the mass of food will stimulate intestinal peristalsis. Zhao and Chen, in their article on food therapy, recommend the following porridges: Coix (30 grams, fried in advance) and ordinary rice (50 grams) Lotus seed (20 grams, fry in advance and powder) and ordinary rice (50 grams) Dioscorea (30 grams), citrus (6 grams), and ordinary rice (50 grams) Roasted ginger or dry ginger (6 grams) and ordinary rice (50 grams) Dioscorea (30 grams) and glutinous rice (60 grams, fried in advance). Guava leaves (10 leaves, chopped in small pieces) and ordinary rice (50 grams, fried to yellow color) Crataegus (20 grams, fried in advance), raw ginger (3 slices), brown sugar (15 grams) Red date (10 grams, without seeds; boil in advance) and saussurea (9 grams). In sum, the patient should avoid or minimize use of the restricted foods, and rely instead on rice, millet, coix, lotus seeds, and other bland foods, vegetables, low-fat meats, and appropriate fruits (e.g., apples: these contain pectin; the astringent crab apples are especially recommended by Chinese dietitians; crataegus, especially for persons with fat malabsorption problems and those who are obese). It should be noted from Western research that, for those who have lost weight due to diarrhea, zinc deficiency should also be treated, as diarrhea contributes to lowered zinc levels and this also reduces the ability to taste foods, hence having an appetite-reducing action and furthering the loss of weight.



Terminalia, another commonly used herb for diarrhea; it is an astringent. Terminalia is often combined with nutmeg, dioscorea, and lotus seeds as mild astringent herbs.

Atractylodes, one of the commonly used herbs for diarrhea; it tonifies the spleen and dries dampness. Atractylodes is often combined with ginger and either ginseng or codonopsis to aid spleen function.

REFERENCES 1. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology (vol. 3), 1996 New World Press, Beijing. 2. Yang Shouping and Jiang Yuren, Application of Xiang Cheng San in treatment of chronic protracted diarrhea in children, Journal of Traditional Chinese Medicine 1995; 15(3): 214–219. 3. Cheung CS and Belluomini J (translators/editors), Spleen, stomach, and intestines, Journal of the American College of Traditional Chinese Medicine 1983; 4:27–49. 4. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. 5. Zhao Lichen and Chen Fang, Food therapy for diarrhea, Journal of the American College of Traditional Chinese Medicine 1984; 1:22–25. 6. Li Fandong, Diarrhea without pathogenic microbes in middle aged and elderly patients treated with Fuling Lizhong Tang, Journal of Traditional Chinese Medicine [Chinese] 1996; 37(3): 169. 7. Weng Jianxin, Treatment of senile diabetic diarrhea with traditional Chinese drugs, Journal of Traditional Chinese Medicine 1999; 19(4): 264–267. 8. Liu Jilin and Peck G, Chinese Dietary Therapy, 1995 Churchill Livingstone, London. July 2010

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INTERNET JOURNAL OF THE INSTITUTE FOR TRADITIONAL MEDICINE AND PREVENTIVE HEALTH CARE Chinese Herbal Therapy for Endometriosis

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Web Posting Date: May 2002 Key medical terms: endometriosis, endometrium, dysmenorrhea, laparoscopy, amenorrhea Key Chinese medical references: blood stasis, qi stagnation, cold syndrome, kidney yang deficiency Drugs: gossypol, Danazol, Lupron, Buserelin, Goserelin, Nefarelin, methyltestosterone, medroxyprogesterone Western herbs: cotton root Chinese herbs: succinum, rhubarb, turtle shell, trogopterus, typha, sparganium, zedoaria, myrrh, frankincense Chinese formulas: Shixiao San, Shaofu Zhuyu Tang, Xuefu Zhuyu Tang, Neiyi Wan Chemical constituents: sterols, aucubin, iridoids, triterpenoids SUMMARY: Endometriosis occurs in women after menarche and usually involves severe abdominal pain due to bleeding and tissue sloughing from endometrial cysts in the pelvic cavity. Modern treatments include surgical removal of the cysts and hormonal blockage, but these therapies are often not satisfactory. In China, endometriosis is sometimes treated with the herbal drug gossypol, claimed to be superior to Danazol, but which has too many side effects to be used in the West as an herb therapy. Complex, non-toxic herb formulas are also used in China and these could be used world-wide. Most of those formulas involve treatment of a blood-stasis syndrome, often with a combination of herbs (e.g., rhubarb, typha, salvia) and animal substances (e.g., turtle shell, leech). The Chinese researchers report a significant success rate in alleviating endometriosis symptoms when using these formulas. The historical development of Chinese herb therapy for endometriosis is reviewed here to illustrate the thinking of Chinese herb specialists as to how this disorder should be treated. Chinese herbs for endometriosis are usually prescribed by licensed health professionals, such as acupuncturists, who determine which of the formulas would be best to use and how to alter them, if necessary, throughout the menstrual cycle.

CHINESE HERBAL THERAPY FOR ENDOMETRIOSIS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Endometriosis is named after the tissues lining the uterus, called the endometrium. The uterine endometrium is shed during each menstrual cycle. Endometriosis develops from endometrial tissue that is in the pelvic cavity outside the uterus. This tissue adheres to various pelvic organs, it responds to the hormones of the menstrual cycle (especially estrogen), and sloughs tissue and blood as does the endometrium of the uterus. However, unlike menstrual bleeding, the blood and displaced cells from these abdominal segments of endometrium have no means of being discharged. This results in layers of fibrous tissue developing from the sloughed material which then form masses that can grow to considerable size. These cyst-like masses are called pseudocysts, which usually appear dark blue to brown (the latter called "chocolate cysts"); the endometrial tissues may appear, instead, as lesions prior to formation of the fibrous surrounding tissue. The primary symptom of endometriosis is dysmenorrhea (severe pain during menstruation), while additional symptoms that can arise include increased menstrual bleeding, pain during intercourse, general pelvic pain (possibly due to adhesions), and changes in bowel conditions with menstruation (due to cysts adhered to the intestine; there can even be rectal bleeding). The possibility of having endometriosis is suggested by such symptoms, particularly severe pain during menstruation, but it is confirmed only by laparoscopy, which is the insertion of a small viewing tube into the abdomen. It is common practice to perform laparoscopic surgery (laparotomy) during the diagnostic procedure, thus removing some of the cysts as they come into view, using tiny knives or lasers attached to the viewing tube to release them and aspirators to remove them. Endometriosis is one of the major causes of dysmenorrhea. This painful symptom of endometriosis often occurs two to three years after initiation of the menstrual period, though sometimes it is delayed for several years if the cysts are small or if the biochemical changes associated with symptoms, such as unusual prostaglandin and endorphin levels, are not very great.

According to retrospective studies, 41-43% of women with endometriosis report experiencing dysmenorrhea before age 20. Pain during periods eventually affects nearly all of those who have symptomatic endometriosis, and about 60% of these women also have abdominal pain between periods (e.g., with bowel movements and/or with intercourse). A heightened awareness of endometriosis came about largely as the result of an intense interest in treating infertility that developed during the 1980s as more women delayed childbearing into their 30s and were then surprised to have difficulty becoming pregnant. Current estimates are that 30-47% of women suffering from this disorder are infertile and, conversely, that about 30-50% of all infertile women have endometriosis. It is not always clear, however, that endometriosis is the cause of infertility, or was merely diagnosed because infertility was already a concern and possibly due to other causes. Fertility in women begins to decline, on average, starting at age 27, and first diagnosis of endometriosis is often after this age. Endometriosis sometimes vanishes altogether with a pregnancy, or disappears for a while only to return later; it does fade with menopause. Estrogen replacement therapy for menopause can cause endometrial hyperplasia and restimulate endometrial cysts, but combined therapies with progesterone and its derivatives usually avoid this problem. The historical evolution of endometriosis is not known, but the disease was first defined in 1920, and there were around 20 reports about it in the worldwide literature in 1921. Examination of the earlier medical literature has suggested to some that the disorder had been found, even though not specifically identified, during the 19th century. It has taken some time for endometriosis to gain recognition among the majority of medical practitioners. During the 1980s, women who had endometriosis symptoms in their teens experienced a delay of more than 8 years in receiving a diagnosis of endometriosis and often had to visit several doctors before gaining a diagnosis. The situation has improved during the past 20 years, though there is often still a delay of a year or more between reports of symptoms and confirming the diagnosis, perhaps in an effort to avoid unnecessary laparoscopic examinations at a time when surgical or hormonal treatments might be put off for a time anyway. Also, some women do not seek diagnosis and treatment for dysmenorrhea until they are older and it has been found to persist or worsen. It is currently estimated that, during their menstrual years (typically from age 13-48), about 14% of the female population have a symptomatic manifestation of endometriosis. The incidence of endometriosis appears to have rapidly increased during the 20th century. The cause of endometriosis is not known: how does the endometrial tissue get into the pelvic cavity? One concept is that there is a back flow of menstrual blood with endometrial tissue gaining entrance to the abdominal cavity; another is that the bits of endometrium are there at birth. It has been suggested that delayed childbirth is responsible for the rapid rise of this syndrome. Having early and repeated pregnancies, as was the case before the 1950s, would likely halt the growth of any endometrial cysts that were present for whatever reason. The effects of delayed childbirth and having fewer or no children have been noted in other ways, such as being associated causally with the rapid rise in breast cancer during this same time period. Once the first pregnancy has been substantially delayed in a woman who has endometriosis with enlarging cysts, the larger cysts are less likely to shrink after a pregnancy and becoming pregnant itself becomes more difficult. Investigations into other potential contributors have yielded some insights, though few conclusions. Autoimmune processes have been suggested to be involved in the progression of the disease; such autoimmune disorders may have a genetic component. Drug therapy for endometriosis is often unsatisfactory. Most of the current drug therapy is aimed at altering the estrogen-based hormonal stimulus of the endometrial tissue. Examples are the testosterone derivatives Danazol or methyltestosterone, progesterone and related progestogens (e.g., medroxyprogesterone), or using Buserelin, Goserelin, Lupron, Nefarelin, or other Gn-RH (ganodotropin-releasing hormone) agonists. These usually cause significant side effects, particularly androgenic responses including weight gain and facial and body hair growth. However, there are some reported beneficial effects, such as alleviating sleep disturbances and anxiety-depression. One can also use analgesics that block prostaglandins to relieve the severe dysmenorrhea. Surgical removal or aspiration of endometrial cysts usually provides only temporary benefits (a year or two) and may cause secondary problems, including persistent abdominal pain due to adhesions that form. Therefore, alternative treatments are of interest to those who suffer from endometriosis. The experience of Chinese doctors is instructive, as Chinese medical treatments have been reported to be highly successful and several of them can be obtained in the West, though one of the main therapies, gossypol, is not available here and can not be recommended due to its potential for serious adverse reactions and toxicity. Information about endometriosis, its possible causes, incidence level, diagnosis, symptoms, and treatments is available from the Endometriosis Association, an organization established in 1980 with international headquarters in Milwaukee, Wisconsin via their website (http://www.endometriosisassn.org) and their newsletter (1). The World Congress on Endometriosis is convened at three-year intervals, the latest one (Eighth Congress) was held in San Diego during February 2002.

THE SITUATION IN CHINA

In China, endometriosis is called neiyi, meaning internal lump. Laparoscopy, as needed to detect these lumps, was introduced into China around 1960, and reports about this disease first appeared in the literature soon after that. The incidence of endometriosis in China, like that in the U.S., is reportedly increasing (2). China had adopted a policy of recommending women do not have children until at least age 26, with a maximum of one child per family in most cases, a likely contributor to the increased incidence of the disorder. Up to 30% of patients undergoing pelvic laparotomies for any reason are found to have endometrial cysts, and these procedures have increased during the past three decades from 3.8% to more than 10% of admissions to the large Beijing Union Medical College Hospital. About 13% of women in China between the ages of 18 and 25 suffer from dysmenorrhea, of which a substantial portion-perhaps half-is due to endometriosis. In an evaluation of more than 1,500 infertile women it was found that about one-third of them had endometriosis. Before reviewing the traditional herbal treatments, the intensive investigation into a new herbal drug, gossypol, will be reviewed because the Chinese literature on endometriosis is dominated by reference to this herbal drug. Research into its use for endometriosis began in 1979. A review of gossypol research was published in Recent Advances in Chinese Herbal Drugs (2) and information here comes from that review plus several abstracts of recent studies published in Abstracts of Chinese Medicine (3).

GOSSYPOL THERAPY Gossypol is the active component of cotton roots and seeds that is being used extensively in China as a male contraceptive. Its action in this application is not via a hormonal mechanism, but rather by interfering with cellular regulation mechanisms affecting sperm. It is also used for treating female gynecological disorders such as uterine myoma (fibroid) and menopausal bleeding, and it functions partly via a hormonal mechanism in these cases, with effects similar to the Gn-RH drugs. Gossypol is reported to antagonize the action of estrogen and progesterone, and alter other hormone levels, and may thus cause some symptoms characteristic of menopause during prolonged use. These hormonal and functional alterations, including amenorrhea, are correlated with the cumulative dose of gossypol ingested, and eventually return to normal. The effect of gossypol on endometrial tissues is not, however, purely a result of the anti-estrogenic action. The applications of gossypol were discovered after it was found that some men became sterile and that some women experienced amenorrhea when they used crude cottonseed oil in cooking over an extended period of time. The fact that gossypol was then shown to cause atrophy of endometrium led clinicians to test it for treatment of endometriosis. Several studies have shown that the short-term effectiveness of gossypol for endometriosis is close to 90%, and that long-term effects-one to three years after treatment-are maintained in 54-63% of those treated. Its use relieves symptoms of excessive menstrual bleeding (menorrhagia) and dysmenorrhea and can result in persisting reduction of endometrial cysts and uterine myomas. Following a typical treatment of several months duration, a majority of women will also have amenorrhea, which persists for up to six months (in about 80% of women treated), and up to a year (in 16% of those treated); a small number (4%) have amenorrhea lasting beyond one year. There are two methods of administering gossypol, a high-dosage, short-term therapy, in which the beneficial effects are more rapidly experienced but there is higher incidence of side effects, and a lower-dosage, longer-term therapy that has nearly as good a response after some delay, with fewer side effects. Both methods produce close to total relief of symptoms and signs of endometriosis. When endometrial cysts were examined, 91% completely or partially resolved in the high dosage group, but only 76% resolved in the low dosage group. Coexisting myomas were reduced in size in about 90% of patients using the high dosage regimen and in nearly 85% of those using low dosage. Using a high dosage regimen, 83% of a test group experienced amenorrhea, while in the lower dosage group only 62% experienced this effect. Aside from amenorrhea, a frequently cited side effect of gossypol (which is severe in about 10% of cases) is hypokalemia (potassium deficiency). The drug strongly promotes potassium secretion, and in high dosage is suspected of impairing renal tubule function. The problem can be counteracted by using slow-releasing potassium salt, which is now standard procedure in China, and also by relying on the lower dosage method. When using the high-dosage program, there is some tendency for liver enzymes to elevate (indicating liver dysfunction), but this occurs only rarely with the lower dosage. The high dosage program can also cause nausea, edema, and palpitation. Other side effects of the drug include skin rash (possible allergic response), poor appetite, and tiredness (gossypol may inhibit both thyroid function and mitochondrial energy metabolism). In a clinical trial of gossypol for endometriosis (31 cases), functional uterine bleeding (117 cases), and uterine myoma (44 cases), reported in the Chinese Journal of Integrated Traditional and Western Medicine (1988), all the cases of endometriosis were effectively treated and more than 90% of the women with the other gynecological disorders also had satisfactory results. Gossypol acetate was taken 20 mg, once daily along with 10% potassium citrate (10 ml, thrice daily); treatment time was just 2-3 months. Amenorrhea occurred in 75% of the women. In another study reported in the Chinese Journal of Integrated Traditional and Western Medicine (1989), gossypol acetate was administered to 12 women with endometriosis at 20 mg, once daily for just 10 weeks and then 20 mg, twice per week for several more weeks (total time 5-6 months), thus following a particularly

low-dosage method for most of the treatment. It was noted that dysmenorrhea disappeared and endometrial cysts shrank in most cases; amenorrhea often occurred. Serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) increased; progesterone decreased; while estradiol and prolactin were unaffected. Gossypol is not readily available for use in the West and would need to be introduced as a drug product (which is highly unlikely) rather than an herb product. The effects of gossypol have been compared in China to that of Danazol, a drug that has been widely used in the U.S.; the latter is faster acting, but its action is less sustained; Danazol was said to have more side effects (mainly strong androgenic effects) than gossypol. It should be noted that cotton roots had been utilized in the southern part of the United States in folk medicines for nearly 200 years to treat dysmenorrhea, amenorrhea, and uterine tumors. The information about gossypol has been described here in some detail to demonstrate the success rates, dosage, and side effects, which will serve as a basis for comparison with other approaches. The main alternative to gossypol in China is the use of complex Chinese herb formulas. These formulas usually do not cause substantial side effects, though it is always possible to experience gastro-intestinal disturbances from the ingestion of almost any herbal combination (especially at higher dosage ranges) and a small number of individuals may experience allergy or hypersensitivity reactions.

COMPLEX FORMULAS FOR STAGNANT BLOOD The use of non-toxic complex herb formulas (typically comprised of a dozen herbs) for endometriosis has been discussed by several Chinese physicians. According to the theories of traditional Chinese medicine, endometriosis is best described by the traditional Chinese category of blood stasis syndrome with formation of abdominal lumps. Blood stasis, a condition where small vessels are not capable of carrying normal blood flow, is believed to be the cause of severe pain, especially lower abdominal pain, and it is believed responsible for many cases of excessive menstrual bleeding and infertility. The underlying causes of the blood stasis, in turn, are mainly the syndromes of qi stagnation (restricted circulation caused by emotional distress) and coldness (impaired metabolism and circulation), sometimes described as kidney yang deficiency. Therefore, when applying the ideas of traditional Chinese medicine, endometriosis will usually be treated by herbs that vitalize blood circulation as the primary therapy. There may be additional herbs administered to address the underlying and concurrent syndromes (e.g., qi stagnation) or specific symptomatic manifestations (e.g., excessive bleeding), such herbs may be added after the initial therapy to resolve the lumps. The herbs most commonly mentioned in clinical reports on endometriosis are outlined in Table 1. Table 1. Herbs Frequently Cited in Complex Herb Formulas for Treatment of Endometriosis. Herb (Common Name and Transliterated Chinese Name)

Role in Endometriosis Therapy

Description of Use

typha (aka bulrush) puhuang

vitalizes blood, reduces pain; when fried or carbonized, inhibits excessive menstrual bleeding

Almost always paired with trogopterus, based on an ancient formula using equal parts of those two herbs, called Shixiao San.

trogopterus (aka pteropus) wulingzhi

vitalizes blood, reduces pain

Almost always paired with typha, based on an ancient formula using equal parts of those two herbs, called Shixiao San.

sparganium (aka scirpus) sanleng

breaks static blood, reduces masses

Almost always paired with zedoaria to treat blood stasis masses.

zedoaria ezhu

breaks static blood, reduces masses

Almost always paired with sparganium to treat blood stasis masses.

pangolin scale (aka anteater scale) chuanshanjia

disperses swellings, eases menstruation

Often combined with sparganium and zedoaria to treat masses in the abdomen.

red peony chihshao

improves blood circulation Usually paired with either salvia or moutan or both to improve blood circulation.

achyranthes (or cyathula) huiniuxi or chuanniuxi

improves blood circulation Achyranthes nourishes the blood and aids circulation; cyathula has similar effects but is usually used for more severe blood stasis.

salvia danshen

improves blood circulation Usually paired with either red peony or moutan or both to improve blood circulation.

bupleurum chaihu

regulates qi circulation, which, in turn, aids the circulation of blood

Usually paired with cyperus to treat stagnated circulation in the lower abdomen.

cyperus xiangfuzi

regulates qi circulation, alleviates pain

Usually paired with bupleurum to invigorate circulation.

persica taoren

breaks up static blood to relieve pain

Usually paired with either moutan, rhubarb, or carthamus to vitalize blood circulation; rhubarb with persica is laxative as well.

tang-kuei danggui

nourishes blood, circulates Usually paired with peony or blood, improves qi bupleurum or both to improve circulation circulation of qi and blood.

cnidium chuanxiong

promotes blood circulation, Usually paired with tang-kuei to alleviates pain treat pain and regulate menstruation.

cinnamon (twig or bark) guizhi or rougui

improves circulation, Usually paired with tang-kuei, warms the body, alleviates peony, or red peony to improve pain circulation and relieve pain.

gleditsia spine zaoci

resolves swellings

Typically used for abscesses and other swellings.

oyster shell muli

softens masses

Commonly used for abdominal masses.

corydalis yanhuuo

promotes blood circulation, Added to formulas for treatment of alleviates pain painful syndromes, especially of the abdomen.

rhubarb dahuang

promotes blood circulation, Usually combined with persica for relieves swellings, abdominal masses and constipation. laxative; when carbonized, inhibits bleeding.

eupolyphaga zhechong

breaks up static blood, relieves pain

Combined with rhubarb and persica in an ancient formula, Dahuang Zhechong Wan, for treatment of hardness and pain in the abdomen and excessive menstrual bleeding.

leech (aka hirudo) shuizhi

disperses stagnant blood, promotes easy menstruation

Combined with eupolyphaga in formulas for abdominal blood stasis with formation of masses.

myrrh moyao

breaks up static blood, aids Usually paired with frankincense or tissue repair, relieves pain corydalis to treat pain.

frankincense (aka mastic or olibanum) ruxiang

invigorates blood circulation, controls bleeding, relaxes muscles, controls pain

Usually paired with myrrh to treat blood stasis and pain, particularly with injuries or bleeding disorders.

calamus gum (aka dragon's blood) xuejie

breaks up static blood, alleviates pain, inhibits bleeding

Usually combined with tang-kuei or myrrh to promote circulation and alleviate pain.

melia chuanlianzi

regulates circulation of qi, alleviates pain

Usually combined with corydalis to treat abdominal pain.

prunella xiakucao

resolves lumps

Sometimes added to treatments for lumps that are due to qi stagnation.

Shanghai is one of the main centers of research for the application of traditional Chinese medicine for gynecological disorders. The Hospital of Obstetrics and Gynecology of the Shanghai First Medical College has been in the forefront of much of the research. In 1975, they held a conference to develop criteria for evaluating the effectiveness of treatments for gynecological disorders, including endometriosis. There was a rush of research work on endometriosis in Shanghai during the period 1979-1982. In 1980, researchers at that hospital published the first report (4) of a large scale clinical trial of Chinese herbs for endometriosis. The 156 patients were divided into three groups according to syndrome and given one of three possible treatments. Group one was treated for qi stagnation and

blood stasis and given a combination of sparganium and zedoaria (used for masses associated with blood stasis); gleditsia spine (for gynecological masses); cyperus, bupleurum, and tang-kuei (for regulating qi circulation); and bulrush (typha), and pteropus (for abdominal pain) in decoction, plus an "endometriosis powder" made with earthworm, tabanus, centipede, and leech (for dredging the stagnated blood). Bulrush and pteropus together represent an ancient two-herb combination called Shixiao San (see Appendix 1) widely used for treating severe abdominal pain; the Chinese name for the combination means the formula for returning the smile. Group two was given a similar combination, but the qi regulating herbs bupleurum, cyperus, and tang-kuei were replaced by codonopsis, astragalus, and cimicifuga. These three ingredients treat a condition known as "sinking qi," that occurs secondary to qi deficiency, which often produces symptoms of distended pain in the lower abdomen. In both of these groups, the formula would be modified further with additions or deletions according to specific symptoms. The third group received a daily intravenous drip of salvia extract (the single herb). This rather inconvenient therapy delivers an extract of an herb currently used for normalizing blood circulation. The members of this treatment group would usually also receive some herbs in decoction to address their individual needs. Each of the groups received the treatment for two to three menstrual cycles. The purpose of having the three groups was not to compare one treatment to another, but to treat the women according to the Chinese style diagnosis of their syndrome. According to the report, 128 of the women (82%) had their symptoms mostly or entirely alleviated, while 28 of the women (18%) had either no effect, or the benefits of the treatment were lost soon after stopping use of the herbs. A Chinese review article describing the theory of treating endometriosis was published by workers at this hospital in 1982, and later translated by Dr. C.S. Cheung and his colleagues of the American College of Traditional Chinese Medicine (5). The article presented two prescriptions from the famous physician Wang Qingren, who during the latter part of the 19th century expounded upon the theory of blood stasis. One of the formulas, Persica and Achyranthes Combination (Xuefu Zhuyu Tang), is today used for numerous painful disorders, including headache and chest pain (see Appendix 2). The formula contains bupleurum, tang-kuei, and chih-ko to regulate the qi (chih-ko is more often used for central or upper torso stagnation rather than the lower body stagnation treated cyperus), and herbs for promoting the blood circulation, including red peony, cnidium, raw rehmannia, persica, carthamus, and achyranthes (or cyathula), as well as two auxiliary herbs: platycodon and licorice. It is sometimes modified by adding other herbs, and typical additions are typha and trogopterus for intense abdominal pain, and sparganium and zedoaria for treating lumps. The other formula by Wang Qingren mentioned in this article is Cnidium and Bulrush Combination (the Chinese name for the formula, Shaofu Zhuyu Tang, is translated as the decoction for driving out blood stasis from the lower abdomen). It is used when blood stagnation syndrome is caused by a cold syndrome, which is usually induced by weak metabolism and possibly resulting from certain emotional conditions including profound fear, but it may also be caused by environmental factors and diet. The formula contains the spicy herbs dry ginger, fennel, and cinnamon bark for warming up the body, and the blood circulating herbs tang-kuei, red peony, cnidium, bulrush (typha), trogopterus, myrrh, and corydalis (the formula is briefly mentioned in Appendix 2). A third formula mentioned in the article is a modification of Persica and Red Peony Combination (Taoren Chengqi Tang ), which is a formula for treating acute abdominal pain based on the purgative and blood vitalizing herbs rhubarb and persica. This formula is traditionally used for the condition whereby a heat syndrome causes the blood to escape the vessels and cause obstruction. The formula includes the blood vitalizing herbs red peony, moutan, Artemisia anomala, salvia, corydalis, and achyranthes, and it also has chih-shih; these last two herbs aid the downward circulation. The combination of persica and rhubarb play a prominent role in an endometriosis pill that was developed ten years after this initial report, as described in the next section. At another site in Shanghai, the Shanghai College of Traditional Chinese Medicine, Dai Deying worked with 30 cases of endometriosis and reported his results in 1982 (6). The basic formula for patients with endometriosis having dysmenorrhea as the main symptoms was: bupleurum, cyperus, saussurea, and melia for qi stagnation; red peony, moutan, salvia, corydalis, typha, and trogopterus for blood stasis and pain; and patrinia, prunella, and oyster shell for resolving the abdominal masses. During the week before menstruation and during menstruation, the corydalis dosage would be increased (to help alleviate pain), and the remainder of the formula would be modified slightly. The basic formula for patients with endometriosis having heavy menstrual bleeding as the main symptom was: codonopsis, astragalus, and atractylodes for tonifying qi; peony, moutan, and salvia for circulating blood; oyster shell and prunella for resolving the abdominal masses, and eclipta, fried typha, agrimony, and raw rehmannia for inhibiting bleeding. The formula would also be adjusted somewhat during and after menstruation. The effective rate for treating the symptoms addressed was reported to be 80%. Workers at the Shanghai First People's Hospital and at the Hangkou District Hospital in Shanghai reported on their experience in treating 43 cases of endometriosis (7). There were three

formulas; all of them including qi and blood vitalizing combination of cyperus, tang-kuei, salvia, red peony, and calamus gum. The formula for treating dysmenorrhea as the main symptom also included cyathula, cinnamon, pangolin scales, gleditsia spine, lacca, zedoaria, and sparganium; a similar nodule-dispersing formula was given for patients with large cysts, replacing zedoaria with sargassum and curcuma. The formula for heavy bleeding cases, added fried typha, achyranthes, peony, ophicalcite (a mineral), and rhubarb to the base formula. The herb combinations were further modified according to specific symptoms that were present. The effective rate was reported to be 88%, with four of the women getting pregnant. Despite the good resolution of symptoms and the finding that cysts were reduced in size, there were no cases observed in which the cysts vanished. A three-step treatment with differing herb formulas before, during, and after menstrual bleeding, was reported in 1983 (8) by workers at the Ruijin Hospital of the Second Medical College of Shanghai. For the week following menstruation, a formula comprised of cinnamon, red peony, moutan, persica, eupolyphaga, and vacarria for treating blood stasis; laminaria for resolving masses, and epimedium and cynamorium for tonifying yang and warming the abdomen was given along with the traditional prescription Xiao Yao San (Bupleurum and Tang-kuei Formula; a well-known qi regulating formula). Then, for a week during the premenstrual phase, a formula for blood stasis and pain-containing typha, trogopterus, salvia, achyranthes, frankincense, myrrh, sparganium, zedoaria, and artemisia, plus pills made from sanqi (raw tien-chi ginseng)-was taken. Finally, during menstruation, typha, trogopterus, phellodendron, limestone, lindera, cnidium, carbonized cyperus and carbonized rhubarb (the carbonized herbs reduce bleeding), astragalus, and cinnamon bark were used for three to five days. As before, the formulas might be varied somewhat according to specific needs. Of 60 patients treated by this method, 29 showed marked improvement, 18 showed some improvement, 11 improved but then relapsed with ceasing the use of herb formulas, and 2 failed to respond. The effective rate (for showing improvement without relapse soon after) was thus reported to be 78%. Treatment time varied from 3-12 months. According to these reports from Shanghai, the effect of administering the herbs on a daily basis for 2-3 months is that 78-88% of patients experience relief of common symptoms, such as dysmenorrhea and excessive menstrual bleeding. The dosage of herbs used, as indicated in the medical journal articles, is typically 6-15 grams per day for each ingredient in the formula (as is standard practice), and the dosage of the entire formulation is typically 150 grams or more. This is a large dosage of herbs, and usually requires drinking at least two cups of strong tea per day (normally, the herbs are discontinued only during 3-4 days of menstrual bleeding, after the first day of the period). Some patients may need to continue the therapy longer than a few months-perhaps a year-in order to maintain the effects. After this rush of research activity in Shanghai, reports from studies in other cities appeared detailing similar efforts. For example, a report (9) from the Sichuan Medical College in Chengdu (1985) described treatment of 42 cases of endometriosis. The prescriptions given were varied according to needs, but were made up of warming tonics for kidney deficiency (morinda, epimedium, dipsacus, cuscuta), qi tonics (codonopsis and astragalus), a qi regulating herb (cyperus), plus blood stasis removing herbs (moutan, persica, carthamus, typha, rubia, red peony, myrrh, and frankincense). The herbs were given as a decoction, taken after menstruation, 15-20 batches (one batch is a one day dose) per menstrual cycle, used for three to six months depending on the development of the case. After that, the herbs might be continued for several months with less frequent use, as needed. Most patients consumed about 100 batches of herbs (thus 5-6 months). With this therapy, 5 patients were said to be free of symptoms (with 1 pregnancy), 23 were markedly improved (with 6 pregnant), 11 were somewhat improved, and 3 failed to respond. Thus, about 67% had substantial improvement and 93% showed positive responses. After one year, only 3 of the improved cases had recurrence of the original disorder later. A report (9) from Anhui College of Traditional Chinese Medicine (1988) described the use of a formula that promotes circulation of qi and blood, Tongjin San, made with tang-kuei, peony, moutan, carthamus, cyperus, curcuma, melia, zedoaria, lindera, corydalis, and cnidium. The herb powder, with modifications as deemed necessary, was decocted and taken a few days after beginning menstruation, continued for seven to ten batches per menstrual cycle. 30 patients were treated for six months following this method: 9 of them were markedly improved (with 4 pregnant), 18 were improved, and 3 showed no effect; thus a 90% effective rate. Another report (10), this time from the Xiyuan Hospital in Beijing, described the use of Cnidium and Bulrush Combination (Shaofu Zhuyu Tang ) described previously, but modified slightly if necessary to treat qi stagnation, qi deficiency, or heat accumulation syndromes. Forty patients were treated, of which 25 had the cold type syndrome for which the base formula is designed, 10 had the qi stagnation syndrome, 3 the qi deficiency syndrome, and 2 the heat syndrome. Treatment time ranged from one month to two years, with a total effective rate of 97.5%. A study (11) at the Zhejiang Medical University was carried out with Chinese herbs differentiated for qi stagnation or qi deficiency type syndrome. In the former case, the combination of salvia, red peony, bulrush, pteropus, tang-kuei, cyperus, sparganium, zedoaria, and corydalis was given; in the latter case, codonopsis and astragalus were added. Of 76 patients treated with herbs (there were an additional 9 cases treated with Danazol), 69 had alleviation of menstrual pain (91% effective rate), and among 30 of the cases that had menstrual irregularity, 22 had it normalized.

Among 18 cases of pain during intercourse, 9 had relief of that symptom. In 1989 a lengthy review of endometriosis was published in English, again in the Journal of the American College of Traditional Chinese Medicine (12). The report was compiled by He Xianlin, a physician at the Guangzhou Municipal Hospital. More than two dozen formulas are presented in the review, including some of those already mentioned above, and there are suggestions for acupuncture therapy as well. A comment about treatment worth noting is this: "Although there are many ways to achieve the same goal, one thing is agreed upon by all sources with regard to endometriosis. The major pathology is that of qi and blood stagnation. Both problems will need to be addressed but at the root of it all is the kidney qi deficiency syndrome. Attention should also be paid to treatment according to cycle phase and predominance of the most severe symptom (usually dysmenorrhea or excessive uterine bleeding)." The Chaozhou Hospital issued a report (13) in 1990 on treatment of 30 women with endometriosis, using Shixiao Guijie Tang (a modification of Shixiao San) composed primarily of typha, trogopterus, calamus gum, san-chi, and tang-kuei. This formula contains none of the qi regulating herbs or kidney tonic herbs, but includes only the blood vitalizing therapies. It was reported that 12 cases had symptoms completely alleviated, 16 cases showed improvement, and 2 cases did not respond, with a total effective rate of 93%. Along the same lines, a report (14) from the Tianjin College of Traditional Chinese Medicine (1990) referred to treatment using sparganium, zedoaria, melia, red peony, cinnamon twig, hoelen, persica, moutan, corydalis, salvia, gleditsia spine, and prunella during the menstrual cycle except during menstruation, at which time the formula was changed to rubia, typha, trogopterus, melia, angelica, myrrh, artemisia anomala, corydalis, asarum, and san-chi. Of the 45 patients treated, 38 responded favorably (84% effective rate). The combined results of the studies reported during the period 1980-1990 were that the success rate (yielding some degree of improvement) for treatments with herbal decoctions ranged from 78% to 97.5% with an aggregate effective rate of about 86%, close to that found for low dosage gossypol therapy. There were also additional studies not described here, but which had similar therapeutic strategies and a similar reported level of success. Although numerous formulations were utilized at the different hospitals and for women with slightly different syndromes, the herbs listed in Table 1 appeared repeatedly throughout the reports, indicating a basic agreement in the selection of herbs that would be valuable for endometriosis using complex herb formulas.

A NEW TREATMENT METHOD FROM SHANGHAI: SIMPLIFIED THERAPY The Shanghai College of Traditional Chinese Medicine affiliated hospital reported (17) in 1991 an apparently successful simplified treatment for endometriosis-Neiyi Wan #1 (endometriosis pill)comprised of just three herbs: turtle shell, vinegar-treated rhubarb, and succinum. These materials were powdered, made into pills, and taken in the amount of 2.5 grams each time, twice daily. This approach differs from those mentioned above in that very few herbs are used and the herbs are in the form of pills rather than decoctions, with the dosage to be taken is very modest. The initial study involved 76 cases of endometriosis, with 61 said to be effectively treated, a success rate of 80%, which is comparable to what was claimed with the more complex decoctions. In particular, of 63 patients with dysmenorrhea as the prominent symptom, 89% were relieved. The herb formula was able to "thin the blood" (reducing the abnormally high viscosity of the endometriosis patients) and reduce excess populations of immunoglobulins, C3 (complement protein), and CD-8 Tcells in peripheral blood. The herbs were taken for three months, and could be continued during menstruation. Pharmacological studies have shown that rhubarb and turtle shell inhibit autoimmune responses. A follow-up study (18) by the same research team was carried out with Nei Yi Wan #1, and reported the following year. There were 95 patients; the effective rates claimed were: dysmenorrhea 99%, pelvic pain 88%, coitus pain 90%, irregular menstruation 80%, anal or rectal pain with downbearing 78%. The formula was later slightly modified to produce Nei Yi Wan #2, comprised of turtle shell, rhubarb, succinum, and defatted persica. In a trial (19) reported in 1993, the pills were given in a dosage of 3.5 grams each time, twice daily (the extra 1 gram each time compared to the Nei Yi Wan #1 dosage is due to the added persica). Additional herbs or formulas might be given for treatment of specific symptoms or underlying conditions. In the trial with 37 endometriosis patients, 4 were said to be cured, 26 effectively treated, and only 7 not responding, with a total effective rate of 81%. There was no obvious benefit to adding the persica.

CONTINUING EFFORTS: RETURN TO COMPLEX FORMULAS Despite the successes with and convenience of N e i Yin Wan , work with complex formulas in decoction form continued. In part, this may reflect the discomfort that traditional practitioners have with giving patients a simple formula that is not designed for the patient's specific underlying syndrome. An application of the previously-mentioned theory that the underlying cause of endometriosis is a kidney deficiency syndrome, which is then complicated by stagnation of qi and stasis of blood, was pursued by Li Xiangyun in Shanghai (20). He used epimedium, curculigo, rehmannia, and dioscorea to tonify the kidney, cyperus to disperse stagnant qi, and a combination of sparganium, zedoaria,

millettia, and salvia to treat blood stasis. Additional herbs could be added for various syndromes. In particular, for kidney yang deficiency he would add aconite and cinnamon bark or for kidney yin deficiency add ligustrum and lycium root bark. For severe pain, he would add trogopterus, typha, myrrh, and frankincense. According to the report, of 74 women so treated, 38 were cured (of which 24 became pregnant), and 33 others had various degrees of relief. Treatment time ranged from three to six months. Along similar lines, workers at the Suzhou Medical College (21) gave endometriosis patients a warming formula of aconite, evodia, fennel, dipsacus, dioscorea, tang-kuei, saliva, corydalis, cnidium, and persica. This would be modified for various syndromes, including the use of epimedium and cinnamon bark for kidney yang deficiency, rehmannia and ligustrum for kidney yin deficiency, and trogopterus and typha for pain. Of 54 women treated by this method, 25 were reported cured, and 26 others showed improvement, with a total effective rate of 94% (21). This research was followed up at the same hospital (this time in collaboration with a Shanghai Medical University hospital) with a study reported in 1998, comparing an herb formula with Danazol (29). The herb formula included the blood vitalizing herbs sparganium, zedoaria, leech, eupolyphaga, and pangolin scale with kidney yang tonifying herbs, such as cuscuta and epimedium, the decoction (or factoryproduced liquid extract) was taken once per day for three months. Danazol was administered in doses of 200 mg each time, three times daily. The relief of dysmenorrhea between the two groups did not differ significantly, but the herbs yielded better results in curing infertility. The herbs were shown to reduce prostaglandin levels, and regulate hormones and immune responses. Despite this focus on the theory that kidney yang deficiency syndrome with abdominal coldness underlies many cases of endometriosis, a report from the Heilongjiang College of Traditional Chinese Medicine affiliated hospital in Harbin in 1992 (22), showed that blood vitalizing herbs were the key ingredients. The study involved 64 patients who were treated with a decoction of salvia, trogopterus, sparganium, zedoaria, cyperus, corydalis, and loranthus. Modifications were made as deemed necessary, and treatment was generally continued for two to three menstrual cycles, without interruption. It was reported that 18 had all symptoms alleviated (28%), 26 were markedly improved, 16 improved, and 4 did not respond. Blood and plasma viscosity levels and red blood cell electrophoretic time were noted to be high in women with endometriosis before treatment compared to normal values, and these were reduced to near normal levels after treatment. Two publications appearing in 1995 are representative of the ongoing work in Shanghai. In one study (23), 48 patients were treated with a basic formula, which was then modified according to one of five differentiated types. The syndromes of qi stagnation with blood stasis and kidney deficiency with blood stasis were the types most often encountered. The basic formula contained 9 grams each of sparganium, zedoaria, leech, and liquidambar, and 12 grams each of pangolin scales, sappan, eupolyphaga, and prunella. It was reported that 10 patients were alleviated of all symptoms, 5 markedly improved, and 28 somewhat improved. Ten pregnancies occurred among 14 women in the study that had been considered infertile. In the other study (24), 47 patients were treated with 9 grams each of zedoaria, sparganium, persica, cinnamon twig, and turtle shell, 15 grams of prunella, and 6 grams of rhubarb. The formula was modified according to syndromes. Treatment time was one to three months, and effectiveness was 83%, with two of the patients free of symptoms. It was demonstrated that the treatment had marked effects on beta-endorphins, which are abnormal in women with endometriosis who have pelvic pain, and which are normalized by the herbal intervention. Of the 900 women treated in the studies of complex herb formulas cited above which were conducted over a period of about 20 years, the results indicate that only 12% failed to respond to the therapies. The implication of the results to date is that with use of Chinese herb formulas elimination of symptoms is possible and a likely impact of the therapy is a reduction in symptoms and an increased chance of pregnancy. Overall, required treatment times appear to be three to six months in most cases, a duration similar to that necessary with gossypol and Danazol. It is likely that the shorter treatment times are more appropriate for those with less severe endometriosis or shorter term of the disease. Longer treatment times, up to one year, were used in some cases, but this was not the rule.

METHOD OF THERAPY AND DOSAGE Decoctions are the main form of therapy that has been used with the complex formulas. These usually involve a high dosage of herbs: as indicated in the two most recent reports, decoctions with about 100 grams of herbs per day (including the modifications to the base formulas) are the basic approach even with formulas that have obviously been simplified since the earlier efforts. Pills made from powdered herbs, as reported in three recent studies, seemed to work nearly as well as the decoctions but, even so, the decoctions are the method most often utilized. It is possible that a treatment based on using pills for part of the therapy (perhaps initially for easy administration as a trial approach to get notable symptom relief) and decoctions for another part of the therapy (to prevent recurrence by treating the underlying imbalances) would be most appropriate.

U.S. EXPERIENCE As described above, English language information about Chinese medical treatment of endometriosis first appeared in 1983, and there have been reports in journals and books appearing regularly since about 1988. The Institute for Traditional Medicine has mentioned this literature and had received some reports about U.S. experience of treating endometriosis patients in the early 1990s.

It appears from such reports that after initiating treatments the first menstrual cycle is sometimes more painful than previous ones (possibly due to incomplete alteration of circulatory patterns), the second menstrual cycle involves discharge of large clots (demonstrating some progress in altering the blood flow), and the third and subsequent cycles begin to show the alleviation of symptoms. The experiences during the first two cycles of treatment tend to be discouraging and may lead to unnecessary changes in therapy or cessation of the method. If such reactions occurred in China, patients would have been strongly encouraged to continue the therapy. Not all patients experience this sequence of events, but it is valuable to advise patients of this possibility before they begin therapy. A three month period of treatment, however, should be sufficient to demonstrate notable improvements, based on this experience. Nearly all the herbs described in the Chinese literature are available to Western practitioners. Pangolin scale is on the endangered species list, making it unsuitable for common use (it is not banned from trade, but requires special licensing for import). Success rates lower than those reported in the Chinese medical journals could arise from failure to use adequate dosage or from noncompliance of patients with the long course of taking herbs, especially if they are in the form of decoctions. The Institute for Traditional Medicine (ITM) has been producing several herb formulas in a convenient tablet form, under the name Seven Forests since 1987 for the purpose of carrying out research (25). There are currently over 150 formulas in this form, prescribed by licensed health professionals. Some of these contain herbs mentioned above for treatment of endometriosis, including Lindera 15 (a formula for regulating qi and blood and alleviating pain), Corydalis 5 (based o n Shixiao San with corydalis), Lower Palace Tablets (based on Shaofu Zhuyu Tang), and Turtle Shell Tablets (based on Neiyi Wan #1). Two small endometriosis studies were organized by Arthur Shattuck, an acupuncturist and herb specialist. In the first study (1992), 17 patients participated, of which 15 completed a course of 16 weeks of therapy. Of the two drop-outs, one had become pregnant (a desired outcome) and one was non-compliant with the protocol. All participants had endometriosis confirmed by laparoscopy, and the age range was 21 to 47 years. The women consumed two herbal formulas, one throughout the menstrual cycle (Lindera 15), and one only if pain was noted (Corydalis 5). According to the study report (26), 47% of women who completed 16 weeks of therapy had noted substantial pain relief, and 27% noted slight pain improvement. Of the 11 women who noted pain improvements, 5 also reported improvements in cycle regularity. If one includes the two drop-outs, one with a successful outcome and one with a failed outcome, then it can be said that the total effective rate was 75%, somewhat similar to that claimed in China. Lindera 15 was taken in the amount of 3 tablets three times per day, with just 6.3 grams of herbs (during pain episodes, Corydalis 5 would be taken in doses of 2-3 tablets per day, thus raising the total dosage to up to 12.6 grams). Neiyi Wan #1 has been produced in tablet form (Turtle Shell Tablets, Seven Forests) for evaluation in the United States in 1993. Initial reports from ITM's An Hao Natural Health Care Clinic in Portland, Oregon were favorable. However, the rhubarb component causes intestinal cramping and/or diarrhea in some users, so the formula was adjusted; half of the formula is the original Neiyi Wan, and the other half is comprised of herbs that are frequently mentioned in the more recent medical reports from China (sparganium, typha, red peony, cinnamon twig, and persica). This change has solved the problem of intestinal reactions, though the formula should still be avoided if a person tends to get intestinal cramping and diarrhea for any reason. Arthur Shattuck initiated a treatment program involving four sites in 1993 (two in Wisconsin and two in Illinois), using the Lindera 15 and Corydalis 5, plus Turtle Shell Tablets in some patients. Improved paperwork for tracking outcomes was developed and the trial was planned to last for six months rather than four months. He reported (27) that of the 14 clients under care, all described a decrease in symptoms during the initial treatment period. However, he found that many people discontinued treatment after getting some relief, so that while the benefits were obvious, the full research project was not completed. In 1994, Christine Harrison in Denver organized a trial for evaluation of Chinese herbs in the treatment of dysmenorrhea. Patients received Tang-kuei 18 (a blood nourishing and blood vitalizing formula) for two weeks after menstruation and Lindera 15 for the following two weeks. The recommended dosage was 5 tablets each time, three times daily (daily dosage is 10.5 grams of herbs). Patients were treated for 12 weeks and also received acupuncture therapy. The patients were given surveys to evaluate the effects. In the study group of 18 women, 83% reported substantial improvement in pain and 72% reported other health benefits from the herbal treatment (28). While these initial studies were rather informal in their structure, they revealed that one could conduct such evaluations so long as the treatment time is not too long (12-16 weeks was satisfactory), and the treatment protocol involved tablets (with 9-18 per day), which yields better compliance than decoctions. The outcomes appeared positive. A more formal study can now be readily designed. The formulas mentioned here are not currently available to the public except by prescription from health professionals.

REFERENCES 1. Endometriosis Association, Newsletter, 1980-present, Endometriosis Association, 8585 N. 76th Place, Milwaukee, WI.

2. Han ML, Treatment of endometriosis with gossypol, in Recent Advances in Chinese Herbal Drugs (Zhou JH and Liu GZ, eds.), 1991 Science Press, Beijing. 3. Chang HM (ed.), Abstracts of Chinese Medicine, 1986-present, Chinese Medicinal Materials Research Centre, Shatin, Hong Kong. 4. Shao GQ, et al., Clinical and experimental research on 156 cases of endometriosis treated by therapy of promoting blood circulation and removing stasis, Shanghai Journal of Traditional Chinese Medicine 1980; 3:4-6 5. Cao LX, Endometriosis as treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1983; 1:54-57 6. Dai DY, 30 cases of endometriosis treated by taking Chinese herbs orally, externally, and by enema, Shanghai College of Traditional Chinese Medicine 1982; 3:34-35. 7. Cai XS, et al., 43 cases of endometriosis treated by differentiation of syndromes, Shanghai Journal of Traditional Chinese Medicine 1982; 4: 12-13 8. Liu DF, et al., A mechanism approach and clinical observation on endometriosis treated by therapy of promoting blood circulation and removing stasis, Chinese Journal of Integrated Traditional and Western Medicine 1983; 3(4): 207-209. 9. Fu Kezhi, personal communication, 1992. 10. Lin YQ, et al., An approach to treatment of endometriosis by traditional Chinese medicine, Fujian Journal of Traditional Chinese Medicine 1988; 19(6): 21-23. 11. Lin YH, et al., Analysis of 85 cases of endometriosis treated by integrating traditional and Western medicine, Zhejiang Journal of Traditional Chinese Medicine 1989; 24(4): 159160. 12. He XL and Frosolone S, The treatment of endometriosis with traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1989; 7(12):31-48. 13. Zhuang B and Xia GC, Correlation between treatment of syndrome differentiation and basic body temperature in 21 cases of endometriosis, Shanxi Journal of Traditional Chinese Medicine 1990; 11(12): 537. 14. Jin JL, 45 cases of endometriosis treated by blood circulation promoting and stasis removing therapy and laboratory analysis for nail-fold microcirculation, Shanxi Journal of Traditional Chinese Medicine, 1990; 11(9): 402-403. 15. Tang BJ, Traditional Chinese herbal and acupuncture treatment for female infertility (part II), International Journal of Oriental Medicine 1991; 16(3): 151-161. 16. Jin YC, Teaching rounds: endometriosis, International Journal of Oriental Medicine 1992; 17(4): 1206-210. 17. Wang DZ, Wang ZQ and Zhang ZF, Study on the treatment of endometriosis with removing blood-stasis and purgation method, Chinese Journal of Integrated Traditional and Western Medicine 1991; 11(9): 524-526. 18. Wang ZQ, Zhang ZF, and Wang DZ, Clinical and experimental studies of stasis-reducing and viscus-opening therapy for endometriosis, Shanghai Journal of Traditional Chinese Medicine 1992; 9: 8-12. 19. Yu CQ, Influence of Nei Yi Wan #2 on levels of beta-EP and DynA in endometriosis, Chinese Journal of Integrated Traditional and Western Medicine 1993; 13(1): 7-9. 20. Li XY, Method of kidney tonifying and stasis removing for 74 cases of endometriosis, Shanghai Journal of Traditional Chinese Medicine, 1991; 7:20-21. 21. Jiang JN, et al., Clinical observation of 64 cases of endometriosis treated by blood vitalizing and stagnation-eliminating therapy, ACTA Chinese Medicine and Pharmacology 1992; 1:38-39. 22. Qu JZ and Liu GZ, Wen Hua Yin combined with ear-pressing therapy for the treatment of 54 cases of endometriosis, Shanxi Journal of Traditional Chinese Medicine 1992; 13 (5): 198-199. 23. Hu GZ and Li XY, 48 endometriosis patients treated by the principle of eliminating stagnation and activating blood circulation, Shanghai Journal of Traditional Chinese Medicine 1995; 2: 38-40. 24. Yu CQ, Effect of Nei Yi Fang on plasma endorphin levels during the menstrual cycle in women with endometriosis, Chinese Journal of Integrated Traditional and Western Medicine, 1995; 15(1): 6-8. 25. Dharmananda, S, A Bag of Pearls, 2002 Institute for Traditional Medicine, Portland, OR. 26. Shattuck, A, personal communication, 1993. 27. Ibid. 28. Harrison, C, personal communication 1995.

29. Liu Jian, Li Xiangyun, and Hu Xiaomei, Clinical observation on patients with endometriosis treated by tonifying kidney and removing blood stasis, Chinese Journal of Integrated Traditional and Western Medicine, 1998; 4(3): 166-169. 30. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990, Eastland Press, Seattle, WA. 31. Hsu HY, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 32. Jia Kun, Treatment and Prevention of Carcinoma with Traditional Chinese Medicine, 1985, Commerical Press, Hong Kong. 33. Xu Xiangcai (chief editor), English-Chinese Encyclopedia of Practical Traditional Medicine (volume 4: Simple and Proved Remedies), 1990 Higher Education Press, Beijing. 34. Wang Qi and Dong Zhilin, Modern Clinical Necessities for Traditional Chinese Medicine, 1990 China Ocean Press, Beijing. 35. Wong KC and Wu LT, History of Chinese Medicine, 1973 AMS Press, Inc., New York. 36. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. 37. Yan Jingxi and Pan Guodong, Review of pharmacology studies and applications of Xuefu Zhuyu Tang, Journal of the Shandong College of Traditional Chinese Medicine 1993; 17(6): 423-425. 38. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (vol. 2) 1995-6 New World Press, Beijing. 39. Yang Yifan, Chinese Herbal Medicines: Comparisons and Characteristics, 2002 Churchill Livingstone, London.

APPENDIX 1: Shixiao San Shixiao San is a formula of the Taiping Huimin Hejiju Fang, a famous formulary of the Song Dynasty. It is one of the simplest of formulas, comprised of just two ingredients in equal amounts, ground to powder, to be swallowed down with water mixed with a little vinegar. It is indicated for blood stasis syndrome that causes pain. The formula name literally means the powder for the lost smile, but has been translated also to describe the effect of taking the formula, namely as the "sudden smile powder." In the book Chinese Herbal Medicine Formulas and Strategies (30) it is depicted this way: Before taking this formula, the patient for whom it is indicated has pain so severe that it is difficult to tolerate. After taking the formula, the pain disappears so fast that it brings a sudden smile to the face. As relayed further in Formulas and Strategies, the Hejiju Fang indicates that the formula is for post-partum pain that is so severe that the patient wants to die; that other medicines are ineffective, but this one is rapidly effective. Later generations of traditional doctors have extended its use to other painful conditions related to blood stasis, most recently for treatment of angina pectoris and its causes in vascular blockage and arterial spasm. One of the ingredients of Shixiao San is puhuang, the pollen from the well-known plant called cattail because of its long, round shoot that is about the width of a cat's tail. This plant is a marsh plant with a hollow stem, similar to a rush, and often referred to as the bulrush. The Chinese name for plants of this nature is pu; the pollen is bright yellow (huang), yielding the Chinese name puhuang. The botanical names of the main plant sources are Typha latifolia and Typha angustifolia, so the common name given for it is typha or bulrush. Little is known about it chemical constituents and pharmacology, other than the fact that it is rich in flavonoids, a group of compounds that have been associated with improving blood circulation. The other ingredient of Shixiao San is wulingzhi, which is the dung collected mainly from Trogopterus xanthipes (flying squirrels), but also from Pteropus pselaphon (known as flying foxes, which are, actually, fruit bats). These are rare species of cave dwelling rodents. Little is known about the active constituents of this material or how they might act to aid blood circulation or relieve pain. The Chinese name refers to the "grease of the spirit of the five elements (31)." This mysterious reference may be to its use as a topical application, perhaps in ointment form (grease), for treatment of skin diseases; the dung has antibacterial properties. According to Li Shizhen (who wrote the Bencao Gangmu and described this substance in his book that was published in 1596) that the substance is affected by the spirit of the five elements. To improve its blood vitalizing properties, it is usually prepared by frying with vinegar. Wulingzhi has been included in a number of anticancer formulas, because of its implied ability to resolve blood-stasis masses. According to Jia Kun, in his book Treatment and Prevention of

Carcinoma with Traditional Chinese Medicine (32), wulingzhi is bitter, sour, pungent, and sweet, with moderate nature, and no toxicity. It is indicated for amenorrhea, menorrhagia, dysmenorrhea, and pain caused by stagnation and obstruction. It relaxes spasms of the smooth muscles, as indicated by laboratory animal studies. It has become a common practice to combine one or both of the herbs from this traditional formula with corydalis (yanhusuo) and/or salvia (danshen) to improve the blood vitalizing and pain relieving effects. In the English-Chinese Encyclopedia of Practical Traditional Medicine (33), a formula for dysmenorrhea is presented, in which 9 grams each of trogopterus and typha are combined with 30 grams of salvia for a one day dose (taken all at once). The recommended use is for five days administration prior to each menstrual period. A simple formula for treating abdominal pain due to blood stasis, Shounian San, relayed in Danxi Xinfa (Teachings of Danxi, published in 1481) combined equal amounts of trogopterus, corydalis, myrrh, and caoguo, a type of cardamon (30). In the book Modern Clinical Necessities for Traditional Chinese Medicine (34) two highly effective prescriptions used in clinical trials for treatment of dysmenorrhea are described: the Dysmenorrhea Powder, comprised of trogopterus, salvia, corydalis, sparganium, zedoaria, carthamus, cinnamon, saussurea, and tang-kuei and the Notoginseng Powder for Dysmenorrhea, comprised of typha, trogopterus, corydalis, notoginseng (sanqi), cnidium, fennel, saussurea, and borneol (the main active component of cardamon). It should be noted that when puhuang is fried and carbonized, it helps stop bleeding, a property commonly found with carbonized herb materials; trogopterus may be prepared similarly to stop bleeding. In these formulas for pain, the cattail pollen and the trogopterus dung are not carbonized. When preparing typha and trogopterus in decoction form, the materials are put into a cloth bag; this is because they degenerate upon cooking and the dregs are hard to filter out afterward.

APPENDIX 2: Xuefu Zhuyu Tang and Shaofu Zhuyu Tang for Treating Blood Stasis Xuefu Zhuyu Tang is a widely used formula in China designed by the medical reformer Wang Qingren (1768-1831). Wang's interest was in the correct description of the internal organs (zangfu). Chinese physicians had avoided detailed investigation of the body during the previous centuries due to proscriptions against performing autopsies (and public refusal to allow dead bodies of their relatives to be dissected) and limitations on performing internal surgery. Instead, physicians and scholars had relied upon ancient drawings of the internal organs, derived from a small number of investigations before these restrictions came to force. Those anatomical drawings were crude, and had become a mere illustration to accompany descriptions of organ function that had been derived from theoretical considerations and a variety of observations of patients viewed from the outside. During the Song Dynasty, some new and superior drawings were made after physicians and artists were ordered to dissect and report on the internal organs of some captured bandits. But it was not until Wang Qingren published a small work of two volumes called Yilin Gaicao (Correction of Medical Errors; 1850) that Chinese anatomical studies revived. Soon after, many Chinese doctors adopted the modern anatomical texts, already highly advanced, introduced by Western physicians. It has been suggested by his contemporaries that Wang's work on anatomy had a number of errors, including observations that led to his formulation of Xuefu Zhuyu Tang. Some of his errors were considered worse than the ones he was trying to correct, so that critical commentators said: "the more Wang corrects, the more errors are made." One of the problems he encountered was the ancient Chinese correlation between blood vessels and the acupuncture meridians. The Chinese had nearly always described the flow of qi and blood as a unitary function, and had not made any distinction between the blood vessels and the acupuncture meridians that were being mapped for Chinese medical purposes. However, the meridian maps that had evolved centuries earlier did not closely follow the actual blood vessels, so that when Wang saw where the vessels actually ran, he was particularly distressed at the discrepancy. Wang had condemned those who wrote about physiology based merely on guesswork-without direct observation of the body-thus raising a complaint that is scientific in nature: conclusions must be drawn from careful investigation, not simple application of dogma. He commented (35): To write a book without knowing thoroughly the internal organs, is it not comparable to a man speaking in a dream? To treat a disease without knowing thoroughly the internal organs, how does it differ from a blind man groping in the dark? Based on Wang's analysis, it has been suggested that upon carrying out his investigations of dead bodies he observed that blood was often found pooled in the chest cavity. He considered that blood stasis in the chest cavity must have been associated with disease. Modern doctors recognize that this pooling of blood most likely occurred because of changes at death, rather than having anything to do with disease. Nonetheless, Wang designed his formula to treat blood stasis in the chest, which was designated as the "blood palace" (xue = blood; fu = residence of an official, translated as palace or mansion). The formula is comprised of two parts, one to regulate qi circulation and the other to vitalize blood.

For regulating qi, he used a modification of the ancient Sini San, comprised of four herbs: bupleurum, peony, chih-shih, and licorice. Since blood vitalizing was to be an important component of therapy, he substituted red peony for peony. He also replaced chih-shih (zhishi) with chih-ko (zhiqiao). Chih-shih and chih-ko have similar properties and functions; they are the immature and mature fruit, respectively, of a type of orange. However, one difference between them has been described as their direction of action. Chih-shih is used to drain downward, thus having a vertical action. It is commonly used in formulas for treating constipation. Chih-ko has a more limited downbearing effect, but is considered valuable for spreading the qi around the central region, and is thus said to have a horizontal action; it is commonly used for problems of the stomach and lungs, and Wang used it to smooth the flow of qi in the chest. Both chih-shih and chih-ko have the shared function of preventing adverse upward rushing of qi that can cause stuffiness in the chest, which is of relevance to this formula. Wang added platycodon to this portion of the formula as an herb to direct the action of all the herbs to the chest. In particular, the combination of bupleurum, which opens the upward flow of liver qi through the liver meridian passing though the sides of the chest, and platycodon, which opens the lung qi, are considered a highly focused pair for relieving stagnation in the chest area. For the blood vitalizing portion, he selected Persica and Carthamus Combination (Tao Hong Siwu Tang), which is simply Siwu Tang (Tang-kuei Four Combination; tang-kuei, peony, cnidium, rehmannia) plus persica (taoren) and carthamus (honghua). Peony is again mentioned here, with red peony included as above. In addition, the blood vitalizing herb achyranthes, or as specified in many modern texts, the substitute herb cyathula, was added. Cyathula (chuanniuxi) is considered to be a type of achyranthes (huainiuxi) ; it helps drain the excess blood from the upper body to the lower body. In particular, achyranthes or cyathula with chih-ko helps prevent upward rushing of qi and blood that might result in congestion and accumulation. The formula is (36): Xuefu Zhuyu Tang Bupleurum 6 g Chih-ko 9 g Red peony 9 g Licorice 6 g Platycodon 6 g Tang-kuei 9 g Cnidium 6 g Rehmannia, raw 9 g Persica 12 g Carthamus 9 g Cyathula 9 g Its function is "to promote blood circulation and remove stasis, as well as activate the flow of qi and relieve pain." Its primary indications are headache and chest pain due to blood stasis or poor blood circulation. The chest pain is attributed to such things as coronary heart disease, rheumatic heart disease, and injury to the chest; the headaches are attributed to concussion as well as any circulation disorder. Because of its regulatory effects on the flow of qi, the formula is also recommended for persistent hiccough. Xuefu Zhuyu Tang, regardless of its potentially flawed basis in physiology, turned out to be highly effective. It is today employed routinely in the treatment of a number of diseases and injuries and is frequently mentioned in medical journals. In a review article on its pharmacology and applications, the following effects were among those listed (37): Pharmacology: promotes capillary microcirculation increases tissue perfusion inhibits platelet aggregation enhances immune functions lowers serum triglyceride and LDL Clinical Applications: coronary heart disease, hypertension, arrhythmia, heart failure, cor pulmonale, rheumatic heart disease silicosis, asthma liver cirrhosis, chronic hepatitis, and primary liver cancer chronic gastritis, duodenal ulcer migraine, trigeminal neuralgia, headache in children epilepsy, schizophrenia, refractory insomnia, head injury polyarteritis nodosa, thromboangitis obliterans, subcutaneous hematoma infertility due to fallopian tube obstruction, menopausal syndrome, menorrhalgia

urticaria, post-herpetic neuralgia Many of these conditions do not involve the chest or upper body. Chinese doctors have come to view the formula as one that is generally suitable for blood stasis syndromes. One of the benefits of this formula, according to the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (38) is that it "removes blood stasis without consuming blood, and releases stagnant liver qi without consuming qi." This comment refers to the fact that the formula is potent, but still does not cause adverse effects. Normally, there is a concern that strong blood vitalizing formulas and strong qi regulating formulas will cause some damage (consume the blood and qi), thus limiting the duration of their use and restricting their use to persons of strong constitution.

SHAOFU ZHUYU TANG AND GEXIA ZHUYU TANG Wang Qingren also produced two blood vitalizing formulas for the lower body that are still widely used today. One is called Shaofu Zhuyu Tang (shaofu here refers to the lower palace) and the other is called Gexia Zhuyu Tang (ge = diaphragm, xia = below). The two formulas are similar: Shaofu Zhuyu Tang Pteropus 9 g Bulrush 9 g Corydalis 3 g Tang-keui 9 g Red peony 6 g Cnidium 3 g Cinnamon bark 3 g Dry ginger 3 g Fennel 1.5 g Chih-ko 5 g Licorice 9 g

Gexia Zhuyu Tang Pteropus Carthamus & Persica Corydalis Tang-kuei Red peony Cnidium Moutan Lindera Cyperus

9 g 9 g 3 g 9 g 6 g 3 g 6 g 6 g 3 g

Five of the herbs used for vitalizing blood circulation in each of the formulas match exactly, and i n Gexia Zhuyu Tang, the blood vitalizing combination of carthamus and persica simply replaces bulrush in Shaofu Zhuyu Tang. The major differences between these two prescriptions are that Shaofu Zhuyu Tang includes the kidney-warming trio of cinnamon bark, dry ginger, and fennel, while Gexia Zhuyu Tang has the qi regulating trio of cyperus, lindera, and chih-ko. Both are indicated for abdominal pain due to blood stasis. Shaofu Zhuyu Tang would be selected for stasis due to cold (cold-caused congealing of blood) and Gexia Zhuyu Tang would be selected for blood stasis associated with qi stagnation. An herb common to all these formulas by Wang Qingren is cnidium (chuanxiong). This herb is described at length in the book Chinese Herbal Medicines: Comparisons and Characteristics (39), and the explanation reveals the herb's suitability for these formulas: Chuanxiong is pungent and warm, and enters the liver, gallbladder, and pericardium meridians. Pungency can disperse congealed blood and warmth can activate the blood circulation and dissipate the obstruction. Chuanxiong is a very effective herb for invigorating the blood and promoting its circulation. It is characterized by high moving speed and strength. It moves upwards, downwards, inwards, and outwards, and can reach every part of the body, so it is regarded as 'the herb that moves qi and blood.' In clinical practice, it is often used to remove congealed blood and stop pain. It is particularly effective in the treatment of headache when the pain is in the sides of the head, such as in headache caused by stress or migraine. It is also used to relieve pain in intercostal neuralgia, coronary heart disease, and stenocardia, trauma, and arthritis. Since it can reach any part of the body, it can be used to treat cold and cramping pain of the fingers and toes, dysmenorrhea, amenorrhea, and irregular menstruation, which are caused by qi and blood stagnation complicated by cold. Combined with other herbs, it can be prescribed for excess, for deficiency, for cold, or for heat syndromes. ACCESS: Seven Forests herb formulas are available only by prescription from a licensed health care professional. You can find a practitioner who can prescribe Chinese herbs here Further information links: To provide your comments [no medical consultations can be offered], e-mail: [email protected]

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ESTROGEN DEPENDENT TUMORS AND HERBS: How Modern Conditions Change Traditional Practices essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

A few years ago, if I were able to confidently provide women with an herbal therapy, especially one in a convenient form, that would boost their own production of estrogens, the demand for such an item would have been difficult to meet. For, at that time, millions of women were taking exogenous estrogens (or faced with the prospect of doing so in the near future) that were derived from animals or synthetically produced from plant precursors. These hormones have been used to alleviate menopausal symptoms for several decades, but there was a growing movement (among a minority of women, however) to reject that approach and seek something they deemed more natural as an alternative. Some were opposed to pharmaceutical interventions on general principle (that it is not natural and, therefore, harmful). One specific fear of the pharmaceutical estrogens was that they could increase the risk of breast cancer; this increased risk was interpreted, by most of these concerned women, as the result of using an unnatural product. Therefore, a natural means of increasing estrogen was thought to be safer. For a while, women turned to certain products that were held out to be natural estrogens: for example, extracts of wild yam (Dioscorea sp. ) which were claimed to either contain natural estrogens or to provide precursors that the body could transform to estrogens. Today, most women have learned that this was a fallacy: wild yam neither contains estrogens nor does it contain precursors that can be modified by the body; however, it does contain precursors that can be modified in the pharmaceutical factories to yield estrogens. Other herbs have been described as containing phyto-estrogens, plant compounds that act like estrogen or can indirectly induce an estrogen-like response. As with wild yam, these herbs have been sought after by women, but most of the herbs have extremely weak estrogen activity, especially in the dosage form usually provided. The situation has changed completely in the past few years. No longer does anyone ask if an herb therapy can provide estrogens, nor does anyone ask if an herb can increase the body's production of estrogens, unless they are hoping and praying that it won't do so. I am not asked for sources of estrogen enhancing herbs for women entering menopause, but, instead, I am asked to provide assurance that an herb therapy won't increase estrogen levels at all. Why the change? Because modern research has shown that estrogen, whether naturally occurring in the body or introduced externally from any source, can stimulate the growth of breast cancer cells (and ovarian cancer cells; but with breast cancer being so much more common, it will be the focus of this article). Some breast cancer cells are more sensitive to estrogen than others: they have a relatively large quantity of a particular type of estrogen receptor; these cells are called estrogen-dependent or estrogen-receptor positive. While estrogen apparently doesn't cause cancer by itself, it has been learned recently that metabolites of estrogen (such as the 4-hydroxy derivatives) that are naturally produced in the body can transform normal cells to cancer cells. These metabolites are produced in varying amounts, dependent on factors that have not yet been fully determined (high alcohol consumption has been linked to higher risk of breast cancer and may be due to induction of liver enzymes that produce the 4-hydroxy estrogen derivatives). In addition, estrogen and its metabolites can increase the chances that a cell that already has the cancer-promoting genetic structure will multiply rather than disappear: this is the role of the estrogen receptors at the cell membrane. Thus, for women who fear experiencing breast cancer (for the first time or as a recurrence), avoiding estrogen-regardless of source-is the objective based on the current medical model. Researchers and doctors have known for decades that there is a connection between estrogen and breast cancer, because it was known that removing the ovaries (which is the body's single largest source of estrogen) could inhibit breast cancer growth. But much more has been learned during the past decade, with testing now available to determine whether cancer cells (removed by biopsy or surgery) are highly estrogen-dependent or not. Such testing has not allayed the fears of those with the cancers that have low estrogenactivation; the word in the literature is that when a person has breast cancer, estrogen is bad. While dietary cancer-promoting substances and environmental chemicals are sometimes blamed for the relatively high incidence of breast cancer observed in modern times, especially in the U.S., the change in child-bearing practices and the longer lifespan appear to be the dominant causes. Lifetime pregnancy rates have dropped dramatically over the past century and pregnancies are mostly occurring later in life than before. Epidemiological research shows that full-term pregnancy early in life is the most effective natural protection against breast cancer in women. Most breast cancer cases still occur late in life, even though the premenopausal cases are particularly of concern. The incidence of cancer in general, not just breast cancer, and the incidence of other life-threatening diseases increase with age due to a variety of age-related factors. The average female life span is now about 25 years past menopause-more than a decade longer than the average a century ago. The resulting change in breast cancer incidence related to these factors has led to intensive measures to warn women about every contributory risk known or suspected in relation to this disease. Herbal therapies have become one of the targets of this warning.

CHINESE HERBS AND ANTI-AGING THERAPIES While breast cancer can strike at a relatively early age (usually because of strong genetic factors), most cases occur after age 40. At this stage of life, there are usually several signs of aging compared to earlier years, such as dryness of skin and hair, graying of hair, weakening of bones, loss of muscular tone, lowered stamina, and, for many people, onset of some degenerative conditions, perhaps affecting connective tissue, the vascular system, or the nervous system. If a woman goes to a practitioner of Chinese medicine at this time in her life, regardless of her specific medical complaint, the remedy is likely to be one that includes the "anti-aging" type of herb ingredients. The inclusion of such medicinal materials need not be based on any patient request to deal with a specific concern about aging, but, instead arises because the diagnosis will almost always take into account factors that are characteristic of the persons advanced age. Many of these herbs are classified as tonics, though not all of them are in that category. In the pre-modern era of Chinese medicine, the treatments for men and women of this age group were aimed, at least in part, at nourishing the kidney and liver and replenishing the essence (and/or preserving the essence from loss). When modern scientific

investigation of Chinese herbs was introduced during the 20th century, Chinese researchers designed experiments to determine what the herbs do, from a biochemical and physiological viewpoint, when they provide this anti-aging effect. One of the findings is that they enhance the endocrine system functions: they help to restore earlier levels of hormones that had declined with age (see: The endocrine impact of Chinese medicine). Thus, for example, here is a statement from an article on anti-aging herbal medicines (6): The functional status of the endocrine system is also closely related to aging. To various extents, most of the endocrine functions deteriorate along with the increase in age. Derangement of any of the regulatory steps in the neuro-endocrine setup, whether neurotransmitters, releasing hormones, stimulating hormones, or target hormones, will inevitably accelerate the aging process....Some of the herbs known to possess gonadal hormone-like effects or gonadotropic effects include epimedium, gecko, deer antler, cordyceps, and ginseng. Galenicals [formulas] such as Zhibao Sanbian Wan, Kangbao, Huangjingjian, and Shoutao Wan can elevate the body gonadal hormone levels. A point worth mentioning here is that all these individual herbs and compound prescriptions have been traditionally employed as 'kidney-replenishing' medicines. Many people in the West involved with anti-aging approaches are aware of the potential benefit of hormones such as DHEA (dehydroepiandrosterone; an adrenal hormone, precursor to testosterone and other sex hormones), melatonin (pineal gland hormone that regulates the sleep cycle), growth hormone (usually referred to as human growth hormone), and, the sex hormones testosterone, estrogen, progesterone, and their variants. All of these hormones are present in relatively larger amounts early in life (before age 30), and decline, sometimes dramatically, later in life. Administering these hormones can sometimes alleviate characteristic signs of aging; Western conferences and publications on slowing the aging process are filled with reports on the use of hormones. The increased level of hormones in the bodies of older persons is what the Chinese had accomplished through administering herbs, rather than administering hormones (see: The treatment of menopausal syndrome with Chinese herbs) . Had isolated or partially purified hormones (including estrogen) been accessible to the Chinese in ancient times, there is little doubt that they would have been used and proclaimed "first class" remedies. Herbal therapies are not the only Chinese medical practices said to increase endocrine function and improve estrogen levels. In a report on the anti-aging effect of qigong practice, it was reported that menopausal women who practiced qigong would experience a substantial increase in the level of estradiol (the estrogen compound which is deemed one of the strongest promoters of breast cancer of all the naturally-occurring estrogens). This increase in estradiol is reported as evidence of the benefits of qigong practice. The authors state that: "This finding is particularly important in anti-aging treatment, especially for post-menopausal patients, as it has generally been accepted that ovary degeneration and decreased estradiol level in this period of life is an irreversible process." As with the proposed effect of qigong, a therapeutic result of taking herbs that is characterized by increase in endocrine function and more hormones flowing through the blood would have been hailed as a great contribution to natural health care only a few years ago. Indeed, in a 1998 publication showing that kidney tonic herbs (mainly rehmannia, epimedium, dioscorea, cuscuta, cornus) could raise estrogen levels substantially during menopause and even 10 years after menopause, the authors wrote: "The results indicated that the hormonal disorders in post-menopausal females could be corrected by kidney tonic herbs by way of raising the levels of estrogen and calcitonin, and reducing the levels of parathyroid hormone." The authors took the view that the problem with hormone replacement therapy was the use of a single hormone which can present side effects, where as "kidney tonic herbs mobilize all positive factors through general regulation." Now, as a result of publicized concerns about the impact of estrogen on cancer, all women who wish to avoid having any more estrogen in their system must avoid the use of Chinese herbs (perhaps qigong as well), at least many of the herbs that are aimed at treating the characteristic symptoms the woman is facing at this stage in her life. The reason that many of the herbs-rather than just tonic herbs-come into question is that there is theoretical and clinical evidence to support the ability of herbs other than tonics to accomplish the same goal. Tonic herbs are just the most frequently used group of herbs to treat the deficiency syndrome that often characterizes menopause. In the book Aging and Blood Stasis (7), menopausal syndrome is described by differentiation in three categories: heart spirit bewildered and chaotic; heart blood deficiency; and liver qi depression and binding. In each case, consistent with the thesis of the book that aging involves blood stasis syndrome, a significant portion of the formula involves herbs that "quicken the blood and transform stasis," such as salvia, tang-kuei, cnidium, carthamus, and persica. According to the author, these herbs may be combined with others that have functions such as calming the heart (spirit) and regulating the liver qi. Regardless of the specific ingredients, if the therapy is successful, it is possible, perhaps even likely, that the endocrine system has responded and produced a somewhat higher amount of estrogen. In the continuation of their article on anti-aging Chinese herbs (mentioned above), Chen and Li list the following herbs as having an "estrogen action:" curculigo, cuscuta, schizandra, rubus, lily, cyperus, soja (processed soy bean), and rhubarb. These herbs come from several therapeutic categories of the Materia Medica and not all of them fit the usual concept of anti-aging remedies as tonics. In one recent study, a therapy claimed to consist of Chinese herb extracts to be used for prostate cancer patients was reported to have a strong estrogenic activity, similar to that of standard medical hormone therapy (see: Questionable cancer therapies). Only one of its ingredients, ganoderma, might fit into the usual category of anti-aging herbs. Most of the concern related to estrogen levels and herbs is currently focused on women who have a diagnosis of breast cancer (even if it is fully in remission) or ovarian cancer. In these cases, Chinese herbs cannot be advocated as part of the therapeutic regimen. The same restriction would apply to other herbs that are not classified as Chinese, and also to men with prostate cancer who are concerned about the adverse impact of testosterone on cancer development (certain testosterone metabolites stimulate growth of prostate cancer cells). While herbalists may believe that the beneficial effects of the herbs outweigh any risk (associated with raising estrogen levels), there is a lack of convincing evidence that this is actually the case; therefore, one cannot make a reliable claim. In the near future, one can expect the concern about use of these herbs to be raised for any woman who is deemed at elevated risk of getting breast or ovarian cancer, such as those who have a family member that experienced the disease. This is especially so in light of the recent studies suggesting that estrogen metabolites produced in the body can actually cause cancer (8). As hormone replacement therapy advances, the large scale clinical trials will demonstrate that there are some combinations of hormones that have a high rate of

effectiveness for alleviating menopause-related problems (e.g., osteoporosis) with a very low rate of risk for breast cancer, ovarian cancer, and other disorders (in current medical practice, the risk of these cancers is only marginally elevated or not at all, depending on the study). In addition, new non-hormone treatments for osteoporosis and other menopausal concerns are becoming available. Women and their physicians will naturally ask if the Chinese herbs administered for similar purposes have the same effects and the same lack of risks, and it will have to be admitted that there is inadequate evidence to determine whether or not they are comparable. There is no easy way out of the conundrum. One recent laboratory animal experiment, designed to show that a food component, tangeretin (found in citrus fruits) might inhibit breast cancer in the same manner as Tamoxifen does (based on initial in vitro experiments), turned out to indicate that this natural compound canceled out the effect of Tamoxifen. While the results of this initial study may not end up applying to humans due to some differences in the metabolic pathways, at this time, there is no evidence to contradict the concern that the study raises. Most doctors and their patients would rather err on the side of caution. Tangeretin is a citrus flavonoid; other flavonoids might also have this effect, they simply haven't been tested yet. Flavonoids are found in several herbs and in some herbs they are major active constituents; the Chinese rely on more than a dozen citrus materials in making herbal prescriptions (see: Synephrine: Is chih-shih toxic?), and each of them contains flavonoids that either include tangeretin or molecules very similar in structure and effect. The citrus materials are used by the Chinese to aid digestion, help resolve breast lumps, and regulate the bowels, all of which are areas of concern in menopausal women. Thus, women with breast cancer or at risk for breast cancer who are taking Tamoxifen might be cautioned about taking herbs (or including the otherwise healthful citrus fruits in their diet).

CONSIDERATIONS FOR ANTI-DEPRESSANTS AND MAO LEVELS Many women with breast cancer take anti-depressants: having a diagnosis of breast cancer may, in itself, be depressing; the Chinese medical view is that depression is one of the contributors to developing cancer (see: Oriental perspectives on cancer and its treatment; and How emotions may contribute to cancer) . Doctors caution against taking anything that inhibits an enzyme system called MAO (monoamine oxidase; an enzyme system that helps transform some of the neurotransmitters, which are monoamines, into an inactive form) when taking the anti-depressant drugs. This caution, which is applied especially to some drugs that are strong MAO inhibitors themselves, is made to avoid having the antidepressant (or other) drug therapy yield harmful levels of the neurotransmitters. Recently, a popular Western herbal remedy for depression, St. John's Wort (also traditionally used by the Chinese, but not for depression), was reported to inhibit MAO, which led to quick calls for avoiding its combination with Western drugs and separating its use from that of drug therapies by three weeks time. It appears that this report was fallacious, but the response to it made it quite clear that use of herbs in this circumstance has become a serious concern. With aging, MAO levels increase. This increase in the enzyme causes the level of neurotransmitters to decline, with resulting losses in memory, clarity of thought, and neuromuscular control. Thus, the MAO increase contributes to some of the symptoms of aging, including those that women complain about during menopause. Anti-aging herbal approaches may inhibit MAO; as with the increases in hormones, this is regarded, by Chinese researchers, as an advantage to the use of the herbs (restoring MAO levels closer to those of youth). Even if an herb therapy is at a dosage that is too low to affect MAO (see: MAO inhibition and Chinese herbs), the effective level for the herbs is not well-defined and doctors may advise erring on the side of caution. Therefore, here is yet another reason to avoid Chinese herbs-or other herbs-in women with breast cancer. At this time, there is no direct evidence that use of Chinese herbs increases the risk of breast or ovarian cancer (or prostate cancer in men), nor that Chinese herbs cause harm when combined with anti-depressant drugs. Rather, the concerns are based on pharmacology research and its connection to clinical and epidemiological observations. This is one of the ways in which modern conditions affect the practice of traditional medicine. Not everyone will worry about the potential interactions of herbs with the hormonal system and drug therapies, but these are questions increasingly raised. Certainly, the impact of Chinese herbs is expected to be dependent on the dosage administered. In terms of affecting risk factors for a disease that will occur much later, such as the role of increased estrogen on breast cancer, the biggest concern will be the duration of use. Though short-term administration of low to moderate doses of herbs may still cause some people to be worried, the practice is less likely to produce any adverse effect than either high dosage or long-term administration of herbs.

ONE POSSIBLE TREATMENT FROM THE ORIENT Epidemiologists have noted a lower incidence of breast cancer in Japan compared to the U.S., an incidence level that usually changes when Japanese women move to the U.S. Originally, the difference in incidence rate was thought to be due to a difference in saturated fat intake. However, a recent large-scale evaluation of diet and breast cancer has indicated that the role of dietary fat was probably overestimated and may be minor (elevated dietary fat is still believed to have an impact on cardiovascular disease, colon cancer, obesity, and other health problems). It is now proposed that one reason for the lower Japanese incidence of breast cancer in Japan is the elevated use of soy products in Japanese cuisine (see: The role of dietary and herbal flavonoids in gastro-intestinal health). Age-adjusted breast cancer death rates are 2-8 times higher in Western countries (U.S. and Western Europe) than in Asian countries (China, Japan, Korea). On average, women in the Orient consume 20-50 times more soy products than women in Western countries. The countries with relatively high soy intake also have lowered incidence of prostate and colon cancers. Prostate cancer, like breast cancer, is often hormone-dependent; colon cancer is strongly influenced by dietary components, since the unabsorbed components have direct contact with intestinal cells. Soybeans contain substantial amounts of two isoflavones, one is genistein and the other is daidzein (see: Soybeans for cancer patients; Soybeans for health; & Legumes). Daidzein is metabolized in the intestines to produce equol, which may be the most potent of the isoflavones in terms of alleviating menopausal symptoms, but genistein has been studied most intensively in relation to cancer and it appears to be of some potential benefit to women who are concerned about estrogen dependent tumors. Genistein is classified by some as a phytoestrogen. This term is somewhat misleading, in that genistein neither has a chemical structure like estrogen nor does it act in the body in the same way as estrogen. It does interact with estrogen receptor sites, but it appears to interact preferentially with a subclass of estrogen receptors that do not stimulate tumor cells. That is, genistein can interact with receptors that will alleviate some estrogen-deficiency symptoms (e.g., hot flashes) with little stimulus to the receptors that affect the tumors. In addition, it appears that genistein can inhibit the growth of breast cancer cells by promoting the internally-programmed cell death, which is otherwise halted by the cancerous condition (9).

Therefore, by consuming genistein, women may be able to help alleviate menopausal symptoms (but, certainly, not all aging symptoms) without the risk of stimulating breast cancer cell growth. Genistein is found in most legumes, but especially in peanuts, soybeans, and yellow peas. Genistein-enriched soy products, and encapsulated or tableted genistein products are also available. Effective levels for treatment are not firmly established, but ingestion of soy isoflavones in the dosage range 60-180 mg/day appears reasonable with the current state of knowledge. The research is still preliminary. But, for those who are initially seeking Chinese herbs as a remedy and who are concerned about their potential estrogenic effects, the practitioner may wish to shift the emphasis away from the use of Chinese herbs to a genistein-based therapy. It will be necessary for both practitioners and patients to keep up with the emerging literature in order to assure that the most appropriate therapy is followed. As with all traditional, alternative, and complementary therapies, the evidence for effectiveness and safety is limited and views are subject to change, as has been described above.

GENISTEIN AND BREAST CANCER Breast cancer cells alter their metabolism and growth (production of new cells) in response to various stimuli. Not all growth stimulants have been identified, but two stimulant groups are the estrogens (the main one being estradiol, called E2) and the peptide growth factors (such as epidermal growth factor, EGF). When one of the growth stimulants interacts with a cancer cell surface receptor, a cascade of signal transducers lead to DNA stimulation, which then manages the reproductive cycle of the cell. It is here, in the DNA, that abnormalities in growth and life cycle characteristic of the cancer cell are stored. One of the steps in the pathway to the DNA is an enzyme called tyrosine protein kinase (TPK). Genistein has been shown to inhibit both estrogen- and peptide-growth-factor-stimulated growth of breast cancer cells. Cancer cells not only have the ability to grow more rapidly under certain stimuli, but there are other stimuli can inhibit cancer cell growth. For example, the p53 protein induces cell death (apoptosis) in cancer cells. Studies have shown that people with a genetic background that leads to low p53 levels are more susceptible to experience cancer and die from it. Genistein has been shown to help induce apoptosis of breast cancer cells via the p53 protein. Further, cancer cells have a mechanism for protection against apoptosis; this protective mechanism includes the production of stress proteins. The stress response is inhibited by genistein. In human breast cancer cells, another protein, p21, is especially important to the reproduction of the cells. In vitro experiments show that genistein induces expression of p21, resulting in arrest of the cancer cell cycle. These various mechanisms of action, mostly observed in laboratory studies and not yet in humans, may help explain the reduced incidence of breast cancer among women who consume a considerable amount of soy products on a regular basis. It may also indicate a means of aiding the treatment of breast cancer, probably relying on a larger dosage of genistein than is characteristic of dietary levels that help prevent cancer. The in vitro studies usually rely on levels of genistein that exceed (by a factor of 10 or more) the levels experienced by cancer cells in the breasts of women who consume soy foods. The fact that soy isoflavones reduce menopausal symptoms and yet may help prevent or even help treat breast cancer seems contradictory. It has been postulated that this apparent contradiction may arise from different binding capabilities or different primary binding sites for phytoestrogens compared to estrogen. In rat tissues, the isoflavones tend to bind more strongly to estrogen receptor beta (ER-b), while it is estrogen receptor alpha (ER-a) that estrogen binds to in producing several estrogenic effects; breast tissue is mainly supplied with ER-a receptors; there is only weak expression of ER-b in human breast tumor cells. Therefore, while an estrogen-like action is observed in relation to menopause, the estrogen-dependent tumor cells remain unstimulated.

ONE POSSIBLE TREATMENT FROM THE WEST A nutrient substance, coenzyme Q10 (CoQ10), has been investigated since 1957 by a research group headed by Karl Folkers (who was involved in the initial isolation, identification, and animal testing of the compound). The researchers have been pursuing the possibility that CoQ10 may have preventive and therapeutic effects in the treatment of cancer for more than ten years, and much of their efforts have focused on breast cancer. Coenzyme Q10 is best known for its effects on cardiac muscle, which is where this substance is concentrated (CoQ10 is utilized mainly in the mitochondria of all cells; this organelle carries out energy transformation, and is needed to keep the heart pumping). Originally, tiny amounts of CoQ10 were obtained from beef hearts; a technology for large scale production in batch culture was developed in Japan in 1974, which made it possible for CoQ10 to be utilized as a therapeutic substance. CoQ10 already has a limited role in breast cancer therapy. It can be used to protect the hearts of patients who are being treated with chemotherapy regimens that includes the commonly-used drug adriamycin (as well as analogues with similar properties), which produces significant risk of heart damage. Evidence for the possibility that CoQ10 might have some additional value for women with breast cancer, regardless of estrogen receptor status, includes the following: 1. There is a significant prevalence of low blood levels of CoQ10 in patients with breast cancer. Typically, these patients have about 2/3 the CoQ10 level found in non-cancer patients. In one study, a correlation was found between the extent of the deficiency and poor outcome of the breast disease (11, 12). 2. Administration of CoQ10 significantly raises blood levels of this substance, showing that oral administration is a viable method of delivering adequate doses. The therapeutic doses raise the blood levels above those normally encountered and the raised blood levels correlated with cases of tumor regression in women with breast cancer (13). 3. Animal studies indicate anticancer and immune-enhancing properties of CoQ10 (14). 4. A small number of uncontrolled human trials have indicated tumor shrinkage in some patients and possible prolonged survival in those without tumor shrinkage with administration of CoQ10. Breast cancer patients with and without metastatic cancer, have been treated with CoQ10 and reported to respond. Antioxidants and essential fatty acids were also administered in one trial (15). Unlike some other proposed natural therapies for cancer (see: Questionable Cancer Therapies I: PC-Spes), this one has been pursued at several research institutes and the effort has been joined by investigators aside from the original group (from Denmark). CoQ10 is already an approved drug (listed in the Physicians Desk Reference, but not indicated for cancer therapy at this time) and is a well-established food supplement (unregulated; available for sale without prescription). This substance is currently under investigation

for possible therapeutic benefits in the treatment of atherosclerosis and heart disease, early-onset diabetes, deafness, Parkinson's disease and other degenerative neurological disorders. It is not purported to be a cure for cancer or any of these other diseases, but a contributor to improved outcomes. The therapeutic dosage may be as low as 60 mg per day in some cases, but the most recent studies with women having breast cancer relied on 390 mg per day (a few practitioners have tried even higher doses, but there is no evidence to support the need for more than this amount). Although CoQ10 is a natural product, the doses given therapeutically are higher than occur naturally. The dietary levels are normally only a few milligrams per day; this fat soluble compound is mainly found in beef and pork, fatty fish (such as sardines and mackerel), wheat germ, and soybean and sesame oils. Women pursuing a low fat and mostly vegetarian diet aimed at maintaining health and reducing cancer risk may have very low dietary intake of this nutrient. CoQ10 is also produced in the human body from tyrosine, but the combination of dietary sources and biosynthesis will yield a blood plasma level that usually does not exceed 1 ug/ml in healthy individuals, while supplementation at 390 mg of CoQ10 daily has been shown to increase the level to over 3 ug/ml in patients with breast cancer. There is no known impact of CoQ10 on hormone levels and, at this time, no reason to suspect a significant effect on estrogens or other sex hormones. CoQ10 administration is currently considered safe by most authorities and there are few adverse effects (at the high dosages, some nausea or bloating may occur, which is generally alleviated by dividing the dosage into smaller amounts taken more times per day; there may be some changes in the urine at doses of 200 mg or more per day). In laboratory animals, life-long feeding of high levels of CoQ10 did not produce any evident adverse effect and did not affect life span (16). Although there are several natural substances that are under consideration for prevention of cancer (4, 17), CoQ10 is one of the few that has been specifically aimed at use in treatment of breast cancer. Therefore, as with soy isoflavones, this substance is of potential interest to practitioners who are pressed to natural therapies that are not likely to increase the perceived risk associated with endocrine system enhancement.

REFERENCES 1. Peterson G and Barnes S, Genistein inhibits both estrogen and growth factor-stimulated proliferation of human breast cancer cells, Cell Growth and Differentiation 1996; 7: 1345-1351. 2. Li Yiwei, et al., Induction of apoptosis in breast cancer cells MDA-MB-231 by genistein, Oncogene, 1999; 18(20): 31663172. 3. Yung HC, et al., Genistein-induced G2/M arrest is associated with the inhibition of cyclin B1 and the induction of p21 in human breast cancer cells, International Journal of Oncology 1998; 13:391-396. 4. Boik J, Cancer and Natural Medicine, 1995 Oregon Medical Press, Princeton, MN. 5. Barnes S, et al., Soy isoflavonoids and cancer prevention: Underlying biochemical and pharmacological issues, Advances in Experimental Medicine and Biology, 1996; 401: 87-100. 6. Chen Keji and Zhang Wenpeng, Advances on anti-aging herbal medicines in China, Abstracts of Chinese Medicine 1987; 1(2): 309-330. 7. Yan Dexin, Aging and Blood Stasis, 1995 Blue Poppy Press, Boulder, CO. 8. Cavaljeri EL, et al., Molecular origin of cancer, Proceedings National Academy of Sciences 1997; 94: 10,937-10,942. 9. Li YW, et al., Induction of apoptosis in breast cancer cells MDA-MB-231 by genistein, Oncogene 1999; 18(20): 3,1663,172. 10. Bracke ME, et al., Influence of tangeretin on tamoxifen's therapeutic benefit in mammary cancer, Journal of the National Cancer Institute 1999; 91(4): 354-359. 11. Folkers K, et al., Activities of vitamin Q10 in animal models and a serous deficiency in patients with cancer, Biochemical and Biophysical Research Communications 1997; 234(2): 296-299. 12. Jolliet P, et al., Plasma coenzyme Q10 concentrations in breast cancer: prognosis and therapeutic consequences, International Journal of Clinical Pharmacology and Therapeutics, 1998; 36(9): 506-509. 13. Lockwood K, et al., Progress on therapy of breast cancer with vitamin Q10 and the regression of metastases , Biochemical and Biophysical Research Communications 1995; 212(1): 172-177. 14. Hodges S, et al., CoQ10: Could it have a role in cancer management? Biofactors 1999; 9 (2-4): 365-370. 15. Lockwood K, et al., Apparent partial remission of breast cancer in high risk patients supplemented with nutritional antioxidants, essential fatty acids, and coenzyme Q10, Molecular Aspects of Medicine 1994; 15 (supplement): 231-240. 16. Lonnrot K, et al., The effects of lifelong ubiquinone Q10 supplementation on the Q9 and Q10 tissue concentrations and life span of male rats and mice, Biochemistry and Molecular Biology International 1998; 44(4): 727-737. 17. Ren S and Lien EJ, Natural products and their derivatives as cancer chemopreventive agents, Progress in Drug Research 1997; 48: 147-171. 18. Kuang Ankun, et al., Research on anti-aging effect of qigong, Journal of Traditional Chinese Medicine 1991; 11(2): 153158. 19. Liu Hedi, et al., The influence of kidney tonic herbs on relative parameters and bone mass density in post-menopausal females, International Journal of Oriental Medicine, 1998; 23(4): 205-207. September 1999





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Famous Chinese Physicians of the Past Source of Illustrations

Pien Ch'iao (Bian Que; ca. 500 B.C.)

Tsang Kung (Cang Gong; ca. 200 B.C.)

Wang Shu-Ho (Wang Shuhe; 180-270 A.D.)

Huang Fu (Huangfu Mi; 214-282 A.D.)

Ch'ao Yuan Fang (Chao Yuanfang; 550-630 A.D.)

Sun Ssu-mo (Sun Simiao; 581-682 A.D.)

Chang Chung Ching (Zhang Zhongjing; 150-219 A.D.)

Hua To (Hua Tuo; 110-207 A.D.)

Ko Hung (Ge Hong;

T'ao Hung-Ching (Tao Hongjing; 452-536 A.D.)

281-341 A.D.)

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TREATMENT OF AVASCULAR NECROSIS OF THE FEMORAL HEAD WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Avascular Necrosis of the Femoral Head (AVN-FH) refers to a progressive weakening of the knobby head of the thigh bone (femur), resulting in eventual collapse of the bone structure if not remedied in time. This disorder involves disrupted circulation (hence the term avascular), leading to death (necrosis) of bone cells that maintain the solid bone matrix. It is seen in children and young adults as the result of injuries and various genetic bone disorders, and it may occur later in life as the result of abuse of drugs (corticosteroids and alcohol are the main culprits) and secondary to chronic diseases (e.g., systemic lupus) that affect the vascular system. The disorder is sometimes referred to as aseptic necrosis, meaning that it does not involve a bone infection. It is usually diagnosed after a person complains of pain and restricted motion of the hip, where the pain is worsened with activity and improved by rest; one or both hips can be involved; in cases other than traumatic injury, one side is affected first, and the other may develop the condition later. Surgical replacement of the femoral head is the primary therapy, undertaken when day-to-day activities become impaired. The femur sustains considerable force while holding up the body in upright position, and can be exposed to much higher forces when the body weight comes down on one leg, such as when running (yielding about 5 times the impact of body weight when standing). The femur structure is designed to withstand these pressures by the development of a thick outer layer of compact bone. Upon close examination, the femur bone reveals lines of compression along the pathways in which force is transmitted (see Figure 1; the femoral head is the protrusion at the upper right of the illustration). These lines appear as a result of formation of struts, called trabeculaehardened material laid down by the cells of the initially soft bone. If the blood circulation is severely restricted or blocked, the trabeculae will eventually deteriorate, collapsing the femoral head and producing osteoarthritis of the hip at an early age (individuals with this disorder often present with osteoarthritis by age 40). It is estimated that more than 10,000 new cases of AVN-FH are diagnosed in the U.S. each year.

Figure 1. Cross section of the femoral head. The arterial supply to the femoral head is principally provided by an arterial ring at the base of the femoral neck with branch vessels reaching upward to the femoral head, and by arteries of the round ligament that attaches at the femoral neck. These large vessels approaching the femoral head terminate in small arterioles at its surface. Blockage of circulation may occur via damage to the main arteries or clogging of the arterioles. Examination of the bone by x-ray, MRI, or CT scan, reveals the status of the bone trabeculae, allowing staging of the disease progression. At stage I, there are only spotty changes; at stage II there are somewhat larger patches and general haziness of the trabeculae as they are degenerating; at stage III there is evident necrosis, with slight collapse of the femur head, showing an enlargement of the joint space; at stage 4, the femur head is flattened and deformed and may be collapsed; the joint space also collapses, becoming narrowed, as seen in osteoarthritis. From the perspective of traditional Chinese medicine, gushi (gu = bone; shi = corroded), as the disorder is described, involves bone weakening and impaired circulation. Therefore, it is treated primarily with herbs that strengthen and repair the bone, most of which are classified as kidney yang tonics, and herbs that vitalize blood circulation and resolve blood stasis, such as those listed in the following table. Herbs Used to Treat Avascular Necrosis of the Femoral Head (AVN-FH)

Common Name Pin Yin Name

Botanical Source Part Used

Materia Medica Classification Reasons for Use in AVN-FH

Achyranthes niuxi

Achyranthes bidentata root

vitalize blood; achyranthes also nourishes blood and brings blood down from upper to lower body

Astragalus huangqi

Astragalus membranaceous root

tonify qi; astragalus also raises sinking qi and aids circulation of blood

Carthamus honghua

Carthamus tinctoria flower

vitalize blood; carthamus is considered specific for treating trauma and painful joints

Cibotium gouji

Cibotium barometz rhizome

tonify yang; cibotium is commonly used for pain and weakness of the lower body

Cnidium chuanxiong

Ligusticum walichii rhizome

vitalize blood; cnidium also alleviates pain and nourishes blood

Cordyceps dongchong xiacao

Cordyceps sinensis mycelium

tonify yang; cordyceps is used for degenerative conditions and alleviates pain of the lower body

Deer Antler/Gelatin lurong/lujiaojiao

Cervus nippon antler or its gelatin

tonify yang; antler and its gelatin are used for nourishing the bones and alleviating pain

Dipsacus Xuduan

Dipsacus asper root

tonify yang; dipsacus also vitalizes blood circulation and is commonly used to treat broken bones

Drynaria gusuibu

Drynaria fortunei rhizome

tonify yang; drynaria is also important for vitalizing blood, and is a key herb for repairing bone

Epimedium yinyanghuo

Epimedium sagittatum whole plant

tonify yang; epimedium is considered valuable for treating joint pain of the lower body

Eucommia duzhong

Eucommia ulmoides bark

tonify yang; eucommia is mainly used for weakness and pain of the lower body

Loranthus sangjisheng

Loranthus parasiticus stem

nourish yin; loranthus is used to treat soft bones and to alleviate pain of the lower body

Lycium fruit gouqizi

Lycium chinense fruit

nourish blood; lycium is used for weakness and soreness of the lower body

Millettia jixueteng

Spatholobus suberectus stem

vitalize blood; millettia also nourishes blood and treats pain of the lower body

Polygonatum huangjing

Polygonatum sibericum root

nourish blood; polygonatum also tonifies qi and essence, and is used for lower body pain

Salvia danshen

Salvia miltiorrhiza root

vitalize blood; salvia also nourishes the blood and enhances circulation in the arterioles and capillaries

Tang-kuei danggui

Angelica sinensis root

nourish blood; tang-kuei also vitalizes blood circulation and alleviates pain

Tortoise shell guiban

Chinemys reevesii plastron

nourish yin; tortoise shell is used to strengthen bones and nourish blood

Turtle shell biejia

Amyda sinensis dorsal shell

nourish yin; turtle shell is thought to nourish the bone marrow

Several clinical reports have appeared in Chinese medical literature describing therapies for AVN-FH, with herb therapies being a key feature. All of the reports claim a high degree of success (typically 90% or more of patients show improvement) in alleviating symptoms of pain and stiffness and showing at least partial reversal of the bone deterioration observed by x-ray. The report involving the largest number of patients is by Wang Lulin of the Dongya Institute of Osteopathy in Beijing (1). Of the 1286 patients examined and treated, most were in the age range of 18-59 years, with about half the cases involving both sides. The suspected causes were outlined as follows: Suspected Cause or Predisposing Factor

Number of Cases (%)

Chronic use of steroids

669 (52.0)

Trauma to hip

376 (29.2)

Childhood maldevelopment of hip

87 (6.8)

Alcoholism

46 (3.6)

Remaining cases, undetermined factors

108 (8.4)

Total

1286 (100)

Most of the patients had well-advanced disease, at stage III or stage IV (1,051 cases were at these stages). The formula applied was not described, but the main herbs were said to be cordyceps, which represents the bone-nourishing kidney yang tonics, and tang-kuei, which represents the blood vitalizers. The herbs were made into pills, each dose being 6 grams, taken three times daily for three months as a therapeutic course, which would be repeated as necessary to gain the maximum results. The treatment times ranged from 3 months to 2 years, with a median duration of 10 months. On average, clinical symptoms were said to be partially or completely eliminated during the first three months, and an improvement in bone condition- determined by x-ray-would occur within about six months. The few failures or marginal results occurred mainly with elderly patients who had stage-IV disease progression. The author interpreted the positive effects of treatment this way: The capability of repair of femoral head necrosis is closely related to the patient's age, constitution, and degree of necrosis. In children and youngsters, the capability of repair is relatively strong, and if the necrotic femoral head is not collapsed, basic cure of the disease can be expected after herb treatment. Even if the necrotic head is collapsed, its shape after repair is usually better [in these young patients] than that of the middle-aged or old patients. The duration of treatment to repair the damage depends upon the severity of the necrosis, and is significantly shorter in the cases of stages I and II than that in cases of stages III and IV. For the cases at stages I and II, the symptoms can be expected to disappear with the necrotic femoral head recovered to its original shape. This view about the capability of repair among different patients was echoed by other researchers in their summarization of results. A more comprehensive therapeutic regimen was described by Lu Wenzhi of the First Municipal Hospital of Qiqihaer in Heilongjiang Province (2). According to his report, 230 patients with femoral head necrosis were treated by a combination of herb therapy, foot massage, leg traction, and exercises. The herb therapy involved pills containing a mixture of more than 30 different herbs, including astragalus, ho-shou-wu, cibotium, eucommia, sea horse, cordyceps, lycium fruit, tang-kuei, turtle shell, tortoise shell, pearl, scorpion, agkistrodon, achyranthes, and cloves. The formula is aimed at nourishing the bone, warming the circulation, and alleviating pain and spasm. These herbs were prepared as a honey pill (6 grams herb materials, 3 grams honey) to be taken two pills at a time, once per day, preferably swallowed down with water that was used to boil an egg and a slice of fresh ginger, to enhance the efficacy of the herbs in pill form. A course of treatment was 3 months, to be repeated as necessary; most patients utilized 1-4 courses of therapy. Massage therapy was focused on the affected leg, with some attention paid to stimulating acupuncture points, such as yongquan (KI-1), sanyinjiao (SP-6), the two x i points, taixi (KI-3) and xiaxi (GB-43), and zusanli (ST-36). The meridians of the leg, such as kidney, spleen, and gallbladder, all pass through the hip area. The massage was vigorous, and would last for 20-30 minutes, to be administered 1-2 times per day, for one week, in order to get a course of therapy started. This could be repeated as necessary. The goals of the massage are: to enhance circulation through the meridians up to the affected part, relying mainly on the shu (stream) points; to enhance the yang-qi; warm the meridians; free up the circulation of qi and blood; strengthen the tendons and bones; and promote the health of the joints. For several hours per day, the patient would lie in bed and stretch out the leg to a point of comfort in the hip and retain that position for 2 or more hours. This would be accomplished by tying the person's ankle to the foot of the bed and then having the patient stretch himself out by pulling at the head of the bed to get the best position for the hip, and then lie in that position, readjusting as necessary. The purpose of this self-traction is to reduce local pressure on the femoral head to avoid further collapse, reduce severe pain due to dead bone pieces in the joint cavity, and reduce recurrent pain that might still be present during the initial process of treatment. In addition, the patient would be encouraged to do exercises for the hip joint. The amount of exercise would depend on the ability and tolerance of the individual and would be limited to avoid damage to the blood vessels at the affected hip. Recommended actions included a passive motion of the hip joint while in bed by moving the rest of the body, and a regular joint exercise involving active movement of the leg along three directions, such as side, up, and angled, as well as by bending and stretching; these latter exercises could be done while standing or in bed, as necessary. In addition, a pedaling exercise, using a stationary bike with adjustable resistance, was recommended. The purpose of all these exercises include: improving blood circulation through the hip; maintaining strength and flexibility; and assuring that the bone recovery occurs in the context of enabling increased movement of the joint. In another report, focusing mainly on treatment of femoral head necrosis in children, the herbal therapy was prepared and administered at the Qufu Municipal Hospital of TCM in Shandong Province (3). The formula included tang-kuei, millettia, salvia, carthamus, pyrite, drynaria, astragalus, loranthus, tu-huo, coix, epimedium, cyperus, centipede, and borneol. The fibrous herbs were boiled with water, then the water decoction was concentrated and dried; this extract was next mixed with the carthamus, centipede, pyrite, and borneol, which had been ground into fine powder. The resulting mixture was put in capsules for oral administration, at 400 mg/capsule, 1-2 capsule a time, three times a day, with three months as a course of treatment. Most patients underwent 1-3 course of therapy, with an average duration of 7 months. Some of the patients also were treated with a type of traction to alleviate pressure at the affected joint, and with local application of heat and herbs, and massage (these local therapies were not described in detail). According to the author of the report, some alleviation of symptoms was usually noted during the first month and those with earlier stage of disease were better able to gain complete or near complete recovery. A report from the Wendeng Hospital of Orthopaedics and Traumatology in Shandong Province described treatment where the

majority of patients were adults (4). Herb therapy was the main method used, and the formula administered was: 10g salvia, 10g cnidium, 10g deer antler gelatin, 10g angelica, 10g sinapis, 15g achyranthes, 15g drynaria, 20g astragalus, 5g calamus (gum), 15g epimedium, and 30g polygonatum (total: 150 grams; 25 doses). These herbs are ground to powder and taken in doses of 6 grams a time, with warm water, twice a day. Three batches of this formula (75 doses, about a five week quantity) make a course of treatment, which is followed by a one-week interval between two courses. In a laboratory animal study of AVN-FH, performed at the Laboratory of Neurology & Morphology, Institute of Orthopedics and Traumatology in Beijing, the tested formula (called the femoral head necrosis decoction) contained tang-kuei, cnidium, dipsacus, drynaria, asarum, eupolyphaga, and pyrite (5). The authors stated: The experiment indicated that femoral head necrosis decoction can relieve pain, improve endurance during movement, reduce inflammation, stimulate trabecular formation and ossification, and activate the healing process. Further study is required to demonstrate the mechanism of action of the herbs. Pyrite (zirandong), included in the above formulation and in the formula used for the study focusing on childhood AVN-FH, is natural ferrous sulfide, a mineral, that also contains a small amount of copper. It is traditionally used to unite fractured bones, disperse stagnant blood, and control pain. Potentially, several other minerals may also be of value in helping repair the damaged femoral head, including calcium, the dominant bone constituent. A broad-spectrum mineral supplement that includes calcium, iron, and copper among other ingredients may be a suitable modern substitute. Several of the formulas mentioned included animal materials, known in China as chong (literally, crawling creatures), such as eupolyphaga, scorpion, centipede, and agkistrodon; these are understood as aids to clearing the obstructed circulation and alleviating pain. Other animal materials, including sea horse (no longer available for use due to endangered species status), turtle and tortoise shells (from animals raised in ponds), deer horn glue, and pearl, are used as tonics. Most of the ingredients of the formulas in this report are available outside of China. Combinations similar to the ones mentioned are made in prepared form, as pills or tablets, and formulas containing such ingredients can be provided in the form of dried hot-water extracts, to be made into instant teas. Therefore, it is possible to utilize treatment strategies of the type described for those who wish to attempt resolution of AVN-FH without resorting to surgery. However, as indicated in the Chinese reports, in older patients and those with more advanced disease, the extent of repair to the femoral head may be substantially limited. Three clinical reports on treatment of AVN-FH from China involved complex therapeutic measures that cannot be duplicated outside China, including introduction of herb extracts into the femur head arteries by use of a catheter. The treatments were administered at the Yizhou Kuitun Hospital in Xinjiang Province (6), the Luoyang Hospital of Traditional Chinese Orthopaedics and Traumatology in Henan Province (7), and the Second Hospital of the Guangxi College of TCM in Nanning City of Guangxi Province (8). The key herb in these treatments was salvia; the catheter method was said to produce quicker results than oral therapies. Salvia, as well as the other herbs, can be used orally outside China. The Institute for Traditional Medicine (ITM) has prepared several formulations that are suited to AVN-FH. They may be administered under the guidance of qualified health professionals, such as acupuncturists, trained in the use of Chinese herbs. As an example of a treatment approach using the ITM formulary, the following items might be included (the suggested doses are for adults, and based on using the combination of items listed, but not using any other supplements, such as over-the-counter dietary products): Drynaria 12 (Seven Forests), a formula designed on the basis of Chinese clinical reports on effective therapy for osteoarthritis, comprised of drynaria, dipsacus, rehmannia, astragalus, millettia, tang-kuei, achyranthes, eucommia, deer antler, cnidium, pine node, and tu-huo. Nine of the 12 ingredients of this formula are listed in the table of herbs used for treating AVN-FH. Suggested dose is 5 tablets, three times daily (about 10.5 grams of herbs, including 2 herbs as extracts). Antler 8 (Seven Forests), a formula designed to provide deer antler, is comprised of deer antler and antler gelatin (4:1 ratio of these ingredients), salvia, rehmannia, polygonatum, ginseng, tang-kuei, alpinia, and cardamon. Four of the 8 ingredients of this formula are listed in the table of herbs used for treating AVN-FH. Suggested dose is 2 tablets each time, three times daily (about 4.2 grams of herbs). Dan Shen Pian (Pine Mountain), a concentrated extract of salvia, for promoting circulation. Suggested dose is 1 tablet each time, three times daily (about 1.6 grams of herb extract). Boswellamine (White Tiger), a combination designed to provide glucosamine sulfate, widely used to nourish the joints in cases of osteoarthritis; the formulation also contains dipsacus extract, myrrh, and frankincense. Suggested dose, 1 tablet each time, three times daily (the herb portion represents about 1.8 grams of materials). This item might be deleted in early stage disease. Bromelgin (White Tiger), a combination designed to provide bromelain, an anti-inflammatory enzyme widely used in treatment of injuries; it also contains drynaria extract. Suggested dose is 1 tablet each time, three times daily (with 1.5 grams of drynaria extract). Calmagnium (White Tiger), a combination of minerals and vitamins, particularly useful for nourishing the bones, as occurs with osteoporosis (it does not contain iron, but its vitamin C content promotes iron absorption). Suggested dose is 1 tablet each time, three times daily. The total amount of herb materials (powders and extracts) in this large number of tablets is about 20 grams, somewhat higher than the amounts for adults mentioned in the clinical reports (12-18 grams). The average body weight of Westerners is higher than that of their Chinese counterparts (at least, during the time when the therapies were administered; Chinese body weights have been catching up with Western weights more recently). This therapy also provides additional materials, such as glucosamine sulfate, bromelain, and the broad spectrum of minerals and vitamins, which were not part of the Chinese treatments. Glucosamine sulfate may substitute for turtle and tortoise shell, and some other animal ingredients in the Chinese formulations. For children, the dose of herb formulas would be reduced, and the Boswellamine and Bromelgin might be deleted; Calmagnium could be replaced by a formulation aimed at childhood requirements. The primary herbs of this treatment are drynaria, dipsacus, deer antler, salvia, rehmannia, and tang-kuei. These herbs invigorate the

yang and nourish the kidney, vitalize the blood and nourish the blood, and help repair bone. A three-month course of therapy might be tried in order to determine whether or not this approach is adequate for any individual. Additional therapeutic measures, including massage and/or acupuncture, exercises, and self-traction might additionally be employed to optimize the outcome.

REFERENCES 1. Wang Lulin, Clinical observation on therapeutic effects of Guzhizaisheng Wan for treatment of aseptic necrosis of the head of femur, Journal of Traditional Chinese Medicine, 1997; 17(2): 127-129. 2. Lu Wenzhi, et al., 230 cases of aseptic necrosis of the femoral head treated by combining therapy, China Journal of Orthopedics and Traumatology, 2000; 13(2): 98-99. 3. Wang Guanglu, et al., A report on 46 cases of child early femur-head necrosis treated with Fuhuokang Capsule, Journal of Traditional Chinese Orthopedics and Traumatology, 2000; 12(7): 44. 4. Jiao Minghang, et al., Clinical curative observation on bone-generating powder in treating 127 cases of early femur-head avascular necrosis, Journal of Traditional Chinese Orthopedics and Traumatology, 2000; 12(8): 31. 5. Anonymous, The Preliminary Report of Experimental Herbal Study for Femoral Head Avascular Necrosis, Web posted at http://www.cyberweb1.com/csom/html/avascular_necrosis.html 6. Zuo Qinyun and Shen Jianmin, 11 cases of aseptic necrosis of the femoral head treated by catheter therapy with salvia, dextran-40, and urokinase, China Journal of Orthopedics and Traumatology, 2000; 13(2): 106-107. 7. Guo Huili, et al., Clinical study on catheter therapy for the treatment of avascular femur-head necrosis, Journal of Traditional Chinese Orthopedics and Traumatology, 2000; 12(7): 10-11. 8. Liu Ruzhuan, Observation on curative effect of catheter therapy by integrating TCM and Western medicine for the treatment of ischemic femur-head necrosis, Guangxi Journal of Traditional Chinese Medicine, 2001; 24(3): 13-14.

December 2002

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CHINESE HERBS AND FERTILITY by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Chinese herbs have a long history of use in aiding fertility. Records indicating herbal treatment of infertility and miscarriage date back to 200 A.D., including mention of formulas that are still used for those purposes today, in the famous medical text Shang Han Lun. The first book devoted solely to gynecology and obstetrics, The Complete Book of Effective Prescriptions for Diseases of Women , was published in 1237 A.D. In modern China, herbs are used to treat infertility in both men and women and the results of large scale clinical trials are reported in Chinese medical journals; these results have been abstracted in English by a research group in Hong Kong since 1986, and translations of whole articles are obtained, by request, from several translators. The Institute for Traditional Medicine has acquired dozens of these reports and has analyzed the information to aid practitioners in selecting the appropriate herbs for different infertility cases and to explain the dosage, duration of treatment, and prognosis.

THE HERBS USED TO AID FERTILITY No individual herb is considered especially useful for promoting fertility. Rather, more than 150 different herbs, usually given in complex formulas comprised of 15 or more ingredients, are used in the treatment of infertility with the purpose of correcting a functional or organic problem that caused infertility. The design of the formulas has varied somewhat over the centuries, based on prevailing theories and available resources, and individual practitioners have a preference for particular herbs, thus accounting for some of the variations among formulas that are recommended. However, differences among individuals being treated accounts for the greatest variation in the selection of herbs and formulas to be used. There are some "exotic" materials that are frequently found in fertility formulas, such as deer antler and sea horse, but the prominent materials are derived from roots, barks, leaves, flowers, and fruits. Formulas for men and for women tend to be different, but there is considerable overlap in the ingredients used.

HOW THE HERBS ARE ACQUIRED AND CONSUMED In China, a number of fertility formulas can be purchased off the shelf in public pharmacies, and for uncomplicated cases, this is often adequate. However most men and women in the Orient are treated for persistent infertility by obtaining prescriptions from a doctor who is expert in Chinese herbs. In the U.S., it is uncommon to find fertility-promoting formulas in stores or other outlets; rather, they are prescribed by acupuncturists, naturopaths, or medical doctors who are familiar with Chinese herbs. The Institute for Traditional Medicine maintains a listing of such practitioners, to aid individuals anywhere in the U.S. to find a local expert in this field. Depending on the circumstances, one may be asked to ingest herbs in the form of pills, tablets, granules, or decoctions (teas). Some of the treatment plans involve using a single herb combination regularly, while others suggest using two, or even three, different formulas at different times of the menstrual cycle. All of these means can be effective, so long as the correct formula and correct dosage are used for an adequate period of time.

THE SUCCESS RATE FOR CHINESE HERB TREATMENTS Although the outcome for any given individual cannot be predicted, the clinical studies conducted in China indicate that about 70% of all cases of infertility (male and female) treated by Chinese herbs resulted in pregnancy or restored fertility. Depending on the particular study and the types of infertility treated, success rates ranged from about 50% up to more than 90%. Included in these statistics are cases of infertility involving obstruction of the fallopian tubes, amenorrhea, absent ovulation, endometriosis, uterine fibroids, low sperm count, nonliquification of semen, and other causes. In China, due to the greater experience with using herbs, the ability to directly integrate traditional and modern methods of therapy, and the willingness of individuals to consume relatively large doses of herbs, the success rates are probably somewhat higher than can be achieved in the U.S. at the present time. Nonetheless, U.S. practitioners have had many experiences of success in treating infertility.

DURATION OF TREATMENT TO ATTAIN FERTILITY In the Chinese clinical studies, daily or periodic use of herbs usually resulted in restored fertility within three to six months. Many Chinese doctors feel that if pregnancy is not achieved within about eight to nine months, then it is unlikely that the treatment will be successful with continued attempts. In Japan, where doctors give lower dosages of herbs and are restricted to using a smaller range of herbs, treatment time is usually longer: from six to fifteen months. In the U.S., nearly the full range of Chinese herb materials are accessible, but the dosage to be used is usually lower than in China; as a result, it is estimated that pregnancy can be achieved within six to twelve months. It must be remembered, however, that approximately one-third of infertility cases may fail to respond to all reasonable attempts. One advantage of the Chinese herbal approach is that even if pregnancy does not occur, benefits to health can be attained because the herbs address imbalances that affect other aspects of health besides infertility.

SAFETY OF THE HERBS Chinese herbs are used in the U.S. as traditional foods and not as drugs. As such, there has been no formal testing of either the safety or efficacy of any of the individual herbs or formulas. The Chinese have had long experience using these herbs; from all informal reports and clinical studies, the Chinese claim that the herbs are not only safe to use, but that healthy children are usually born without any problems during delivery. However, it is important to recognize that the use of Chinese herbs is relatively new in the U.S. and that Americans today may have more stringent safety standards than the Chinese have had in the past. Therefore, one should pay attention to perceived adverse responses to the herbs. The Chinese herbs that are used in the U.S. are not overtly toxic, but there are a few possible adverse reactions which are rare and can usually be avoided by slight adjustment in formulation or method of administration. These reactions may include dizziness or headache, dry mouth, nausea, flatulence, or change in bowel conditions. If such reactions are not resolved naturally within about three days or if they are severe, the prescribing physician can make an appropriate adjustment. In any case, by discontinuing use of the herbs, any of these reactions will disappear promptly. Allergic reactions to herbs are rare, but if a person suffers from "environmental allergy syndrome," then the herbs can also cause the same reactions as other materials encountered in the normal environment.

MECHANISM OF ACTION

The mechanism of action of the herbs is not known precisely, and undoubtedly varies according to the type of infertility problem being treated and the herb formula that is used. The traditional Chinese views are that infertility tends to arise from one or more of three prominent causes: 1. A "deficiency" syndrome prevents the hormonal system from properly influencing the sexual and reproductive functions. This is said to be a weakness of the "kidney and liver" which may influence various body functions producing symptoms such as frequent urination, weakness and aching of the back and legs, impotence, irregular menstruation, and difficulties with regulation of body temperature. Deficiency syndromes are treated with tonic herbs that are said to nourish qi (e.g., ginseng, codonopsis, atractylodes, astragalus), blood (e.g., tang-kuei, peony, ho-shou-wu, gelatin), yin (e.g., lycium fruit, ligustrum, eclipta, ophiopogon), or yang (e.g., epimedium, cistanche, cuscuta, eucommia), and are selected according to the overall evaluation of symptoms. 2. A "stagnancy" syndrome prevents the sexual and reproductive organs from functioning despite normal hormone levels and normal ability to respond to hormones. This is said to involve a stagnancy of "qi and blood," which has the impact of restricting circulation to the tissues involved. Qi stagnation is often noted by tense muscles, restrained anger, and digestive disorders; herbs for resolving the stagnancy include bupleurum, cyperus, lindera, and various citrus products. Other symptoms that might arise include abdominal pain or bloating, chronic inflammation, and formation of lumps (including cysts and tumors). Blood stagnation often occurs following childbirth, surgery, injury, or severe infection and is typically noted when there is severe pain (such as dysmenorrhea), or hard swellings and obstructions; abnormal cell growth, including dysplasia and cancer, are thought to involve blood stagnation. Herbs such as salvia, red peony, persica, and carthamus may be used. 3. A "heat" syndrome, which causes the affected organs to function abnormally. Heat syndromes may be associated with an infection or inflammatory process. This type of syndrome can produce abnormal semen quality leading to male infertility, while gynecologic infections can maintain female infertility by blocking the passages, altering the mucous membrane conditions, or influencing the local temperature. Herbs that inhibit infections and reduce inflammation are used, including gardenia, phellodendron, patrinia, and lonicera. In each case, the purpose of the Chinese herbs is to rectify the underlying imbalance to restore normal functions. Western medicine can diagnose tubal blockage (which usually corresponds to blood stagnancy in Chinese medicine) and infection (which corresponds to heat syndromes of Chinese medicine) and in many cases can successfully treat these causes of infertility. However, Western medicine often fails to diagnose deficiency syndromes and most of the stagnancy syndromes. Therefore, the majority of Chinese herb formulas to be applied in the U.S. are those that counteract the deficiency (called tonics) and those that resolve the stagnancy (called regulators). A description of Chinese herb formulas used for infertility is presented in the appendix to Chinese Herbology, a training manual produced by the Institute for Traditional Medicine. The hormonal effects of Chinese herbs used to treat impotence and infertility and to prevent miscarriage have been demonstrated in laboratory experiments. For example, the laboratory evaluation of Huanjing Decoction (composed of rehmannia, ho-shou-wu, ligustrum, morus fruit, achyranthes, dipsacus, cynomorium, astragalus seed, and cuscuta) was administered to senile mice for four months, two weeks treatment, one week break. Estradiol and dihydrotestosterone receptors in the nucleus of thymic cells were decreased to levels found in young mice; cytosol estradiol receptors increased. Also, the formula influenced the immune system: it increased thymus weight, thymic index, and prevented atrophic changes in the ultrastructures of thymic lymphocytes and epithelial reticular cells.

COMBINING CHINESE HERBS AND WESTERN THERAPIES In China, the combined use of modern drugs or other Western medical techniques along with Chinese herbs is not uncommon; some doctors are trained in both methods, and Western and traditional doctors often work together in Chinese clinics and hospitals. When the modern methods are applied, the herb therapies do not usually need to be altered compared to cases where the herbs are used alone. Most of the cases of infertility successfully treated in China do not rely on techniques such as in vitro fertilization, which are quite expensive and have only a modest rate of success in the U.S. where the modern fertilization methods are most highly developed.

INFERTILITY PROBLEMS NOT OVERCOME BY USING CHINESE HERBS It is not advisable to suggest that something simply cannot be accomplished in the field of health care (because there are almost always exceptions), but there are some areas where chances of success are considered quite low. Some women suffer from amenorrhea that is associated with a very low body fat content. This is apparently exacerbated by strenuous exercise (e.g., distance running). Changes in diet and exercise may be necessary before Chinese herbs or other therapeutic methods can be effective. In a few cases, a woman's immune system will attack her husband's sperm and thus make fertilization virtually impossible; this can not be overcome with Chinese herbs. People who are under very high levels of stress or who have multiple health problems may need to have these things addressed-partly with use of Chinese herbs-before a reasonably high chance of success can be expected in the specific treatment of infertility.

USE OF HERBS WHEN PREGNANCY OCCURS The herbs for inducing fertility are usually discontinued once pregnancy is suspected or confirmed. In most cases, it is not necessary to use herbs during pregnancy. Women with a history of miscarriage or who are deemed at high risk for miscarriage (somewhat more common among women who have experienced prolonged infertility) may wish to take herbs that are traditionally used in such cases by Chinese women. Certain herbs can be used during pregnancy to enhance the health of the mother and to counteract symptoms of morning sickness. In addition, it is reported that labor can be made easier by proper application of herbs and acupuncture. Books on the subject of herbal health care for pregnancy and nursing can be traced back to such important works as A Precious Medical Book on Obstetrics for Home Use, published in 1184 A.D.

THREATENED MISCARRIAGE Threatened miscarriage, if due to an imbalance in the mother's system (but not if due to genetic problems with the fetus), can often be overcome with application of herbs and possible adjunct therapy with moxa or acupuncture. The method to be used and the procedures to follow should be discussed early in the pregnancy so that appropriate steps can be taken should bleeding, fetal agitation, or early contractions occur. It is important to note that most cases of early miscarriage (sometimes called spontaneous abortion) are not related to an imbalance in the mother's system but are rather a natural and fairly common event, possibly due to a development problem of the

embryo. Later in the pregnancy, weaknesses in the mother's system or excessive fetal movement, become a more prominent factor. There is a particular herb formula, called Tang-kuei and Peony Formula ( Dang Gui Shao Yao San ), which forms the basis of most treatments aimed at avoiding miscarriage-but the formula is intended to be used mainly as a daily preventive therapy rather than an emergency treatment. Extensive testing in the Orient indicates that this formula is safe to use and it appears highly effective; modified versions of this formula, such as Tang-kuei Formula ( Dang Gui San), are used to address specific concerns and are probably of equal safety and efficacy. Other formulas, such as "An Tai Yin " (which means Peaceful Fetus Formula) and "Shou Tai Wan " (which means Fetus Longevity Pill) are popular remedies in China for use during the latter part of pregnancy.

ROLE OF ACUPUNCTURE Chinese clinicians appear confident that most fertility problems can be overcome solely or primarily with the use of herbs; most medical books describing Chinese methods of treating infertility do not mention acupuncture. However, acupuncture therapy may address particular symptoms of concern either directly related or unrelated to infertility, and might be influential in speeding up the development of normal fertility. In the event that infertility is mainly due to functional disorders, it is possible that acupuncture alone could resolve the problem.

August 1996

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CHINESE HERBAL THERAPY FOR UTERINE FIBROIDS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Uterine fibroids are known by many names, including uterine myoma, leioma, fibroma, fibromyoma, or as hysteromyoma; these are equivalent designations for benign growths of smooth muscle tissue in the uterine wall. Occasionally, the fibroid grows outside the uterine wall as an "exterior" mass in the abdominal cavity. The fibroid masses occur in about 20% of women over the age of 20, with most frequent occurrence between ages 35 and 45 (affecting 40% of women in this age range). However, the fibroids frequently go unnoticed until they grow rapidly during a peri-menopausal phase around age 41-45. Most often, fibroids decline substantially with menopause. The strategy for non-surgical treatment is to limit the size and symptoms of the fibroid(s) until spontaneous shrinkage occurs with menopause, typically just a few years after the initial diagnosis. Only 10-20% of fibroid cases require surgery; interventions such as Chinese medicine may remove the need for surgery in some of these cases, especially if treated early. Small uterine myomas are usually asymptomatic, but larger masses can cause excessive menstrual bleeding, and very large fibroids can contribute to miscarriage, abdominal pain, profuse bleeding (with resultant anemia) and other symptoms for which surgical removal of the fibroids is recommended. Modern laser surgery and the new non-surgical method of fibroid embolization are distinct improvements over total hysterectomy or major abdominal surgery, but women may still seek natural approaches to resolving the masses. It is important to become familiar with fibroids and the treatment options so that patients can be properly advised. Many times, the expectations for "alternative" treatments are excessive: that a brief and convenient treatment without adverse effects will make even large fibroids vanish. On the other hand, fears of modern medical treatment are sometimes blown out of proportion; most women recover fully within weeks of conservative surgery, though there is always a risk of complications, some of which may be serious. Chinese doctors believe that uterine myomas up to the size of a goose egg can be successfully treated with herbs to reduce the size to a comfortable level and, in many cases, to eliminate them. Larger myomas are usually treated with surgery in China as they are elsewhere, though pre-treatment with Chinese herbs may reduce the complications of surgery. To better understand the sizing of uterine myomas, the following table is provided; most gynecologists rank the size in centimeters; this table shows the measurement of some well-known objects. A "goose egg," as designated in the Chinese literature, is about 6.5 cm; a "fist-sized" mass is about the 10 cm. In a woman who has never had children, the average uterus is about 8 cm x 5 cm (and 2.5 cm thick); women who have had children will have a slightly larger uterus. Shrinkage of "grapefruit sized" fibroids is not usually expected and attempting to do so might be an unnecessary burden for the patient. Item

Size

Item

Item

Pea

1 cm

Apple/Pear

7.5 cm

Walnut

3 cm

Orange

9 cm

Lemon

5.5 cm

Grapefruit

11.5 cm

The effectiveness of the Chinese herbal treatments for small to medium size fibroids has been demonstrated by clinical trials conducted in China and Japan. American practitioners of Chinese medicine have frequently reported success in treating fibroids, at least to the extent of alleviating common symptoms and thus avoiding surgery for their patients.

CHINESE MEDICAL THEORY OF ABDOMINAL MASSES, SUCH AS FIBROIDS The first depiction of uterine fibroids in the Chinese literature was in the Ling Shu (ca. 100 B.C.), which defined shijia, a stony tumor (shi = stone; jia = mass). From this text arose the general concept of abdominal masses as zhengjia, which denotes two types of masses: zheng refers to one in fixed position that is painful, and jia is a mass that can be moved, and only hurts when pressure is applied. These masses were described in the Ling Shu (1) scroll on water swellings, zheng corresponds to uterine masses and jia corresponding to intestinal masses (bracketed statements are inserted to aid explanation of the text): Cold qi is a guest [that is, it takes residence there] in the outer [wall of the] intestines, and battles with the protective qi. The qi does not receive nourishment, and because cold qi and protective qi are tied together [in battle], indigestion comes from internal confusion. The sick qi then rises [e.g., upward flux of stomach qi], and sick flesh is born [below]. At the commencement of its birth, the mass is as large as a chicken's egg. Gradually, it increases its sized until it reaches the its conclusion with a shape like carrying a child. For a long time, that is, with years intervening, if the hand is then used to press [on the abdomen], it will feel solid, but if it is pushed, it will move [hence, it is due to an accumulation of stagnated qi]. The menstrual period will be in accord with the tides [i.e., will be regular]. [These are the symptoms when the intestines are affected…alternatively,] the abdominal masses begin in the middle of the womb. Cold qi is a guest at the mouth of the womb. The mouth of the womb is blocked and obstructed. Qi cannot penetrate. Sick blood should leak out but does not leak. The bleeding at times is detained and stops, day by day, [the womb] will increase in size so that the appearance will be like pregnancy. The menses do not respond to the tides [they are irregular]. Based on these concepts, one of the earliest methods of herb therapy for the uterine mass was to use the five ingredient formulation called Guizhi Fuling Wan (Cinnamon and Hoelen Formula), first described in the Jingui Yaolue (ca. 220 A.D.). The cold qi is dispelled by using cinnamon twig; the water stagnation is dispelled by hoelen (poria); the blockage and obstruction of blood flow is treated by the combination of persica, red peony, and moutan. In the Jingui Yaolue (2), the situation was described whereby menstrual bleeding would cease for three months, followed by incessant bleeding indicating that a mass had formed. This scenario is consistent with the concept that the womb is blocked and obstructed (hence the lack of bleeding), but then it develops a mass, which causes the incessant bleeding. The condition was distinguished from pregnancy, where menstrual bleeding would stop, and a mass would begin to form in the abdomen, but incessant bleeding would not follow. Guizhi Fuling Wan halts the incessant bleeding by removing the mass.

In the modern text Practical Therapeutics of Traditional Chinese Medicine (3), the distinction of the two mass types as understood today is presented: Zheng describes solid masses (concretions) with defined physical form and fixed location, accompanied by pain in a specific location. In these cases, pathological changes have taken place in the visceral organs; thus, these patterns usually involve the blood. Jia, on the other hand, describes masses without a distinct physical form (conglomerations), manifesting and dispersing without apparent pattern. Accompanying pain is not fixed in location. In these cases, pathological changes have taken place in the bowel organs. Hence, these patterns involve qi. Despite the differences between zheng and jia, the two are closely related in terms of pathogenesis and are difficult to differentiate, hence the use of the compound term zhengjia. An extensive review of the theoretical basis for the etiology and treatment of abdominal masses, including fibroids, is found in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (4); it is reproduced here with only slight editing. Gynecological examinations were not a practice in China until the recent introduction of modern techniques, so fibroids could not be specifically identified and differentiated during the development of the theories outlined here. Fibroids are now frequently diagnosed before they reach a size that causes pain, which had been one of the first signs of a problem for people lacking modern routine examinations and an integral part of the ancient description of the masses. For the more serious and advanced stage masses described here, symptoms described, such as pain and loss of appetite (and accompanying weakness and weight loss), may not be presented as significant symptoms by patients today because analgesics and other therapies already have been skillfully employed to minimize those effects. Further, some of the cases included in the description may be cancers of the reproductive or abdominal organs, which produce severe systemic effects as they progress. The masses are here divided into two broad groups: qi masses (called ju; these are like the ones referred to as jia) and blood stasis masses (called ji; like those referred to as zheng). Parenthetical statements are added for explanation of the original text. Background The most marked symptoms of abdominal masses, which are called jiju (that is: ji-type masses and ju-type masses), are abdominal distention and pain. Ji refers to visible abdominal masses (that is, they cause an observable protrusion or are easily felt by palpation), which produce pain with a fixed location. They involve the blood system and are generally caused by disorders of the zang organs (e.g., liver, spleen). Since ji forms over a period of time, the pathological condition is severe and so ji is difficult to cure. Ju refers to invisible masses that produce pain without a fixed location (generalized abdominal aching, or pains that occur in different places at different times). It involves the qi system, and is mostly caused by disorders of the fu organs (e.g., gallbladder and stomach). Ju feels like a mass when qi accumulates, but this mass disappears when qi disperses. Since this type of mass forms over a short period, its pathological condition is mild and it is generally easier to deal with than ji. Abdominal tumors (e.g., fibroids), enlargement of the liver and spleen, hyperplastic intestinal tuberculosis, functional gastrointestinal disturbances, and incomplete intestinal obstructions can be diagnosed and treated according to the following descriptions. Etiology and Pathogenesis Among the causes of abdominal masses are mental depression, an improper diet, and attacks by pathogenic cold-dampness or toxin-heat. The (underlying) internal cause of abdominal masses is a deficiency in the body's anti-pathogenic qi (normal qi). Classics on traditional Chinese medicine hold that "People with strong resistance (those with strong qi) do not have abdominal masses, only weak people (those with weak qi) are likely to suffer from them." Abdominal masses gradually develop when the body's antipathogenic qi fails in its struggle against the attacking pathogenic factors. This disease is principally related to the liver and spleen. The stagnation of the qi and the blood and phlegm retention play a major role in the pathogenesis of abdominal masses. The three basic causes are: 1. Mental Depression and Qi and Blood Stagnation. Mental depression causes the stagnation of liver qi, which produces ju lumps. This leads to blood stagnation, which over a long period forms masses, thus producing ji masses. 2. Improper Diet and Production of Turbid Phlegm. An improper diet refers to voracious eating or overindulgence in alcohol. This damages the spleen and stomach, producing turbid dampness whose accumulation forms phlegm; this further results in qi and blood stagnation. These combine with phlegm to cause abdominal masses. 3. Attack by and Retention of Pathogenic Factors. When pathogenic cold, dampness, heat, or toxins attack, they may remain for a long time. This impairs the functions of the affected zangfu organs, causing qi and blood stagnation and turbid phlegm. Over a long time, abdominal masses are produced. Any one or combination of these causes may produce abdominal masses. For example, abdominal masses can be caused by pathogenic wind-cold combined with phlegm due to improper diet, or by mental depression coupled with wind-cold and phlegm. Differentiation and Treatment The pathological changes that occur with ji and ju are different. In the ju syndrome, the disease is located in the qi system and the basic principle of treatment is to soothe the liver, regulate and circulate qi, and disperse accumulation, with the major focus on regulating qi. In the ji syndrome, the blood system is affected and treatment seeks to activate blood circulation and remove stasis, soften hardness and disperse the masses, with the major focuses on treating the blood. If ju syndrome is treated properly in its initial stages, then the symptoms will improve and the disease may even be cured. A prolonged ju syndrome produces blood stagnation, thus transforming itself into a ji syndrome. According to the duration of the disease and its pathological manifestations, ji syndrome is divided into initial, middle, and late stages. Since the abdominal masses are small and soft during the initial stage, and the resistance (qi) is still strong, treatment aims at eliminating pathogenic factors. The masses increase in size and become harder during the middle stage because the body's resistance is weaker than the pathogenic factors; elimination of the masses must therefore be combined with reinforcing the resistance. At the late stage, the abdominal mass becomes very hard and the resistance is greatly damaged. Treatment then focuses on strengthening resistance; strong drugs for eliminating pathogenic factors should not be used (as they may further weaken the qi).

Ju Syndromes (Qi Masses) Ju usually involves liver qi stagnation and/or retention of food and accumulation of phlegm. Liver Qi Stagnation: Qi accumulates and flows to the chest, hypochondrium, epigastrium, and lower abdomen, causing pain in these areas. This condition changes according to the patient's emotional state. Other manifestations include mental depression, a thin and sticky tongue coating, and a taut pulse. Mental depression leads to liver qi stagnation, which causes accumulation of qi and its movement in all directions, resulting in distensive pain. Qi accumulates following mental depression and disperses when the patient is free of emotional stress. A taut pulse suggests liver disorders. An example of herbal treatment is Muxiang Shenqi San (Saussurea Qi-Smoothing Powder). In the recipe, citrus, blue citrus, chih-ko, saussurea, melia, lindera, cardamom, atractylodes, cnidium, and cyperus help the qi to circulate and soothe the liver; cinnamon bark, acrid and warm in nature, disperses cold and helps the qi to circulate; licorice, sweet and mild, relieves pain in the middle burner. If there are any indications of heat, such as a bitter taste in the mouth and a red tongue, then cinnamon bark should not be used and Zuojin Wan (comprised of coptis and evodia) should be added to dissipate any liver heat. The presence of grief, weeping, and absent-mindedness is due to liver qi stagnation and heart deficiency; in this case, the decoction of licorice, wheat, and jujube can be prescribed to nourish the heart, clam the mind, and relieve qi stagnation. Retention of Food and Phlegm: Retained food in the intestinal tract impairs transportation and transformation, and thus produces phlegm-dampness, which, combined with retained food, blocks the qi circulation, thereby causing abdominal pain, constipation, and a poor appetite. When this condition is combined with stagnant qi, cord-like masses occur in the abdomen; these disappear when the qi of the fu organs circulates freely and retained food is sent downwards. An example of treatment is Liu Me Tang (Decoction of Six Ground Herbs). In this recipe, rhubarb, chih-shih (or chih-ko), and areca seed separate retained food from stagnant qi by relieving constipation; aquilaria, saussurea, and lindera circulate qi. If liver qi combines with phlegm to block the throat, Banxia Houpo Tang (Pinellia and Magnolia Combination) can be added to circulate qi and resolve phlegm. Although in most cases ju syndrome is caused by an excess of pathogenic factors, repeated attacks may damage the spleen qi. In this case, Xiang Sha Liu Junzi Tang (Saussurea and Cardamom Combination) can be prescribed at the same time as the other herbs to replenish qi and invigorate the spleen. Ji Syndromes (Blood-Stasis Masses) Ji syndromes are divided into three stages: qi and blood stagnation; retention of stagnant blood; and qi deficiency with accumulation of blood stasis. Initial Stage: Qi and Blood Stagnation. Stagnant qi and blood form abdominal masses. At the initial stage, pathogenic factors move to the blood system from the qi system. The masses have only recently formed and so they are still soft to the touch. Distensive pain, a blue tongue, and a taut pulse are indications of stagnant blood caused by liver qi stagnation. An example of herb therapy is Da Qiqi Tang (Major Decoction of Seven Qi-Regulating Herbs) combined with Shixiao San (Powder for Dissipating Blood Stasis). In the former, citrus, blue citrus, platycodon, and pogostemon circulate qi and disperse masses; cinnamon twig, sparganium, zedoaria, and cyperus remove vascular obstruction by providing warmth. In the latter formula, typha and pteropus active blood circulation, remove stasis, and relieve pain. Middle Stage: Retention of Stagnant Blood. The protracted presence of abdominal masses and gradual aggravation of blood stagnation explain the hard enlarged masses and fixed pain. The stagnation of qi and blood impairs the ability of the spleen and stomach to transport and transform, giving rise to a dark gray complexion, emaciation, lassitude, and a poor appetite. The accumulation of stagnant qi and blood causes disharmony between the nutrient qi (yingqi) and the defensive qi (weiqi) which brings fever (or feverish feeling) and an aversion to cold. Amenorrhea, a purple tongue, and an unsmooth pulse are all caused by the internal accumulation of stagnant blood. A taut and smooth pulse suggests liver hyperactivity. An example of treatment is Shaofu Zhuyu Tang (Decoction of Lower Palace). In the formula, persica, carthamus, tang-kuei, cnidium, pteropus, and red peony activate blood circulation and remove stasis; cyperus, lindera, and corydalis circulate qi, relieve pain, and assist in the removal of stasis; and licorice replenishes qi and relieves pain in the middle burner. Melia, sparganium, and zedoaria can be added to circulate qi and blood. If abdominal masses are hard and produce pain that is aggravated by pressure, Biejiajian Wan (Turtle Shell Pills; a large formula including many animal materials, indicated for masses with poor appetite, emaciation, and abdominal pain) can be administered to remove blood stasis, soften the masses, and relieve pain. In order to eliminate pathogenic factors and reinforce resistance, the above two formulas can be taken alternately with Liu Junzi Tang (Six Major Herbs Combination). If the abdominal masses increase in size and feel hard and painful, eupolyphaga (and other strong agents for dispersing blood stasis) and sargassum should be added to resolve stasis, relieve accumulation, and soften the masses. Late Stage: Anti-Pathogenic Qi Deficiency and Accumulation of Blood Stasis. Prolonged accumulation of blood stasis in the vessels gives rise to hard masses and violent pain. This also damages the spleen and stomach qi and impairs transport and transformation; thus the appetite is greatly reduced and emaciation results. Accumulation of blood stasis also prevents the production of new blood, leading to extreme deficiency of nutrient qi; its symptoms include sallow or dark-yellow complexion. A purple tongue is the result of blood stasis; a gray and coarse tongue coating or a red and glossy tongue without coating, a thready and rapid or taut and thready pulse are indications of fluid depletion and consumption of qi and blood. As an example of treatment, Bazhen Tang (Tang-kuei and Ginseng Eight Combination) combined with Pill for Relieving Masses can be used. In the former, the ingredients of Si Junzi Tang and Siwu Tang greatly replenish qi and blood. In cases of extreme yin fluid deficiency with signs of a glossy red tongue without a coating, rehmannia, adenophora, and dendrobium are prescribed to nourish yin and produce fluids. Xiaoliu Wan (The Pill for Relieving Masses; with sparganium, zedoaria, cyperus, areca seed, sappan, arca shell, pteropus, etc.) softens the masses, resolves stasis, and activates blood circulation. This therapy gradually achieves therapeutic results. In the treatment of ji syndromes at any stage, external application of herbs can also be adopted. Summary of Concepts Presented by the Advanced Textbook Chapter on Abdominal Masses Characteristic

Ju (Qi Masses)

Ji (Blood Stasis Masses)

Origin

Qi stagnation, such as emotion-caused liver-qi disorder or retention of food and phlegm due to overeating and weak spleen. External factors, such as wind-cold, can contribute.

Develops from prolonged ju, as blood stasis occurs secondary to qi stagnation. Exposure to heat-toxins (e.g., viruses, poisonous substances) that are retained for a long time may contribute to transformation of ju to ji.

Nature

Develops and enlarges with stress; may retreat with calmness. Pain, or mild aching, does not have a fixed site. Involves disorder of fu organs (e.g., gallbladder, stomach)

Develops over a long period, progressing from soft to hard mass, with fixed site of pain. Involves disorder of zang organs (e.g., liver, spleen), and with the pathologic influence gradually weakening the normal qi.

Examples

Bloating and distention after eating; swelling of the liver and spleen (modern medicine designation); intestinal obstruction with constipation, early stage fibroids (small uterine swellings).

Ovarian cysts, uterine fibroids, tumors of the cervix, uterus, bladder, colon, etc; advanced liver cirrhosis and fibrosis; endometriosis; surgical adhesions.

Therapy

Aromatic-spicy herbs (e.g., citrus, chih-shih, blue citrus, saussurea, lindera, aquilaria, cardamom, cyperus) that regulate qi and soothe the liver are used as the main therapy. Digestive aids, such as shenchu, atractylodes, and ginger, may be added.

Strong blood-vitalizing herbs that remove stasis of qi and blood, such as sparganium, zedoaria, and insects; also, softening agents (such as seashells and seaweeds) are used as part of the therapy. Tonification becomes important for hard, painful masses in weakened patients.

Qi dispersing therapies are usually warm in nature; watch for heat symptoms and, if necessary, add coldnatured herbs such as melia and coptis. Observe cases of weakness of spleen and treat qi deficiency that is complicated by stagnation.

As the disease progresses, the patient's normal qi weakens; use formulas to reinvigorate the qi, while vitalizing blood and dispersing masses. For larger masses, more emphasis must be placed on strong stasis-resolving herbs, usually along with animal materials; regulate qi as necessary to halt progression.

Qi regulating therapies should have quick effects; success depends on regulating diet and learning to control emotions. Failure to treat successfully can lead to development of ji-type mass.

Ji are difficult to treat, especially as they progress to form harder masses with weaker resistance from the patient. Therapy must be aggressive and may be prolonged. Failure to treat successfully can lead to life-threatening conditions and may require surgery and/or toxic treatments.

Adjustments

Prognosis

CLINICAL PRACTICE IN CHINA Several reports about traditional Chinese medicine treatments for uterine myoma were published during the period 1980-1993, and relatively few have appeared since then, probably because of the widespread introduction into China of surgical methods for treating fibroids and a conclusion that the herb therapies had been adequately tested to reveal their level of effectiveness. A representative selection of herbal treatment strategies is presented in the following summary of descriptions found in books and journals. A review of the early portion of this literature was presented by Dr. Hong-yen Hsu in 1984 (5). Herbal therapies involve qiregulating herbs, herbs to vitalize blood and dispel stasis, and agents for removing food stagnation and resolving phlegm masses. First, he mentions the book Essentials of Conformation in Chinese Medicine and four recommended therapies, laid out here to display the common categories of herbal effects and overlapping ingredients: Da Qiqi Tang

Xiang Leng Wan

Kaiyu Erchen Tang*

Kaiyu Zhengyuan San

Citrus

Blue citrus

Citrus

Citrus

Blue citrus

Chih-ko

Chih-ko

Blue Citrus

Cyperus

Saussurea

Cyperus

Cyperus

Sparganium

Sparganium

Sparganium

Corydalis

Zedoaria

Zedoaria

Zedoaria



Platycodon



Pinellia

Platycodon





Arisaema

Clam shell

Malt, Shen-chu, Crataegus, Alpinia, Pogostemon, Cinnamon Ginger, Hoelen, Areca, Red Melia, Fennel, Clove Ginger, Atractylodes, bark, Licorice Atractylodes, Licorice Cardamon, Hoelen, Licorice *Cang Fu Daodan Wan , with areca, zedoaria, and sparganium removed, is mentioned in this text, but the version of formula presented here is more commonly recommended. The first two rows include citrus materials (chenpi, qingpi, zhike) and the next row the aromatic qi-regulating herbs cyperus or saussurea; all these items are used to regulate qi and resolve accumulations. The next two rows allow for listing of blood-vitalizing herbs

(sparganium zedoaria, corydalis); and the next two rows are for phlegm-resolving herbs (platycodon, pinellia, clam shell, and arisaema). A final row lists other ingredients, which are mainly those to improve digestive functions and invigorate circulation of qi. As described in Practical Therapeutics (3), Da Qiqi Tang is best for cases where qi stagnation dominates; Xiang Leng San is best for cases where blood stasis dominates, and the two kaiyu (resolving stagnation) formulations are most suited for cases of phlegm-damp accumulation. Recommendations similar to these are relayed in the Encyclopedia of Practical Traditional Chinese Medicine (see Appendix 1). Hsu also presents treatment options from the book Chinese Obstetrics. It lists Guizhi Fuling Wan (Cinnamon and Hoelen Formula) as the ancient formula of choice for use today in both China and Japan. The book also lists the above formulations, and adds a massresolving formula comprised mainly of sparganium, zedoaria, leech, tang-kuei, persica, rhubarb, calamus gum, sargassum, cinnamon, aconite, and astragalus. A similar mass-reducing formula is described in the book as one of the Chinese treatments for ovarian tumors, which presents initially as a simple lower abdominal mass, like a fibroid: zedoaria, tang-kuei, red peony, areca seed, laminaria, saussurea, cinnamon, turtle shell, rhubarb, persica, succinum. The combination of turtle shell, rhubarb, persica, and succinum is also used as a basis for treating endometrial cysts. In a Japanese book quoted by Hsu, Survey of Chinese Medicine, its authors point out that "curing egg-sized uterine myomas with Chinese herb formulas is possible, but a larger size proves difficult to cure. Only in one case that they know of was a patient with a fistsized myoma cured after using Wenjing Tang (Tang-kuei and Evodia Combination) long term. The cure probably had something to do with the patient's menopause." Japanese doctors usually prescribe formulas with cinnamon twig, persica, and moutan for dispelling blood stasis in the lower abdomen. Examples are Guizhi Fuling Wan (Cinnamon and Hoelen Formula), Taohe Zhengqi Tang (Persica and Rhubarb Combination), and Zhechong Yin (Cinnamon and Persica Combination); rhubarb is included in treatments when constipation is presented In the book An Illustrated Guide to Antineoplastic Chinese Herbal Medicine (1990), three formulas for hysteromyoma are outlined. One is used for toxic syndromes, as occur with malignancies, but the other two are used mainly for common fibroids. A tested formula is Gong Zheng Tang (Decoction of Uterine Palace), with the following ingredients: Zedoaria Sparganium Tang-kuei Persica Pangolin scale Vaccaria

12 g Achyranthes 9 g Cyperus 12 g Prunella 12 g Dipsacus 12 g Laminaria 9 g Coix

12 g 12 g 12 g 12 g 15 g 30 g

The original report about Gong Zheng Tang (Decoction of Uterine Palace) was presented in English in the Journal of the American College of Traditional Chinese Medicine (6). 136 cases of uterine myoma were treated with that formula, which might be modified as needed by adding 2-3 herbs (e.g., codonopsis and pseudostellaria for qi deficiency; millettia and peony for blood deficiency; atractylodes and hoelen for stomach/spleen deficiency; or lycium, morus fruit, and eclipta for liver/kidney deficiency). In addition, sparganium extract was injected intramuscularly for seven days starting with the onset of menstruation. The course of treatment ranged from 1-8 months. It was reported that 72 of the cases (53%) were cured and that another 37 cases (26%) were significantly improved. Of 38 cases where the myoma was the size of a fist, only 6 were cured (16%), but of 98 cases in which the size was that of a goose or duck egg, 66 were cured (67%). It was stated that "surgical measures are advised for large tumors." Of 22 cases that did not respond to therapy, half of them resorted to surgery. The cure rates reported here may be somewhat high, since ultrasound and other definitive tests were not conducted to confirm elimination of the fibroids; the data mainly refers to alleviation of symptoms and of easily palpable masses. The other formulation mentioned in the Illustrated Guide is a modification of Cinnamon and Hoelen Formula, with sparganium, zedoaria, tang-kuei, astragalus, and crataegus added. Review articles about treatment of uterine myoma repeatedly mention Cinnamon and Hoelen Formula as a central therapy. Four sample reports help illustrate the reliance on this ancient prescription. A modified version called Gui Ling Xiaoliu Wan (Cinnamon and Hoelen Mass Reducing Pill) is made by adding turtle shell and pangolin scale (7). The herbs are powdered, made into honey pills (with about 6.6 grams of herbs per pill) and taken two pills per day for three months (on all days except during menstruation). For patients requiring higher doses or modified formulations, a decoction would be used in place of pills. It was claimed that 18 of 30 patients were cured (symptoms alleviated, little if any uterine enlargement remaining) and that 5 were notably improved. Another example is use of Cinnamon and Hoelen Formula with a variety of modifications according to syndrome such as (8): larger fibroids or those resistant to treatment: add turtle shell and pangolin scale obesity with phlegm-damp syndrome: add pinellia, fritillaria, prunella, sargassum, and laminaria qi deficiency: add codonopsis, astragalus, and atractylodes blood deficiency: add tang-kuei and gelatin qi stagnation: add blue citrus, bupleurum, sparganium zedoaria, melia, corydalis, typha, and pteropus. The formulas were administered in decoction form, with typical individual ingredient amounts of 9 grams (less for cinnamon twig, at 3-6 grams) per daily dose, given in two divided doses. Treatment time was 3-10 months, and it was reported that of 28 patients, 12 were cured and 14 others improved. A similar study relied on the use of Cinnamon and Hoelen formula as a decoction, modified with the addition of achyranthes, oyster shell, and salvia plus others according to syndrome; the decoctions would have about 80-120 grams of herbs (9). There were 100 patients treated with these formulas, and it was claimed that 46 cases had the mass eliminated, and 34 had it shrunk by at least half. Treatment time was 1-7 months. In another study (10), a pill of Cinnamon and Hoelen Formula plus turtle shell, oyster shell, artemisia, blue citrus, dipsacus, phellodendron, astragalus, and selaginella (often used as an anticancer herb) was used; the herbs were powdered and formed into pills with honey, about 6.6 grams of herbs per pill, one pill taken each time, three times daily. Of 60 patients treated, 43 were said to

be cured and 11 markedly improved using from 1-9 months of treatment. In several additional clinical reports on fibroid treatment, three herbs in Guizhi Fuling Tang were retained: persica, red peony, and moutan, but the herbs that give the formula its name, cinnamon and hoelen, were replaced by others that vitalize blood and regulate qi, such as zedoaria and cyperus. In others, the Cinnamon and Hoelen Formula was retained intact, and herbs were added to address bleeding, anemia, pain, or qi deficiency. In a Japanese study of the mechanism of action of Cinnamon and Hoelen Formula, it was mentioned that shrinkage of uterine myoma occurred in 62% of the 110 cases treated, and that the treatments alleviated excessive menstrual bleeding and resulting anemia as well as dysmenorrhea (11). There were no significant changes in plasma levels of several hormones, including LH, FDH, PRL, and estradiol, indicating that the mechanism of action did not involve reduction of hormone stimulus to fibroid growth. It was noted that small myomas with smooth surface generating elevated levels of CA-125 appeared to be most responsive to treatment; elevated CA-125 often indicates adenomyosis, a fibroid-like condition with small masses of the uterine wall. As indicated by these recommendations and studies, a wide range of formulas, most with qi and blood regulating properties, as well as herbs for warming the abdomen and herbs for resolving phlegm accumulation, have been used to accomplish reduction of fibroids. Complete resolution of fibroids has been reported several times, and substantial reduction of myoma size is apparently common in all but the largest or most aggressively growing fibroids. Treatment times are typically in the range of 1-8 months, with some lasting up to 10 months.

REFERENCES 1. Wu Jingnuan (translator), Ling Shu, or The Spiritual Pivot, 1993 Taoist Center, Washington, D.C. 2. Hsu HY and Wang SY, Chin Kuei You Lueh, 1983 Oriental Healing Arts Institute, Long Beach, CA. 3. Yan Wu and Fischer W, Practical Therapeutics of Traditional Chinese Medicine, 1997 Paradigm Publications, Brookline, MA. 4. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (vol. 3) 1996 New World Press, Beijing. 5. Hsu HY, Chinese herb therapy for uterine myomas, Bulletin of the Oriental Healing Arts Institute 1984; 9(6): 294-298. 6. Cheung CS and Carney L (translators), Preliminary report of 136 cases of uterine myoma treated by Gong Zheng Tang, Journal of the American College of Traditional Chinese Medicine 1982 (1): 64-66. 7. Pang Huali, Treatment of hysteromyoma with Gui Ling Xiaoliu Wan-A report of 30 cases, Beijing Journal of Traditional Chinese Medicine 1989; (6): 31-31. 8. Zhang Zhuen, et al., Clinical observation of 28 cases of hysteromyoma healed by integrated traditional and western medicine, Chinese Journal of Integrated Traditional and Western Medicine 13(3): 180-181. 9. Yang Shenshan, A modified Ghuzhi Fuling Wan for the treatment of 100 cases of hysteromyoma, Zhejiang Journal of Traditional Chinese Medicine 1984; 19(4): 180. 10. Huang Chunduan, Guizhi Fuling Wan in treating 60 cases of hysteromyoma, New Traditional Chinese Medicine 1982; (10): 24-26. 11. Sakamoto S, et al., Pharmacotherapuetic effects of Guizhi Fuling Wan on human uterine myomas, American Journal of Chinese Medicine 1992; 20 (3-4): 313-317. 12. Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, (vol. 12) 1989 Higher Education Press, Beijing. 13. Shao Nianfang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine, 1990 Shandong Science and Technology Press, Jinan.

APPENDIX 1. Additional Descriptions of Fibroid Treatment Strategies The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (12) presents uterine fibroids in three categories: qi stagnation, blood stasis, and phlegm-dampness. The recommended formulas include two mentioned previously, namely Xiang Leng Wan (which is indicated in this text for cases where qi stagnation dominates, rather than blood stasis) and Kaiyu Erchen Tang (which is indicated for phlegm-dampness). The formula recommended for blood-stasis dominating is: Huoyu Sanjie Fang Zedoaria Sparganium Cnidium Chih-ko Prunella Cyathula Cinnamon twig Persica Red peony Tang-kuei Salvia Oyster shell Modifications recommended include: For copious menses and abdominal pain, remove prunella and oyster shell, but add typha and pteropus; For persistent bleeding, remove sparganium and zedoaria but add pseudostellaria and san-chi.

The formulas are presented in this text with dosage recommendations for preparation as decoctions, where the amount of each ingredient is typically 6-12 grams, except high doses of oyster shell and salvia, each at 30 grams. The total dosages range from 75-150 grams for a one day dose of the decoction, which is to be divided into two servings, one taken in the morning and one in the evening. The formula is similar to Xiao Liu Fang (see Appendix 2), the main difference is inclusion of ingredients from Cinnamon and Hoelen Formula here: cinnamon, persica, and red peony, and the replacement of rhubarb by salvia. A similar prescription was recommended by Shao Nianfang in his book on treatment of difficult diseases (13). For uterine myomas that originate with liver qi stagnation and develop as a blood stasis mass, he recommended a formula similar to that above, with zedoaria, sparganium, citrus, blue citrus, bupleurum, cyperus, cnidium, persica, melia, corydalis, red peony, and moutan; the formula details to be adjusted as needed, with some added herbs. He commented: Excessive menstrual bleeding is a common symptom of uterine myoma, and is due to stagnation. To resolve stagnation will arrest bleeding. Therefore, be not afraid to use drugs to soften the hardness, to activate the blood and resolve stagnation, such as zedoaria, sparganium persica, and typha, assisted with some hemostatic herbs. San-chi is very precious because of its effect, combining activating blood, resolving stagnation, and hemostasis. In chronic cases, with deficiency of spleen and kidney, with qi unable to control blood flow, be brave to use reinforcing in those cases, that is, to restore the qi and the capacity to resolve stagnation thereby. In other words, use blood-vitalizers even though there is bleeding, and use tonics even though there is accumulation, so long as the differential diagnosis indicates the appropriate underlying cause.

APPENDIX 2: Xiao Liu Fang A clinical study about treatment of uterine fibroids with tracking of results by ultrasound was published by Jiang Xinglei and Luo Xianchu (Clinical observation on Xiao Liu Pian applied to treat 30 cases of hysteromyoma, Chinese Journal of Integrated Traditional and Western Medicine 1992; 12(3): 185-186). The formula ingredients are aimed at strongly dispersing both qi and blood stagnation. Thirty patients (ages 26-50) were treated. TCM diagnosis revealed 22 cases suffering from a combination of qi and blood stagnation and 8 cases with qi deficiency with blood stagnation. In general, the tongues of the patients looked dark, and the pulses felt deep, or stringlike, small, and uneven. As a result of herbal therapy, 15 patients experienced either elimination of the fibroid or substantial reduction in fibroid size, and 13 more had some degree of fibroid shrinkage with symptoms alleviated. Of 21 cases examined by ultrasound, the average myoma size was 6.35 cm before treatment and only 3.54 cm after treatment. Symptoms associated with the fibroids included excessive bleeding, pain, and a bloated feeling, and these were virtually eliminated in all but 2 cases. The formula that was used in a clinical trial, which was called Xiao Liu Pian (Mass Reducing Tablets), had the following ingredients reported: Salvia Eupolyphaga Pangolin scale Rhubarb Prunella Bupleurum Blue citrus Cyperus Ginseng, white San-chi Gelatin Cremastra In this formulation, salvia, eupolyphaga, pangolin scale, and rhubarb serve to vitalize blood circulation and remove stasis; prunella bupleurum, blue citrus, and cyperus regulate qi and overcome qi stagnation that forms masses; ginseng tonifies qi; oyster shell softens masses; san-chi and gelatin help restrain excessive bleeding; cremastra (maocigu or shancigu) is an "antitumor" herb used to resolve a toxin that contributes to formation of the lump. According to the report, the herbs were prepared as an extract (using "appropriate amounts"), with the resulting material formed into tablets with 0.3 grams extract per tablet. The tablets were administered at a dosage of 20 each time, three times daily (providing a total of 18 grams of extract, derived from about 100 grams of raw materials). This formula was administered continuously (except during menstruation) for three months. For the past 10 years, ITM has made available to U.S. practitioners a related formula, Xiao Liu Fang. The clinical response to this formula in the hands of Western practitioners and patients is not known because there has not been a means of formal reporting. However, to attempt to attain results comparable with the Chinese report, one should observe the following: 1. In the Chinese clinical trial, the dosage of extracted herb material was 18 grams per day (6 grams, three times daily). Xiao Liu Fang (or Huayu Sanjie Fang, also available), as provided by ITM, is in the form of loose powders that were made by extracting the herbs into hot water and then spray-drying the concentrated liquid. To match the amount of herbs used in the clinical trial, the dosage should be 6 grams each time, three times daily. A teaspoon of the powder is approximately 3 grams; so the dosage is 2 teaspoons each time, three times daily. For convenience, a patient could take 3 teaspoons twice daily. The powder is placed in a cup, boiled water is added, the mixture is stirred, and then consumed as a tea. 2. San-chi (sanqi) is not readily available as an extract and is normally not prepared as an extract in China. Xiao Liu Fang does not include this ingredient. San-chi may help prevent fibroid bleeding; bleeding can worsen during the use of bloodvitalizing herbs, so the inclusion of san-chi may be helpful. ITM has san-chi (also known as tien-chi ginseng) available in a tablet form (Pine Mountain brand), which is to be taken 2-4 tablets each time along with the dose of herb powder, for a total of 6 tablets/day. 3. The formula should be taken daily, except during menstruation, for a three-month period. For larger fibroids, Turtle Shell Tablets, made with additional blood-vitalizing herbs, can be used as an adjunct. For women with cold-damp symptoms, a second granule formula, Cinnamon and Hoelen Formula, can be taken along with Xiao Liu Fang. After the three-month

course of therapy, the patient should continue taking herbs to consolidate the effects. A more convenient tablet-to replace the granules-may be used for this follow-up treatment, relying on a formulation such as Sparganium 12 (Seven Forests, see below). This tablet is initially taken at the dosage of 6 tablets (or more for those of large body weight), three times daily, and then the dosage may be tapered when fibroid symptoms have been absent for at least one month. This formula should be used for about three months and may need to be taken for longer periods. 4. Symptom alleviation is an expected result of therapy, but fibroid shrinkage may be limited. In the Chinese women who were monitored for fibroid size, the average amount of shrinkage was slightly less than 50%. Although some women experienced disappearance of fibroids, this was not the general case. Fibroids tend to shrink spontaneously after menopause, so that if the fibroid size is not too large and symptoms are not a significant problem until menopause, surgery is unnecessary. Xiao Liu Fang Sparganium 12 Sparganium 10% Sparganium 12% Zedoaria 10% Zedoaria 12% Oyster shell 8% Oyster shell 8% Bupleurum 8% Bupleurum 8% Cyperus 8% Cyperus 8% Blue citrus 8% Blue citrus 8% Prunella 8% Tang-kuei 8% Dandelion 8% Persica 8% Rhubarb 8% Vaccaria 8% Salvia 8% Achyranthes 8% Arca Shell 8% Dipsacus 8% Gelatin 8% Cinnamon twig 4% In deriving Xiao Liu Fang from Xiao Liu Pian, white ginseng was deleted as a non-essential ingredient (qi tonification should be applied as a separate formula if needed and can be given in pill form); the insect eupolyphaga is replaced by sparganium and zedoaria (two herbs that are commonly used for blood-stasis masses, especially fibroids); pangolin scale, not currently available, is replaced by arca shell, which is reputed to vitalize blood and resolve masses; and cremastra, a rarely-used herb that is not available in the U.S. as an extract, is replaced by dandelion (both serve as "anti-toxin" herbs). Xiao Liu Fang, like Xiao Liu Pian, regulates qi (with bupleurum, blue citrus, cyperus), cracks static blood (sparganium, zedoaria, rhubarb, salvia, arca shell), and resolves masses (prunella, oyster shell). Sparganium 12, which is the tablet that can be used in follow-up therapy, is similar to Xiao Liu Fang, but has added tonic herbs (tangkuei, achyranthes, and dipsacus) for nourishing the liver and kidney; these herbs also vitalize blood circulation. This formula does not include herbs for cleaning toxin and controlling bleeding, the problems that should have been resolved by the initial therapy with Xiao Liu Fang. For additional information about bleeding with fibroids, see the article: "The qi keeps the blood within the vessels: the story of Gui Pi Tang."

September 2003

TREATMENT AND PREVENTION OF LIVER FIBROSIS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Liver fibrosis is one of the processes that occurs when the liver is damaged. Such damage may be the result of: viral activity (e.g., chronic hepatitis types B or C) or other liver infections (e.g., parasites, bacteria); chemicals (e.g., pharmaceuticals, recreational drugs, excessive alcohol, exposure to pollutants); immune processes (e.g., autoimmune hepatitis); metabolic disorders (e.g., lipid, glycogen, or metal storage disorders); or cancer growth (primary or secondary liver cancer). Fibrosis is both a sign of liver damage and a potential contributor to liver failure via progressive cirrhosis of the liver. In China, liver fibrosis due to viral hepatitis is the major concern because the level of hepatitis B (and, to a lesser extent, C) viral infection is very high. Detection of the underlying liver disease is often delayed and effective medical treatment for viral hepatitis (e.g. interferon, which has a limited success rate) may not be readily available; thus, many people in China have moderate to advanced cirrhosis when they first seek treatment. In a recent issue (June 2002, English language version) of the Chinese Journal of Integrated Traditional and Western Medicine , 10 articles were devoted to the subject of liver diseases, with 5 original research articles (1-5) plus one review (6) about liver fibrosis specifically. The current article summarizes what was presented about liver fibrosis therapy in that issue of the journal and adds commentaries to aid in interpreting the results. In addition, another review article about liver fibrosis (7) appeared a year earlier in the Journal of Traditional Chinese Medicine (June 2001); it provided few details of the treatments, mainly focusing on possible mechanisms of action for herbal therapies. The introduction to that article, written by Du Bin of the Nanjing University of TCM and Pharmacy, succinctly describes the process of liver fibrosis and is reproduced here: Liver fibrosis is a gradual process of increased secretion and decreased degradation of extracellular materials. Most authors hold that the process is initiated by the damage of hepatic cells, which leads to activation and secretion of multiple cellular factors from Kupffer cells [macrophages which line the liver sinusoids]. These factors-along with the cellular factors secreted by damaged hepatic cells, thrombocytes, and endothelial cells of the hepatic sinusoid, and some chemical mediators-are activators of hepatic stellate cells. Being activated, the hepatic stellate cells differentiate into myofibroblasts, and, via self-secretion and parasecretion, proliferate and synthesize a massive amount of extracellular materials, which gradually accumulate and lead to formation of liver fibrosis. Since fibrosis is a common development in a variety of chronic liver diseases, prevention against its formation is of great importance. Essentially, damaged liver cells activate stellate cells that dump materials (e.g., collagens) into the matrix outside the cells; the materials accumulate and form fibrous masses.

BRIEF SUMMARY OF THE ORIGINAL RESEARCH ARTICLES Chinese research publications frequently display flaws in research design and reporting that make it difficult to interpret the results. In his review article on liver fibrosis (6), Nie Guang commented: "It is worth pointing out that the level of recent studies is low, with many concrete tasks waiting to be done." Almost all published reports from China about traditional Chinese medicine therapies are positive ones. In the following outlines of the journal articles, the basic nature of the study is presented, but the details of the results are left out. Instead, a quotation from the study author(s) reflecting on their interpretation is provided, edited as necessary for clarity.

Study 1: Treatment of Liver Fibrosis with Qinggan Capsule (1) In traditional Chinese medical therapy, attempts are often made to address several aspects of a disease rather than only one of its manifestations. The Qinggan Capsule is an example of a broad formulation to treat hepatitis symptoms with a focus on the accompanying hepatic fibrosis in patients with chronic hepatitis B. In this study, 63 out-patients were treated with a preparation of B vitamins with glucurone as the control substance, while some patients additionally received Qinggan Capsules, containing 16 herbs: astragalus, salvia, white peony, capillaris, polygonatum, licorice, codonopsis, rehmannia, shen-chu, tang-kuei, curcuma, crataegus, alisma, dioscorea, isatis root, and chin-chiu. The dosing of the herbs was three capsules each time (made from 2.75 grams of crude herbs), three times daily. A therapeutic course was 6 months. The authors stated: So far, there is no proof that Qinggan Capsule has an inhibitory effect on the hepatitis B virus itself; therefore, the effects of Qinggan Capsule in improving pathological changes in the liver, particularly the antifibrosis effect, may be through mechanisms other than antiviral action....Liver fibrosis is the pathological process of fibrous connective tissue development secondary to inflammatory necrosis of liver cells. Once it happens, fibrosis could further accelerate the inflammatory necrosis process by way of cytokines or by affecting the intrahepatic microcirculation. Hans Popper [a famous hepatologist in the U.S. during the 20th century] has pointed out that "anyone who can stop or delay liver fibrosis would be able to cure most chronic liver diseases." Hence, in treating chronic hepatitis B, attention should be paid to both stopping liver fibrosis and killing the virus. Qinggan Capsule consists of 16 Chinese herbal drugs. Some components, such as salvia, tang-kuei, and astragalus, have been proven to have antifibrosis action.

Study 2: Treatment of Liver Fibrosis with Ginkgo Leaf (2) Gingko leaf (see: Ginkgo) is a blood vitalizing herb that has flavonoids and glycosides as active components. In this study, 86 outpatients with chronic hepatitis B were treated either with ginkgo tablets that each contained 2.4 mg ginkgolide and 9.6 mg flavones or with Yiganling Tablet (for which the main active component was silymarin, extract of milk thistle, 35 mg/tablet). The dosing was 10 tablets each time of the ginkgo and 3 tablets each time of the silymarin (silybin), three times daily. In addition, all patients received

appropriate medical care that did not include other agents known to have anti-fibrosis activity or immune effects. Treatment time was three months. To determine effect on liver fibrosis, measurements were made of blood content of hyaluronic acid, collagen type IV, laminin, pro-collagen peptide type III, and platelet activating factor (PAF). In addition, some patients underwent liver biopsy. The authors commented: It was found in this study that the serum level of PAF was elevated in patients with chronic hepatic cirrhosis, and in those after anti-fibrosis treatment [the gingko tablets], it could be lowered along with improving of the liver fibrosis in a positively correlated manner, suggesting that PAF participates in the genesis and development of liver fibrosis in chronic hepatitis. Ginkgo glycoside ß, one of the chief components of ginkgo leaf, is a strong PAF receptor antagonist....It was reported that good effect was obtained by using composite ginkgo leaf granule, containing ginkgo leaf and 9 other Chinese herbs to treat early stage liver fibrosis, with evident improvement in blood level of superoxide dismutase [SOD, a well known antioxidant] and malondialdehyde [MDA, an indicator of lipid peroxidation activity]. It illustrated that the ginkgo preparation has anti-lipid peroxidation effects and can reduce the injury by oxygen free radicals on liver cells. Similar therapeutic effect has also been obtained by the authors by applying the ginkgo preparation in treating acute hepatitis with severe jaundice. Results in this study showed that, after treatment for three months, the clinical effect of ginkgo preparation was markedly superior to that of Yiganling Tablet (silybin)....These results indicate that ginkgo leaf has obvious effects of liver protection, anti-inflammation, and anti-fibrosis, and may even reverse liver fibrosis.

Study 3: Treatment of Liver Fibrosis with Ruangan Granules (3) Preparations of astragalus and salvia are frequently used to vitalize blood circulation and treat chronic diseases involving blood stasis. In this study 120, out-patients with chronic hepatitis B were treated with either Ruangan Granules, consisting of several herbs including astragalus, salvia, prunella, turtle shell, red peony, bupleurum, atractylodes, zedoaria, notoginseng, and cordyceps, or Biejia Ruangan Tablets (undefined contents). The Ruangan Granules contained the extract of 2.63 grams of crude herb materials in each gram of granules, and was administered 20 grams each time, three times daily (hence, the equivalent of about 158 grams of crude herbs per day). In addition, some patients in each of the groups received an IV drip of glycyrrhizin (the main active component of licorice, shown to have antiviral action), along with cysteine and glycine (the combination of these two amino acids is said to prevent some of the sodium/potassium imbalance that can arise with high dose licorice treatments). To monitor liver fibrosis, the researchers measured serum levels of fibronectin, laminin, and hyaluronic acid. Ultrasound tests were conducted to monitor the morphology of the liver. Treatment time was three months. The authors commented: We consider that liver fibrosis is caused by evil damp-heat left behind by chronic hepatitis, and by the combination of liver stagnancy, spleen deficiency, and blood stasis resulting from the long-term course of the disease. In the early stage of liver disease, a TCM syndrome of pathogenic excess, such as qi stagnation and dampness accumulation, is manifested along with spleen qi deficiency. The syndrome of insufficient essence [yin deficiency] would occur with the further development of the disease. Therefore, for patients with liver fibrosis, qi deficiency with yin deficiency is the root syndrome and blood stasis impeding the collaterals is the branch. The appropriate therapy involves nourishing yin, supplementing qi, activating blood circulation, and softening the hard mass to dissolve accumulation. Studies in recent years showed that the pathogenesis of liver fibrosis is directly related to the activation and metabolism of the extra-cellular matrix of the liver, liver stellate cells, and cytokines; the non-collagen glycoproteins also play a key role in liver fibrosis formation. Fibronectin and laminin have an effect on the extra-cellular matrix, and they also regulate the cellular function. Large amounts of hyaluronic acid deposited in the liver blood sinus is the key basis of liver fibrosis and portal hypertension formation. This study showed that beside the effect of improving liver function, Ruanguan Granules could regulate the serum levels of fibronectin, laminin, and hyaluronic acid and reduce the size of the spleen and width of the portal vein, indicating that it has definite effects in reverting the formation of liver fibrosis in the course of chronic hepatitis.

Study 4: Pharmacology Study of Benefit Liver Granules (4) The Benefit Liver Granules (Yigan Tang or Yigan Chongji) is a formulation based on the use of astragalus and salvia as a treatment for chronic liver diseases. Its ingredients, for a one day dose in clinical application, are derived from: 45 grams salvia, 30 grams isatis root, 12 grams each of white atractylodes and white peony, 10 grams each of tang-kuei tails and curcuma, 8 grams each of astragalus, gallus (chicken gizzard lining), and magnolia bark, and 6 grams each of hoelen and citrus. The researchers tested this formulation, as well as the decoction of just salvia and astragalus, in rats which were induced to have liver fibrosis via treatment with liver toxic chemicals, namely carbon tetrachloride initial treatment followed by alcohol regular treatment. The authors stated: TCM holds that hepatic fibrosis is mainly caused by blood stasis, which manifests chiefly by symptoms such as hepatomegaly, splenomegaly, expanded venation on the abdominal wall, blood nevi [skin patches of red color, also called spider moles, similar to congenital moles], liver palm [palmar erythema; palms redden and feel hot], and wiry, unsmooth pulse. Medicines which promote blood circulation to remove blood stasis are effective in treating these disorders and have been applied widely. Studies have illustrated that Chinese herbal medicines for promoting blood circulation, removing blood stasis, dredging the channels, and nourishing the liver have the effect of anti-liver fibrosis. For example, research conducted by Wang Baoen, et al., proved that the Composite 861, consisting of salvia, astragalus, spatholobus [jixueteng], etc., could prevent liver fibrosis formation and block its development, even reversing the pathological progress. Benefit Liver Granules is an effective drug for treatment of chronic hepatopathy prepared by professor Yao Xixian and his colleagues, consisting of high doses of Chinese herbal medicines for promoting blood circulation to remove stasis, such as salvia and tang-kuei. It possesses the effects of improving symptoms of chronic hepatopathy, lowering transaminase, subsiding jaundice, softening the liver, and shrinking the spleen. The essential elements of Benefit Liver Granules, such as

salvia and tang-kuei, could lower the portal venous pressure in dogs with liver cirrhosis. Salvia has a good effect of antihepatic fibrosis, raises the superoxide dismutase activity [SOD, a well known antioxidant] in the liver, and reduces the content of liver malondialdehyde [MDA, an indicator of lipid peroxidation activity] significantly. It was demonstrated that anti-lipid peroxidation action may be an important mechanism of its anti-hepatic fibrosis effect. In another article of the study, the concentrated decoction of Benefit Liver Granules showed significant effect in abating hepatic fibrosis and pathological ultrastructural changes of the liver in rats, and in reducing the deposition of collagens in liver tissue. Further, the effects could be enhanced by prolonging the therapeutic course.

Study 5: Applying Salvia Active Component to Hepatic Stellate Cells (5) Salvia (see: Salvia and the history of microcirculation research in China) is one of the most commonly used agents for treating fibrosis. One of the proposed mechanisms is to inhibit the hepatic stellate cells that proliferate and contribute substances to the hepatic extracellular matrix, forming the fibrotic mass. An active fraction of salvia, labeled IH764-3, was applied to cultured hepatic stellate cells. The authors stated: Recent studies showed that to inhibit hepatic stellate cell (HSC) proliferation and promote HSC apoptosis would be helpful in reverting liver fibrosis. The effect of IH764-3 in different concentrations on HSC proliferation was observed in this study....The results showed that IH764-3 is effective in obviously inhibiting HSC proliferation....The apoptotic rate of HSC as revealed with brown staining in the IH764-3 group was significantly higher than that in the blank control group....It is held in TCM that the chief function of salvia is activating blood circulation and removing blood stasis. By modern pharmaco-chemical studies, the active fraction was found to consist chiefly of tanshinone, salviol, and tanshiol, etc....The mechanism of salvia in treating liver fibrosis may be multisided and very complex, and the mechanism of salvia in inducing HSC apoptosis remains for further study. Some further study has been conducted, indicating that a particular protein (caspase-3) is expressed in HSC exposed to this salvia component, which may contribute to apoptosis of the cells (8).

BRIEF OUTLINE OF THE REVIEW ARTICLE ON TREATMENTS FOR LIVER FIBROSIS (6) The review article in the Journal of Integrated Traditional and Western Medicine relays information from articles published from 19922001. It concisely mentions test methods and results with some complex formulas, single herbs, and active components. Here are the therapies reported: Modified Minor Bupleurum Combination (Xiao Chaihu Tang) plus salvia injection for 30 patients with chronic hepatitis B. Bupleurum Granules (Chaihu Chongji), with undisclosed ingredients other than bupleurum, for 104 patients with chronic hepatitis B. Modified Persica and Carthamus Combination (Tao Hong Siwu Tang) in laboratory study with rats suffering from chemicalinduced liver damage. 861 Granules, also called Composite Salvia Granules (comprised of 10 herbs, the main ones being astragalus, salvia, and spatholobus), used in both laboratory animal studies and clinical work, with two clinical studies, one with 60 patients, the other with 49 patients having chronic liver diseases. Ruangan Yin (see above report on Ruangan Granules, which includes ingredients list); the review includes earlier work with this formula. Guzhang Tablet (which includes notoginseng, salvia, red peony, tang-kuei, and curcuma) given to 61 patients with liver cirrhosis. Fuganjang Granules (which includes salvia, red peony, tang-kuei, bupleurum, astragalus, and curcuma) in a trial involving 163 patients, some of which also received salvia single herb tablet. Tetrandrine, an alkaloid isolated from Stephania tetrandra, was given to 115 patients, treated for 6-36 months, and in another study with 33 patients for 18 months. Salvia extract: several laboratory animal studies were cited, demonstrating several possible mechanisms of action. Persica extract and cordyceps: several laboratory animal studies were cited, showing inhibition of fibrosis with either herb alone or, in one study, the two herbs together. Notoginseng (sanqi): two laboratory animal studies were described.

SUMMARY AND ANALYSIS The reports mentioned here include laboratory studies (both cell cultures and animal tests) and clinical trials. The principle of vitalizing blood circulation is the dominant therapy claimed to be of some benefit, and key herbs are salvia, tang-kuei, persica, notoginseng, curcuma, and red peony. A few other herbs commonly used to treat liver diseases are sometimes used as well, including bupleurum and white peony. Tonic herbs are mentioned in some cases, the main ones being astragalus and atractylodes. Licorice, which is classed with the qi tonics, is the only herb included in these studies for which a possible viral inhibitory action has been proposed; all the other herbs are thought to primarily impact the process by which a virus (or chemical assault) induces fibrosis. There are several mechanisms by which the herbs can inhibit liver fibrosis, including: inhibition of hepatic stellate cells; reduced production and deposition of fibrotic materials (e.g., collagen); regulation of cytokines; reduction in oxidation reactions; and possible degradation and reabsorption of fibrotic materials. These, and other possible mechanisms, may be triggered by a single herb with multiple actions (as proposed, for example, with salvia). Alternatively, several mechanisms that ultimately serve to reduce fibrosis may be stimulated by properly combining herbs, each of which impacts one or two of the mechanisms. The laboratory studies described here are especially relevant to acute processes of liver damage, but don't readily address the problem of chronic liver disease. The clinical studies involved patients with advanced hepatitis B disease, the most common chronic hepatovirus infection that occurs in the Chinese population. There is no reason to believe that the effects would be any different with

hepatitis C. Treatment times for clinical evaluations ranged from a minimum of three months up to a maximum of three years. Unless the underlying cause of liver fibrosis is removed, the treatment may need to be continued indefinitely, or, at the least, repeated from time to time. Some herbal materials have been proposed as viral inhibitors, such as oxymatrine (from sophora root) and glycyrrhizin (from licorice root). However, it is unclear whether these herbs or isolated active components can completely remove the virus, as opposed to only reducing its activity while the substances are administered. Imperfections in the research methodology and reporting limit the interest that can be generated among researchers outside China to pursue the Chinese herb treatment of liver fibrosis in greater detail. However, Chinese researchers have already provided adequate data on the effects of salvia to justify further expenditure on research in this area. Salvia has the advantages of being non-toxic, inexpensive, readily available, well-defined chemically, and already subjected to numerous pharmacology studies revealing mechanism of action (5, 8, 9, 10, 11, 12, 13) and clinical trials suggesting positive effects (1, 3, 14, 15). It is possible that results superior to using salvia alone might be attained by utilizing a small herb formula in which salvia is a key ingredient, but further confirmation of salvia's effects-or that of its active components-would be essential in order to form the basis for future study of a more complex therapy.

REFERENCES 1. Yang Liuming, et al., Clinical pathological study on effect of qianggan capsule in treating patients of chronic hepatitis B and liver cirrhosis, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 8(2): 90-94. 2. He Yun, et al., Clinical study on treatment of liver fibrosis of chronic hepatitis B patients with ginkgo leaf, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 8(2): 95-99. 3. Li Xiuhui, et al., Clinical observation on effect of ruangan granule in treating chronic hepatic liver fibrosis, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 8(2): 100-104. 4. Yao Xixian, et al., Study on the anti-liver fibrosis effect of benefit liver granule and its mechanism in rats, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 8(2): 118-121. 5. Zhao Dongqiang, et al., Study on effect of IH764-3, an active principle of salvia, in inducing hepatic stellate cell apoptosis, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 8(2): 126-129. 6. Nie Guang, Recent studies on the molecular mechanism of treatment of liver diseases by traditional Chinese medicine, Chinese Journal of Integrated Traditional and Western Medicine, 2002; 8(2): 152-155. 7. Du Bin and You Songxin, Present situation in preventing and treating liver fibrosis with TCM drugs, Journal of Traditional Chinese Medicine, 2001; 21(2): 147-152. 8. Zhang XL, Liu L, Jiang HQ, Salvia miltiorrhiza monomer IH764-3 induces hepatic stellate cell apoptosis via caspase-3 activation, World Journal of Gastroenterology, 2002; 8(3): 515-159. 9. Chen Y, et al., Amelioration of carbon-tetrachloride-induced hepatic fibrosis in rats by treatment with Salvia miltiorrhiza and taurine, Chinese Journal of Liver Diseases, 2002; 10(2): 148-149. 10. Nan JX, et al., Anti-fibrotic effects of a hot-water extract from Salvia miltiorrhiza roots on liver fibrosis induced by biliary obstruction in rats, Journal of Pharmacy and Pharmacology, 2001; 53(2): 197-204. 11. Liu CH, et al., Effects of salvianolic acid-A on rat hepatic stellate cell proliferation and collagen production in culture, Acta Pharmacologia Sinica 2000; 21(8): 721-726. 12. Liu P, et al., Effects of salvianolic acid-A on liver injury: action on hepatic peroxidation, Liver 2001; 21(6): 384-390. 13. Nan JX, et al., Anti-fibrotic effects of a hot water extract from Salvia miltiorrhiza roots on liver fibrosis induced by biliary obstruction in rats, Journal of Pharmacy and Pharmacology 2001; 53(2): 197-204. 14. Liu Sandu, 160 cases of chronic viral hepatitis B treating mainly with large doses of salvia, Journal of Integrated Traditional and Western Medicine for Hepatitis 1993; 3(3): 23-24. 15. Xiong Lilan, Zhu Shicai, and Cao Guoming, Clinical study on treatment of decompensated liver cirrhosis with combination of Radix Salviae Miltiorrhizae and magnesium sulfate, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(3): 207-209.

August 2002

FLOATERS AND THEIR TREATMENT WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The nature of floaters can be understood in terms of the fluid in which they occur, namely the vitreous. This is a gel matrix filling the vitreous cavity, making up about 2/3 the volume of the eye. In front of it is the lens structure, behind it is the retinal structure. The vitreous is a transparent gel, about 98% water, but it is 2-4 times more viscous than water, mainly due to the content of sodium hyaluronate (the salt of hyaluronic acid, a component of many fluid structures in the body). The hyaluronic acid molecules are large coils that hold water; in the vitreous they are entrapped in a matrix of collagen fibers (type II, the main fiber making up cartilage). Most of the collagen is at the surface region of the vitreous, where it comes in contact with the rest of the eye, giving it a somewhat more solid surface. There is less collagen in the central region, which is a more liquid portion, comprised of about 99% water. Collagen fibrils attach the vitreous gel to points around its margin, particularly to the retinal and lens structures. The vitreous mainly functions as a transparent fill for the eyeball. The fluid maintains the shape of the eye, acts as a shock absorber, allows transmission of light to the retina, and helps maintain the contact between the retina and the back wall of the eye by applying a mild pressure. It contains no blood vessels and is essentially cell free. A few cells may be present near the retina, including hyalocytes that appear to be responsible for producing hyaluronic acid; these are similar to immune cells called macrophages. Aside from hyalocytes, there are other sources of the vitreous components among the various types of cells of the eye structure, though it is not yet established which ones play a key role. The original three-dimensional net-like structure of collagen fibers begins to deteriorate once body growth has halted at adolescence. This deterioration is slow and involves having some strands of collagen clump up, and some of the original compartments of gel merge into larger compartments. At this point, "floaters" may begin to appear. Many people believe that these floaters are materials released into the eye, when, in fact, they are shadows on the retina from light encountering the irregularities in the gel matrix. Such irregularities are mainly caused by coalesced collagen filaments, forming fibrils. The floaters are especially visible while looking at a plain, well-lit background.

It is not until middle age, around age 40, that there are significant changes in the vitreous that generate floaters. The vitreous begins to slowly dry out, and the collagen becomes more clumped, leaving the vitreous almost entirely a free flowing fluid with some intervening gel lumps. These produce the floaters that are most frequently reported. They tend to "float" more easily because of the breakdown of the gel matrix. Nothing needs to enter the vitreous to make these floaters and nothing is present to break down the floaters, so they remain for many months. They may eventually degrade or settle out, or they may persist. With further aging, the vitreous will dry, thicken, and shrink to an extent that it starts to pull away from the retina (the condition is called posterior vitreous detachment). This process may be the result of a sudden drying of the fluid, rather than the gradual drying that is normally expected. When a sudden vitreous shrinkage occurs, there can be a substantial appearance of floaters over a short period. While vitreous detachment through a gradual process is common by age 70, it occurs more often and sometimes earlier in people who are nearsighted, have undergone cataract surgery or laser eye surgery, or who have an inflammatory disease of the inner portion of the eye, such as retinitis. When the vitreous gel pulls away from the retina, nothing may happen (vision remains basically the same), but this pulling can cause some retinal tears. Tearing of the retina may allow some blood cells to flow into the vitreous cavity, which accounts for some of the new floaters; other floaters may appear as a result of contraction of the fibers that had been attaching the vitreous to the retina. When a retinal tear occurs, some of the vitreous fluid can penetrate into the torn areas and lift away the rest of the retina, which is extremely thin, leading to partial or full detachment. During retinal tearing or detachment, flashes of light (like flurries of fireflies) are detected by the patient, and the vision may be blurred, particularly in certain portions of the visual field. The torn retina should be examined carefully, as it may require treatment, such as laser photocoagulation, cryopexy (freezing), or surgery, to avoid complete retinal detachment or to treat a detached retina. The condition of the vitreous fluid and the nature of floaters are observed by dilating the eye (applying eye drops to do so), and then examining the region through the pupil. There are no medical treatments for floaters. Some floaters, particularly those that occur as a young adult, will eventually disappear as the gel matrix changes. Other floaters, particularly those that occur in later years, may disappear as they settle out of the fluid. In persons suffering from severe disorders of the vitreous, which occurs in some cases of diabetes or where injuries have allowed blood into the vitreous, a vitrectomy may be performed; the vitreous is removed and placed with an artificial substitute liquid called hyaluronate.

POSSIBLE CAUSATIVE FACTORS Little is known about what causes the changes in the vitreous with age, and what can speed up or slow down the process. It is relatively easy to speculate on some potential causes. It is known that excessive exposure to sunlight can cause damage to the eyes and skin, and is a contributor to cataract formation and drying, wrinkling skin. There is no reason to think that these types of effects could not occur in the vitreous to some extent, perhaps contributing to the clumping of the collagen fibers and the drying of the fluid. Hence, a rational protective effort would be to utilize good quality sunglasses and, in cases where there is considerable exposure to sun, to utilize shading (such as a visor or hat). Similarly, one should be careful about exposure to bright lights from copy machines, lasers, and other indoor sources. The drying of fluid within the eyes may be accelerated by poor circulation in the retina (capillary bed circulation) and by general lack of hydration. Blood circulation can be worsened by high blood sugar, high blood fat, and high oxidative levels in the blood, while it can be improved by maintaining healthy blood conditions and having a diet rich in flavonoids and antioxidants; hydration is improved by drinking plenty of water, juice, tea, or other healthy beverages. Thus, protecting the eyes and maintaining good circulation and hydration are potential preventive measures for floaters, retinal tearing, and retinal detachment.

CHINESE MEDICAL VIEWS In the Yinhai Jingwei (Essential Subtleties on the Silver Sea), a text on ophthalmology from the time of the Ming Dynasty (1), there is a discussion of floaters, described as "black blurred specks in the eyes resembling fly wings." The pathology is said to be related to the "water of the kidney" refers to the kidney yin, as distinguished from the "fire of the kidney," which corresponds to the kidney yang or mingmen fire: [Floaters] are a sign of weakness of the water of the kidney. The kidney is the mother of the liver. If the water of the kidney can not nourish the wood of the liver, the liver will display deficiency heat. The gallbladder lies beside the liver. If the wood of the liver is withered and parched, the qi of the gallbladder will be insufficient. As a result, whenever one starts or halts a movement of the head, black specks resembling fly wings float in the spirit water of the eyes. To regulate this condition, one must first employ Zhuling San (Polyporus Powder) to return the evil fire in one's liver and in the kidney to normalcy. Next, one employs Heishen Tang (Scrophularia Decoction) to cool the liver. Then the conduit of the gallbladder will no longer be invaded by evil heat. Afterward, one employs Bushen Wan (Supplement the Kidney Pills). Then the black specks will disappear by themselves. The formulas mentioned for this condition are as follows: Instructions: grind the ingredients to powder; one dose is 9 grams, to be consumed with salty water.

Zhuling San (Polyporus Powder) Polyporus Akebia Rhubarb Gardenia Cibotium Talc Polygonum Plantago seed Red atractylodes

30 g 30 g 30 g 30 g 30 g 30 g 30 g 15 g 15 g

Actions: This formula clears damp-heat of the liver/gallbladder and the kidney/bladder; it is comprised mainly of bitter herbs of cold nature. Most of the herbs are classified as diuretic in modern terms; rhubarb and gardenia purge the gallbladder.

Heishen Tang (Scrophularia Decoction) Scrophularia Scute Raw rehmannia Chrysanthemum Red peony Celosia Tribulus

Instructions: to grind the ingredients in equal parts to powder. Each dose is 12 grams, with the powder boiled in water for a brief time and the resulting decoction consumed.

Bushen Wan (Supplement Kidney Pills)

Instructions: grind equal amounts of these herbs to powder, mix with honey to form pills. The quantity of the herbs to be used for each dose is unclear.

Ginseng Hoelen Peony Alisma

Acorus Lycium Cuscuta Cistanche

Actions: These herbs clear heat from the blood and dispel wind-heat from the eyes.

Actions: This formula nourishes the kidney and moistens the essence.

The same text includes a description of retinal detachment, as "the eyes turn dull and develop specks:" Retinal detachment is caused by depletion in the kidney. Even though the eyes belong to the orifices [that is, the eyes are the orifices associated with the liver], they are tied to the kidneys as their ruler. When the kidney is depleted, the eyesight will become dim. Greed, licentiousness, overindulgence in pleasures, and an unrestrained passion for wine and women weaken and exhaust the kidney. Or, when a person's original qi and essence are incomplete, or when essential spirits have become insufficient, all this causes the pupil and the spirit water to lose their clarity and the eyes to be without strength. As a result, the eyes develop specks and the patient is unable to watch anything for an extended time. To regulate this condition, one must employ Bushen Guijing Wan (pills to nourish the kidney and return the essence). They cause the yin water to be sufficient again, and to return everywhere. Bushen Guijing Wan (Pills to nourish the kidney and return the essence)

Ginseng Atractylodes Hoelen Licorice

Chiang-huo Equisetum Chrysanthemum Siler

Tribulus Buddleia Celosia Cistanche

Peony Cnidium Achyranthes Cuscuta

The instructions are to grind the herbs to powder, combine with honey, and form pills, or boil the powder in water to make a decoction. The total amount of herbs to be consumed for each dose is unclear. This formula includes several herbs for nourishing the eyes and dispelling wind-heat. According to this text, the fluid in the vitreous cavity is viewed as an integral part of the kidney water, or yin essence. When the kidney's yin essence is depleted, not only does the eye fluid become drier, but the wood of the liver/gallbladder system dries out. This causes a turbid essence to go upward from the gallbladder, and a weak fire to arise from the liver and kidneys, which combines with invading wind and distorts the fluid contents of the eye. The gallbladder channel starts at the corner of the eye (tongziliao; GB-1, a point indicated for redness and pain of the eyes, failing of vision, and excess tearing). The remedy is to lower the fire, clear it, and then replenish the fluids. Just as modern medicine recognizes the vitreous fluid as an original fluid of the developing eye, the Chinese doctrine views it as part of the "original water" associated with the kidney, but located in the upper body (referred to as heavenly original water; tian yizhi shui) . It degrades by the weakening of the kidney and the invasion of pathogenic influences, such as internal heat from the liver/gallbladder and external wind-heat. A formula devised after the Yinhai Jingwei was written, Qi Ju Dihuang Wan (Lycium, Chrysanthemum, and Rehmannia Formula), is an example of an eye nourishing prescription used to treat this basic condition. Similarly, the eye-brightening formula, Mingmu Dihuang Wan (Eye-brightening Rehmannia Formula) is aimed at alleviating the dry deficiency of kidney and liver. Yet another formula, Yiqi Congming Tang , is designed to clear the deficiency heat and dispel wind-heat, while benefiting the kidney water indirectly, by nourishing the spleen. It is indicated for deteriorating vision with aging. In the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (2), there is a short section on diseases of the vitreous. The clinical manifestations are said to range from mild cases with black shadows floating up and down like flying flies (but no other change in vision) to severe cases, where the eyes seem to be covered by a membrane. There are three categories of causation listed: Accumulation and steaming up of damp-heat and attack of turbid qi. This corresponds to the disorder of the gallbladder described above. A recommended formula is modified Sanren Tang (Three Seed Decoction), which clears damp-heat. Stagnation of liver qi, resulting in blood stasis and extravasation of blood. This corresponds to the leakage of blood into the vitreous cavity, perhaps as a result of retinitis. A recommended formula is modified Jiawei Xiaoyao San (Bupleurum and Peony Formula). Deficiency of kidney and liver, resulting in flaring up of deficiency fire. This corresponds to the weakness of the kidney water, and associated heat that causes drying of the vitreous. The recommended formula is a modified Zhibai Dihuang Tang (Anemarrhena, Phellodendron, and Rehmannia Formula).

SUMMARY Floaters are rarely caused by release of materials into the eye, and are not a sign of blood deficiency, as is often relayed to Western acupuncturists. Rather, they are a result of natural processes that may be exacerbated or accelerated by overexposure to sunlight, poor circulation in the retina, and lack of hydration, along with deficiency of yin essence and associated flaring of deficiency heat or accumulation of damp-heat. Although there is no proof that the formulas described in the Chinese texts can eliminate floaters and prevent retinal detachment, the use of the herbs and formulas described here is consistent with the basic tenets of the Chinese medical system. In general, one wishes to clear deficiency heat, gently dry damp-heat, and nourish the fluids, particularly the kidney yin, to assure the moistness of the vitreous.

REFERENCES 1. Kovacs J and Unschuld PU, Essential Subtleties on the Silver Sea, 1998 University of California Press, Berkeley, CA. 2. Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 17: Ophthalmology, 1994 Higher Education Press, Beijing.

December 2002

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CHINESE HERB RESPONSE TO FLU PANDEMIC Avian Flu and Other Epidemics alert by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon, March 2006

There are growing concerns about a possible pandemic of virulent influenza, possibly from mutations of a "bird flu" (or, avian flu) that has now occurred across much of Asia and Europe. Thus far, the avian flu has been transmitted primarily from bird to bird or from bird to human, and the number of human cases has been small, because it is necessary to have some direct contact with infected birds (those infected mainly involve people who raise chickens, ducks, or geese). However, it has been found that this virus can infect other animals (e.g., pigs, ferrets), and recent reports indicate that common pets, such as cats, are also at risk. Currently, when this flu virus infects humans, there is a greater than 50% death rate associated with it, which is one of the reasons for the expressed fears about it. The primary concern is that a mutation will arise that allows human to human transmission; in other words, that the flu could be a sneeze away. Already, researchers have noted some genetic variations in viral samples indicating changes towards capability to transmit among humans. If the mutation occurs that permits relatively easy human-to-human infection, the virus may be less lethal than it is now, but would still be a formidable agent of disease. Recent analysis has shown that the bird virus is genetically similar to the "Spanish flu" that caused the deaths of about 50 million people worldwide in 1918-1919 (when the world population was less than one-third what it is now). Those deaths included people who were relatively healthy; the death rate from the Spanish flu was only about 5%. There is a possibility that a human epidemic of this virus will come in the next flu season (2006-2007). Extensive efforts are being used to control this flu; for example, by destroying chicken populations that are infected, as well as eliminating potentially contaminated fowl and wild animals in the immediate vicinity. This approach has had some success, but the growing number of bird farms infected over a widening geographic area is worrisome. With the benefits of modern genetics and pharmaceutical science, a vaccine may soon be developed; vaccines were not part of the technology available in 1918 for the Spanish flu, nor in the other two large epidemics of 1957-1958 and 1968-1969. Looking back at the public reaction to the flu vaccine shortage in America that occurred in the 2004-2005 season, there are great concerns about the supplies of flu vaccine that would have to be developed. Substantial efforts are underway to enhance production capabilities. An analysis presented in 2005 indicated that flu vaccines may have a lower efficacy rate than had been previously assumed, as low as 30% (which is still sufficient to justify their use in people who are at risk of death or severe debility from the flu). There are also flu drugs now coming into broader use, such as the inhalant Relenza (zanamivir), which was approved by the FDA in 1999, and the pill/syrup version called Tamiflu. Several countries are stockpiling supplies. The efficacy of these drugs is also limited, but the initial claims (which may be adjusted as more people use the drugs under varying circumstances) indicate a good response: interrupting flu development when used early enough in 80% of cases; reducing symptom severity by about 40%; and reducing duration of the flu symptoms by about 30%. The avian flu is only one of the possible scenarios for a serious flu epidemic. Other flu viruses might be able to spread more extensively than before. A 2004 U.S. planning document, not based on the avian flu, depicted a scenario where 89 million Americans became sick with influenza, flooding hospitals and overwhelming the medical system, with as many as 207,000 deaths. During ordinary influenza years, the disease is thought to kill at least 20,000 in the U.S. (some estimates double that number), mostly elderly persons with other existing health problems, particularly those who are immobilized by stroke or heart attack; those who have serious respiratory ailments such as pneumonia, chronic obstructive pulmonary disease, asthma, and emphysema; and those with compromised immunity (such as those undergoing therapies that have immunosuppressive effects, as with some cancer drugs and anti-arthritis treatments). In the 2003-2004 season, the flu strain that affected the U.S. was particularly virulent. It caused an unusually high number of fatalities in children (a total of 152 childhood deaths due to influenza for the 2003-2004 season). The influenza season usually peaks in November-February, with some early cases appearing in October and some lingering spread of the disease in March (in 2003, the peak occurred during the week of December 13-20), but the 2004-2005 season started slowly and the peak did not occur until February. Outside of these months, there are relatively few cases of influenza, but there are other diseases that present symptoms similar to influenza and may not be distinguished from it without medical testing. A common intestinal infection, the Norwalk virus (and related Noroviruses) produces what is sometimes called "intestinal flu." Toward the end of the 2004-2005 flu season, a California strain arose that appeared to cause very severe symptoms (the vaccine for the 2005-2006 flu season included protection from that virus, as well as from two other strains, one from New Caledonia and one from Shanghai). Vaccine supplies appear to be adequate for all those in high risk groups as well as others who are in circumstances where becoming infected is likely (health care workers, school teachers, etc.), so long as the spread of the disease follows the typical patterns.

CHINESE HERBS AND INFLUENZA Unlike the vaccines, which are made in response to flu strains as they appear, Chinese herb therapies for influenza are not specific for the viral strain. Instead, they may provide general actions, such as to help boost the immune response so that it is able to eliminate the virus faster. At high enough dosage the herbs may have some direct inhibitory effects on viral reproduction; they may also ameliorate some of the symptoms, thus making a serious infection seem mild. Instead of having a single herb or a single formulation as the response to flu, there are a collection of herbs and formulas that have developed a good reputation. During the period from the 1950s to the 1970s, several large scale studies were undertaken in China to evaluate the use of traditional herb formulas and newer herbal remedies to prevent and treat influenza, with favorable results reported for several compounds. These findings appeared in medical journals and in books summarizing progress in Chinese herb research. The

information has been gathered at ITM, while many of those original publications are no longer available due to limited print runs. While there is insufficient proof from these studies that Chinese herbal therapies can cure or impede influenza because of problems in methodology and reporting, practitioners of Chinese medicine and their patients are convinced of the efficacy of this approach. Routine prescription of Chinese herbs for influenza or other therapeutic applications remains limited primarily to the countries where herbal medicine is officially recognized, such as China, Japan, and Korea. In other countries, the herbs have been made available mainly through the work of licensed acupuncturists, naturopaths, and other non-M.D. practitioners, as well as through direct marketing of products to consumers. The non-toxic herbs found useful in these studies have been incorporated into formulations that ITM has produced for practitioners to use. Several of the formulations, such as Ilex 15, have been available for more than 15 years, so that there is some experience gained through several influenza seasons. Practitioners of Chinese medicine in the U.S., Canada, and Europe will be called upon to provide natural therapies for influenza this year as before, with a potential for higher demand and with more concern about prevention strategies. Even though such therapies are not proven to be effective, many people will feel the need to do everything that seems reasonably possible. Thus, it is worthwhile to review the therapeutic approach described by the Chinese and to offer some of the readily available remedies (ITM formulary items will be described here; others are easily obtained).

A REGIMEN FOR SEVERE INFLUENZA Chinese herb therapy, applied to address the first signs of influenza, might prevent the infection from developing into the full symptomatic disease. For persons who are highly susceptible to influenza and those who tend to experience severe symptoms, as well as during influenza seasons that are defined as being highly virulent or dangerous, it may be prudent to treat even the initial symptoms as though a severe disease was about to develop. These herbal remedies would be used in persons who are developing symptoms despite having been vaccinated (since there is the possibility of vaccine failure, especially later in the season when new strains might dominate) and could also be used along with drugs such as Tamiflu, which are not completely efficacious on their own. To review key herbs that are used in these treatments, please see these articles: Forsythia and Lonicera (antiviral herbs) Shuanghuanglian (this article focuses on three antiviral herbs; the two herbs in the article above, plus scute) Schizonepeta and Mentha (these herbs are used to alleviate symptoms) Yin Qiao San (this article describes a common anti-influenza formula used in China; it includes forsythia, lonicera, schizonepeta, and mentha). The Jade Screen (article about a formula for preventing infections and aiding recovery afterward) A protocol using ITM formulations (which are prescribed by health professionals and are not sold in stores) could be designed in this manner (these dosages are for adults): Ilex 15: 5-6 tablets each time, three times daily Myrolea-B: 1 tablet each time, three times daily Calmagnium: 1 tablet each time, three times daily Quercenol: 1 tablet each time, three times daily Ilex 15 (Seven Forests) is a complex formulation of Chinese herbs that are used to treat upper respiratory system infections. The pattern of herb combining follows principles used in producing two popular patent remedies from China: Yin Qiao Jie Du Pian and Gan Mao Ling. This formula has been used for 15 years. It is suitable for use by itself in the early stage of common influenza and other upper respiratory viral infections. ITM also provides a modification of the original Yin Qiao Jie Du Pian (Pine Mountain), which has been modified with herbs indicated as effective for influenza by ongoing research in China. In addition, there is a potent broad-spectrum antiviral combination called Isatis 6 that may be used alternatively or along with Ilex 15. Myrolea-B (White Tiger) is a simple formulation of highly concentrated extracts from four Chinese herbs and one Western herb. The Chinese herbs include forsythia and lonicera, two of the key ingredients of Ilex 15 (and the main antiviral ingredients of Yin Qiao Jie Du Pian), thus boosting the dosage of these essential ingredients. Myrolea-B also contains the antiviral agents scute (huangqin) and terminalia (hezi) . The Western herb in this formulation is olive leaf, which is one of the primary anti-viral herbs derived from the European tradition. Calmagnium (White Tiger) is a comprehensive mineral and vitamin supplement (not a Chinese formula). The concept behind its use is that by providing optimal or even high levels of certain nutrients, the immune system has a stronger effect against pathogens. For example, it is considered possible that vitamin C, zinc, and selenium contribute to antiviral activity. The point of providing a broad nutritional supplementation, rather than just focusing on a few of the established ingredients, is to assure a more balanced effect. In China and Japan, it is increasingly common to prescribe nutritional supplements, similar to this, along with herb remedies. Quercenol (White Tiger) is an antioxidant mixture. It has recently been reported that influenza causes oxidative stress that adversely affects the lungs, perhaps increasing symptoms and susceptibility to secondary lung infections. There is a decline in vitamin E levels. Quercetin, the main ingredient in Quercenol, has been shown to increase pulmonary concentrations of the antioxidants catalase, reduced glutathione, and superoxide dismutase. By taking Quercenol, the vitamin C intake from Calmagnium is increased (total of 1162 mg per day with the above suggested dosing) as is the vitamin E intake (total of 337 IU per day with above dosing). In addition, zinc supplementation is often recommended for to boost immune responses; the use of Quercenol with Calmagnium at the suggested dosing provides 25 mg of zinc. Selenium from Calmagnium alone at the dose of 1 tablet three times daily is 75 mcg, but adding Quercenol

brings it to 175 mcg. The antiviral agents are expected to have their best effect at the earliest sign of infection and for the phase of the disease where the amount of virus is exponentially growing, perhaps the first two to three days of symptoms. After that, the virus comes under some degree of control, even though symptoms can persist. However, additional symptoms can be generated if a bacterial infection arises; typically, a bronchial infection develops, and it may persist for several days or weeks if not successfully treated (if herbal therapy is not successful, antibiotics should be used in cases of bacterial infections). After the initial viral development phase, one may focus more on symptomatic relief, for example, deleting Ilex 15 in the regimen above and replacing it with another formula; aimed at relief of symptoms, such as for nasal congestion, sore throat, or bronchial infection with cough. Examples of those therapies include these Seven Forests formulas: Belamcanda 15: suited for respiratory bacterial infection that accompanies or follows influenza Chyrsanthemum 9: for headache, fever, sinus congestion accompanying influenza Gardenia 7: for sore throat Lily 14: for dry, irritated throat and dry cough

PREVENTION STRATEGIES For those who are concerned about high susceptibility to influenza (due to past experience of frequent infection by viruses or a high level of exposure to crowds), immune enhancing formulas, such as Jade Screen Tablets o r Astragalus 10+, may be taken during the flu season (e.g., for up to about 16 weeks) in an effort to avoid developing a symptomatic infection after exposure. Jade Screen Formula (with astragalus as a major constituent) and its variants are the most widely studied prescriptions for prevention of upper respiratory tract infections. ITM's version of the formula includes additional herbs benefiting the lungs: the anti-infection herb houttuynia, the yin nourishing glehnia, and the congestion-alleviating centipeda (an herb, not to be confused with the insect centipede). Astragalus 10+ is especially suitable for persons of middle age or older, as it also contains tonics for the kidney/liver as part of the therapeutic approach to immune enhancement. Greater immune enhancing effects may be attained by including, along with one of these tonifying formulas, a high dose of either astragalus (using Astragalus Extract Tablets) or cordyceps (using Cordyceps Tablets); these herbs also strengthen the lungs. ITM has received reports that some patients successfully use Ilex 15 as a preventive; this formula may function in this role by helping inhibit the virus as soon as exposure occurs, perhaps being effective at dosages lower than those described for treatment of the disease once symptoms appear. It is important to note that high doses of the tonic formulas with astragalus may not be effective when the infection begins producing symptoms. The flu symptoms include the adverse impact of a high immune response, and attempts to elevate that immune response will not only fail to have a substantial extra impact on the virus but may contribute to the severity of the symptoms. Thus, one should be careful about attempting to apply this approach. Generally, the immune based therapies are applied either during a preventive health care phase of treatment or during a recovery phase when the dominant symptoms are reducing rather than at the time when the symptoms of an infection are first noted. Some of the suggested ITM formulations are relatively new, including Myrolea-B, Yin Qiao Jie Du Pian, Chrysanthemum 9, Astragalus Extract Tablets, Cordyceps Tablets, and Gardenia 7. All of these, and the other formulations mentioned here, are included in the book A Bag of Pearls (2004). Additional suggestions for treatment of influenza or its symptoms may be gleaned from the pages describing the formulas and in the index of formula indications. PLEASE NOTE: The side-by-side presentation of the following formulas is not intended to suggest any particular pairings, it is for presentation only. Standard Anti-Influenza Formulations Ilex 15 maodongqing Ilex

Yin Qiao Jie Du Pian jinyinhua

Lonicera

12%

jinyinhua

Lonicera

9%

lianqiao

Forsythia

12%

lianqiao

Forsythia

7%

niubangzi

Arctium

12%

banlangen

Isatis root

7%

banlangen

Isatis root

10%

bohe

Mentha..

7%

chuanxinlian

Andrographis (e)

10%

juhua

Chrysanthemum

7%

jiegeng

Platycodon

10%

zhushagen

Ardisia root

7%

dandouchi

Soja

10%

jiegeng

Platycodon

7%

danzhuye

Lophatherum

8%

lugen

Phragmites

6%

bohe*

Mentha

8%

jingjie

Schizonepeta

6%

jingjie

Schizonepeta (e)

8%

fangfeng

Siler

5%

* a high menthol content extract is used

qianghuo

Chiang-huo

5%

ganjiang

Ginger

5%

wuzhuyu

Evodia

4%

gancao

Licorice

4%

14%

Supplemental Influenza Formulations: may be added to the above or used instead

Myrolea-B

Isatis 6

jinyinhua

Lonicera

25%

daqingye

Isatis

25%

lianqiao

Forsythia

25%

huzhang

Hu-chang

15%

Olive leaf

25%

xiakucao

Prunella

15%

huangqin

Scute

20%

baihuasheshecao

Oldenlandia

15%

hezi

Terminalia

10%

chuanxinlian

Andrographis

15%

jinyinhua

Lonicera

15%

Nutritional and Antioxidant Therapy: key elements are quercetin, vitamins C and E, and zinc. Quercenol

Calmagnium

Two tablets provide: percentage of U.S. RDA in parentheses

Four tablets provide: (percentage of U.S. RDA in parentheses)

Minerals:

Silybum marianum (e)

250 mg

400 mg

Proanthocyanadins

125 mg

10 mg



Green tea polyphenols

150 mg

Calcium

550 mg

(100)

Magnesium

(67)

Zinc

(100)

Manganese

(75)

Copper

2 mg 1.5 mg 1 mg

Vitamins: Mixed carotenoids Vitamin E

300 IU

Vitamin C

500 mg

(167)

Chromium

200 mcg

(143)

Selenium

100 mcg

Minerals:

(67)

Molybdenum

50 mcg

Vitamins: Vitamin A

(67)

Zinc

(143)

Selenium

5,000 IU

β-carotene

10,000 IU

(1333)

Vitamin B1

20 mg

(1176)

Vitamin B2

20 mg

(210)

Vitamin B3

40 mg

(400)

Vitamin B5

40 mg

(2000)

Vitamin B6

40 mg

(3333)

Vitamin B12

200 mcg

(200)

Folic acid

800 mcg

(333)

Biotin

(833)

Vitamin C

(75)

Vitamin D3

(167)

Vitamin E

(125)

Vitamin K 1

30 mg

(1000) (830)

(100)

400 mg



(55)

Boron

Flavonoids: Quercetin

1 mg 500 mg 300 IU 50 IU 100 mcg

Formulas for Prevention via Immune Enhancement; also for recovery phase

10 mg 100 mcg

Jade Screen Tablets

Astragalus 10+ Astragalus (e) Eleuthero (e)

huangqi

Astragalus

25%

huangqi

fangfeng

Siler

18%

ciwujia

baizhu

Atractylodes

15%

lingzhi

Ganoderma

ebushicao

Centipeda

12%

maimendong

Ophiopogon

10%

yuxingcao

Houttuynia

12%

nüzhenzi

Ligustrum

10%

beishashen

Glehnia

12%

heshouwu

Ho-shou-wu

8%

gancao

Licorice

6%

roucongrong

Cistanche

7%

baizhu

Atractylodes

7%

gancao

Licorice

6%

renshen

Ginseng

6%

wuweizi

Schizandra

6%

sangshen

Morus fruit

6%

(e)

(e)

12% 12% 10%

Immune Boosters; may be added to the formulas above Astragalus Extract Tablets

Cordyceps Tablets

huangqi

Astragalus

75%

chongcao

Cordyceps

34%

danshen

Codonopsis

25%

wujiashen

Eleuthero

33%

hongjingtian

Rhodiola

33%



Formulas for Secondary Effects: Lung congestion and infection; headache and sinus congestion Belamcanda 15

Chrysanthemum 9

shegan

Belamcanda

8%

yejuhua

Chrysanthemum

16%

yuxingcao

Houttuynia

8%

manjingzi

Vitex

12%

shishangbo

Selanginella

8%

gegen

Pueraria (e)

12%

lugen

Phragmites

7%

chouwutong

Clerodendron (e)

10%

xingren

Apricot seed

7%

sangye

Morus leaf

10%

sangye

Morus leaf

7%

chuanxiong

Cnidium

10%

zhuli

Bamboo sap

7%

niuxi

Achyranthes

10%

jiegeng

Platycodon

7%

tianma

Gastrodia (m)*

10%

baibu

Stemona

7%

baijili

Tribulus

10%

maimendong

Ophiopogon

6%

zhebeimu

Fritillaria

6%

* gastrodia mushroom, Armillaria mellea, is used as a replacement for gastrodia

niubangzi

Arctium

6%

baiqian

Cynanchum

6%

ganjiang

Ginger

5%

gancao

Licorice

5%

Formulas for Sore Throat and for Dry Throat and Dry Cough

Gardenia 7

Lily 14

zhizi

Gardenia

30%

baihe

Lily

jiegeng

Platycodon

15%

muhudie

Oroxylum

9%

gancao

Licorice

15%

maimendong

Ophiopogon

9%

hezi

Terminallia

10%

yuzhu

Yu-chu

8%

bohe

Mentha

10%

dihuang

Rehmannia

8%

shengdi

Rehmannia

10%

mingdangshen Changium

7%

niubangzi

Arctium

10%

pangdahai

Sterculia

6%

nanshashen

Adenophora

6%

beishashen

Glehnia

6%

xuanshen

Scrophularia

6%

niubangzi

Arctium

6%

jiegeng

Platycodon

6%

zhebeimu

Fritillaria

6%

gancao

Licorice

5%

12%

IMPORTANT REMINDER: There is no clinical evidence that the specific formulas mentioned above provide any protection from or effective treatment for influenza (or related disorders). The information about these formulas is given here to illustrate the types of ingredients that practitioners of Chinese herbalism (such practitioners are usually licensed acupuncturists) might give to their patients, including the dosage, the timing in relation to beginning of influenza symptoms, and the duration of use (a nutritional supplement comprised of vitamins and minerals is also mentioned). Such practitioners might recommend these specific formulas or many others that have a similar design. Several articles are referenced in the above description as a resource to learn more about certain of the ingredients and about related formulas described in the Chinese herbal literature .

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Treatment of Frozen Shoulder Using Chinese Medicine by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Frozen shoulder is the commonly used term for adhesive capsulitis, named for thickening and contracture of the capsule, the connective tissue surrounding the bony structures of the shoulder joint. The disorder was originally known as shoulder periarthritis or periomarthritis, because the inflammation surrounds the shoulder joint, but those terms are no longer preferred. Frozen shoulder is usually painful, but stiffness and restriction in movement are the primary characteristics resulting from the capsule contracture and are often likened to the immobilization of freezing versus the loosening of thawing. The disorder primarily affects people past the age of 40, particularly women; certain diseases increase the incidence of frozen shoulder, especially diabetes and thyroid diseases. Injuries are a common cause of frozen shoulder; for therapeutic purposes this condition should be distinguished from other injuries causing shoulder stiffness and pain, such as a torn rotator cuff. Range of motion tests (or, if necessary, x-rays or scans) can reveal the site of injury. Frozen shoulder will often resolve gradually without intervention, but this can take many months (up to three years). The pain associated with shoulder movement is often relieved by use of ordinary anti-inflammatory drugs; in severe cases, steroids may be used temporarily. Physical therapy, based on stretching or range-of-motion exercises for the shoulder may hasten the improvement considerably and are the current standard therapy. Chinese medical interventions, especially acupuncture, have been claimed to be helpful. The first description of frozen shoulder was provided by the French physician E.S. Duplay in 1872. During the 20th century a corresponding Chinese term arose: "50-years shoulder" (wushi jian), referring to the typical age of onset of the disorder; the term frozen shoulder (jianning) is also used in China. While there are numerous references to traditional style Chinese medical treatments for problems of the shoulder area, investigations into the use of the therapies specifically aimed at frozen shoulder have only been described in the last few years.

ACUPUNCTURE WITH DISTAL POINTS One of the earliest Chinese reports of acupuncture treatment of frozen shoulder was published in 1991 (1), based on a simple treatment method. The author of the article, Zhang Maohai, claimed to have found an effective therapy through his experiences. He focused on one acupuncture point, yanglingquan (GB-34), located on the leg, which he said seemed more effective than treating multiple points. The point was needled on one side only, the same side as the affected shoulder. In rare cases where this same side treatment did not seem to be helpful, the point was needled on the other leg instead. The technique used was deep insertion (2.0-2.5 cun), followed by rotating and thrusting to get the qi reaction; the reducing technique was used for all patients, but deficiency patients were administered the treatment with both reducing and reinforcing techniques. The needle was maneuvered again every 3-5 minutes to maintain the stimulus. In the meantime, the patient was advised to move the shoulder joint. Total needle retention time was about 30 minutes, and five daily sessions made one course of treatment. After two courses of treatment (with a break of a day or two between courses), the frequency of treatment was reduced to every other day until the condition was resolved to a satisfactory extent. In the event of acute shoulder pain, electrostimulation of the needles was used (intermittent waves, strong intensity). It was claimed that as a result of this therapy, 64% of the 172 patients so treated were cured, and all the rest (except 8 patients) showed some degree of improvement. In two cases that were detailed, the total treatment involved 10 sessions in one case and 20 sessions in the second case. The selection of this acupuncture point is of interest. Traditionally, yanglingquan is mainly indicated for treatment of lower limb disorders, such as pain and numbness in the legs and knees, but the effects of stimulating this point are thought to also extend upward along the gallbladder meridian, which traverses the costal region to the shoulder. There, the meridian passes through the point jianjing (GB-21), indicted for stiffness of the neck, pain of the shoulder and upper back, and for difficulty moving the arm. A further basis for using yanglingquan is its reputation for soothing and moistening the sinews. Since the shoulder capsule is contracted, this action is considered important to healing the disorder. A report on uses of yanglingquan was provided by Lü Jingshan in 1993 (2). Treatment of this point was described as being valuable for pain of the shoulder, elbow, costal region, lower back, and knee. Regarding shoulder pain, Lü wrote: Shoulder pain is most often due to periarthritis of shoulder or injury to soft tissues due to invasion of wind and cold, or damage to channels or tendons that obstruct passage of qi and blood and result in pain. Following the principle of 'malady above treated by selecting relevant acupoints below, the author treated pain in the shoulder by acupuncture at yanglingquan (GB-34) with fairly satisfactory results, particularly in cases of short duration or caused by contusion or sprain. He described a treatment strategy similar to that outlined above, with 30 minute needle retention and stimulus at the beginning and then at intervals (but, in this case, 10 minute intervals), while the patient exercised the shoulders. Application of acupuncture to yanglingquan on the side opposite the affected shoulder was used by another group, who reported on several successful uses of contralateral therapy (3). A similar method was described in a report by Feng Zhengen (4), using the extra point lingxia, located 2 cun below yanglingquan (GB-34). The point on the same side as the affected shoulder was needled, while sanjian (LI-3), on the hand, was needled on the

opposite side. The patient would move the affected arm during the acupuncture therapy. Treatment was given daily for 10 sessions, followed by a 2 day break and then another 10 sessions. It was reported that of 210 patients treated, 158 cases were resolved, and that all but 12 cases showed some improvement. The selection of lingxia, rather than yanglingquan was based, according to the author, on the fact that he found a marked tender point at this spot which, when pressed, alleviated the shoulder pain.

A point in this same area of the leg was selected for treatment of frozen shoulder by K.O. Sun and his colleagues in Hong Kong (5). They chose zhongping, an extra point located 1 cun below zusanli (ST-36). Deep needling (2.5 cun) was used with stimulus to get deqi, with additional stimulation every 5-6 minutes, and total retention time of 20 minutes; this treatment was administered twice per week for six weeks. The study was somewhat small, with 22 patients in a control group doing only the recommended shoulder range of motion exercises, and 13 patients doing exercise plus getting acupuncture. Both groups showed improvement, with a significant advantage to the acupuncture group. Another acupuncture point in this same area of the leg that is used for shoulder disorders is tiaokou (ST-38). It is especially considered for treating acute shoulder pain, and is stimulated while the patient moves the shoulder. Jorge Vas and Emilio Perea-Milla compared the effects of needling tiaokou on shoulder pain when the treatment either did or did not elicit deqi, finding that deqi was important to gaining the desired prompt alleviation of pain (6). The successful use of tiaokou for frozen shoulder had been mentioned in an early publication by German acupuncturists (7).

ACUPUNCTURE WITH LOCAL POINTS The points chosen to treat frozen shoulder are often selected from those on the small intestine meridian, especially from SI-9 through SI12, which run across the shoulder area. A key point is bingfeng (SI-12) at the attachment zone for the shoulder capsule. Bingfeng (grasping the wind; which became the title of a book about the names of acupuncture points; 8), is located by raising the arm, which produces an indentation at this spot. It is used to relieve disorders where there is shoulder pain accompanied by difficulty raising the arm, as occurs with frozen shoulder. In a report published in 1998 (9), results from treating 60 patients with "shoulder-arm" syndrome were relayed. Although this report did not address frozen shoulder, it claimed to produce marked effects through use of this single point (a second point would be treated for manifestations of the disorder in the forearm or hand). Local treatment was the primary focus of a recent report by Jin Dongxi and Li Zhingtai, who described treatment of 50 patients with frozen shoulder using acupuncture and massage (10). They stimulated several points on the shoulder, including bingfeng, as well as others on the hand and arm of the same side as the affected shoulder. The points selected for treatment were: extra point taijian (the name means "lift shoulder;" it is located 1.5 below the anterior part of the acromion); extra point jubi (the name means "raise arm;" located 3.5 cun below the anteroinferior part of the acromion); tianzhong (SI-11); bingfeng (SI-12); and houxi (SI-3) naohui (TB-13) and jianliao (TB-14) quchi (LI-11) and hegu (LI-4) During each acupuncture session, 4-8 points were selected for treatment, with stimulation maintained by electro-acupuncture, relying on the highest stimulus tolerated by the patient (with a loose-dense alternating waveform). Manipulation of the arm so as to relax the tendons around the affects shoulder were also performed, as well as other arm movements and kneading of the muscles. It was reported that the condition resolved in 48 cases and that all other cases had some degree of improvement. The elbow point quchi (LI-11) included in the above protocol is traditionally utilized for treating pain in the shoulder and arm, and it considered especially useful when the pain prevents the arm from being lifted. In 1999, an article by B.H. Ma (11) described use of three acupuncture points for frozen shoulder, recommending two points along side of quchi (LI-11; one cun anterior and one cun posterior to the point) plus jianyu (LI-15) located at the shoulder. This area (shoulder and upper arm) is to be treated by cupping about 15 minutes after the needling is done, followed by a massage therapy with rapid motion of the palm against the arm and then shaking of the arm by holding at the wrist and lifting the arm to 90 degrees, then shaking with a downward pressure.

A treatment method relying primarily on local points is presented in the Encyclopedia of Practical Traditional Chinese Medicine volume on acupuncture (12). The recommended points are mainly from three yang channels of the hand-arm-shoulder area: jianyu (LI15), binao (LI-14), quchi (LI-11), and hegu (LI-4) of the large intestine meridian; jianzhen (SI-9) and houxi (SI-3) of the small intestine meridian, and waiguan (TB-5) of the triple burner meridian. In cases where the pain radiates to the neck and back, additional small intestine meridian points would be added, such as bingfeng (SI-12) and quyuan (SI-13). Combining acupuncture and moxibustion was also suggested, with moxibustion especially at jianyu (LI-15) for 20 minutes. Treatments featuring both the local points (shoulder/arm) and distal points (leg) have also been described in the context of clinical reports. Emad Tukmachi, in England, wrote an article on treatment in the journal Acupuncture in Medicine describing his approach (13). This report was not about a controlled trial, but about treatment of a series of 31 patients. He asserted that treatment effect will usually be noted within about 6 sessions and that successful treatment may require from 4-19 sessions. In a summary of this report, he noted that: Ashi or trigger points around the shoulder should be carefully sought and needled superficially; tiaokou (ST-38) with strong manipulation is useful. Deqi should be sought in the robust patient, with less stimulus in the weak patients. Electroacupuncture at quchi (LI-11), jianyu (LI-15), jianjing (GB-21), and jianzhen (SI-9) at 5 Hz helps; yanglingquan (GB-34) bilaterally for 2 minutes alone often controls pain and releases stiffness. Auricular therapy at shenmen, shoulder, shoulder joint, clavicle, and adrenal points is helpful. The patient should exercise faithfully with a slow warm-up. Dr. Li Lingling offered data from her work with frozen shoulder, which is presented on a website (14), and involves the local and distal points, with points on the large intestine dominating the shoulder/arm selections. According to the report, 61 patients were treated using electro-acupuncture and massage. The main acupoints treated were jianyu (LI-15), jianzhen (SI-9), quchi (LI-11), binao (LI-14), and tiaokou (ST-38), and the primary supplemental points were jianliao (TB-13), shousanli (LI-10), houxi (SI-3), taiyuan (LU-9), and yinlingquan (GB-34). Treatment was set up with two groups of points for each patient, one group of five points treated one time, and another group of five points treated the next time. Massage therapy included massaging various muscles and certain acupuncture points in the shoulder area. After about five treatments it was reported that 25 of the patients had the problem resolved and that all but three others showed some degree of improvement. Finally, the use of scalp acupuncture should be mentioned. This treatment is frequently used for chronic pain syndromes and was the subject of an evaluation involving 210 cases (15). A point was treated along the vertex-temporal line, which runs from the head vertex baihui (GV-21) to the temple at xuanji (GB-6), about 40% of the way from the vertex to GB-6, which is in the zone corresponding to upper extremity disorders. The needle was threaded about 30 mm (about an inch) towards the temple (a second needle, inserted close to the same point but angled 45 degrees to the first and crossing its path, was often used to get more intense stimulus). If only one shoulder was affected, the contralateral side would be treated; with both shoulders affected, both sides would be treated. The patient was advised to relax, focus on the affected shoulder, and carry out shoulder movements during the treatment, while the practitioners manipulated the needles (with repetitive rapid withdrawal about 3 mm, then slower return) at least every 5 minutes and sometimes also massaged the shoulder. The needles would then be retained for 1-2 hours, or up to 1-2 days for severe cases. Typically, treatment was carried out every 1-2 days with seven sessions as a course of treatment. It was claimed that on the basis of this therapy, 72% of the cases were resolved after one course of treatment, and that all but 3 of the patients showed some degree of improvement; the first 3-5 sessions of scalp acupuncture were said to often bring significant relief.

COMMENTARY ON ACUPUNCTURE THERAPY As is often noted for treatment of acupuncture therapy, the methods used for frozen shoulder involves diverse ideas about selection of points. There are two main strategies: involving either local or distal treatments. Many of the local points chosen are ones at the shoulder and then some others on the affected meridian (mainly small intestine and large intestine meridians) along the arms and hands. Distal points may be used instead (as in the case of several below the knee points, and also for scalp acupuncture). In some cases, contralateral treatment is relied upon; other times, both local and distal points are on the affected side. Less often, both local and distal points are used. In terms of the points most frequently selected, the local points jianyu (LI-15), bianao (LI-14), and quchi (LI-11) of the large intestine meridian and jianzhen (SI-9), bingfeng (SI-12), and houxi (SI-3) of the small intestine meridian are emphasized. The commonly used distal points are yanglingquan (GB-34) and tiaokou (ST-38) plus several extra points between or to either side of these points were each mentioned. Acupuncture therapy was supplemented by massage and/or the patient's own exercises in virtually every case. Sometimes physician-managed manipulations would be used (see illustration, below).

HERB THERAPY Pain in the upper body is often deemed a disorder related to invasion of wind, and a condition with stiffness is often associated with coldness, so frozen shoulder fits the ancient category of wind-cold invasion. Modern thinking on the subject of persisting pain at a fixed site suggests that blood stasis may also be involved. A typical traditional formula considered suitable for "50-years shoulder" is Juanbi Tang , which has the wind dispelling herbs chiang-huo and siler and the blood vitalizing herbs turmeric, tang-kuei, and peony. These herbs are used in a base of tonification therapy that is suited especially to those who are elderly and suffer from a disorder in which there is easy invasion of wind and development of stagnation due to qi and blood deficiency. Hence, in addition to the blood nourishing herbs tang-kuei and peony, the qi tonic and center strengthening combination of astragalus, fresh ginger, jujube, and licorice is included. An herbal preparation described on the internet (16) as a successful remedy for frozen shoulder has the following main herbs: chiang-huo, siler, tu-huo, cinnamon twig, chin-chiu, vitex, cnidium, millettia, and salvia. Here, cnidium, millettia, and salvia serve to vitalize blood and nourish blood, while the other herbs dispel wind and warm the meridians.

REFERENCES 1. Zhang Maohai, Treatment of periomarthritis with acupuncture at yanglingquan (GB-34), Journal of Traditional Chinese Medicine 1991; 11(1): 9-10. 2. Lü Jingshan, The clinical application of yanglingquan (GB-34) point, Journal of Traditional Chinese Medicine 1991; 13(3): 179-181.

3. Liu G and Wang S, Needling at contralateral yanglingquan in treatment of shoulder periarthritis: report of 115 cases, International Journal of Clinical Acupuncture, 1993; (4): 297-300. 4. Feng Zhengen, 210 cases of shoulder periarthritis treated by needling lingxia and sanjian, Journal of Traditional Chinese Medicine 2003; 23(3): 201-202. 5. Sun KO, et al., Acupuncture for frozen shoulder, Hong Kong Medical Journal 2001; 7: 381-391. 6. Vas J and Perea-Milla E, Immediate effects of puncture of tiaokou ES38 in the painful shoulder and the importance of the deqi, http://www.meridiens.org/acuMoxi/VAS.htm. 7. Pothmann R, Weigel A, and Stux G, Frozen shoulder: differential acupuncture therapy with point ST-38, American Journal of Acupuncture 1980; 8:65-69. 8. Ellis A, Wiseman N, and Boss K, Grasping the Wind, 1989 Paradigm Publications, Brookline, MA. 9. Liu Hongyan and Zhang Caihong, 60 cases of shoulder-arm syndrome treated by electroacupuncture at bingfeng (SI-12), Journal of Traditional Chinese Medicine 1998; 18(4): 256-258. 10. Jin Dongxi and Li Zhongtai, Acupuncture and the elevation manipulation of massage for treatment of frozen shoulder, Journal of Traditional Chinese Medicine 2003; 23(3): 212-213. 11. Ma BH, The three points of shoulder for periarthritis, International Journal of Clinical Acupuncture 1999; 10: 321-324. 12. Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, (vol 6) 1989 Higher Education Press, Beijing. 13. Tukmachi ES, Frozen shoulder: a comparison of western and traditional Chinese approaches and a clinical study of its acupuncture treatment, Acupuncture in Medicine 1999; 17(1): 9. 14. Li Lingling, 61 Patients with periarthritis of shoulder treated by combined treatment of acupuncture and massage, http://www.acuhealing.com. 15. Jia Huaiyu and Li Qiaoju, Treatment of periomarthritis with scalp acupuncture therapy, Journal of Traditional Chinese Medicine 1993; 13(3): 199-201. 16. HerbChina2000, Frozen Shoulder, http://www.herbchina2000.com/therapies/MFS.shtml.

May 2005

TREATMENT OF GALLSTONES WITH CHINESE HERBS AND ACUPUNCTURE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Cholelithiais (chole = gall; lith = stone), commonly called gallstones, is a frequent health problem and one of the major reasons for abdominal surgery, responsible for over half a million cholecystectomies (gallbladder removals) in the U.S. each year. Surgery is performed to prevent several potential problems: severe abdominal pain due to movement of a stone into the bile duct; potential blockage of bile flow causing liver and pancreatic damage; and inflammation of the gallbladder (cholecystitis), causing fever, pain, and digestive disturbance. Laparoscopic cholecystectomy, a relatively new surgical technique, requires only a small incision in the navel plus two other slits made elsewhere in the abdomen to gain access to the gallbladder with microsurgical tools. This procedure results in minimal damage to surrounding tissues and quick recovery time; most patients go home within 24 hours of the procedure. About 98% of all gallbladder removals can be accomplished with this technique rather than standard abdominal surgery. After gallbladder removal, most patients are relieved of symptoms that they have suffered, including some chronic digestive disturbances and abdominal aches that might not have been recognized initially as being related to gallstones or gallbladder inflammation. Another result of cholecystectomy is reduced bile excretion with a meal. Bile excretion, with or without a gallbladder, is an ongoing process that involves a pump-like action in the liver biliary system, dispensing fluid about six times per minute. With the gallbladder present, there is an additional pump-like action, in which bile is stored and then excreted in larger quantities during digestion of a meal. Thus, those who have their gallbladder removed can lead a normal life, but may have to be careful about eating any large quantity food at one time, particularly fatty foods, since bile is a valuable contributor to efficient digestion of fats, solubilizing the fats for enzymatic breakdown and for absorption. Despite the improvements in surgical techniques and the generally positive outcomes, many people diagnosed with gallstones would prefer to avoid surgery and retain their gallbladder. This is to be accomplished by dissolving the stones and/or purging the stones from the gallbladder via the intestines. One alternative to surgery that was tried, but later discarded, was lithotripsy. This procedure was used for patients with large stones that involved breaking the stones into small pieces with powerful sound waves. Unfortunately, there were too many cases of bile duct blockage from the pieces of stone as they were excreted to consider this procedure generally successful. A stone dissolving therapy with bile salts, mainly ursodeoxycholic acid, is another procedure that has been tried; administered only in cases of relatively small stones. About 6-24 months of continuous use is required to attain the desired results, which is complete removal of stones. The therapy has some drawbacks, such as causing symptoms of gas, bloating, and nausea in some patients, but it is still being investigated to find improved methods that might yield superior results. A problem with these and other alternatives to surgery is that when the gallbladder has not been removed, it is common for recurrence of gallstones because the stone-forming processes are still present. Nonetheless, those who are willing to make adequate changes in diet and exercise may be able to avoid producing stones that are of a dangerous size. Chinese medicine is commonly sought out as an alternative to surgery by those diagnosed with gallstones. It is evident from comments made by these individuals, and by Western practitioners of Chinese medicine, that many patients hope to take only a small amount of herbs in a convenient form to remove the stones. Further, they expect to do so without risk of adverse effects, such as abdominal pain due to stones becoming caught in the bile duct during expulsion; otherwise, they reject further consideration of the therapy. In order to determine whether or not such expectations are reasonable, it is necessary to examine how Chinese doctors actually treat gallstones in order to learn of the herbs to use, their dosage, duration of treatment, and incidence of adverse reactions. Acupuncture is a therapy that commonly accompanies use of herbs and is also mentioned here. In China, the diagnosis of gallstones is a new one: it has not been part of traditional Chinese medicine prior to the introduction of modern Western medicine. Symptoms of gallstones were no doubt detected in the past, such as findings of abdominal pain and reactions to fatty foods, but the cause of such symptoms would usually be attributed to disorders such as qi stagnation and abdominal accumulation, rather than gallstones, which cannot be detected directly by traditional Chinese diagnostics. However, since ancient times, the Chinese have been aware of the gallbladder (identified as one of the six fu organs) and aware of its ability to form stones. Gallstones of the ox (niuhuang) have long been used in traditional medicine: they were listed in the Shennong Bencao Jing (ca. 100 A.D.). It is thought that the medicinal use of the ox gallstone may have originated in India, from which it was then adopted in China (1), along with other ancient Indian remedies, such as ginger root. In the Chinese tradition, ox gallstone is used to "open the orifices of the heart," when there are symptoms of delirium, convulsions, and loss of consciousness in feverish diseases, and also to treat swellings in the throat and mouth. This latter application is addressed by the popular patent formula Niuhuang Jiedu Pian (Tablet of Ox Gallstone to Remove Toxins). In China, the extracted bile or the whole gallbladder (with bile) from several animals has been used medicinally, such as snake gallbladder given as a health tonic and as a treatment for phlegm disorders, and bear gallbladder as a treatment for injuries and back pain. The Western treatment for dissolving gallstones, ursodeoxycholic acid, is the main bile salt found in bear bile (urso = bear), though the clinical material is not obtained from bears. In modern China, bear bile (combined with curcuma and capillaris) was developed as a treatment for gallstones and gallbladder inflammation (cholecystitis). Even with the Chinese knowledge of gallstones from animals used in medicine, early Chinese medical references to the gallbladder in humans did not include problems specifically related to stone formation. Rather, there was an understanding that the gallbladder stored and, at times, poured out bile. In a review of liver and gallbladder functions and disorders (10), this was explained: The liver forms and secretes bile with the aid of "overflowing liver qi" that flows into and is stored by the gallbladder. The function of secretion and excretion of bile are two of the most important aspects of the liver dredging function. If there is a disturbance in the dredging function, there may be a disturbance in the secretion of bile, resulting in jaundice, bitter taste in the mouth, emesis of bile, distention and pain in the subcostal regions, abdominal distention, and decreased food intake....

Liver qi congestion and entanglement are manifestations of the liver's inability to dredge and maintain the smooth flow of liver qi. This dysfunction is defined as an imbalance of qi function and, more specifically, as qi congestion and qi stasis. The etiology may be emotional trauma, invasion of external wet-heat evil, and an insufficiency of liver blood. Liver qi congestion and entanglement is chiefly manifested as emotional depression, disturbance of qi functions, and dysfunction of the secretion of bile. Any disturbance in the secretion or excretion of bile may alter the physiology of the spleen, stomach, and intestines, resulting in disturbance of both the qi functions and mental or emotional activities. Put another way, the normal flow of bile is a manifestation of the smooth flow of liver qi; liver qi stagnation-often caused by emotional depression, leads to lack of bile flow. When there is a reduction of bile flow, this will disrupt the qi functions and lead to further problems, generally involving emotional distress, and thus reinforcing the pattern of stagnancy and abdominal distress. As we know now, the low level of bile flow contributes to stone formation. Since the diagnosis of gallstones, rather than simple stasis of bile flow, is a modern one, it is valuable to examine modern information of gallstones.

MODERN KNOWLEDGE OF GALLSTONES, THEIR SYMPTOMS, AND THEIR CAUSE The gallbladder is a pear shaped organ that rests under the liver in the right abdomen; it is attached to the liver via the biliary ducts (see Figure 1). The gallbladder receives bile from the liver, where it is continually produced. Bile is made from cholesterol and is comprised almost entirely of a mixture of cholesterol-like fatty substances known as bile acids, mainly cholic acid and desoxycholic acid (see Figure 2). It also contains bilirubin (breakdown products of hemoglobin) and cholesterol. The bile acids combine with minerals, such as sodium and calcium to form neutral salts. Under normal physiologic conditions, the gallbladder gradually collects bile that is being pumped out of the liver and expands to hold the bile, and then releases most of the collected bile, via the bile duct, into the duodenum (upper part of the small intestine) upon stimulus from eating. The bile combines with the partially digested food material: starches are digested during chewing, proteins upon mixing with stomach acids. In the duodenum, bile helps solubilize the fats in the food to make digestion easier, and digestive enzymes from the pancreas, including a group of lipases to break down fats, complete most of the digestive process. In cases of insufficient secretion of bile, fat metabolism can be aided by oral administration of ox bile salts, usually given in a dose of about 300 mg with each meal. Although the exact mechanism of gallstone formation is not established, it is believed that it occurs primarily when there is a lack of sufficient bile flow-when there is stagnation of the fluids in the gallbladder. During an extended period of low bile flow, cholesterol can begin to crystallize. It is possible that defects in cholesterol processing in the liver lead to easier crystallization of the excreted material in the gallbladder. Excessive cholesterol excretion, even of normal cholesterol, can lead to easier nucleation of the crystals, since the cholesterol becomes saturated in relation to the total bile fluid. Gallstones are primarily comprised of cholesterol and calcium, as calcium bilirubinate or calcium palmitate. Depending on the precise composition, the stones may be soft (more cholesterol) or relatively hard (more calcium). There may be a large number of small sticky stones, or just one large hard stone, as well as many intermediate conditions, such as a few medium size firm stones (see Figure 3). The presence of stones may be accompanied by inflammation of the gallbladder wall (cholecystitis). Cholecystis may stimulate stones to form, or the stones may induce such inflammation, with each condition progressively worsening the other. Gallstones are usually diagnosed when they produce obvious symptoms. Since only about half of persons with gallstones experience significant symptoms, many people are unaware that they have a condition that could be diagnosed. Colicky pain is one of the symptoms of gallstones that often leads to a medical visit for diagnosis; it is due to gallbladder contractions, which may last for a few minutes to several hours, with pain usually located in the gallbladder region, though it may radiate to other areas of the abdomen or to the back. A fatty meal may trigger this type of painful reaction, which can be accompanied by bloating, nausea, or vomiting. If the bile duct becomes obstructed by a stone (see Figure 4), the person can experience jaundice as the bile backs up into the liver and into the blood, while the stool becomes whitish, being deprived of the coloring bilirubin. Jaundice is often accompanied by fever and nausea. In cases of cholecystitis, a steady dull pain may be experienced instead of sharp pain. Even so, the pain may become severe at times, and usually remains localized to the upper right abdomen; additionally, there may be fever and nausea. If the gallstones do not yield evident symptoms when they first form, the person may remain asymptomatic for many years. A relatively sudden appearance of symptoms is likely an indication that gallstones have recently formed or recently enlarged. Persons with long-term gallstone disorders are more likely to discover their disorder only if there is an ultrasound screening for other complaints. Even in the chronic asymptomatic cases, however, gallstone disorders will eventually cause symptoms in some individuals as the severity of the disease slowly progresses and causes more stagnation of the bile flow. The major threat of untreated or unsuccessfully treated gallstones is the possibility of a gallstone blocking the bile duct. This blockage can lead to pancreatitis, which potentially develops into a life threatening condition. Also, gallstones can lead to the development of cholangitis, an infection of the bile ducts within the liver; this condition can rapidly become fatal. Since bile duct blockage is associated with strong pain, the combination of pain and threat to health are usually sufficient reason for going ahead with emergency gallbladder surgery. Gallstones mainly occur in association with the combination of having a sedentary life style with a diet that is high in fat and low in fiber. While the process of stone formation may be slow, with stones forming over a period of years, gallstone formation can be accelerated in some circumstances. The two known situations that acutely increase the risk of gallstone formation and gallstone growth are: a substantial rapid weight loss (as occurs when obese persons follow a drastic weight control diet), and pregnancy (women who become pregnant several times are especially susceptible to stone formation). Hospital procedures, including major abdominal surgery, total parenteral nutrition (which is usually given in association with abdominal surgeries), and non-surgical gallstone treatments make a patient more likely to develop gallstones by contributing to bile stasis and/or gallbladder irritation. Finally, the use of cholesterollowering drugs, mainly the fibrates and the somatostatin analogue octreotide, are associated with increased incidence of gallstones. Women are more likely than men to develop gallstones, particularly after age 40. The most typical profile of a modern gallstone sufferer

is a woman in her 40s or 50s who has had two or more children, is obese, and has participated in weight loss programs to attain rapid weight loss. Practitioners of natural healing should be alerted to the fact that coffee is a stimulant to bile flow and that having patients suddenly cease coffee consumption due to the belief that coffee is harmful can increase the chances of gallstone formation and gallstone enlargement. This is particularly of concern for obese patients who adopt a dietary change that successfully reduces body weight. Additionally, recommending a diet that is too low in fat may cause further problems by reducing the bile flow.

MODERN CHINESE TREATMENTS FOR GALLSTONES Treatments aimed specifically at removal of gallstones with Chinese herbs were first described in the Chinese literature of the postrevolutionary period. A review of accomplishments in this field was published in the English language Journal of Traditional Chinese Medicine, in a 1986 article: Advances in the treatment of cholelithiasis by expulsion of the gallstones (2). Beginning in the 1950's, various gallstone expulsion decoctions (referred to as lithogogues) were devised by doctors working on this problem and these were proclaimed moderately successful. The decoctions mainly contained herbs from three therapeutic categories: regulating qi to improve the flow of bile and vitalizing blood to alleviate abdominal aching; dispelling heat and dampness that are the main physiological causes of the qi stagnation; and removing stagnation by purgation. The most frequently mentioned herbs in the various decoctions were: bupleurum, saussurea, chih-shih (or chih-ko), and melia for regulating qi; curcuma and corydalis for vitalizing blood; lysimachia, scute, gardenia, and capillaris for clearing damp heat; and rhubarb and mirabilitum for purgation. Sample decoctions are (9): lysimachia (100 grams), saussurea (15 grams), chih-shih (15 grams), scute (15 grams), melia (15 grams), rhubarb (10 grams) lysimachia (100 grams), saussurea (25 grams), chih-shih (25 grams), hu-chang (100 grams), rhubarb (25 grams), gardenia (20 grams), corydalis (25 grams). According to laboratory animal studies, these decoctions relaxed Oddi's sphincter (this is mainly attributed to the action of rhubarb) and promoted duodenal peristalsis (most strongly affected by mirabilitum). It is believed that the expulsion of stones came about primarily from increasing the flow of bile (herbs with this property are called cholegogues and this action is accomplished mainly by the herbs that clear damp-heat) while relaxing the sphincter that controls the output of bile, thus allowing stones to exist. This method of therapy relies on heavy dosage decoctions with quick action, usually taken over a period of just one week. Although most patients so treated would excrete some stones, the effectiveness of this method was somewhat limited in terms of the proportion of patients who could become either free of stones or have very few residual stones, so new methods were developed, mainly during the 1970's. The new methods involved a "general attack therapy" aimed at an even stronger and more rapid stone expulsion. The method had three steps: 1. Herbs were used to stimulate the liver's production and excretion of bile to the gallbladder; 2. Herbs and drugs were then given to contract Oddi's sphincter in order to get a temporary retention of bile; 3. Herbs and acupuncture were administered to relax the sphincter and drain the bile. The whole procedure lasts about 2 hours. The phase of retention of bile is carried out as long as the patient can tolerate it, which is usually about 40 minutes. The explanation of how this method works is that "with the bile rushing out in large quantities and the pressure in the bile ducts falling suddenly, stones in the latter are expelled in one fell swoop or in quick succession." This approach is carried out in the hospital and, with all diagnostics and any repeat treatments, takes only a few days, though patients may be hospitalized for longer in order to check for residual stone problems. It is claimed that this general attacking method of therapy gives a higher rate of success than the simple stone-expelling decoctions tried previously. The strong therapy, using heavy doses of mirabilitum (magnesium sulfate) and injection of herb extracts or drugs intramuscularly, is not something that could be used in the West. Indeed, in order to tolerate the retention of bile phase and the potentially painful expulsion of larger stones, continuous anesthesia was applied via an epidural catheter in some cases. As detailed accounting of one of the regimens was outlined in Pharmacology and Applications of Chinese Materia Medica (9): 8:30 Lithogogue decoction, 200 ml orally, is given. This stimulates bile secretion. 9:30 Morphine, 5 mg, is injected. This restricts Oddi's sphincter, builds up bile pressure, and relieves pain. 10:10 Amyl nitrite, 1 ampoule, is inhaled. This relaxes Oddi's sphincter to allow bile to flow out. 10:15 33% magnesium sulfate, 40 ml, is given orally. This induces rapid bile flow and duodenal emptying. 10:20 0.5% dilute HCl, 30 ml, is given orally. This further stimulates flow of bile. 10:25 Rich meal (2-3 fried eggs). This stimulates further dispensing of bile. 10:30 electroacupuncture for 30 minutes. This causes the gallbladder to contract and alleviates symptoms of stone passage. A similar method was reported in the Xinjiang Journal of Traditional Chinese Medicine (11). Patients with cholecystitis or cholelithiasis were hospitalized for an average of 34 days. They were treated daily with a lithogogue decoction containing bupleurum, capillaris, lysimachia, clematis, gardenia, curcuma, crataegus, chih-shih, and rhubarb. The general attacking method was then administered for four consecutive days using the procedure outlined above, except with a higher doses of magnesium sulfate (50 ml of 50% solution), and an additional injection of atropine. After waiting 3-5 days, the four-day course of therapy might be repeated if residual stones were detected. For chronic cholecystitis, a longer course of 10 days was utilized. Another example of the general attacking method involves using mirabilitum along with electroacupuncture stimulus at riyue (GB-

24) and qimen (LV-14; see Figure 5). The same treatment was recently tested again and claimed to be effective in expelling gallstones (3). The patients first took 30-40 ml (about one fluid ounce) of 33% solution of magnesium sulfate, and then strong electrostimulation was given to the acupuncture points on the right side only (that is, on the side where the gallbladder is located) for 30 minutes, followed by decreased stimulus for 15-20 minutes, and strong stimulation again for 10 minutes. This procedure was performed three days consecutively, once per day, to produce a full course of treatment that would expel stones. Using such vigorous stone-expelling methods, it was reported that stones somewhat over 1 cm in diameter could be excreted. The largest stones expelled are long but not too wide, with a maximum length of about 3 cm, but a width of no more than about 1 cm. When expelling large stones, it is common for the patients to experience what is called a "stone expulsion reaction," with biliary colic, and temporary fever and jaundice (the result of stones becoming temporarily caught in the duct). Rates of such reactions are as high as 90%. Silt-like stones, which are easy to pass because of their small size, are reportedly not excreted well because they tend to adhere to the wall of the gallbladder. In the West, one of the greatest fears associated with applying a stone-expelling therapy is the problem of billiary colic as the stone becomes stuck in the bile duct, especially at the sphincter. The pain can be extreme and may require an emergency visit to the hospital, with the usual recommendation at the hospital of immediate surgery to remove the gallbladder. By contrast, in China, the herbal procedure may be carried out at the hospital and measures are taken to alleviate the pain while continuing with the procedure. Based on the Chinese reports of the stone-expelling reactions, it appears that the rapid method of stone removal will not be acceptable in other countries. According to the information from this review of the medical literature through 1985, the largest stones that appear capable of being passed are on the order of one centimeter in diameter. This size is probably a reasonable upper limit for anyone considering a nonsurgical procedure and may represent the maximum dilation of the duct. The gentler stone-expelling methods to be used by Western practitioners who are not working in a hospital setting may not be able to expel stones of quite this size, since the strong build up of bile pressure and the sudden relaxation of the sphincter are unlikely to be accomplished. Therefore, somewhat smaller than 1 cm stones may be the largest one can expel and patients seeking to expel larger stones should be cautioned about the lower chance of success.

STONE SHRINKING WITH CHINESE HERBS One way to pass stones more easily is to first shrink them. The ability to reduce the size of stones using herbs or other methods is not an established fact. However, certain Chinese herbs have been selected as stone-dissolving herbs. There is one traditional-style formula that is reputed to dissolve stones, called San Jin Tang , or the Decoction of Three Golds. The three golds (jin = gold) are jinqiancao, haijinsha, and jineijin. The formula was devised at the Shuguang Hospital of the Shanghai College of Traditional Chinese Medicine. Jinqiancao (literally, golden coin weed) refers to a group of herbs that are used interchangeably, and are identified by the region of China in which the herb is found: Sichuan Da Jinqiancao also called guoluhuang, is from Lysimachia christinae (see Figure 6); Sichuan Xiao Jinqiancao is from Dichondra repens; Guang Jinqiancao is from Desmodium styracifolium (see Figure 7); Jiangxi Jinqiancao is from Hydrocotyle spithorpioides; Jiangsu Jinqiancao is from Glechoma hederaea (see Figure 8); and Kunming Jinqiancao is from Lysimachia kunmingcensis. The first two are from Sichuan Province, one being large leaved ( da) and the other being small leaved (xiao). The next is from the "guang" region of China, which includes Guangdong, Guangxi, and Hunan (formerly, Huguang); the next three are from Jiangxi Province (north of Guangdong), Jiangsu Province (on China's central east coast), and from the area of Kunming, the capital of Yunnan Province (in southwest China), respectively. In general, these herbs are said to be sweet, cooling, and able to promote urination. They are mainly used to treat damp-heat syndromes that involve urinary retention, and they are reputed to dispel urinary stones. The herbs are mild in nature and often used in high dosage (e.g., 15-60 grams of the dried herb per day in decoction, and double that dose for the fresh herb, with some recommendations of up to 250 grams fresh herb per day). San Jin Tang was originally made with Guang Jinqiancao (Desmodium). The species of jinqiancao obtained in the West will depend on the market source relied on by the herb supplier. Among the most commonly supplied items in the West are Desmodium and Glechoma; However, the widely-used common name for the herb is lysimachia and the most frequently referenced material in Chinese texts, as well as the species listed in the Pharmacopoeia of the PRC, is Lysimachia christinae. Haijinsha is a very slippery material, that looks like yellowish sea sand (hai = sea, jin = gold, sha = sand); it is the spores of a fern, Lygodium japonicum, commonly called lygodium (see Figure 9). The slippery quality is associated with the ability to dissolve stones. The material is described as sweet and cold in nature, and it is diuretic. Like jinqiancao, this herb is mainly used for damp-heat syndromes with urinary retention and it is said to help remove urinary stones. The usual daily dosage is 6-12 grams in decoction, or 2-3 grams in powder form. Jineijin is the inner lining of the gizzard of the chicken (ji = chicken; nei = inside), commonly called gallus (the genus name of the chicken). The chicken gizzard is capable of reducing hard food masses to small pieces; it is included in some herb formulas because it is thought to resolve masses. The material has a sweet taste, a neutral property, and is used mainly to eliminate food stagnation. The usual dosage is 6-12 grams and it may be used in decoction or a smaller amount, 1.5 to 3 grams, taken as a powder. The entire Three Golds Formula includes three additional herbs for damp-heat that affects the kidney and bladder, thus making it a treatment for urinary stones in persons with damp-heat syndrome and urinary retention. The three herbs are pyrrosia (shiwei), abutilon (dongkuizi), and dianthus (qumai) and this combination is derived from Shiwei San, a traditional formula for blocked urinary flow that

contains those three herbs plus plantago and talc. A variant of the Three Golds Formula retains the talc and plantago seed of Shiwei San but replaces dianthus with achyranthes (or cyathula), vaccaria, magnolia bark, and chih-shih. The three golds may be added to any traditional formula for urinary blockage when stones are diagnosed. A typical recommendation is to add 30 grams lysimachia, 9 grams of lygodium, and 9 grams of gallus (15). The original urinary stone formula can be adjusted to treat gallstones by replacing the three herbs for damp-heat of the kidney/bladder with herbs for damp-heat of the liver/gallbladder. The herbs suitable for this purpose generally have a bitter taste, a cold property, and a dispersing or purging action; for example, one can administer bupleurum, scute, capillaris, and rhubarb. One can also add to the therapy herbs to disperse liver-qi stagnation and accumulation, such as saussurea, magnolia bark, chih-shih, and areca peel. Urinary stones are generally comprised of uric acid, calcium oxalate, and calcium phosphate and their formation may be related to processes similar to those involved in forming gallstones, namely low fluid flow through the renal tubules. Low water consumption, with corresponding low urinary excretion, is a major risk factor for kidney stones (high levels of dietary oxalate and high levels of acidic components in foods and beverages can also contribute to urinary stone formation). It is reasonable to question whether herb components that help to dissolve and pass urinary stones would also effectively dissolve and pass gallstones, given the differences in stone composition. Jinqiancao, one of the three golds, has been incorporated into numerous modern Chinese therapies for both liver and gallbladder diseases, including most formulas for treating gallstones and cholecystitis. In the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (8), lysimachia is said to be useful for stone expulsion, including gallstones: "For its effects in expelling stones, this drug is frequently used to treat hepatic, cholecystic, and urinary stones. To achieve the desired results, it is usually used in large dosage and administered for a long time." The same text mentions that jineijin "removes stones and is indicated for urinary calculus and biliary calculus." On the other hand, haijinsha is only mentioned in that text as a treatment for urinary stones. Whether or not jinqiancao actually dissolves stones, it is known to stimulate bile secretion; further, haijinsha has been used clinically in some formulas for treating gallstones (9) and was mentioned as one of the more commonly used herbs for that purpose in a recent review article examining 40 different gallstone formulas (12). There are two main uses for a stone-dissolving formula: one is to attempt to shrink stones prior to expelling them, by reducing the outer layer that has recently been deposited and is most susceptible to re-suspension into the bile fluid, and the other is to prevent stones from forming or enlarging in persons who have a history of developing stones. The stone dissolving therapies are given for at least 2-3 months.

STONE EXPULSION WITH CHINESE HERBS The herbs used in the strong stone expelling decoctions, as described earlier, have been formulated into easy to use tableted patent formulas that are given at much lower dosage. For example, Lidan Pian (Gallbladder Normalizing Tablets) and Lidan Paishi Pian (pai = expel; shi = stones) are readily available patent remedies recommended for cholecystitis and cholelithiasis. These tablets have a milder action than the corresponding decoctions and may be used in a complete program of gallstone therapy for treating smaller sized stones or mild gallbladder inflammation. Lidan Pian contains lysimachia, scute, saussurea, capillaris, bupleurum, isatis leaf, lonicera, and rhubarb. Isatis leaf and lonicera are included as anti-infection herbs for cholecystitis. Lidan Paishi Pian contains lysimachia, saussurea, capillaris, rhubarb, areca peel, magnolia bark, chih-shih, curcuma, and mirabilitum. The amount of mirabilitum present is relatively small and does not cause a strong purgative effect. The latter formula is based on the traditional Da Chengqi Tang (Major Rhubarb Combination) of the Shanghan Lun, comprised of rhubarb, mirabilitum, magnolia bark, and chih-shih, which had been formulated as a purgative therapy for severe abdominal stagnation. This formula's action has been extensively investigated (see Appendix 1). The modification to make Lidan Paishi addresses stagnation of qi and blood in the abdomen. A decoction of the Lidan Paishi formula was tested in patients who were monitored for gallbladder function (4). The treatment, using 10 grams of each ingredient, increased the frequency of bile excretion and did so to an extent greater than that accomplished by Da Chengqi Tang , indicating a valuable contribution for the added herbs. Lidan Paishi Tablets are produced by several Chinese companies. One company lists the following ingredients, with proportions used in manufacturing: lysimachia (250 grams), capillaris (250 grams), scute (75 grams), saussurea (75 grams), curcuma (75 grams), and rhubarb (125 grams); this formula listing leaves out areca peel, magnolia bark, chih-shih, and mirabilitum. Treatment time with stone expelling formulas is usually several months, though excretion of gallstones may begin to occur within days. In one clinical report (14), a formula called Dandao Paishi Tang (dan = bile or gallbladder; dao = movement) was administered twice daily. The formula included lysimachia, chih-ko, saussurea, scute, lonicera, gardenia, peony, red peony, atractylodes, gallus, rhubarb, and glauber's salt (xuangmingfen; sodium sulfate); in addition, mirabilitum was given separately, 40 ml each time, twice daily, at 33% solution. Treatment time ranged from one month to 10 months (a few cases continued for longer). A formula called Paishi Tang (Stone Expulsion Decoction) was reported to be moderately effective for treating residual stones in the biliary tract after gallbladder surgery (13). The decoction contains lysimachia, capillaris, bupleurum, cyperus, melia, chih-ko, saussurea, citrus, and rhubarb (mirabilitum was given separately, 30-40 ml of 50% solution, once or twice daily). Complete removal of stones was claimed for just over half of the patients treated.

PROPOSAL FOR COMPREHENSIVE GALLSTONE THERAPY A patient presenting with gallstone reduction or elimination as the objective of treatment should be provided with a substantial number of therapeutic approaches to be used in combination. These include: 1. A diet and exercise program that emphasizes a low fat, high fiber diet and regular daily exercise. For obese patients, a carefully monitored diet with appropriate caloric controls should have a goal of gradual weight loss of not more than 2 pounds per week on average. A digestive enzyme preparation that includes ox bile and lipase may be used to help treat symptoms of poor fat digestion. 2. A regular meal schedule that encourages the gallbladder to fill completely between meals. This means minimizing snacking

(which is an approach contrary to some dietary recommendations for managing eating disorders and some other health problems). 3. Daily consumption of stone dissolving substances, including the "three golds" and, if possible, bile salts. 4. Consumption of moderate amounts of coffee (with or without caffeine) and/or other herbs that promote bile flow (mainly herbs that treat qi stagnation and damp-heat). 5. Acupuncture therapy to regulate circulation of qi, purge the gallbladder, and alleviate pain in the gallbladder region (see Appendix 2). 6. A gallstone purging therapy to eliminate stones that have a diameter of less than 1 cm, to be taken over a period of several days. This therapy would include rhubarb and mirabilitum. The dietary program is no different than that widely recommended for maintaining health and normal body weight, such as following the U.S.D.A. food pyramid recommendations or the modified food pyramid for a high flavonoid diet (see: The role of dietary and herbal flavonoids in gastro-intestinal health). The exercise program is also no different than that generally recommended, which involves a daily minimum of 20-30 minutes of moderate exercise (e.g., fast walking), with more vigorous exercise for those who are physically capable. The dosage of stone-dissolving substances should be relatively high, corresponding to about 50-60 grams per day in decoction, or about 10-12 grams per day in dried extract form. As with the treatment using bile salts, stone-dissolving therapies may require as much as six months continual treatment. The gallstone flushing therapy, relying on purgative herbs, may be accompanied by a high fat meal to stimulate gallbladder emptying (some Western practitioners use the so-called "liver flush" which is actually a gallbladder purge, comprised of a large dose of olive oil moderated by lemon juice).

REFERENCES 1. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 2. He Ruilin, Advances in the treatment of cholelithiasis by expulsion of the gallstones, Journal of Traditional Chinese Medicine 1986. 3. Lu Longzhang, 26 patients with cholelithiasis treated by acupuncture therapy, Chinese Acupuncture and Moxibustion 1996; (2): 8. 4. Deng Xuejia, et al., Video-choangiographic study of the effect of Li Dan Pai Shi Tang on biliary dynamics in 130 cases, Chinese Journal of Integrated Traditional and Western Medicine 1985; 6(5): 338-339. 5. Jiang Tingliang and Fu Hangyu, Progress of experimental studies on prescriptions designed by Zhang Zhongjing, Journal of Traditional Chinese Medicine 1996; 16(1): 55-64. 6. Jiang Yongsheng and Chen Yehua, Treatment of biliary colic by water injection in the region of qimen, riyue, and juque points, Journal of Traditional Chinese Medicine 1995; 15(3): 185-188. 7. Wang Tianjun and Xiao Shaoqing, Auricular acupoint pellet pressure therapy in the treatment of cholelithiasis, Journal of Traditional Chinese Medicine 1990; 10(2): 126-131. 8. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, 1995-6 New World Press, Beijing. 9. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, 1986 World Scientific, Singapore. 10. Cheung CS and Belluomini J (translators), The liver and gallbladder, Journal of the American College of Traditional Chinese Medicine 1983; (2): 30-44. 11. Zhang Xiangde and Ma Zonglin, Treatment of 127 cases of chronic cholecystitis and cholecystolithiasis mainly by traditional Chinese medicine, Xinjiang Journal of Traditional Chinese Medicine 1985; (4): 25-28. 12. Pan Tianfu, A review of treatment of cholelithiasis, Journal of the Shandong College of Traditional Chinese Medicine 1994; 198(3): 203-208. 13. Zhang Shiguo, Treatment of post-operational biliary tract residual cholelithiasis by integrated Chinese and Western medicine, Sichuan Journal of Traditional Chinese Medicine 1986; 4(1): 32-33. 14. Chen Ying, Treatment of 67 cases of choelithiasis by integrated Chinese and Western medicine, Chinese Traditional Patent Medicine 1989; 11(10): 24-25. 15. Yan Wu and Fischer W, Practical Therapeutics of Traditional Chinese Medicine, 1997 Paradigm Publications, Brookline, MA. August 2001

APPENDIX 1: Da Chengqi Tang In the Shanghan Lun, three formulas named Chengqi Tang were presented: Da Chengqi Tang , Xiao Chengqi Tang, and Tiaowei Chengqi Tang. All three are purgative preparations with rhubarb as the common ingredient. Tiaowei Chengqi Tang includes mirabilitum and licorice, while Xiao Chengqi Tang includes chih-shih and magnolia bark. Da Chengqi Tang includes all the ingredients except licorice. These formulas have been studied as part of a larger and ongoing evaluation of Shanghan Lun formulas (5). All the prescriptions stimulate intestinal peristalsis, with Da Chengqi Tang having the strongest action. Rhubarb acts as a secretory purgative that stimulates the large intestine; it produces a delayed laxative action and cannot soften hard stool; mirabilitum acts as an osmotic purgative, affecting mainly the small intestine. By combining mirabilitum with rhubarb, the laxative action is quicker (due to the effect of mirabilitum on the small intestine) and the moisture retaining effect of magnesium softens the stool. In Western studies of gallbladder function, mirabilitum is known as a useful agent to induce bile flow and to purge the duodenum. Magnolia bark and chih-shih act mainly on the large intestine and have a milder effect than rhubarb and mirabilitum; magnolia bark and chih-shih also serve to dispel gas and

bloating. When rhubarb and licorice are cooked together, as in Tiaowei Chengqi Tang , there is a reduced laxative effect, due to binding of licorice ingredients with anthraquinones, the main laxative component of rhubarb. But, without the mirabilitum, the laxative effect is more limited, so that Xiao Chengqi Tang has the mildest laxative action of the three Chengqi formulas.

APPENDIX 2: Acupuncture for Gallstones It is unclear whether acupuncture, by itself, can cause expulsion of gallstones, but acupuncture is used to treat symptoms of gallstones, such as billiary colic. The two acupuncture points mentioned in this article, qimen (LV-14) and riyue (GB-24), are the main ones mentioned in the literature. These points lie over the liver on the right side, and are located one rib apart and directly below the nipple. Only the right side is treated. An extensive analysis of the value of these points was presented in an article on treatment of biliary colic (6), along with brief mention of the nearby point juque (CV-14). In the discussion of their treatment, the authors stated: The theory of acupuncture and moxibustion of Zhang Zhongjing [author of Shanghan Lun] is an important component part of his academic thinking, of which the frequent use of qimen point is quite characteristic. The indications of qimen point include fullness of abdomen, delirium, fullness of the chest and flanks, distention of gastric region resistant to pressure, and fever or alternative spells of fever and chills, which are similar to the clinical manifestations during a bout of biliary colic.... We found that the most sensitive and tender point of qimen [among our patients with biliary colic] is in the area defined by the lines connecting qimen, riyue, and juque points, which, according to traditional Chinese medicine, is the dividing line between the liver and the gallbladder, and is indicated mainly for treating diseases of the internal organs in the vicinity. Qimen is the mu point [alarm point] of the liver, riyue is the mu point of the gallbladder, and juque is the mu point of the heart. The front mu points are used mainly in the treatment of diseases of the internal organs. Various painful lesions are the result of failure of the heart and liver to remove stagnancy of vital energy, leading to impediment to the flow of qi of the gallbladder, thus producing the pain. Basing on the principle of treating pain by needling the location where pain exists, the most marked tender spot was detected in the region of the three points.... Other points frequently mentioned in the literature for treating gallstones include the lower leg points yanglingquan (GB-34), qiuxu (GB-40), and zusanli (ST-36); in addition, there is an extra point known as the gallbladder point (dannangxue), just below GB-34 (about 1-2 cun lower). The nausea and pain associated with cholecystitis and with billiary blockage is treated at neiguan (PC-6) and zhigou (TB-6), above the wrist. In explaining the use of these points, the Advanced Textbook of Traditional Chinese Medicine and Pharmacology states: Qimen and riyue are the front mu points of the liver and gallbladder meridians respectively; zhigou and yanglingquan can relieve hypochondriac pain, while zusanli helps strengthen the spleen and disperse dampness-heat. Ear acupuncture developed a reputation for being a method for expelling gallstones during the 1980s (7). It was reported to be especially effective for the damp-heat type and less so for the qi-stagnation types of patients, but not effective for those with qi deficiency. Over 60 auricular points have been used in the treatment of gallstones, making it difficult to pick out points that might be particularly effective. Not surprisingly, the most commonly used points were those associated with the liver, gallbladder, bile duct, pancreas, duodenum, stomach, spleen, and small intestine. A course of treatment would be thirty days with pressure applied to the point using various kinds of pellets, especially vaccaria seeds (which have a sharp point and may be substituted by the small "ear tacks"). Pressure would be applied for 20-30 minutes after meals (about 15 minutes after eating). Despite the high efficacy of the therapy in alleviating symptoms, the number of cases reported to have complete elimination of stones was usually only about 10%, sometimes as high as 20%. During treatment, stone expulsion would yield a sensation of distention or pain in the region of the gallbladder. Unfortunately, it was found that in patients who had only a portion of the stones expelled, new stones appeared very rapidly, sometimes leading to a worsened condition after treatment. One researcher, Shang Cenruo of the Nanjing College of TCM, cautioned that a higher efficacy of ear acupuncture for stone expulsion should be attained before recommending wide spread use of the technique. Other researchers noted superior effects when ear acupuncture was combined with herbal therapy. In an extensive review of the experiences and opinions expressed by several researchers in this field (8), the editor concluded that: In some reports, the therapeutic efficacy was overestimated or overstated. As far as I know, besides exaggeration, the most important reason for this was that evaluation was not made on a scientific basis....Obviously, it is not sufficient to evaluate the therapeutic effects merely on the basis of presence or absence of subjective symptoms and the amount of gallstones expelled with the stools. At present, auriculo-point seed pressing therapy may be used to expel gallstones, but the evacuation rate is still very low. This remains to be further improved. The therapeutic efficacy [among the results reported by several researchers] was basically the same with different prescriptions of otopoints: part of the gallstones could eventually be expelled from every patient. Local inflammation and clinical symptoms were accordingly alleviated or disappeared with a decrease in the amount of gallstones in the biliary tract. In some patients, the duration of colicky attacks became shorter, and the time interval between two attacks became longer. This is the main reason why this therapy has won the patient's confidence.... I propose that in order to further enhance the therapeutic efficacy of this therapy, the following measures be adopted: Some research centers or cooperation groups headed by a department concerned [with this special topic] should be established; Clinical practice must be combined with experimental research so that the mechanisms of evacuation of gallstones can be clarified, and the most effective methods and otopoints be detected through the latter which, in turn, guide clinical practice; and, Since it is quite difficult to enhance the therapeutic effects by merely using the auriculo-point seed pressing method for treating cholelithiasis, it can only be taken as the main method in a combined therapy.

Figure 1: The gallbladder and biliary ducts.

Figure 2: cholic acid and desoxycholic acid.

Figure 3: Assorted gallstones.

Figure 4: Stones depicted in the gallbladder and biliary duct.

Figure 5: The acupoints riyue (GB-24) and qimen (LV-14).

Figure 6: Lysimachia christinae.

Figure 7: Desmodium styracifolium.

Figure 8: Glechoma hederaea.

Figure 9: Lygodium japonicum.

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THE TREATMENT OF GASTRO-INTESTINAL CANCERS WITH CHINESE MEDICINE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Cancers affecting the digestive tract, including oral, esophageal, stomach, and intestinal tumors, are among the most common of all the cancers associated with aging. These cancers occur mainly after age 50, and their incidence rates increase with age. About one of every fourteen men and women in America will be diagnosed with a gastro-intestinal cancer at some time in their lives, with over 180,000 receiving that diagnosis each year. Genetic propensity to experience certain cancers has been noted: familial history of the disease has been deemed a risk factor and at least one gene has been identified as being associated with the development of colon cancer. Direct causative factors have also been identified: mainly the substances that are ingested. High fat and low fiber diets have been implicated in intestinal cancers: byproducts from metabolism of fats that reach the intestines may be the culprit. The slow transit rate of low-fiber fecal material encourages prolonged exposure of the intestinal cells to the fermenting components. Oral and esophageal cancers have been associated with use of tobacco products as well as certain herbal materials taken as teas. Stomach cancer has been associated with ingestion of food that was improperly stored, thus being contaminated with bacteria and fungi and byproducts of their metabolism. Aging involves a longer duration of exposure to cancer inducers and the loss of cancer-inhibiting capabilities, including reduction in immune system responsiveness. Chronic inflammatory diseases, such as ulcerative colitis, increase the risk of cancer, probably by increasing the rate of DNA activation of the affected cells. Preventive methods, such as dietary changes, stopping use of tobacco products, treating inflammatory diseases effectively, and taking nutritional supplements that aid immune functions, are certainly applicable to these cancers. Still, many people do not pursue these methods and cancer remains a serious health problem. Therefore, treatment of the disease remains an important subject. Modern Western medicine treats gastro-intestinal cancers primarily with the combination of surgery and chemotherapy. If the borders are clearly defined, tumor masses can be excised, and chemotherapy would then be used to treat any remaining cells; if surgery can't be performed, chemotherapy may be the sole remedy. Radiation therapy is utilized when it is believed that the tumor cells are limited to a narrow region without much intervening tissue between the radiation source and the target cells, most often when the tumor is in the head or throat. Because of the high death rate associated with gastro-intestinal cancers (even with treatment 5-year survival rate with stomach cancer is 17% and with colorectal cancer is 78%) and because of the serious side effects of chemotherapy and radiation therapy, many cancer patients seek out alternative and/or complementary methods of treatment. Several of these methods are widely promoted though poorly evaluated. Reviews of some of the methods have been publicized, as in Michael Lerner's book Choices in Healing. Chinese medicine is favorably mentioned there, as well as in other sources, mainly because of its reputation as a complementary rather than alternative approach. It is often used to reduce the side effects of standard Western methods while enhancing the overall outcomes.

CHINESE METHODS OF TREATMENT In modern China, there are two basic methods of treatment that have been explored. One is to rely on herbal combinations as the main therapeutic method, as this has been the only available treatment until recently. The other is to rely on modern Western medicine and to integrate it with herbal medicine in an attempt to increase the survival rates and improve quality of life. The latter has become the dominant method utilized during the past decade in China; however, herb-only treatments are still used in cases where Western medical interventions are deemed unlikely to have any significant clinical benefits. Within the Chinese herbal methodology there are four approaches that will be explored here: 1. Using "anticancer" herbs. These are materials that have a reputation (usually derived from folk medicine practices) for inhibiting tumors; their effects have been confirmed by laboratory animal experiments and, in a few instances, by clinical trials. Because Chinese medical treatment of cancer usually involves a combination of several approaches, rather than use of a single therapeutic agent, clinical trials of individual herbs or isolated herbal constituents as the primary therapeutic method are limited to a few highly effective materials, usually developed as drug products and not available in the West. The anticancer crude herbs have a role similar to that of modern chemotherapy, and, in a few cases, Chinese anticancer folk remedies have been used as a source of new chemotherapy drugs (examples are indirubin, harringtonine, and camptothecine used for leukemia). 2. Using immune-boosting therapies. The herbs are used to counteract side effects of Western medical therapies and also help the immune system attack the cancer. The herbs listed as qi tonics are the primary ones involved in this method, though there are other tonic herbs that have similar benefits. This method of therapy is called "Fu Zheng" therapy, meaning "to support normality." 3. Using blood-vitalizing herbs. These herbal materials are reputed to enhance the effectiveness of Western cancer therapies and also assist the body in responding to the cancer via its normal immunological mechanisms. From the traditional viewpoint, cancers, especially those in the abdomen and any that are physically hard (as opposed to, for example, soft lipomas), involve blood stasis, a condition treated by these herbs. 4. Using phlegm-resolving herbs. This is a strategy based on ancient Chinese ideas about abnormal masses. There is laboratory and clinical evidence that this approach is effective. The traditional concept involves the idea that the tumor mass starts out as an accumulation of "tan," which is translated as phlegm. This division into four categories is based on the theoretical framework that has evolved in China over many centuries (with

This division into four categories is based on the theoretical framework that has evolved in China over many centuries (with concerns about side effects of drugs entering during the past few decades). In the book An Illustrated Guide to Antineoplastic Chinese Herbal Medicine (1), the herbs are divided into these four categories plus three others: herbs for eliminating dampness, miscellaneous herbs, and herbs for topical applications. However, the herbs for eliminating dampness appear to be coincidental: that is, these are herbs that have some antineoplastic properties and happen to fall into the very large class of herbs for regulating moisture. The herbs listed for external use are actually used internally, but are considered so toxic that they are classified as being limited to topical applications. In the book Cancer Treatment with Fu Zheng Pei Ben Principle (2), a chapter on "common principles for treatment with traditional Chinese medicine" has these four subdivisions: supporting vital energy and strengthening body resistance (these are mainly the qi tonics); activating blood and relief of blood stasis; antipyresis and antitoxin (these are the traditional functions assigned to most of the "anticancer" herbs"); and softening hard lumps and dispelling nodes (this is mainly the "phlegm-resolving" method). Many times there is overlap of herbal actions among the herbs that have been separated into the various categories; for example, herbs that directly inhibit cancer cells may also act via the immune system and might also have blood-vitalizing properties. One of the best English language reviews on the individual anticancer herbs is the 1992 publication Anticancer Medicinal Herbs (3). This book does not separate the more than 200 herbs by category of action, but rather combines all into a lengthy presentation. This book was relied upon as the primary resource for the information about cancer-inhibiting actions of herbs in the tables of the current article.

TESTING FOR ANTICANCER ACTIVITY Human clinical trials are so complex (especially when using combination treatments and herbal prescriptions that may fluctuate according to the patient's needs) that confirmation of effectiveness of the herbs is usually carried out in the testing of animals or in cell culture tests. Certain cancer cell lines have been developed for purposes of the laboratory testing. Among the most commonly investigated in China are sarcoma-180 and sarcoma-37, JTC-26, leukemia-16, Ehrlich's ascites, and cervical cancer-14. Typical animal testing methods are to transplant the cultured cancer cells into the animals (usually mice, rats, or guinea pigs), and to administer the test compound to some of the animals, but not in others (control group). In the control group, the tumor cells will usually continuously grow, and will eventually cause death. In the treated group, the successful compounds will limit the size of the tumors. After a certain period of time, the tumor size (or other measure of cancer activity) will be compared and an inhibition rate will be determined; survival time or percent of animals surviving a prolonged period may also be used as a measurement. Successful compounds usually inhibit the tumor growth by at least 20%; some herbs or herbal constituents are reported to reach over 95% inhibition, and, in such cases, the animal longterm survival rates are often over 90%. The effectiveness (inhibition rate) of an herb will often vary from one cancer line to the next. One can also apply extracts of the herbs to cells in culture and determine rates of inhibition. When this in vitro approach is used, one eliminates the role of the immune system, circulatory system, and other complex biological systems and instead determines the direct inhibitory effect of the herbs on the cancerous cells. For controls, one can not only compare to cancer cells untreated by the herbs, but one can also set up a comparison of non-cancer cells to see if the herbs also inhibit those. A potentially useful anticancer agent will strongly inhibit the cancer cells but not the non-cancer cells; otherwise, the side effects of the substance would likely be severe.

ANTICANCER HERBS Anticancer herbs are those that usually have use in treating unexplained swellings, infections, and other syndromes that are thought to reflect a localized pathological process. In the early development of traditional Chinese medicine, these swellings were said to be due to the presence of "du," or toxin. The swelling induced by snakebite (or poisonous insect bite), an abscess induced by bacteria, or a tumor could all produce similar symptoms, which we can now differentiate by detailed examination through modern technologies. Many of the herbs used to treat these conditions are classified as having the property of clearing heat and cleansing toxin. This property most closely matches the description of treating an infection or inflammation (especially if it causes localized heat or a fever) rather than a tumor. It has been noted, in laboratory experiments, that many herbs with potent antibacterial and anti-inflammatory properties also inhibit cancer cells. There are several dozen herbs in this category. Table 1 presents some examples of the herbs that are commonly used for intestinal cancers. These are also used for other types of cancer. TABLE 1: Anticancer Herbs, with Focus on Those Used in Treatment of Intestinal Cancers. Common Name

Latin Binomials

Pinyin

Actions

Agrimony

Agrimonia pilosa

xianhecao

Inhibits sarcoma-180 of mice and guinea pig, and strong JTC-26 inhibition in vitro. Used for treating a variety of cancers by combining with solanum or with curcuma and pteropus.

Ailanthus

Ailanthus altissima

fengyencao

Inhibits sarcoma-180, sarcoma-37, and leukemia-16 in mice.

Akebia fruit

Akebia quinata

bayuezha

Inhibits sarcoma-180 and sarcoma-37 in rats; inhibits JTC-26 by more than 50%. Used for stomach cancer in combination with oldenlandia, scutellaria, and wasp nest.

Coix

Coix lachryma-jobi

yiyiren

Inhibits ascites cancer, Yoshida's sarcoma.

Dryopteris

Dryopteris crassirhizoma

tongbeiguan-chong

not available

Hu-chang

Polygonum cuspidatum

Huzhang

Inhibits sarcoma-180 in rats; inhibits JTC-26.

Lonicera (flower) and Lonicera stem

Lonicera japonica

jinyinhua and jentongteng

Inhibits ascites carcinoma and sarcoma-180.

Oldenlandia

Oldenlandia diffusa; also called Hedyotis diffusa

baihuasheshecao

Inhibits leukemia cells, Yoshida's sarcoma, and Ehrlich's ascites sarcoma in vitro; also inhibits sarcoma-180, ascitic lymphosarcoma, and uterine cancer-14 in mice. Used to treat stomach and rectal cancer by combining with coix and solanum.

Patrinia

Patrinia scabiosaefolia and Patrinia heterophylla

baijiancao

Inhibits JTC-26 and ascites cancer in mice; is used in treatment of esophageal cancer with paris.

Pteris

Pteris multifida

fengweicao

Inhibits sarcoma-180, sarcoma-37, and Walker's cancer-256; inhibition rate on Yoshida's sarcoma is nearly 50%. Used in combination with smilax to treat colon cancer.

Sargentodoxa

Sargentodoxa cuneata hongteng

not available

Scutellaria

Scutellaria barbata

banzhilian

Strongly inhibits JTC-26; inhibits sarcoma-180, Ehrlich's ascites carcinoma and cerbroma-B22 in rats. Frequently combined with oldenlandia for cancer treatment.

Smilax

Smilax glabra and Smilax chinensis

tufuling

Inhibits mice sarcoma-180 and encephalomabeta-22; inhibits JTC-26 in vitro; prolongs survival in patients with ascites sarcoma.

Solanum

Solanum nigrum and Solanum lyrati

loingkue and shuyangquan

Inhibits Ehrlich's ascites carcinoma, lymphatic leukemia-615, sarcoma-180, sarcoma-37, and stomach cancer cells. Its anticancer properties are said to be enhanced by combining with agrimony. Often, the two species of solanum are combined together.

Sophora and Sophora subprostrata

Sophora flavescens and Sophora subprostrata

kushen and shandougen

The alkaloids of these herbs prolong the life of mice with sarcoma-180; they inhibit leukemic cells, and cervical cancer-14 cells. The alkaloid oxymatrine is 7-8 times more effective clinically than mitomycin.

Taraxacum

Taraxacum mongolicum

pugongying

Inhibits sarcoma-180 and ascites cancer in mice; inhibits transplanted human lung cancer cells. Often combined with lonicera.

Wasp nest

Nidus vespae

lufengfang

Inhibits gastric and liver cancer cells in vitro.

USING QI TONICS Modern studies reveal that qi tonic herbs enhance immune functions (as well as having other benefits). This immunological activation can inhibit tumor growth and restore those immune functions impaired by chemotherapy, radiation, or stress reactions (including stress from surgery). Virtually all the qi tonics have the ability to enhance production of white blood cells and enhance immune attack against cancer cells. Further, most have a direct inhibitory effect on certain cancers. The use of qi tonics in cancer therapy arises both from traditional approach and from modern experimentation. From the traditional view, both the systemic and local abnormalities that develop with cancer are thought to be due to weakness and pathology of the qi. Thus, treatment is based on tonifying the qi and clearing the pathological qi (known as xie qi; the "anticancer herbs" help to get rid of xie qi, and the strong normal qi also rids the body of it). During the 1960's, as modern Western cancer therapies were introduced to China, it became clear that side effects of the drugs (and radiation) were impeding the ability of doctors to optimally treat patients. Therefore, a group of physicians and researchers was organized to find ways to counter the side effects. This group developed the method of "Fu Zheng" therapy, which has been relied upon ever since (4). The complete name for the therapy is usually Fu Zheng Qu Xie (support the normal, dispel the evil) or Fu Zheng Pei Ben (or Fu Zheng Gu Ben; support the normal and strengthen the root). Two of the herbs initially found to be very helpful for this type of therapy were astragalus and ligustrum; this information was made available to the Western world in 1983 at an international symposium in Beijing, sponsored by American and Chinese organizations. Astragalus is one of the main qi tonics relied upon by traditional and modern Chinese doctors. Ligustrum is also a tonic herb, but is in the category of yin tonics. It has been found that many of the drug side effects correspond to damage to the "yin essence." However, qi tonics appear to be the most important in the tonic group for the treatment of cancer. According to traditional doctors, tonifying the qi can benefit the yin essence, especially if one pursues a nutritious diet. A book devoted to this method of therapy was recently published in English: Treatment of Cancer with Fu Zheng Pei Ben Principle by Pan Mingji (2). TABLE 2. Qi Tonic Herbs Commonly Used in the Treatment of Cancer. Common Name Astragalus

Latin Binomials Astragalus membranaceous

Pinyin haungqi

Actions Inhibits sarcoma-180 in mice, probably via immune stimulation.

Atractylodes

Atractylodes macrocephala

baizhu

Inhibits sarcoma-180 in mice.

Codonopsis

Codonopsis pilosula

dangshen

Inhibits transplanted sarcoma-180 in mice.

Coriolus

Coriolus versicolor

yunzhi

The polysaccharide fraction inhibits many tumor types in animals and has been used with success in human clinical trials, improving survival rates at 3-6 grams/day.

Eleuthero Ginseng

Eleutherococcus senticosus and Acanthopanax spp.

ciwujia and wujiapi

Inhibits Ehrlich's ascites carcinoma and sarcoma-180 in rats; 90% inhibition on JTC-26.

Ganoderma

Ganoderma lucidum or Ganoderma japonica

lingzhi

Strongly inhibits sarcoma-180 in mice.

Ginseng

Panax ginseng

renshen

Inhibits Ehrlich's ascites carcinoma in rats; inhibits sarcoma-180 and adenocarcinoma-755 in mice; inhibits leukemia in guinea pigs; complete inhibition in vitro of human uterine cervix cancer cell-26; action is enhanced by combining with ganoderma and astragalus.

Gynostemma

Gynostemma pentaphyllum

jaiogulan

It is used extensively as a substitute for ginseng in treatment of cancer patients.

Jujube

Zizyphus jujuba

dazao

90% inhibition rate of JTC-26; inhibition of cancer shown to be dose dependent.

Licorice

Glycyrrhiza uralensis

gancao

Inhibits myeloma implanted in rats; inhibits Ehrlich's ascites carcinoma and sarcoma-180 in rats; inhibits JTC-26 and Yoshida's sarcoma.

BLOOD-VITALIZING HERBS Cancer may be induced by many factors, but stagnation of circulation is considered by many Chinese physicians to be a dominant immediate cause. As described by Pan Mingji (2), "Disharmony of qi and blood occurs when either one of them is defective. Stagnation of qi can lead to stasis of blood. Prolonged stagnation of qi and blood will inevitably lead to occurrence of a tumor." Along similar lines, cancer specialist Jia Kun says (5): The extremity of the seven modes of emotion may disturb the normal circulation of blood and qi and the function of the viscera...Stagnation damages [the] spleen and in turn makes the muscles weak. When weak muscles meet and combat the exogenous pathogenic factors [e.g., toxins: du, or pathological qi: xie qi], a tumor is formed...Persistent stasis of qi finally leads to blood stasis, which accumulates and forms a lump or lumps. Researchers in China have noted that individuals with cancer have abnormal blood conditions which manifest as higher blood viscosity and poorer circulation of blood through small vessels. There are about 140 Chinese herbs that are considered to have the property of activating blood circulation and removing stasis. About three dozen of these herbs are used extensively. One of the most intensively investigated herbs for activating blood circulation is salvia. It is said to be both a blood tonic and mild activator that has essentially the same properties as the famous traditional prescription Tang-kuei Four Combination (Si Wu Tang). There have been many developments in this field during the past few decades. Dr. Pan Mingji (2) mentions the following findings: 1. About 90% of cancer patients have abnormal microcirculation patterns. 2. Most cancer patients have high fibrinogen levels in the blood and higher than normal coagulability of blood. 3. Tumors are often surrounded by a fibrin coating that prevents immune cells from entering. 4. Tumors often have poorly developed circulation and thus the cells survive with low oxygen; such cells are less susceptible to the effects of radiation than those cells which have adequate levels of oxygen. 5. For metastatic cancer cells to attach to tissues, so as to develop a new tumor mass, they require the assistance of "sticky" materials from the blood. 6. Some blood-activating herbs have direct cancer inhibiting actions and others promote immune system attack against cancer cells. 7. Blood-activating herbs reduce the tendency to form adhesions and excessive scar tissue following surgery. 8. Blood-activating herbs reduce some of the side effects of chemotherapy, such as hepatitis and pulmonary fibrosis. It has also been pointed out by Han Dewu and Xu Ruiling (6), that the combination of viscous blood and fibrin coating hinder the penetration of tumors by antineoplastic drugs and by active immune cells. Therefore, blood-activating herbs are usually prescribed to cancer patients in order to promote the positive effects of cancer therapies while limiting their negative impacts, to inhibit the cancer directly, as well as indirectly through immune system attack, and to prevent metastasis. TABLE 3. Herbs for Activating Blood Circulation and Removing Stasis, Used in Treating Tumors.

Common Name

Latin Binomials

Pinyin

Actions

Curcuma

Curcuma longa

yujin

not available

Eupolyphaga

Eupolyphaga sinensis

zhechong

Inhibits cellular respiration in liver and stomach cancer.

Leech

Whitmania pigra

shuizhi

General inhibition of cancer cells; inhibits liver cancer in mice.

Millettia

Millettia dielsiana and jixueteng Spatholobus suerectus

Inhibits JTC-26.

Notoginseng

Panax notoginseng

sanqi

Strongly inhibits JTC-26 in vitro; inhibits mouse sarcoma-180; reported to enhance effects of radiation therapy for nasopharyngeal cancer.

Pangolin scale

Manis petnadactyla

chuanshanjia

Anti-leukemic action.

Rhubarb

Rheum officinale

dahuang

Inhibits sarcoma-27 in mice; emodin inhibits melanoma, rhein inhibits ascites cancer and sarcoma-180 in mice.

Salvia

Salvia miltiorrhiza

danshen

Inhibits Ehrlich's ascites carcinoma and sarcoma-180 in mice; may reduce respiration and glucolysis of cancer cells.

Sparganium

Sparganium stolniferum or Scirpus yagara

sanleng

Inhibits wide range of tumors in laboratory animals.

Zedoaria

Curcuma zedoaria

ezhu

Inhibits sarcoma-180 in mice; the volatile oil injected into tumors causes necrosis; used clinically by injection into cervical cancers.

PHLEGM-RESOLVING HERBS The term "phlegm" is a translation of the Chinese tan, which refers to sticky fluids (other than blood or semen) derived from moisture and fat. From the modern perspective, we might include mucus, synovial fluid, and lymph among the normal manifestations of tan, and fatty tumors, cysts, plaques comprised of fatty substances, and goiters as descriptions of things traditional doctors would lump under the heading of pathological tan. The reason so many different items can be put into one simple category is that Chinese physiological principles are primarily arrived at by projection: a few basic essential components are suggested to make-up the whole body. In contrast, through the methods of modern investigation, each component of the body can be visualized and described in great detail, without a need felt to link the different observations (rather, it is thought that each component can be dealt with individually from the point of view of diagnosis and treatment). Masses of cells are generally thought to represent phlegm masses. These masses are not inherently painful (though they can become so when they press on nerves or organs); when they are large they are somewhat movable during palpation, and the palpable large masses seem to be somewhat soft. These are all characteristics associated with accumulated phlegm. Fluid filled masses, such as cysts and abscesses, are also described as phlegm masses. If the mass or swelling produces sharp pains, it is thought that blood stasis is also present. To treat soft accumulations and poorly defined masses, one applies herbs that are said to resolve phlegm. Most of the herbs will also treat cough or sinus congestion, thus making the link to what we, in modern times, think of as phlegm disorders. These herbs are not as often used in treating intestinal cancers, but they are sometimes applied for that purpose. Following is a table of a dozen phlegmresolving agents commonly mentioned for cancer therapy. TABLE 4. Phlegm-Resolving Herbs Commonly Used in Treating Cancer. Common Name

Latin Binomials

Pinyin

Actions

Citrus, Blue citrus, Chihshih, Chih-ko

Citrus, Blue citrus, Chihshih, Chih-koCitrus aurantium

chenpi, qingpi, zhishi, and not available zhike

Fritillaria

Fritillaria thunbergii and Fritillaria cirrhosa

zhibeimu and chuanbeimu Inhibits JTC-26.

Gleditsia spine

Gleditsia sinensis

zaojiaoci

Inhibits JTC-26 and sarcoma in rats.

Laminaria

Laminaria spp.

kunbu

Inhibit sarcoma-180 and B-16 melanoma, and prolongs survival with lymphocytic leukemia-1210 in rats. Often combined with sargassum.

Oyster shell

Ostrea gigas

muli

Inhibits sarcoma-180 and Kreb's tumor-2.

Pinellia

Pinellia ternata

banxia

Inhibits ascitic sarcoma in rats; inhibits cervical cancer-14, sarcoma-180, and solid liver cancer.

Sargassum

Sargassum kiellanianum

haizao

Inhibits cervical cancer-14, sarcoma-180, and lymphoma-I in animals.

Trichosanthes kirilowii

guolou, tianhuafen, and gaulouren

Inhibits chorioephithelioma, malignant hydatidiform mole, cervical cancer-14, sarcoma-180, ascites cancer, and JTC-26.

Trichosanthes fruit, root, and seed

FORMULAS There are so many cancer treatment prescriptions listed in the Chinese literature for each type of cancer, that an extensive listing of the formulas may not be very instructive, except to show that many of them include herbs from the four tables listed here. Generally, an antitumor prescription should be formulated to meet the needs of the patient involved, taking into account not only the type of cancer but also the utilization of Western therapies. Some formulas for colon cancer are given in the book An Illustrated Guide to Antineoplastic Chinese Herbal Medicine (1). These formulations are from Chinese medical journals published from 1981 to 1986. Ingredients of a formula indicated for carcinoma of large intestine include the following that were mentioned in the tables above: the anticancer herbs akebia fruit, sophora, pteris, oldenlandia, smilax, solanum, sargentodoxa, dryopteris, coix, and scutellaria; the blood-vitalizing herbs salvia and eupolyphaga; and the phlegm-resolving herb trichosanthes seed. A formula indicated for multiple adenoma of the large intestine included the anticancer herbs sophora, sargentodoxa, and scutellaria, the phlegm-resolving herb gleditsia spine, and the blood-vitalizers salvia and pangolin scale. A prescription for carcinoma of the large intestine, ileocecal region (lymphosarcoma), and anal carcinoma included the anticancer herbs sophora, paris, scutellaria, sargentodoxa, coix, and oldenlandia. These three sample formulas indicate primary reliance on anticancer herbs with a few blood-vitalizers. In some cases, herb decoctions are also given by enema (either the same formula as the oral prescription or a slightly different one). In the book Experience in Treating Carcinomas with Traditional Chinese Medicine (7), fourteen prescriptions for intestinal cancers are mentioned. Three examples are cited here. One formula for rectal carcinoma includes the anticancer herbs sargentodoxa, oldenlandia, prunella, and dryopteris; the phlegm-resolving herbs sargassum and trichosanthes seed; and the qi tonic ginseng. Another formula for rectal cancer is virtually the same, except for the addition of the anticancer herb solanum, and trichosanthes root replaces trichosanthes seed. A formula for indurated intestinal carcinoma includes the phlegm-resolving herbs blue citrus, citrus, and chih-shih; the blood-vitalizing herbs sparganium, zedoaria, salvia and curcuma; and the qi tonic astragalus. The last formula is aimed at treating stagnation of qi and blood, rather than relying on anticancer herbs. In the book Treatment of Cancer with Fu Zheng Pei Ben Principle (2), eight prescriptions for internal use are mentioned in the treatment of intestinal cancer. One is labeled "the approved prescription often used by the author," and includes the anticancer herbs patrinia, agrimony, oldenlandia, solanum, lonicera, and coix, and the qi tonic herbs codonopsis, atractylodes, licorice, and gynostemma. This is indicated for recto-colonic carcinoma. A formula for "stagnancy and damp-heat type" carcinoma, corresponding with rectal carcinoma, includes the anticancer herbs patrinia, solanum, agrimony, and coix, and the qi tonic atractylodes. For the "stagnancy and toxin type," corresponding to middle or advanced stage colon carcinoma with chronic intestinal obstruction, the recommended formula includes the anticancer herbs patrinia, scutellaria, oldenlandia, lonicera and solanum; the blood-vitalizing herbs curcuma, red peony, and rhubarb; and the qi tonic gynostemma. These formulas have a relatively large component of the anticancer herbs, with some tonics and blood-vitalizers. In the book Treating Cancer with Chinese Herbs (8), there are five prescriptions mentioned as being used by physicians in China for treatment of cancer of the large intestine. One includes the anticancer herbs oldenlandia, lonicera stem, scutellaria, solanum (both S. lyratum and S. nigrum), patrinia, and sargentodoxa; in cases of intestinal obstruction, the phlegm-resolving herbs trichosanthes root and gleditsia spine, and the laxative blood-vitalizer rhubarb, are added. A second formula, indicated specifically for cancer of the rectum, includes the anticancer herbs oldenlandia, sargentodoxa, solanum, and akebia fruit; the phlegm-resolving herbs trichosanthes root, oyster shell, and chih-shih; the blood-vitalizers salvia and pangolin scale; and the tonic codonopsis. A third formula includes the anticancer herbs scutellaria, coix, and lonicera stem, and the phlegm-resolving herbs chih-shih and laminaria. Among the dozen sample formulas listed here, the herbs that are mentioned repeatedly include the anticancer herbs sophora, oldenlandia, scutellaria, solanum, agrimony, coix, sargentodoxa, and patrinia; the blood-vitalizers salvia and pangolin scales; the phlegm-resolving herbs trichosanthes, gleditsia, and chih-shih; and the tonics atractylodes and gynostemma.

GENERALIZED CANCER FORMULAS Several cancer doctors have sought general formulations for treatment of tumors. One of the best known herbal combinations that has been given for gastro-intestinal cancers is called Ping Xiao Dan, developed by Dr. Jia Kun in 1958. It was originally made as a powder of eight ingredients and was later manufactured as a convenient pill and tablet. The ingredients are chih-ko, curcuma, agrimony, niter, lacca, alum, strychnos, and pteropus. Three of the ingredients, chih-ko, curcuma, and agrimony, are commonly used in the practice of

Chinese medicine in the West. The other ingredients, which include minerals (niter and alum) and potentially toxic herbs (lacca and strychnos) are usually not deemed acceptable here. In 1989, ITM developed an alternative preparation (called Chih-ko/Curcuma Tablets), that included chih-ko, curcuma, and agrimony, with other herbs that substitute for those deemed unacceptable. The formula has the anticancer herbs lonicera, prunella, sophora subprostrata, and wasp nest; the blood-vitalizers myrrh, frankincense, and arca shell; and the phlegm-resolving agents gleditsia spine, fritillaria, oyster shell, sargassum, and inula. According to studies in laboratory animals, Ping Xiao Dan enhances immune functions, despite the fact that its design is based on traditional methods of resolving masses by dispersing stagnation of phlegm and rectifying blood circulation. Trials in eight Chinese clinical institutes from 1958 through 1986 showed that its use increased survival rates and promoted tumor regression in cancer patients suffering from several different types of cancer. It has mainly been used in treating cancers of the esophagus, large intestine, lung, liver, breast, and kidney. Clinical evaluations are still being conducted to elucidate its range of action and degree of effectiveness. A book about the use of Ping Xiao Dan was produced by Jia Kun in 1983, and published in English in 1985 (5). In it, he recommends that 4.5-9.0 grams of the formula be taken each day. Further, he recommends that a prophylactic course of Ping Xiao Dan be taken every six months; 4.5-6.0 grams per day for one week. This is especially important for those who previously suffered from cancer, but it is also suggested to be a useful cancer preventive for otherwise healthy individuals. Jia Kun and his colleagues at the Shanxi Academy of Traditional Chinese Medicine published a report in 1984 (9) summarizing the results of treating patients with malignant tumors for three months or more using Ping Xiao Dan. Response to treatment was rated markedly effective if the main symptoms were eliminated or greatly reduced and if the tumor mass was shrunk by at least half (and did not progress again during the next three to six months); it was rated as effective if there were some symptom improvements and there was a little shrinkage of the tumor or at least no further growth of the tumor mass. For five tumor types-lung, liver, esophagus, stomach, and bone-the results were essentially the same. The treatment was markedly effective in 11.3%-16.7% of the patients treated and effective for 44.4%-58.3% of the cases. In other words, Ping Xiao Dan was able to halt tumor growth in about 2/3 of the cases and was able to substantially shrink the tumor in about 1/7 of the cases. In general clinical practice, Ping Xiao Dan is rarely given as a sole remedy for cancer. In China, it may be used along with high dosage herb decoctions; in America, dried decoctions-in the form of convenient extract granules-or tableted herb combinations are often used instead. Duration of treatment is highly individualistic. In his book, Jia Kun presents several case studies. In one representative example, he tracks a patient's progress through 61 visits to the clinic, over a period of about 8 months (he went to the clinic twice per week). At each visit, slight modifications were made to the formula that he was taking in the form of a tea along with the consistent use of Ping Xiao Dan. At the end of eight months, his cancer tests came out negative and he was basically healthy. He was then told to continue taking an herb tea (similar to the one he had been using at his last visit). On follow-up, he was found to still be healthy and strong more than 12 years later.

DOSAGE OF HERBS It is important to make sure that the herbal ingredients are provided in adequate dosage. Some formulations are suitable for use in small amounts, such as the few grams of Ping Xiao Dan mentioned above. However, many ingredients require substantial dosages to have the desired effect. As an example, Chang Minyi (3) relays information about "a universal anticancer prescription of the Quli Herbal Store in Shanghai." The basic prescription relies primarily on three herbs, Solanum nigrum, Solanum lyratum, and Duchesnea indica (a somewhat poisonous anticancer herb). Each of these herbs is used in a dosage of 45-60 grams in decoction as a one day dose. To treat each specific cancer type, two to four herbs are added to the base prescription, most of them in doses of 15-30 grams each. As an example, for stomach cancer, one adds 30 grams of Scutellaria barbata and 30 grams of Salvia chinensis (this is salvia leaves, which contain different active constituents than found in the roots). Thus, the formulas typically contain about 200 grams of herbs in decoction. Dr. Pan Mingji (2) lists four prescriptions for intestinal cancers that are "by Chinese scholars and folk prescriptions." Two of them are indicated for oral ingestion only: one contains 172 grams and the other 245 grams of herbs to make a decoction. The latter includes 60 grams of smilax, 30 grams each of oldenlandia and agrimony, and 20 grams of solanum. Dr. Hong-yen Hsu (8) relates a formula for treatment of oral cancer (for the gums), which uses 30 grams each of prunella, solanum, taraxacum, and oldenlandia, plus 15 grams of viola, for making a decoction.

DIET AND NUTRITION Jia Kun (5) emphasizes the importance of proper nutrition. Among the recommended foods that he mentions are peanut residue (after extracting the oil), barley, wheat bran, and soy bean. He also recommends a tea made from the mineral stalactite and regular drinking of green tea. These substances provide protein, vitamins, minerals, fatty acids, and other components. They might be replaced, in part, by use of nutritional supplements. For example, stalactite mainly contains calcium; wheat bran is high in vitamin E and some B vitamins. Other constituents, such as saponins and isoflavones in soybeans and flavones (polyphenols) in green tea, are accessible either through these foods or from some nutritional products. Flavones and other flavonoids found in fruits and vegetables (and available in nutritional supplements) are poorly absorbed when ingested, and a substantial portion remains in the gastro-intestinal tract where they can inhibit development of cancer. One of the dietary flavonoids, quercetin, inhibits cancer cell lines that exhibit estrogen binding sites by 50-80%; the isoflavonoid genistein, found in sophora, pueraria, and soy beans, appears to inhibit estrogen and testosterone dependent cancers (10). Pan Mingji (2) recommends taking foods that provide a high level of nutrients, recognizing that many cancer patients have a poor appetite and do not eat enough food to assist the body's fight against cancer. He provides a long list of potentially useful foods, many of them not readily available in the West. Among the more common Western foods suggested are eggs, milk, peanuts, beans and bean products, lean meat, sea food (shellfish and fish), mushrooms, walnuts, fruits, water chestnut, rice, wheat products, cabbage, cauliflower, lettuce, celery, bean sprouts, eggplant, green pepper, asparagus, and other fresh vegetables.

REFERENCES 1. Ou Ming, et al., An Illustrated Guide to Antineoplastic Chinese Herbal Medicine, 1990 The Commercial Press, Hong Kong.

2. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing House, Fuzhou. 3. Chang Minyi, Anticancer Medicinal Herbs, 1992 Hunan Science and Technology Publishing House, Changsha. 4. Dharmananda S, Chinese Herbal Therapies for Immune Disorders, 1992 Institute for Traditional Medicine, Portland, OR. 5. Jia Kun, Prevention and Treatment of Carcinoma in Traditional Chinese Medicine, 1985 The Commercial Press, Hong Kong. 6. Han Dewu and Xu Ruiling, Progress in the research on blood activation and hemostasis removal, Abstracts of Chinese Medicine 1988; 2(4): 466-483. 7. Shi Lanling and Shi Peiquan, Experience in Treating Carcinomas with Traditional Chinese Medicine, 1992 Shandong Science and Technology Press, Shandong. 8. Hsu Hong-yen, Treating Cancer with Chinese Herbs, 1990 Oriental Healing Arts Institute, Long Beach, CA. 9. Jia Kun, Wang Huichuan, and Liu Bianlin, Observation of curative effects of Ping Xiao Dan in treating 180 cases of malignant tumor, Shaanxi Journal of Traditional Chinese Medicine 1984; 5(6): 10-11. 10. Boik J, Cancer and Natural Medicine, 1995 Oregon Medical Press, Princeton, MN.

APPENDIX 1: Books About Treating Cancer with Chinese Herbs The treatment of cancer is a complicated and serious matter. One must study the field diligently. This review is intended to help practitioners select books for study. ITM has in its library ten English language books about anticancer herbs and on treating cancer with Chinese herbs. They are listed in order of copyright date: Treating Cancer with Chinese Herbs by Hong-yen Hsu (Oriental Healing Arts Institute, Long Beach, CA, 1982) Prevention and Treatment of Carcinoma with Traditional Chinese Medicine by Jia Kun (Commercial Press, Hong Kong, 1985) Structure Activity Relationship Analysis of Chinese Anti-Cancer Drugs and Related Plants by Eric Lien and Wen Li (Oriental Healing Arts Institute, 1985) Icones of Medicinal Fungi from China by Ying Jianzhe, et al. (Science Press, Beijing, 1987) The Treatment of Cancer by Integrated Chinese-Western Medicine by Zhang Daizhao (Blue Poppy Press, Boulder, CO, 1989) An Illustrated Guide to Antineoplastic Chinese Herbal Medicine by Ou Ming, et al. (Commercial Press, 1990) Cancer Treatment and Prevention by Binyan Sun (Offete Enterprises, San Mateo, CA, 1991) Anticancer Medicinal Herbs by Chang Minyi (Hunan Science and Technology Publishing House, 1992) Experience in Treating Carcinomas with Traditional Chinese Medicine by Shi Lanling and Shi Peiquan (Shandong Science and Technology Press, 1992) Cancer Treatment with Fu Zheng Pei Ben Principle by Pan Mingji (Fujian Science and Technology Publishing House, 1992) The first thing to note about these books published over a ten year period is that none of them are suitable for reading by the cancer patient. All are too technical for that purpose, either with Western science or Oriental medical terminology, and none are addressed to the patient with explanations of the "how and why" of cancer and its treatment, though such explanations are offered in short form for the practitioner in the introductory chapters to some of the books. Also, there is very little in these books that could be shown to an open, but skeptical, oncologist that might convince such a medical professional to become actively involved in Chinese medical therapy for cancer. Only the Structure Activity Relationship Analysis... is presented in the form of modern scientific investigations, but it only purports to show that chemotherapeutic agents similar to the ones now used by medical doctors have been isolated from Chinese plants. That is a long way from the concept of using complex Chinese herb formulas for management of cancer cases. Cancer Treatment with Fu Zheng Pei Ben Principle is by far the most medically-oriented clinical text, including Western and Chinese treatments, but it contains too many general statements along with the scientific details to impress the Western oncologist; further, the Western medical recommendations are now more than ten years old. Anticancer Medicinal Herbs offers brief pharmacological reviews, but these are compromised somewhat by the apparent assumption that herbs with anti-bacterial properties are also cancer inhibitors (sometimes true, but the connection is not necessarily obvious to the Western observer), by presenting complex formulas that include the herb under discussion as only one of many ingredients, and by not giving references to the claimed results (sometimes book names are mentioned in English but the source is unclear). For the professional audience of Chinese herb prescribers, the next thing to note is the extreme diversity in recommended treatments for cancer of any particular site. This diversity, which has many origins and explanations, demonstrates the fact that no one therapy stands out dramatically as an effective treatment, despite such names as the "anticancer single blade sword" (referring to a formula that kills cancer and relieves pain but does not harm the patient). Although part of the diversity may be explained in terms of adjustments of the formulation to individual cases, the fact is that the majority of variability is a reflection of different methods being tried for the general problem of cancer. The one partial exception to this trend is found in the book Prevention and Treatment of Carcinoma... where a single remedy-Ping Xiao Dan-is recommended for virtually all patients; still, these patients almost always take another prescription, which takes up the more typical variability. In China, physicians often devise their own version of Ping Xiao Dan with several substitute ingredients. This situation is quite different than in America, where Western herbalists might tell their patients to take the "Hoxey Formula" or "Essiac Tea" and offer little or nothing in the way of modification for individual needs; rarely does an herbalist produce an altered version of these formulas based on understanding the principles of cancer treatment. Cancer Treatment with Fu Zheng Pei Ben Principle offers several adjunctive formulas to go along with surgery, chemotherapy,

or radiation therapy; these come with recommendations for numerous alterations depending on specific symptoms. The formula ingredients differ considerably from those offered in other books aimed at treating cancer with herbs alone. The primary value of the book Treating Cancer with Chinese Herbs is that it shows the reader how closely connected modern cancer treatments are to earlier treatments that were probably aimed at diseases other than cancer but which had similar presentations. Put another way, this book reveals that cancer therapies are, largely, not to be separated from all the other therapies used in traditional Chinese medical practice. Most of the formulas predate the introduction of Western therapies (other than surgery). The book Cancer Treatment and Prevention introduces a somewhat unique diagnostic system and places emphasis on the use of warming therapies for treatment of cancer (something not included as a special consideration in any of the other books). The author states that about 80% or more of cancer cases in China are due to cold syndrome, to be treated with aconite, cinnamon bark, dry ginger and other warming herbs, and that an easy measure of the cold condition is the absence or small size of nail lunala (growth marks) and the presence of tooth marks on the tongue and possibly on the inner cheeks. The book The Treatment of Cancer by Integrated Chinese and Western Medicine demonstrates the common practice in China of using standard Western drug therapies along with Chinese herbs. Its lack of explanations, however, makes it difficult to use. Both An Illustrated Guide to Antineoplastic Chinese Herbal Medicine and Anticancer Medicinal Herbs present valuable reviews of individual ingredients used in cancer therapy, with brief presentations of sample formulas. The latter book is more usable, having interesting historical descriptions of the various applications of the herbs, and fairly detailed descriptions of experimental formulas (though the results of using the formulas are rarely presented, and when they are, the details are minimal). The pictures (photos of herbs) in the Illustrated Guide... are interesting but not especially relevant to the practitioner in the West. The pictures (water colors) in Icones of Medicinal Fungi from China are beautiful and make the book valuable as a work of art, but the basis of this book was a series of screening experiments to find the most effective polysaccharide-containing mushrooms, and after a brief mention of identification marks, habitat, and distribution for the species under consideration, a single sentence relates the detected anticancer potential, with reference number (to a long list of Chinese language publications). Experience in Treating Carcinomas presents suggestions of formulas-some traditional, some new-for each type of cancer and devotes most of the pages to case studies: up to two dozen patients with that type of cancer. The studies are accompanied by notes about the patient, type of cancer, and treatment responses, making it especially valuable to practitioners who see a substantial number of cancer patients and who, therefore, might like to know what other practitioners do in a variety of specific cases. There may be too many details for the beginner, however. Of all the books, the one which is perhaps most useful to the Western practitioner is Cancer Treatment with Fu Zheng Pei Ben Principle, so I usually recommend that all practitioners get this book as a primary text.

APPENDIX 2: Where to Get Herbs for Treatment of Cancer Obtaining the desired materials is sometimes problematic. Practitioners who do not maintain a crude herb pharmacy may have difficulty obtaining the herbs for making a decoction. In such cases, it is probably best to obtain dried concentrated extracts of the individual herbs to be combined into formulas; these are imported to the U.S. by about ten suppliers in Taiwan, mainland China, and Japan, and there is at least one manufacturer in the U.S. To obtain the equivalent of a 100-200 gram decoction, as is often used in China, one should recommend a dosage of 18-27 grams per day of the extract granules or powders. This large amount can be consumed in two to three batches of 9 grams each (one teaspoon is about three grams). A one month treatment is thus obtained from about 500-800 grams of extracts. Some traditional prescriptions that are used for treating cancer, such as Lithospermum and Oyster Shell Combination, Tang-kuei Sixteen Herb Formula, and Forsythia and Laminaria Combination are available in extract form, already combined. A formula developed in Japan about forty years ago for treatment of gastro-intestinal cancers, called WTTC (for wisteria, trapa, terminalia, coix), is similarly obtained in this form. The pills and tablets described in the Chinese books on treating cancer are usually not available outside China. Instead, they are prepared for use at the hospital complex where they are utilized, or, in a few cases, prepared for use within China but not for export. For those who wish to do everything possible, dosages can be gradually increased, or additional formulas consumed, but a gradual change in treatment is important to avoid confusion over possible side effects. To overcome lack of expertise in certain areas of the country where Chinese herb therapy is not very common, a patient seeking Chinese medical therapy for cancer may need to travel to a place where many experts are working in this field. To my knowledge, this means coming to a major city along the West Coast of the U.S. (Los Angeles, San Francisco, Portland, Seattle), where herbal medicine has been a standard method of therapy for more than a decade, though there are exceptions (for example, several very competent practitioners can be found in New York City and several other large U.S. cities). Practitioners are cautioned about the too-common practice of simply looking up a formula for a particular type of cancer and using it without a theoretical framework. Cancer patients, like others with serious, chronic diseases, usually experience substantial changes in their condition, especially under the influence of Western medical anticancer treatments. Therefore, one must be prepared to interpret and respond to those changes within the general framework of Chinese medical experience and also in keeping with the understanding of cancer pathophysiology, the effects of the Western therapies, and the therapeutic principles embodied in the herbal formulations.

May 1997

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TREATMENT OF GLAUCOMA WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Glaucoma is a common eye disorder, often associated with aging. It mostly occurs in persons over age 35, with increasing incidence among the elderly: about 2% of persons over age 40, and about 10% of persons over age 70 have chronic glaucoma. This disorder is usually caused by a gradual blockage of the outflow of aqueous humor, the fluid in the front compartment of the eye. If the pressure gets high enough, due to progression of the disease without adequate treatment, the small internal blood vessels and the optic nerve fibers become compressed, eventually causing irreversible damage, with loss of vision or complete blindness. In fact, about 15% of blindness in adults is due to glaucoma. New drug therapies, such as Xalatan, offer hope for keeping glaucoma under control. The simple type of chronic glaucoma is known as "open-angle" glaucoma (the reference is to the iridocorneal angle measured during an eye examination). It usually affects both eyes, has a genetic component (runs in families; the predisposing genetic background may yield an early age of onset), and is more common among diabetics. There is also an acute type of glaucoma, which can become chronic, known as "closed angle" or "angle-closure" glaucoma; this type can rapidly lead to vision loss and there may be obvious symptoms, such as severe eye pain. This is considered an emergency condition, treated by drugs (internal and topical), and sometimes by surgery. It most often occurs in one eye (though the other eye may later become affected). The simple open-angle glaucoma is the main focus of discussion in this article. Glaucoma was not a subject of discussion in traditional Chinese medicine before the introduction to China of tonometry (during this century). In the absence of pressure testing, conducted by tonometry devices, chronic open-angle glaucoma is essentially asymptomatic (the person may experience headaches, but these are not necessarily attributed to the eyes), and one simply experiences deteriorating vision, which can have numerous other causes. Along with the introduction of the diagnostic tool for glaucoma came the Western understanding of the disease nature, that is, a fluid-pressure in the eye. This Western description was then translated by Chinese doctors into a traditional Chinese description.

CHINESE VIEW Fluid build-up is a well-known phenomena in the literature of traditional Chinese medicine. Following the most general principles of yin and yang, fluids, which are inherently of yin nature, tend to be downward draining (just as one sees the downward motion of water in the environment). Therefore, in the absence of other contributing factors, one expects to observe symptoms of fluid accumulation or fluid drainage primarily in the lower part of the body: frequent urination, watery diarrhea, leukorrhea, or swelling of the legs and feet. Other types of disorders, aside from simply having too much fluid, are usually necessary to cause localization of the fluids elsewhere. Thus, for example, fluid accumulation in the skin, muscles, and joints is usually thought to be the result of the influence of "wind," one of the six classically-recognized environmental pathogenic influences: wind causes blockage of circulation, which can yield fluid accumulation at the sites of blockage. Skin swellings, muscle aching, and joint inflammation are often described as a combination of wind and dampness factors resulting in localized fluid accumulation. The wind and dampness may further be influenced by another environmental pathogenic influence, cold or heat, to yield wind-damp-cold (producing a "bi" syndrome, which corresponds to many cases of muscular or articular rheumatism) or wind-damp-heat (producing red swellings, such as wheals, eczema, or arthritic syndrome with red, swollen joints). In the case of an eye disorder that develops gradually and involves fluid-pressure within the eye (an internal site, as opposed, for example, to corneal inflammation, a superficial site), yet another explanation is called for. First, the underlying cause is expected to be internal in nature, rather than environmental (environmental influences more often produce rapid development of disease, and the disease often manifests first in the superficial tissues and later in the internal tissues); internal disorders are often influenced by genetics and aging. Since the fluid is accumulated in the upper body, it is understood that the fluid must be forced upward by something. In the general scheme of yin and yang, it is the yang influences that flow upward. These influences have the nature of fire rather than water. As observed in nature, the flames of fire (and the heated air that accompanies it) travel upward. The combining of internal yin and yang influences to yield a specific fluid disorder occurs in two basic patterns. On the one hand, the yin influence (water) can be dominant and the yang influence (fire) can be secondary. In that case, it is said that the water carries the heat downward (it overcomes the tendency of the heat to rise), and one may experience symptoms of "damp-heat" in the lower part of the body. This kind of syndrome could include, for example, genito-urinary sores and/or infections characterized by colored or thick discharge or burning pain. Sores or other red swellings and irritations on the legs and feet would be a second example. On the other hand, the yang influence can be dominant and the yin influence secondary, in which case the fire carries the water upward (it overcomes the tendency of water to drain downward). The latter is the situation with glaucoma. This is also a common explanation for thyroid swellings, which are thought to represent masses of phlegm (congealed fluid) accumulated at the base of the neck (1). The traditional Chinese description for glaucoma that arises from this line of thought is that a fire syndrome is generated internally which carries fluids upwards, congesting in the eyes. The origin of the fire syndrome may vary from person to person, and the most likely scenario depends upon the age of onset, as well as factors that are revealed by traditional diagnostic indicators (such as pulse and tongue). For those who experience glaucoma at a relatively early age (say before age 55), the most likely cause of the fire syndrome is a chronic stagnation syndrome. The Chinese explain the relation of fire to stagnation by this type of analogy: if you form a large pile of wet leaves and let them sit for a while undisturbed, the center of the pile will become quite hot; in fact, under the right conditions (if the outer leaves dry out), the pile of leaves could burst into flames. This phenomena is often observed today in piles of garbage, especially piles of discarded tires. The heat is generated by the accumulation and stagnation: individual leaves, or piles that are quickly dispersed do not become hot. The common stagnation syndromes are liver qi stagnation, fluid accumulation, and blood stasis. If any of these persist for an

extended period of time, one can experience a secondary fire syndrome. Since blood stasis often generates pain or other obvious symptoms, it is not usually deemed a cause of chronic open-angle glaucoma, which can arise without obvious signs of blood-stasis (note, however, that damage to the microvessels in the eyes occurs after the eye pressure is elevated). Liver qi stagnation and "phlegm-fluid" accumulation are quite common in persons with glaucoma, and are considered the most likely causes. To treat glaucoma (formed by the above-mentioned mechanisms) with traditional methods, one would use a combination of herbs to drain the accumulated fluid from the eyes with additional herbs to decrease the internal fire that drives the fluids upward to cause pressure. Further, one would attempt to reduce the underlying accumulation and stagnation, so that the fire does not continually arise. If glaucoma develops at a later age, the most likely cause is expected to be the consequence of declining yin essences, a natural part of the aging process, which, as a result of genetic factors or diseases, may become a serious problem for some individuals. The deficiency of yin results in dominance of yang forces, which will drive fluids upward. These yin essences, stored in the kidney and nourishing the liver, can be replenished by tonic herbs and foods.

SPECIFIC TREATMENT STRATEGIES Herbs used in the treatment of glaucoma in China that are consistent with the principles described here are listed in the accompanying tables. The formulas that incorporate them are discussed in this section; some formulas include herbs, not listed in the tables, which may not have general application to glaucoma. The primary formula for draining excess fluids is the Hoelen Five Herb Formula (Wu Ling San) . It is comprised of four waterdraining herbs-hoelen, alisma, polyporus, and atractylodes-plus cinnamon twig, which opens the circulatory channels and helps return upward and outward flowing substances to the interior. In recent years, many Chinese physicians have adjusted this formula by adding a large dose of plantago seed, which also has a fluid-draining action. It is appropriate to treating glaucoma because plantago is said to clear away heat, promote diuresis, and improve visual acuity (2). The primary formula for removing heat associated with liver qi stagnation is the modified Bupleurum and Tang-kuei Formula ( Xiao Yao San ), known as Bupleurum and Peony Formula (Jia Wei Xiao Yao San ) . Xiao Yao San is a widely used ancient formula that addresses disorders of liver qi stagnation, especially when fluid accumulation and heat is involved (it contains hoelen and atractylodes for draining dampness). The Bupleurum and Peony Formula is mainly applied when the heat (or fire) syndrome is especially strong, by incorporating the fire-purging herbs gardenia and moutan; gardenia also drains fluids. In cases where fluid accumulation (usually in the form of thickened fluid: phlegm) causes fire, a traditional prescription (3) that is commonly relied upon is modified Antelope Horn Powder (Ling Yang Jiao San ) . The formula is based on the fire-purging action of antelope horn, a substance which is supposed to be especially beneficial for eye disorders associated with liver fire, and the channelopening (that is, obstruction-removing) and drying action of tu-huo and siler. It is usually indicated for conditions in which phlegm is "rushing upward." If there is a more gradual syndrome of upward movement of phlegm, it is common to rely on Pinellia and Arisaema Combination (Dao Tan Tang), made from the traditional Citrus and Pinellia Combination (Er Chen Tang ) by adding arisaema and chihshih (chih-shih has a downward-draining action). These latter formulas do not purge fire, but can be modified to do so by adding antelope horn, or other herbs that accomplish the same, such as uncaria. In the event that deficiency of yin essences results in dominance of yang, one often relies on Rehmannia Six Formula (Liu Wei Di Huang Tang) as a prescription for nourishing the yin, or the modified version, Lycium, Chrysanthemum, and Rehmannia Formula (Qi Ju Di Huang Tang), which adds the two herbs in the formula name; they help treat eye disorders that are due to liver yin deficiency and liver fire. These formulas include hoelen and alisma for draining fluids, and moutan for clearing heat in the blood. The principles of glaucoma treatment are summarized, along with suggested formulas, in the recent compendium English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (4), in which Volume 17 is devoted to ophthalmology. As to cause of openangle glaucoma, it says: Emotional depression of a person may cause stagnation of liver qi that will turn into fire. When the fire goes upward to attack the eyes, the disease occurs. Or, if a person suffers from retention of dampness due to hypofunction of the spleen, phlegm will originate from the retention and form phlegm stagnation which will further convert into fire. When the fire moves upward to attack the eye, the disease is caused. Besides, deficiency of the liver and kidney, a condition called consumption of primordial yin, will result in asthenic fire, and attack of the eye by the fire will lead to the disease. Three sample formulas are given in the encyclopedia. For the case of liver qi stagnation as underlying cause, the following modification of Jia Wei Xiao Yao San is recommended: 9 grams each of bupleurum, moutan, gardenia, hoelen, atractylodes, angelica, chrysanthemum, and prunella, plus 12 grams each of tang-kuei, peony, and uncaria; this is taken in decoction, with 3 grams of antelope horn powder added into the strained decoction at the end of cooking. Prunella, uncaria, antelope horn, and chrysanthemum drain upward rising fire derived from the disturbed liver. These herbs also treat hypertension due to liver-fire. For the fluid-accumulation type of disorder, a modification of Ling Yang Jiao San and Dao Tan Tang is recommended: 9 grams each of pinellia, arisaema, bamboo, and licorice, 12 grams each of plantago seed, red peony, hoelen, ophiopogon, vitex, cassia seed, and chrysanthemum, plus 3 grams of antelope horn. Vitex, cassia seed, and chrysanthemum are commonly used to "direct" the action of an herb formula to the eyes. Pinellia, arisaema, bamboo, plantago seed, and hoelen resolve phlegm and drain fluid. For the yin-deficiency type of disorder, the encyclopedia recommends the following modification of Qi Ju Di Huang Tang: 9 grams each of alisma, plantago seed, and gastrodia, plus 12 grams each of hoelen, codonopsis, peony, rehmannia, chrysanthemum, and lycium fruit.

EFFECTIVENESS OF INTERNAL REMEDIES As to how well such formulas work, we must rely on the small number of published studies for an indication. The published studies usually involve a combination of patients young and old and with both open and closed type glaucoma, as well as acute and chronic cases of the latter. Two studies that involved a large proportion of the simple chronic glaucoma (open-angle type) will provide an indication of

what can be expected. In one study (5) involving 55 patients, Hoelen Five Herb Formula was utilized. The herbs were extracted, made into tablets, and taken 8 tablets at a time, twice daily (equivalent to using 9 grams each of hoelen and polyporus, 6 grams each of atractylodes and cinnamon twig, and 12 grams alisma each day). This formula was used for chronic glaucoma, with either open-angle or closed-angle type. Only the herbs were utilized during the trial period. It was reported that as a result of the treatment, 63.6% of all the affected eyes showed a significant decline in pressure after just one month. No adverse effects of treatment were reported. For purposes of comparison, a physician described (6) an individual case of acute glaucoma successfully treated by Chinese herbs. He used essentially the same formula, but a much higher dose was used and rhubarb was added (rhubarb is used to rapidly drain heat and dampness and is intended to function by causing a laxative action). The formula, in decoction form, contained 30 grams alisma, 30 grams plantago seed, 25 grams polyporus, 25 grams hoelen, 15 grams atractylodes, 10 grams cinnamon twig, and 15 grams rhubarb. In the other large study (7), the specially-designed formula Xie Gan Jie Yu Tang was utilized. It contained platycodon, leonurus fruit, plantago seed, prunella, phragmites, lepidium, siler, scute, cyperus, and licorice. Lepidium is a drastic purger of fluid accumulation; leonurus fruit is thought to nourish the eyes (it contains vitamin A and essential fatty acids). The exact amounts of each were not specified, but routine dosages were used (this usually means 9-12 grams for most of the herbs, with less for lepidium and licorice, more for plantago seed). There were 29 patients, most having the open-angle type of glaucoma. Of 25 eyes affected by the open-glaucoma type, 17 (68%) attained normal pressure by the treatment, and 5 more could remain normal only if 1% pilocarpine drops (a standard Western medical therapy) were continued. As these studies indicate, using herbal formulas internally can result in about 2/3 of affected eyes having an improvement in the pressure without use of drug therapies.

TOPICAL TREATMENTS It should be pointed out that much of the treatment of glaucoma is done by eye drops rather than, or in addition to, systemic treatment, both in Western medicine and in Chinese medicine. In China, the main herb-derived eye drops for glaucoma are pueraria flavonoids (called puerarin), areca seed extract, or, perhaps most commonly, the alkaloids from erycibe ( Erycibe obtusifolia; dinggongteng aka baogongteng). These eye drops appear to work as well or better than the Western eye drops, such as pilocarpine, which is usually used as a comparative standard (8), but they are not available to Western practitioners.

REFERENCES 1. Dharmananda S, Treatment of thyroid disorders with Chinese herbs, 1995 START Group Manuscripts, Portland, OR. 2. Ou Ming (chief editor), Chinese-English Manual of Commonly Used Herbs in Traditional Chinese Medicine, 1989 Joint Publishing Company, Hong Kong. 3. Huang Bingshan and Wang Yuxin, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, 1993 Heilongjiang Education Press, Harbin. 4. Lu Shengnian and Cai Huasong (chief editors), English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, Volume 17: Ophthalmology, 1989 Higher Education Press, Beijing. 5. Guangdong Medical Journal Editorial Department, Clinical observation of curative effects of Wu Ling San for treatment of glaucoma, Guandong Medical Journal 1982; 3(2): 40. 6. Zhang Xiangxu, Personal experience of clinical application of Wu Ling San, Zhejiang Journal of Traditional Chinese Medicine 1983; 516-517. 7. Shi Shouli, Glaucoma treated by modified Xie Gan Jie Yu Tang, New Journal of Traditional Chinese Medicine 1986; 18(10): 29. 8. Zhang Mingsheng et al., Comparison between baogongteng A and pilocarpine eyedrops in the treatment of primary glaucoma, Shanghai Medical Journal 1981; 4(12): 24-27.

TABLES OF HERBS USED IN TREATMENT OF GLAUCOMA The following are some of the herbs commonly used to treat glaucoma in China. They are subdivided by their principal actions, namely draining dampness/resolving phlegm, clearing heat (purging fire), and nourishing the kidney and liver. In some cases, the herbs have overlapping properties; they are grouped by traditional categories. The descriptions in the actions sections retain the wording in reference 2, which is the principal source of the information in this table. Herbs to Drain Dampness Common Name

Source (Latin Binomial)

Part Used

Chinese Name (Pinyin)

Actions in Relation to Glaucoma

hoelen

Poria cocos

whole fungus

fuling

promote diuresis, eliminate dampness, invigorate spleen, alleviate phlegm retention

atractylodes

Atractylodes macrocephala

rhizome

baizhu

invigorate the spleen, deprive dampness and promote diuresis

polyporus

Polyporus umbellatus

whole fungus

zhuling

promote diuresis, for dampness retention syndrome

alisma

Alisma orientale

rhizome

zexie

promote diuresis, eliminate dampness, expel heat

plantago seed

Plantago asiatica

seeds

chequanzi

clear away heat, promote diuresis, improve visual acuity

pinellia

Pinellia ternata

rhizome

banxia

deprive dampness and eliminate phlegm, disperse stagnation

arisaema

Arisaema erubescens

rhizome

tiannanxing

deprive dampness and eliminate phlegm

bamboo

Phyllostachys nigra

stem

zhuru

clear away heat to cool the blood, clear away lung heat to eliminate phlegm

platycodon

Platycodon grandifolium

root

jiegeng

eliminate phlegm

chih-shih

Citrus aurantium

fruit

zhishi

activate vital energy circulation and eliminate phlegm, disperse stagnation

citrus

Citrus reticulata

fruit peel

chenpi

deprive dampness and eliminate phlegm

Chinese Name (Pinyin)

Actions in Relation to Glaucoma

Herbs for Clearing Heat and Purging Fire Common Name

Source (Latin Binomial)

Part Used

antelope horn

Saiga tatarica (now substituted by Procarpa guttorosa, or other species)

horn

lingyangjiao

clear away heat, calm the liver, clear away liver-fire to improve visual acuity

gardenia

Gardenia jasminoides

fruit

zhizi

purge fire, clear away heat and promote diuresis, cool blood, remove blood stasis

moutan

Paeonia suffruticosa

root bark

mudanpi

clear away heat, cool the blood, promote blood circulation, remove blood stasis

bupleurum

Bupleurum chinense

root

chaihu

let off heat, disperse stagnated liver energy

mentha

Mentha haplocalyx

tops

bohe

clear away heat from head and eye

prunella

Prunella vulgaris

spike

xiakucao

clear away liver-fire and calm liver yang, eliminate phlegm and disperse stagnation

peony

Paeonia lactiflora

root

baishao

calm liver yang, soothe the liver, astringe yin

chrysanthemum

Chrysanthemum morifolium

flower

juhua

clear away heat, clear away liverfire to treat eye disease, calm the excess liver energy

vitex

Vitex trifolia

fruit

manjingzi

expel the wind and heat, ease the eye and the head

phragmites

Phragmites communis

rhizome

lugen

clear away heat, promote diuresis

Scute

Scutellaria baicalensis

root

huangqin

clear away heat and deprive dampness

Chinese Name (Pinyin)

Actions in Relation to Glaucoma

Herbs for Nourishing Yin Common Name

Source (Latin Binomial)

Part Used

rehmannia

Rehmannia glutinosa

root

shoudihuang

produce essence and enrich blood, nourish yin

lycium fruit

Lycium barbarum

fruit

gouqizi

nourish yin, enrich blood, benefit essence, and improve visual acuity

cornus

Cornus officinalis

fruit

shanzhuyu

supplement essence and improve visual acuity, astringe and preserve essence

January 1997

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THE QI KEEPS THE BLOOD WITHIN THE VESSELS The story of Gui Pi Tang by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

This article is presented in an effort to help practitioners avoid a common error: linking a symptom to a traditional diagnostic category without considering the totality of the available evidence. The discussion, which eventually focuses on the symptom of uterine bleeding, is presented because I have noted that many Western practitioners of Chinese medicine automatically assign cases of uterine bleeding to the diagnostic category of qi failing to keep the blood within the vessels. Even when a woman presents some signs of qi deficiency (e.g., failures in the transformation and transportation of food essence, or weakness and pallor), I believe one should not necessarily assign to this observation the interpretation that this deficiency is the immediate and principal cause of bleeding. Instead, it is valuable to observe the full realm of symptoms and to take into account the practices of modern Chinese physicians and information obtained from the application of Western medical diagnostics.

QI CONTROLS BLOOD The functions of qi are many. One of those reported in all standard modern texts is maintaining the flow of blood within the vessels. This function of qi is deemed a direct outcome of the spleen's activities. I n The Five Organ Networks of Chinese Medicine (Heiner Fruehauf, ITM, 1998), it is stated that: Qi does not only move body essences, but it also holds them in place. The fact that the blood circulates in the vessels without leaving its proper path is particularly attributed to the restraining function of spleen qi. The Classic of Difficulties (Nanjing) simply states: "The spleen contains the blood [Pi tong xue]." This function of the spleen [associated with the earth element or phase] is evocative of the characteristics of earth: just as the rivers and streams are contained by an earthen bed, the body's blood is contained in the channels. The term "contains" has been used in this particular translation, but it is not the only possible meaning. Pi tong xue literally states: spleen [pi] commands, unifies, draws together, controls, rules [tong] blood [xue] . The meaning of the character tong is rendered in various ways (only some of the versions are given here), usually with the help of a second character following it to give it more specific meaning. As presented in the medical classics, without modification, the statement does not inherently imply retaining the blood within vessels, but that can be one of its interpretations. In fact, this interpretation has been relied upon for some time, though probably not during the centuries immediately following the writing of the Neijing (ca. 100 B.C.) and Nanjing (ca. 100 A.D.), when the phrase was first used. Thus, for example, the book Zhong Zang Jing (probably published around 500 A.D.) has a chapter about diseases of the spleen; despite lengthy mention of numerous serious consequences of spleen disorders, including spleen deficiency syndromes, bleeding is not one of them (1). In the 1984 Dictionary of Traditional Chinese Medicine (2) the phrase Pi tong xue is accompanied by this simple explanation: "The spleen has the function of keeping the blood flowing within the vessels. Its impairment usually leads to chronic hemorrhagic diseases." The persistence of bleeding is one of the factors frequently, though not always, mentioned as a signifier of this type of syndrome. The modern interpretation of the ancient words is widely reported in similar ways, as in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (3): "With the assistance of the spleen, blood circulates inside the vessels, and no blood extravasation [leakage from the vessels] occurs, therefore, 'the spleen controls blood [Pi tong xue].'"

APPLYING THE PRINCIPLE The application of the Pi tong xue principle can be understood from analysis of the historical records and from modern medical journal reporting of contemporary practice of traditional Chinese medicine, especially herbal medicine. It will be noted, upon such examination, that one particular type of blood escaping the vessels is treated by tonifying spleen qi and is mentioned in relation to qi failing to hold the blood within the vessels: uterine bleeding. A second type of bleeding, intestinal bleeding, is also treated by tonifying the spleen qi, but that does not appear (in most instances) to be a direct application of the Pi tong xue principle; rather, it is a consequence of the general practice of treating intestinal disorders by tonifying the spleen, whether or not bleeding occurs. The phrase "blood escaping from the vessels" is designated in Chinese by: "xue bu gui jing." Literally, this means that the blood [xue] does not [bu] return [gui] to the vessels [jing; this is the term that is often translated as meridians; originally, meridians and blood vessels were considered the same; see: Jingluo: Drawing a concept]. In other words, the original concept may have been that the blood was not rigidly contained within vessels, but flowed mainly within them, being able to seep out and seep back. Modern medicine recognizes that, in fact, blood constituents do leave the small vessels (capillaries) and return. A Western approach to treating bleeding is to utilize flavonoids (a plant constituent found in many hemostatic herbs) that reduce the leakage from capillaries. The larger vessels, such as arteries and veins that were depicted as jing and luo by the Chinese, normally do not have direct exchange of fluids across the vessel walls. When there is bleeding from other sites, such as the nose, gums, or lungs, and when there is discharge of blood in the urine, or spontaneous appearance of bleeding beneath the skin (purpura), this is most often interpreted as the result of an excess of heat. This heat excess may be associated with a deficiency of yin and/or blood, so that it is depicted as "deficiency heat"; but that term means that the heat, which is an excess, arises from a deficiency. These symptoms of bleeding usually reflect the traditional principle that heat can cause the blood to run wild and escape from the vessels (unable to return, due to its disorderly exit). Many textbooks will list potential causes for bleeding at these other sites, and include a section on qi deficiency as one potential cause (depicting the patient as having characteristic qi and blood deficiency symptoms and signs), but it is not common to find clinical reports of treatments actually based on this principle, unlike the situation for prolonged uterine bleeding. It is stated in The Foundations of Chinese Medicine (4) that:

When spleen qi is deficient, it can not hold the blood in the vessels and bleeding appears from various sources, such as under the skin, in the stools or urine, or from the uterus. This is bleeding of deficient nature, as opposed to the bleeding from heat in the blood which is of an excess nature. When describing bleeding of "deficient nature," the author is not referring to deficiency heat, but rather, spleen qi deficiency only. The Advanced Textbook... states: "If the spleen and stomach are deficient and affected by cold, or if the qi of the middle jiao is insufficient, either bloody stools or uterine bleeding will occur." Under the subsection of the chapter on bleeding, with the heading "deficiency of qi and blood," it says the clinical manifestations are: "bleeding in the nose or gums, or pores in severe cases...." There is something amiss here in these text book descriptions that is mirrored in the Western practice of Chinese medicine, and I propose it is the spontaneous adherence to a simple traditional statement without due consideration of the full spectrum of clinical presentation. The textbook passages reveal two deviations from what is frequently reported clinically: 1. Most practitioners of traditional medicine encounter numerous patients with spleen-qi deficiency who show no signs of "bleeding from various sources," even though the above statements suggest that the weakened spleen qi "can not hold the blood in the vessels" and that "bleeding will occur." Most other books describing traditional theory correspond to the above statements, implying that there will be bleeding if the spleen qi is weak, even though clinical experience shows that bleeding is only sometimes found in persons with spleen qi weakness. 2. Although some experienced Chinese practitioners have applied spleen-qi tonification principles to treating the conditions mentioned in these two texts, including bleeding under the skin, fecal blood, urinary bleeding, nose and gum bleeding, and bleeding through the pores (probably thrombocytopenic purpura in extreme cases), this is not the dominant approach. While patients with deficiency syndrome are certainly treated with tonic herbs, qi tonics are not frequently employed as the focus of therapy when the patients present bleeding of these types.

GUI PI TANG The best known traditional formula for addressing bleeding that is attributed to spleen-qi deficiency is Gui Pi Tang (Ginseng and Longan Combination). In fact, this formula (or a modification of it) is prominently featured in virtually every text that mentions the herbal treatment of bleeding disorders associated with qi deficiency following the principle of Pi tong xue. One of the few exceptions is a passing mention in the Advanced Textbook... of both Gui Pi Tang and Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination). In some books on formula applications, Buzhong Yiqi Tang (Ginseng and Astragalus Combination) is said to treat this type of bleeding. These three formulas all have the following herbs in common: astragalus, ginseng (with codonopsis often used in modern China as a substitute), atractylodes, licorice; this basic combination of four herbs tonifies qi. The three formulas also contain tang-kuei (danggui), but this is a minor ingredient of Gui Pi Tang. Gui Pi Tang (5, 6) Coarsely grind the ingredients, use 12 grams each time, with 5 slices of fresh ginger and a piece of jujube, and decoct. The recipe is for a two week supply, which is a standard course of therapy for this formula. astragalus ginseng atractylodes hoelen licorice (baked) zizyphus tang-kuei polygala saussurea

30 g 15 g 30 g 30 g 8 g 30 g 3 g 3 g 15 g

The origin of Gui Pi Tang is attributed to the book Ji Sheng Fang (Formulas for Saving Lives) by Yan Yonghe (1253 A.D.). Gui means to return or restore; the formula name appears to mean "the decoction [tang] for restoring the vitality of the spleen [pi]." The original formula did not contain tang-kuei or polygala (yuanzhi); these two ingredients were added in small amounts about 300 years later when the formula was listed in a book on treating women's disorders (Jiaozhu Furen Liangfang). The indication of the formula to treat bleeding was first added about 100 years after the formula was written (6). It is not entirely clear, however, whether the actual effect of this formula is to stop the bleeding by helping the qi to control the blood, as would be implied by the Pi tong xue principle, or to compensate for the blood loss that occurs with bleeding, by generating more blood. Modern interpretations of the formula's actions more often focus on generation of blood. The formula is sometimes described in English as "the decoction for invigorating the spleen and nourishing the heart," referring its ability to nourish heart blood rather than on its antihemorrhagic action. Many times, patients categorized with spleen-qi deficiency who have a bleeding disorder (usually uterine bleeding) receive a modified version of this Gui Pi Tang containing herbs with specific hemostatic properties. In those cases, the hemostatic herbs (common additions are gelatin and fulonggan, also called zaoxintu, the oxidized clay from heating stoves) may have the primary function to halt the blood flow, while the rest of the formula nourishes the depleted blood and quickly restores the vitality of the individual. As an example, in the treatment of metrorrhagia in a women with spleen-qi-deficiency diagnosis, Shang Xianmin recommends (7) a slightly modified Gui Pi Tang as the base formula, with the following comments: "For cases with profuse bleeding, add agrimony and gall, and omit tang-kuei; for cases with prolonged dripping bleeding, add typha and sepia bone." Domei Yakazu (8) reported these indications for Gui Pi Tang, relaying the information recorded in Ji Shi Chuan Su: Hemorrhage of the spleen meridian [bleeding associated with weakness of spleen qi]; insomnia with fever and profuse perspiration; a spleen injured by over worry which in turn leads to poor blood transformation and the resultant reckless acts;

amnesia and melancholy; over palpitation [heart stimulation] causing sleeplessness; the pains of an injured spleen and heart that result in a fondness for lying in bed and poor appetite; a spleen injured by over worry that results in fever and insufficiency of blood; pains in the limbs and trunk; irregular bowel movements; menoxemia; fever in the chest or the interior; scrofula which is suppurating and can't be dispersed, outbursted, or astringed. Relaying information from the Nü Shan Fang Gao, a summary of applications of this formula is given: 1. It is a wonderful prescription used mainly to treat a spleen and heart that are exhausted and injured by excessive thinking and worrying, resulting in amnesia and reckless acts or destructive behavior. 2. For those with insufficient blood in the heart, or for intestinal wind and bloody stools; hematemesis, epistaxis, spermatorrhea, white turbid urine, or dripping and painful urination, or for the strong-willed deep thinkers who have withered, yellow complexions, the prescription has a miraculous effect. 3. It is used for women who are peevish and irritable, can't be satisfied by any man, and can't get what they want. This mental condition leads to jealousy and hostility, resulting in weak and depressed spleen and heart with the accompanying symptoms of reckless acts, palpitation, flare-up of weak fire, white dandruff, paralysis in the feet and hands, fondness of lying in bed, poor appetite, thirst, itching and feverish skin heat, body odor, and pain and swelling or leukorrhea in the genital area. 4. It has an excellent effect in treating all diseases of the female genitalia. For bleeding during coitus, add cimicifuga [shengma] and peony [baishao] to the formula [note: shengma raises qi and peony astringes blood, so this combination is intended to prevent the falling of blood]. 5. It has a marvelous effect in curing the weakness in widows and virgins who are sexually frustrated and, as a consequence, suffer depression and anxiety. Summing up his views on the use of Gui Pi Tang, Domei Yakazu states: It is especially effective for those who have been so worn out in body and mind that they have reached an extremity of exhaustion and fatigue. It is also good for those who have had ceaseless superior and inferior [upper and lower body] hemorrhages, rendering an extreme anemia; for those with amnesia and nervous excitement such that the palpitation and anxiety make them unable to sleep.... From all this description, it remains somewhat unclear whether Gui Pi Tang, the formula almost universally selected to treat patients who are diagnosed with the spleen-deficiency-type bleeding, actually stops the bleeding or treats the "extreme anemia" that occurs as the result of chronic bleeding disorders. Clinical trials conducted in recent years have not shed much light on this subject.

UTERINE BLEEDING Uterine bleeding associated with a qi-deficiency syndrome is characterized in Chinese medical texts by prolonged bleeding (sometimes incessant bleeding), of thin, pale blood (indicates blood deficiency), usually accompanied by chilly sensations (affecting the lower abdomen and legs/feet). Although one can simply state that the cause of the prolonged bleeding is due to the qi deficiency, this is merely a restatement of the Pi tong xue dogma that has developed. What were the causes, as we describe them in modern terms, of such bleeding? Unfortunately, we cannot know with any certainty the reason why women in China, particularly in ancient China (when Pi tong xue was established as a principle related to bleeding disorders), experienced unusual uterine bleeding. Certainly, the conditions that the Chinese women were exposed to differed markedly from those of modern Western women. For example, there were different diets with markedly different levels of important nutrients, there were fewer STD's (sexually transmitted diseases), no use of high-dosage hormone therapies (there may have been some limited use of herbal therapies that affected hormones, but that is not likely to be prevalent), and more and earlier childbirths. These factors and others mean that the particular manifestation of diseases and disorders of the uterus would likely be different than today, even when the symptoms are similar. From the modern perspective, we understand that blood escapes the vessels as a result of the following general causes: 1. The vessels are broken either by physical injury or the result of pathological process such as infection, inflammation, or other swelling. 2. The blood fails to clot properly due to lack of platelets (e.g., as occurs with ITP-idiopathic thrombocytopenic purpura, leukemia, or aplastic anemia), vitamin-K (from dietary deficiency or intestinal flora imbalance), or some other clotting factor (as occurs with hemophilia). As to the first category of causation, injuries were understood in traditional China much as they are today, and the bleeding wasn't correlated with failure of spleen-qi function. Infection, inflammation, and swelling often have a parallel to the traditional concept of heat syndrome (e.g., a lung-heat syndrome leading to hemoptysis would correspond, roughly, to a modern description of lung infection with inflammation, with some bleeding at the site of inflamed and damaged vessels). As to the second category, these particular disorders were probably quite rare; the incidence of ITP, leukemia, and hemophilia have apparently increased markedly during recent decades and were unlikely to be common disorders in ancient times. However, bleeding may also occur as the result of various nutritional deficiencies that rarely affect the modern population, except during illness, but may have been a problem from time to time in China's history even in the absence of illness. In a study of spleen-qi deficiency patients (10), comprised mainly of individuals with chronic gastro-intestinal diseases, it was found that the blood status differed from that of normal patients. Not surprisingly, there was a lower hematocrit, indicating a nutritional deficiency condition, but there was also a reduction in blood viscosity. In such cases, if there is a potential for bleeding, such as when there are distended, inflamed, or damaged capillaries, then it is more likely that bleeding will occur. If Gui Pi Tang helps reduce the gastro-intestinal inflammation, thereby rendering food nutrients more absorbable, the blood viscosity may return to normal and bleeding will be reduced. This may reflect the fundamental mechanism whereby qi-deficiency patients with bleeding report less bleeding after qitonifying and blood-nourishing prescriptions are administered.

Uterine bleeding presents some unique considerations. From the modern perspective, there are three major causes: 1. A uterine fibroid increases the surface area of the uterine lining and the amount of tissue shed during menstruation; they also cause the blood vessels to stretch and become exposed, thus weakening their structural integrity. The weakened vessels can then break easily and cause excessive blood flow. Uterine cancer, uterine polyps, and endometriosis with cysts near the uterine wall, are causes of a similar nature, but are much less common. 2. A disorder of the endometrium (usually a thickening, often caused by a sustained excess level of estrogen or deficiency of progesterone) leading to repeated pulling on blood vessels, breaking them open to bleed. Post-partum hemorrhage is sometimes a related problem. 3. A hormonal imbalance leading to mid-cycle bleeding or persistent bleeding. Perimenopausal bleeding disorders are of this nature. It is estimated that about 25% of the cases of abnormal uterine bleeding (in the West) are due to uterine fibroids. These occur with high frequency in women who are about 35-50 years old (fibroids tend to grow substantially during the years just prior to menopause, and then tend to shrink with menopause), affecting about 20% of all women. These abdominal masses are interpreted from the traditional Chinese viewpoint as a blood-stasis syndrome (usually secondary to a qi-stagnation syndrome). There is also a traditional principle that bleeding occurs at sites of blood stasis because the static blood impairs the normal flow of blood and therefore causes it to exit from the vessels under duress. This traditional principle is reasonably close to our modern understanding of fibroids. The other 75% of cases of abnormal bleeding are related to hormonal imbalances. The thickening of the endometrium is treated in Western medical practice by removing it (d & c procedure) and then administering hormonal pills; this condition would usually be treated by traditional Chinese physicians using blood-vitalizing herbs (with some hemostatics to address the immediate problem of bleeding) followed by a "female formula," that has the effect of regulating menstruation. Modern physicians treat the hormonal imbalance that leads directly to bleeding by using hormone pills (e.g., birth control pills) or by other measures, in some cases, by hysterectomy in women who are approaching menopause. From the Chinese perspective, the treatment would vary depending upon the constitution of the patient and manifestation of the bleeding. Only in cases of weakness and pallor (indicating spleen-qi deficiency) would the imbalance likely be treated with qi-nourishing herbs: specifically, with Gui Pi Tang (weakness and pallor could be the result of the excessive bleeding, rather than the cause). For example, Gui Pi Tang is indicated for the treatment of "preceded menstrual cycle with pale blood," (pale blood indicates a qi and blood deficiency syndrome; darker red blood would suggest a heat syndrome as cause of the bleeding, a condition of short menstrual cycling that corresponds to hormonal imbalance.) The modern Chinese medical practice of utilizing Gui Pi Tang more frequently for treatment of uterine bleeding than other types of bleeding is illustrated by the descriptions in some recent texts. For example, applications of Gui Pi Tang in the book Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (5) are: "...for poor memory due to heart and spleen deficiency, anxiety impairing the heart and spleen, and deficiency of qi and blood, manifesting palpitation, insomnia, night sweating, decreased intake of food, fatigue, sallow complexion, uterine bleeding or menorrhagia, whitish tongue, with thin white coating and thready weak pulse." In an article on spleen disorders by Zhang Hai Feng (10), the section on "tonifying spleen and holding blood in the vessels," states that "It generally occurs in gynecological hemorrhages." Gui Pi Tang is mentioned as the formula of choice. Of course, not all of the Chinese literature focuses on uterine bleeding; this is only the dominant clinical application for the formula (or its modification) in relation to bleeding. In A Comprehensive Guide to Chinese Herbal Medicine (11), the section on bleeding problems lists numerous causes from the traditional viewpoint, as well as the associated therapies. With regard to spleen-qi deficiency, it specifically lists "spitting up of dark or reddish blood" [indicating bleeding in the stomach, hematemesis; bright red blood would indicates bleeding from the lungs] and "melena" [dark feces, usually caused by having bleeding in the intestines]. These are the only bleeding conditions mentioned, implicating bleeding in the gastro-intestinal tract. This focus may have been the result of associating stomach/spleen deficiency, in modern terms, primarily with the gastro-intestinal tract. New Practical Syndrome Differentiation of TCM (12) mentions, under failure of qi in controlling blood, manifestations of "hematemesis, bloody stool, subcutaneous ecchymosis, and metrorrhagia [uterine bleeding that persists apart from the normal menstrual bleeding]." In actual practice, hematemesis, mentioned in both texts, is almost never treated by tonifying qi as the principle of therapy. Before choosing failure of spleen to control the blood as the mechanism involved in a patient experiencing uterine bleeding, one must consider the other causes of uterine bleeding, most notably fibroids, and the appropriate treatment. Fibroids can certainly occur in women with qi deficiency (chronic qi deficiency is one of the traditionally-recognized ways in which pathological processes are able to arise). However, according to Chinese clinical reports, fibroids and resulting uterine bleeding are rarely, if ever, treated by focusing on qi tonification therapy (at least by herbal prescription). In a review I conducted of the Chinese medical literature on clinical experience treating fibroids and uterine bleeding (Treatment of uterine myoma with Chinese herbs ), I found that qi-tonification therapies were briefly mentioned but almost never utilized, with the exception that after the uterine bleeding was controlled via other methods, Gui Pi Wan (the pill form of Gui Pi Tang) was sometimes recommended as a follow-up. A case presentation was made by Shao Nian-fang in his book Treatment of Knotty Diseases... (13), after describing the main categories of concern for functional uterine bleeding, of which deficiency of spleen and kidney was the last one mentioned. A 44-yearold woman presented with menstruation twice per month, each time lasting ten days, with a large amount of blood of light color and no evidence of pathological conditions such as uterine tumors. Today, we would probably describe this as a likely case of perimenopausal menstrual irregularity due to hormonal changes, though this possibility was not mentioned by the author. The woman's constitutional condition was that of qi and blood weakness. The physician's diagnosis was "over strain and over fatigue with impairment of spleen qi, inability to govern the blood, and the debility of the chong a n d re n channels (conception and governor vessels). The formula administered was a modification of Gui Pi Tang, with gelatin (donkey hide extract), cardamon, barley sprout, and magnetite added, and with zizyphus, polygala, and licorice deleted. She took this formula as a decoction for three weeks, and did not have any uterine bleeding during this time. She then took Gui Pi Wan as follow-up for one month (about 6 grams each time, three times daily). The result, according to the author of the report, was that she had normal menstruation for the next six months. Some questions arise: Did the formula restore the ability of qi to control blood? Did the formula alter the woman's hormones to delay a case of premature menopause or prolonged perimenopausal menstrual irregularity? Is there a difference? These questions may be considered by the Western practitioner in defining their own utilization of and reliance upon different models for interpreting symptoms, determining therapies, and

evaluating results of treatment.

CONCLUSION The situation outlined in this article represents one of several cases where modern diagnosis (e.g., gynecological examination, something not done in traditional Chinese medicine until this century) might help to offer guidance in ultimately reaching the correct traditional diagnosis and resulting treatment plan. While a highly skilled practitioner of traditional medicine might be able to make the correct diagnosis without the assistance of modern diagnostic techniques, the more limited training of traditional practitioners in the West makes it imperative that they avoid jumping to conclusions, which seem to be reinforced in several textbooks, based on common phrases (e.g., qi keeps the blood in the vessels). Modern diagnostics may help us get past such natural tendencies of the human mind that lead to erroneous conclusions. I am not proposing that spleen-qi deficiency is never the cause of uterine bleeding (or other bleeding disorder), rather: 1. The finding of spleen-qi deficiency in a patient with bleeding disorder does not necessarily mean that the bleeding disorder is directly caused by that deficiency (to be simply corrected by tonifying spleen qi); and 2. A bleeding disorder, especially chronic uterine bleeding in women past the age of 35, does not automatically qualify as a sign that the patient suffers from spleen-qi deficiency. For the past 650 years Gui Pi Tang has been repeatedly suggested as the remedy for bleeding, especially uterine bleeding, in persons with qi deficiency syndrome. This persistent response suggests that relatively little effort has been expended by Chinese physicians in further analyzing the Pi tong xue principle and the therapeutic methods of addressing it in light of the large number of spleen-qi-invigorating herbs that are available. Modern analyses of the traditionally-defined spleen system have largely focused on its relevance to the digestive system, metabolism, autonomic nervous system, blood constituents, and immune functions (9, 14). Modern analyses of the pharmacological properties and applications of qi-tonic herbs have focused on these same areas (15), without investigating their potential role in treating bleeding disorders.

REFERENCES 1. Yang Shouzhong, Zhong Zang Jing: Master Hua's Classic of the Central Viscera, 1993 Blue Poppy Press, Boulder, CO. 2. Xie Zhufan and Huang Xiokai (eds.), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong. 3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (4 vol.) 1995-6 New World Press, Beijing. 4. Maciocia G, The Foundations of Chinese Medicine, 1989, Churchill Livingstone, London. 5. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. 6. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. 7. Shang Xianmin, et al., Practical Traditional Chinese Medicine and Pharmacology: Clinical Experiences, 1990 New World Press, Beijing. 8. Domei Yakazu, The application of Gui Pi Tang, Bulletin of the Oriental Healing Arts Institute of U.S.A., 1980; 5(3): 21-28. 9. Kuang Yuanliang, et al., A study on hemorrheology in patients with spleen qi deficiency, Journal of Traditional Chinese Medicine, 1988; 8(4): 235-238. 10. Zhang Hai Feng, Spleen and stomach in traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine; 1983; (3): 43-81. 11. Ze-lin Chen and Mei-fang Chen, A Comprehensive Guide to Chinese Herbal Medicine, 1992 Oriental Healing Arts Institute, Long Beach, CA. 12. Wang Qi and Dong Zhi Lin, New Practical Syndrome Differentiation of T.C.M., 1992 China Ocean Press, Beijing. 13. Shao Nian-fang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine, 1990 Shandong Science and Technology Press, Jinan. 14. Wang Jianhua, Modern investigation on the nature of pi (spleen) in traditional Chinese medicine, in Zhou Jinhuang and Liu Ganzhong (eds.), Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing. 15. Dong Zhilin and Yu Shufang, Modern Study and Application of Materia Medica, 1990 China Ocean Press, Beijing.

September 1998

CHINESE HERBAL MEDICINE FOR THE TREATMENT OF HEPATITIS B INFECTION by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

INTRODUCTION Hepatitis B is endemic in Southeast Asia, estimated to infect up to 20% of the population in some areas, such as the crowded subtropical city of Guangdong (Canton), China, with nearly as high infection rates in other major urban areas of China. In a 1983 survey by the Hong Kong Medical and Health Department, it was found that 10% of the local population are hepatitis B virus carriers. Statistics compiled at the Third Teaching Hospital of Zhongshan Medical College (Guangzhou), which specializes in the treatment of liver diseases, indicated about 15% of the local population in 1983 were hepatitis B carriers. Since techniques used at the time could not detect many cases, and because the epidemic has been spreading, figures of 20% infection rates are reasonable estimates of the situation in 1997. Hepatitis B is responsible for considerable morbidity and mortality, contributing to the incidence of liver cancer, the main cause of death in this area: 95% of liver cancer patients in Southeast China test positive for hepatitis B virus. Infection by hepatitis B is a reason for denial of exit visas from China. Further, the Chinese government has announced tentative plans to enforce strict birth prevention measures for those who test positive for viral hepatitis, as part of a larger program to reduce the number of births of children with various kinds of "defects." Hepatitis B is also a major concern in other parts of the world, with its spread increasing to epidemic proportions during the past two decades. The vaccine that is used to prevent infection has not been well-accepted even by Western medical professionals who are at substantial risk of infection from their patients. Nonetheless, today it has become common practice in the U.S. to inoculate newborns against hepatitis B due to the high lifetime risk of infection. Historical records indicate that a disease corresponding to hepatitis B was known to Chinese doctors at least 1,800 years ago. At that time, the primary therapeutic measure was to prescribe a combination of Chinese herbs, usually in the form of a decoction. The ingredients used in making such decoctions-which include some herbs well-known in the West, such as rhubarb, licorice, and cinnamonhave been a matter of record kept for all subsequent generations, so that today it is quite easy to study the traditional Chinese medical theory and specific treatments for infectious hepatitis. In ancient times, the appearance of jaundice was a primary indication of the disease, and relief of jaundice would indicate that the therapeutic measures were effective. Today, jaundice is most frequently associated with hepatitis A, an acute disease which, though often severe in symptoms, is usually self-limiting. Hepatitis B, especially in the chronic cases and in well-nourished individuals, rarely produces obvious jaundice. Therefore, other measures of the disease are relied upon to monitor its progress and cure, such as serum levels of liver enzymes, antibodies to viral antigens, viral antigens, and viral DNA. Beginning around 1950, scientific evaluation of herb materials used for treatment of viral hepatitis was undertaken in China and Japan, including isolation of active constituents, testing of crude herb extracts and purified components in laboratory animals, and clinical studies of complex formulas, individual herbs, isolated components, and synthetically-modified ingredients. Of the more than 6,000 species of plants and animals used as sources of Chinese medicine, about 150 crude materials have been identified as having measurable activity against viral hepatitis. The actions of anti-hepatitis herbs may be subdivided, for purposes of discussion, into two categories. One category is "hepatoprotective," including herbs and isolated compounds demonstrated to protect laboratory animals from the toxic effects of carbon tetrachloride, a liver poison that is frequently used to assay the ability of a substance to alleviate inflammation. Liver protection can reduce the impact of viral hepatitis without necessarily reducing the viral load or the immune response to the virus, though it appears that by using compounds with this property, the activity of the virus is often reduced. This might occur by making it more difficult for chemical and biochemical activators of the virus to affect cell surface receptors or to enter the infected liver cells; the ability of the virus to infect new cells may also be impeded by these compounds. Liver protection appears to be conferred by several processes including antioxidant activity, stimulating bile production and release, and by inhibiting inflammation and fibrinogenesis. The other category is "antiviral," indicating the ability to inhibit viral activity by promoting the production of interferon or other immune responses to viruses (including both cell-mediated and antibody responses to infected cells), or by blocking some step in viral replication, such as reverse transcriptase. In clinical trials conducted in China during the past twenty years, reduction of serum liver enzyme levels (ALT, AP) and seroconversion from HBsAG+ or HBeAG+ to negative are usually used as modern standards of effectiveness, along with various measures of symptom reduction. As revealed in this article, such tests have been used to demonstrate that a wide range of Chinese herbal compounds are highly effective in the treatment of viral hepatitis; specific results vary because of differing treatments and because of selection of differing populations for study. In some clinical trials, up to 2/3 of patients show seroconversion, and clinical improvement to "normal" may be attained for about 80% of the patients. In Japan, medical doctors who prescribe Chinese herbs (up to 40% of all Western-trained medical doctors in that country) report that a diagnosis of hepatitis is one of the principal reasons for starting a patient on a course of Chinese herb therapy and that the Chinese herbs are more effective than Western medicine for treating this disease. An objection that may be raised by Western researchers regarding the published Chinese studies is that the clinical reports may lack sufficient detail to reveal the true impact of the treatments. The number of tests available for analyzing the results of therapeutic interventions has grown in recent years, but not all such tests have been used in the Chinese research, perhaps because of budgetary limitations. The formula described in this article was administered in China to patients who were hospitalized for 12 weeks while taking the herb materials. Antigen tests for both HBsAg and HBeAg, plus PCR evaluation of hepatitis viral DNA, were utilized to confirm the status of the hepatitis infection before and after treatment. Results comparable to previously-published Chinese trials were attained. This confirmation may help alleviate some of the concerns about results reported in other trials, making it possible to further utilize the vast experience of Chinese researchers in order to develop a satisfactory treatment for hepatitis B that is both economical and easily applied.

PRINCIPAL HERBS/ACTIVE COMPONENTS FOR TREATING HEPATITIS B

Licorice and Its Component Glycyrrhizin One of the substances frequently mentioned in the Chinese literature regarding hepatitis B is glycyrrhizin, a component of licorice root (Glycyrrhiza uralensis is the species used in China). Licorice was an ingredient in many of the prescriptions used in ancient times to treat hepatitis. The root is well-known for its anti-inflammatory activity; the root, its crude extract, certain active components, and synthetic derivatives of the active components are used in modern pharmacies for the treatment of gastric ulcer. Glycyrrhizin zinc is useful topically as a treatment for skin inflammation and ulceration. In Japan, recent in vitro studies indicate that glycyrrhizin sulfate may be a useful compound for inhibiting HIV infection of cells, based on antiretroviral activity. Glycyrrhizin ammoniate is a common flavoring agent used in the U.S., so the recognition that glycyrrhizin is safe makes it attractive. Large doses of licorice or glycyrrhizin can, however, lead to increased aldosterone production (by the adrenals) and imbalance of serum sodium and potassium levels (both by affecting NaK-ATPase directly and via the action of aldosterone) in susceptible individuals. This response is not common when glycyrrhizin is used in standard therapeutic amounts for treatment of hepatitis; a typical dosage of glycyrrhizin corresponds to 15 grams per day of crude, dried licorice. Licorice and its active components can be used in the treatment of Addison's disease (characterized by reduced production of aldosterone and other corticosteroids). Glycyrrhizin is an antioxidant and it promotes production of interleukin-2 (IL-2), two actions that help inhibit viral diseases. Glycyrrhizin sulfate appears more active than ammoniate or other forms. Crude licorice extract has the advantage of easy access, low cost, and a combination of several valuable active components, but isolated glycyrrhizin is more readily absorbed than the glycyrrhizin in the total herbal extract. Schizandra and Its Component Schizandrin Schizandrin, a lignan, is an active component of schizandra, the fruit from Schizandra sinensis. Studies conducted in the 1970's in China revealed that schizandra and its component schizandrin could strongly lower ALT and AP in animal models of hepatitis and in human patients. However, it tended to have the problem that when administration of the compound ceased, there was a rebound in these enzyme levels. Screening of various analogues led to the production of a new drug for hepatitis known as DDB (dimethyl 1-4, 4'-dimethoxy5,6,5', 6'dimethylene dioxybiphenyl 1-2, 2'-dicarboxylate). This compound is strongly hepatoprotective, lowering ALS and AP, reducing alpha-fetal protein levels and bilirubin, and reducing liver lesions, as indicated by biopsy. DDB, as a new drug, has undergone numerous trials in China, but is not an accepted drug in the West. Schizandra extract has the advantage of being a safe food product of China that is also widely used in the U.S. as an energy tonic and immune enhancing agent. In China, it is used in the treatment of many ailments, including asthma, poor memory, severe fatigue, enteritis, and diabetes, as well as for viral hepatitis. It enhances adrenal cortical function. In clinical tests of anicteric infective hepatitis, just 3 grams per day of powdered schizandra fruit for one to three months led to a clinical cure in 65% of cases. Higher doses, up to 15 grams per day, have been used in the treatment of chronic hepatitis. It has been reported that schizandra, like its isolated lignans, has a quick action and high rate of effectiveness for reducing plasma liver enzyme levels, but that relapse occurs relatively easily. It has been suggested that schizandra be used with other herbs to increase the therapeutic effect and prevent relapse. Salvia and Its Components the Tanshinones Salvia is perhaps the most frequently used herb in the modern practice of Chinese herbal medicine. Salvia has been known to Chinese doctors for centuries, but had been used in only a few applications, while today it is applied in the treatment of a wide range of diseases and symptoms. Salvia has a complex chemistry, and as a result, the crude herb extract is often used rather than an isolated component. The main active constituents are the tanshinones, a type of naphthaquinone. Salvia is used in China as a health food product; regular ingestion is thought to prevent cardiovascular diseases and other problems of aging. Salvia plays two major roles in the treatment of liver disease. First, it has been learned that in cases of severe or chronic liver disease, there are alterations in microcirculation (capillary bed circulation) that appear to be part of the disease process. Patients treated with salvia who show clinical improvements also show normalization of the microcirculation. Second, salvia inhibits fibrinogen and aids in the resorption of fibrous plaques in the liver. It is thus widely used in the treatment of liver cirrhosis. Salvia is provided as a single herb or in complex formulas in the treatment of both acute and chronic hepatitis. As a single herb, it is given intravenously to quickly improve the condition of patients suffering from liver or kidney diseases. Usual oral dosages of salvia for treating severe diseases are 1520 grams in decoction. Hu-Chang and Its Anthraquinone Components Hu-chang (Polygonum cuspidatum) refers to one of the many species of Polygonum used by Chinese doctors. It contains anthraquinones as main active components, as well as resveratrol, a stilbene. The herb, used alone, or in combination with other herbs, has been reported to cure both acute and chronic hepatitis, though it has been suggested to have greater impact on acute hepatitis. Hu-chang is one of the broad-spectrum antiviral agents under investigation in China and Japan. Hu-chang prevents lipid peroxidation, and thus prevents hepatic degeneration; it also promotes liver cell regeneration through RNA synthesis. The herb has been used in China to rescue patients with severe viral hepatitis who do not seem to recover when given standard Western therapies. In addition, hu-chang influences microcirculation in a manner similar to salvia. Curcuma and Its Essential Oil Components Curcuma (yujin) refers to one of three major species of curcuma used in Chinese medicine, the other two are turmeric (huangjiang) and zedoaria (ezhu) . It contains a complex essential oil that regulates blood lipids and treats infectious hepatitis. In a study of acute and chronic hepatitis involving 33 patients, all but one responded to the daily ingestion of a powder of curcuma (5 grams each time, three times daily), with 2/3 of the patients having subjective symptoms completely relieved. Curcuma stimulates bile secretion. Curcumin, a bright yellow complex ketone found in both turmeric and curcuma, is currently under investigation as an anti-HIV agent; it appears to block a long terminal repeat (LTR) during reproduction of the virus. This action may apply to other viruses and to preventing activation of cancer genes. Curcumin is also a powerful anti-inflammatory agent. Ligustrum and Its Component Oleanolic Acid Ligustrum refers to the seed of Ligustrum lucidum. It is rich in oleanolic acid, a compound that appears to be effective in treatment of liver diseases, acting mainly as a liver-protective agent. It is reported to be efficacious in treating both acute and chronic hepatitis, with a cure rate of 70% for acute hepatitis and it was markedly effective in treating 44% of cases of chronic hepatitis. Ligustrum has been identified as one of the herbs that strongly enhances immune responses, reversing leukopenia from cancer therapeutic agents. Ligustrum is used as a health food in the U.S. to enhance immune functions.

Silybum and Its Component Silymarin Silymarin is a complex flavonoid from Silybum marianum, an herb that was initially introduced as a therapeutic agent by European researchers, but soon taken up by their counterparts in China as a treatment for liver diseases. Its main action is to protect the liver from damage, and it is used, for example, in the early stage of liver destruction due to ingestion of poisonous mushrooms, to save the lives of victims. A concentrated extract of silybum, rich in silymarin, is sold as a health product in the U.S. and the isolate has been sold as a drug in Europe ("Legalon") for the treatment of liver disease for the past 15 years. A dosage of 140 mg/day is reported to be liver protective and a dosage of 420 mg/day is reported to help repair liver damage. It is not clear that silymarin can cure viral hepatitis. Silybum extracts are widely sold as health foods in the United States.

A PROTOCOL FOR TREATMENT The following formula is recommended for treatment of hepatitis B and was the subject of a clinical trial conducted in China during 1994-1996, and later produced as a tablet for use in Western countries (Seven Forests Salvia/Ligustrum Tablets): Salvia (danshen, root of Salvia miltiorrhiza): 21% Atractylodes is included in this formulation as a digestive aid, Licorice (gancao, root of Glycyrrhiza uralensis): 16% though its use can also be justified on the basis of laboratory studies Hu-chang: (huzhang, rhizome of Polygonum cuspidatum): 16% showing that it protects mice from liver injury induced by carbon Curcuma (yujin, tuber of Curcuma longa): 11% tetrachloride and promotes liver cell regeneration; it is also used as Schizandra (wuweizi, fruit of Schizandra sinensis): 10% an ingredient in several complex formulas for treatment of viral Ligustrum (nüzhenzi, fruit of Ligustrum lucidium): 16% hepatitis. Atractylodes (baizhu, rhizome of Atractylodes macrocephala): 11% [total is 101% due to rounding] The herb ingredients are made as a decoction, dried, and formed into tablets of 800 mg each (880 mg in the Chinese clinical trial). The dosage schedule for the herb materials is 9 tablets each time, three times daily, for a total dose of 27 tablets or about 23 grams of herb extracts. This corresponds, approximately, to 94 grams of crude herb materials used to prepare a decoction, after which the decoction is dried [the herb extract was manufactured by Sun Ten Laboratories, Irvine, California]. The daily dosage of licorice, which is the marker compound for determining dosage of the mixture to administer, is 15 grams. A vitamin tablet was used simultaneously, one tablet each time, three times daily in the Chinese trial. Each tablet contained: Silybum extract (8:1): 135 mg In the U.S., this tablet is replaced by two formulas (produced by ITM, White Tiger label): Vitamin C (as calcium ascorbate): 250 mg Quercenol, an antioxidant mixture that includes silybum, and Calmagnium, a mineral/vitamin Beta carotene: 6 mg (10,000 IU) mixture. In addition, some protocols include Alpha-Curcumone (a source of alpha-lipoic acid, Vitamin E: 133 IU an antioxidant used in the treatment of hepatitis). At standard recommended dosage, these Zinc (acetate): 5 mg Selenium (amino acid chelate): 40 mcg supplements provide a larger amount and wider range of nutrients and antioxidants that were applied in the Chinese trial. Quercetin: 100 mg l-Cysteine: 40 mg DURATION OF TREATMENT Vitamin B1 : 5 mg Based on clinical experience in China, a 12-week treatment period is satisfactory as a standard Vitamin B2 : 3 mg course of treatment for chronic hepatitis B, which can be repeated once more if necessary. The Vitamin B3 : 10 mg basis for recommending this treatment period is a compromise between maximizing Vitamin B5 : 10 mg compliance and assuring measurable activity of the prescribed compounds. For the purpose of Vitamin B6 : 12 mg assuring maximum compliance, the treatment duration should be as short as possible. The Vitamin B12: 50 mcg minimum duration of treatment depends on the amount of time that is reasonable to obtain a satisfactory therapeutic effect, which is defined for the purpose of the Chinese study as the Folic acid: 200 mcg ability to attain 50% of patients experiencing both seroconversion (of HBsAg and/or HBeAg), and a decline of ALT and AP to within 1.5 times the maximal level of the normal range. For the other 50% (or fewer) of the patients, a second course of treatment is recommended. A certain number of non-responders is to be expected, even with two courses of treatment. A problem with long-term follow-up in the case of hepatitis B is that reinfection is always possible, especially since the disease can be sexually transmitted and the individual's partner may not have been treated at the same time. On the other hand, it is possible that the primed immune system of the successfully treated patient can prevent reinfection. According to Chinese reports, reversion to positive antigen test response occurs in only about 10% of patients successfully treated with Chinese herbs if followed-up during the first year after conclusion of herb therapy. This apparent conversion to positive hepatitis test is probably the result of activation of remaining latent virus in most cases.

SAMPLE STUDIES Following are brief reviews of eight clinical trials in which a treatment time of three months or less was sufficient to obtain results such as those suggested above. The numbers in brackets after the study summary are the reference codes for the report abstract as found in the journal Abstracts of Chinese Medicine. 1. Study reported in 1989 of treatment of chronic active hepatitis B. The treatment protocol included a decoction, a tableted herb component, and vitamin E, used daily for three months. The control group used biphenyldicarboxylate (in place of herb decoction), plus the herb tablet and vitamin E. The seroconversion rate of HBsAg for those taking the herb decoction was 67%, while that for the control was just 7%; for HBeAg, the rates were 53% and 13% respectively. In a one year follow-up of 20 cases from each group, the relapse rates were 10% and 60% respectively. According to this study, a three month treatment time was adequate to obtain a 50% seroconversion rate. [891191] 2. Study reported in 1989 of asymptomatic carriers with positive HBsAg treated with a decoction given twice daily for one month as a treatment course. If the HBsAg test became negative, the decoction was administered only every other day for one or more additional months, but if it remained positive, an additional herb was added and the treatment continued daily. When the test was negative twice consecutively, the treatment was discontinued. 58 of 80 cases (73%) were cured within three courses of therapy and 17 others had reduced HBsAg titers. This study shows that three months of therapy is adequate to obtain at least 50% seroconversion. [891152]

3. Study reported in 1991 included 304 patients with chronic hepatitis B. They were treated with herbs in pill form for 2 to 3 months. 128 of the patients, 63%, were rated cured, with HBsAg and HBeAg becoming negative. Only 32 patients failed to respond. This study shows that a three month treatment period is adequate for at least 50% seroconversion. [930249] 4. Study reported in 1982 involving 80 patients with chronic or acute hepatitis. Glycyrrhizin was administered along with vitamins to the treatment group and the vitamins were given with injection of inosine in the control group. Treatment time was one month for acute hepatitis and three months for chronic hepatitis. Clinical cure was claimed for 85% of the acute hepatitis group and 75% of the chronic hepatitis group treated with herbs. Only a few of the patients treated here were positive for HBsAg and HBeAg. Of those who were positive, there was no seroconversion in the control group, but seroconversion occurred in about 50% of the glycyrrhizin treated group. Most of the seropositives at the beginning of the trial were in the chronic hepatitis group. This study indicates that 50% seroconversion can be achieved in a three month period of treatment. [Reported in the English language Journal of Traditional Chinese Medicine 1982; 4(2): 127-132] 5. A study reported in 1987 with 104 patients having hepatitis A and 72 having hepatitis B, all acute cases, were treated with a decoction plus vitamin B complex, vitamin C, and diisoproplylamine ascorbate. It was claimed that 158 cases (90%) were cured in 6 to 24 days, average duration of treatment was 16 days. Seroconversion information was not provided. This is consistent with the practice of treating acute hepatitis (A or B) for only about one month. In some other studies of acute hepatitis, a course of treatment was 15 days and might be repeated once. [880291] 6. A study reported in 1987, with 71 cases of hepatitis B with positive HBsAg, were treated with a decoction of herbs. Acute cases were given 3-4 doses per day for 20 days as a therapeutic course. Other cases were given just 2 doses per day for 30 days as a therapeutic course. When HBsAg became negative, the treatment was reduced to once every other day for one month. A control group received Western drugs and, if SGPT was elevated, an herb syrup known to control that condition was given. 47 cases in the treatment group (67%) seroconverted. The exact number of therapeutic courses was not reported in the abstract, but presumably was one to three courses, as standard practice. [880263] 7. In a study reported in 1987, a treatment for hepatitis B in decoction form was given to 31 patients. The effect of this therapy, based on tonic herbs, was not especially great, but it was reported that it took "at least two months" to attain seroconversion. A three month trial with a more effective therapy would therefore appear adequate. [880251] According to this information, among the participants who respond to the therapy, those with acute hepatitis should be cured (or improved) within about two months and those with chronic hepatitis should be cured (or improved) within three months.

POSSIBLE ADVERSE REACTIONS There are some potential adverse reactions to any herb therapy, as follows: a) gastro-intestinal reactions including nausea, bloating, flatulence, diarrhea, constipation, vomiting. b) allergy type reaction, including hepatic reaction. The above reactions are idiosyncratic, that is, they cannot be predicted in advance and do not represent inherent properties of the selected herbs. If such reactions occur, it may be necessary to have the individual experiencing the reaction discontinue the treatment. The gastro-intestinal reactions usually subside within three to five days and thus they should be tolerated for that long before discontinuing unless they are severe. Allergy-type reactions are not expected to resolve with longer use of the herbs. There are some possible specific reactions to the therapies. Licorice may cause excessive aldosterone production, with symptoms of edema, fatigue, and arrhythmia. The dosage of licorice in this protocol is set at a level for which this reaction is rare. Hu-chang, which contains anthraquinones, ligustrum, which contains oils, and curcuma, which increases bile flow, may induce intestinal peristalsis, loose stool, or diarrhea. In most individuals, this response will resolve with continued use of the herbs. However, in rare instances, the problem might persist. In the Chinese clinical trial of the herb formulation described here and in three years experience in the U.S. with the same preparation, adverse reactions to the herb/nutrient treatment have not been observed. In the event that such responses are noted and believed to be due to the herb therapy (as opposed to due to the hepatitis), the herb therapy should be discontinued for two consecutive days, to determine whether or not the observed problems are due to the ingestion of the herbs (for liver hypersensitivity reaction, the duration of symptom persistence could be longer). None of the herbs are inherently toxic in the dosage range recommended.

TRADITIONAL CHINESE MEDICAL DESCRIPTION OF THE HERB THERAPY Hepatitis begins as an acute disease (with manifestations of heat), which is described in Chinese medical terminology as a toxic heat syndrome. As the disease develops, it is said to manifest symptoms of accumulated dampness and liver qi stagnation. In the event that the disease becomes chronic, it is believed that the yin becomes deficient, there is blood stasis (mainly affecting the liver), and the qi is weakened (weakness of qi may be the cause of the acute disease becoming a chronic disease). Hu-chang is the herb that has been selected to treat the toxic heat syndrome. It is described as a cold, bitter, mildly pungent, and sour agent that clears up heat, detoxifies, invigorates blood, and disperses swelling. Antibacterial and antiviral effects have been demonstrated in pharmacology experiments with this herb. Curcuma is the herb that has been selected to treat the stagnant qi that develops. The herb is said to have a cool property, with a bitter and pungent flavor. It is traditionally used to regulate the flow of qi, resolve qi stagnation, disperse stagnant blood, and control pain. It is applied to treatment of liver pain and jaundice. Modern research shows that it stimulates gastric secretion and bile secretion, to improve appetite and improve digestion. Salvia is the herb that has been selected to treat blood stasis. It is described as having a mild cold property and bitter flavor. It is traditionally used to invigorate blood circulation, cool the blood, nourish the blood, and calm mental irritability. Modern research shows

that it rectifies abnormal patterns of capillary bed circulation and successfully treats viral hepatitis when used in relatively large dosage. Ligustrum is the herb that has been selected to treat yin deficiency. It is described as having a neutral property and bitter taste. It is traditionally used for yin deficiency, internal heat, weakness of the lower back and legs, and insomnia. Recent studies indicate that it enhances immune functions and protects liver cells from damage. Licorice has been selected as the qi tonic herb. It is described as having a neutral property and sweet flavor. It is traditionally used to supplement the spleen, replenish qi, clear heat, remove toxin, and harmonize the stomach. It has been applied in the treatment of toxic swellings, diarrhea, thirst, cough, and palpitation. Recent studies show that it has anti-inflammatory action similar to that of the corticosteroids. Atractylodes has been selected as the herb to remove dampness. It is also a qi tonic herb. It is described as having a warm property, sweet, mildly bitter and aromatic flavor. Traditionally, it is used to supplement the spleen, tonify qi, dry dampness, deliver water, harmonize the stomach and spleen. It has been used for treatment of fatigue, loss of appetite, diarrhea, edema, spontaneous sweating, vomiting, and dizziness. Modern research shows that it promotes immune system functions, protects the liver from chemical injury, and has anticoagulant properties. Schizandra has been selected as an aid to the qi tonic (licorice) and the yin nourishing herb (ligustrum). It is traditionally described as having a warm property and sour flavor. It is used to nourish the kidneys, astringe the lungs, control diarrhea, and promote secretion of fluids (e.g., saliva). At higher dosage, it is said to reinforce the qi and nourish the yin. It has been applied to the treatment of fatigue, insomnia, amnesia, thirst, spontaneous sweating, cough, and thirst. Modern research shows that schizandra enhances adrenocortical function, promotes bile secretion, and reduces liver enzyme levels. The complex formula has the properties of tonifying and regulating qi, of nourishing and astringing yin, of vitalizing blood, clearing heat and toxin, and drying dampness. Its quality is cooling, its taste is mainly sweet and bitter, with some sour and acrid (pungent) properties.

HERB DOSAGES Chinese doctors recommend herbal dosages that have been recorded in the classical and modern Materia Medica publications. Modern clinical trials confirm the validity of these dosage suggestions. Generally speaking, when making a complex formula, the dosage of most ingredients is lower than would be utilized if the herb was selected as a sole ingredient, due to the expectation of synergistic action (attaining the same goal through complementary pathways). Because of the relatively short duration of treatment in this study, the dosage of each item has been selected at a relatively high level within the range that is usually recommended. Hu-chang is recommended to be used in the dosage range 9-30 grams/day. A daily dosage of 15 grams has been selected for this treatment. In higher dosage, the herb can cause dry mouth, bitter after taste, nausea, vomiting, abdominal pain, and diarrhea. Curcuma is usually recommended in the dosage range 4.5-9 grams/day. However, in a published trial for treatment of hepatitis, it was used in a dosage (as powder) of 15 grams/day. A daily dosage of 10 grams per day has been selected for this treatment. In higher dosage, this herb may cause abdominal aching and diarrhea. Salvia is recommended in the dosage of 6-15 grams for typical uses, but 15-30 grams to treat severe diseases, and up to 30-60 grams for severe blood stasis syndrome. The extract has been used intravenously in doses of 22.5 grams or higher (raw material equivalent) for treatment of hepatitis. A daily dosage of 20 grams has been selected for this treatment. Higher dosage may cause dry mouth, dizziness, lassitude, numb sensation of limbs, shortness of breath, nausea, vomiting, and gastrointestinal disturbance; these responses tend to subside of themselves without suspending treatment. Ligustrum is recommended in dosages of 6-15 grams per day. Doses of up to 50 grams per day (made as fluid extract) have been used successfully to treat bronchitis. A daily dosage of 15 grams has been selected for this treatment. Higher dosage may cause bloating and diarrhea. Licorice is recommended to be used in doses of 3-6 grams per day. Doses up to 18 grams per day have been used in treatment of tuberculosis. 7.5-15 grams per day have been used to treat gastric and duodenal ulcers. A daily dose of 15 grams has been selected for this treatment. Excessive dosage or long-term use of moderate dosage can cause an adverse reaction in up to 20% of patients, including possible symptoms of edema, weak limbs, spastic numbness, dizziness, headache, hypertension, hypokalamia. Atractylodes is recommended in the dosage range of 3-12 grams. Doses up to 60 grams per day have been used for short-term applications. A daily dose of 10 grams has been selected for this treatment. Adverse reactions to large dosage have not been described, but gastro-intestinal responses might be expected. Schizandra is recommended in the dosage range of 1.5-9 grams per day; with 6-9 grams per day recommended to reinforce qi and nourish yin. Up to 15 grams per day (powdered herb) have been used in the treatment of hepatitis. A daily dosage of 9 grams has been selected for this treatment. Higher dosage may cause heartburn, acid indigestion, stomach ache and anorexia. The total dosage of the seven herbs is 94 grams. In a review of hepatitis formulas listed in modern Chinese books (at the ITM library), formulation characteristics were as follows: except for the one formula used temporarily at very high dosage, the formula size and dosage range is reasonably consistent at 9-12 herbs and 100-140 grams, typically 11-14 grams of each herb. In the formulation described in this article, the number of herbs is only 7, and the total dosage is just 94 grams (average, about 13 grams each). This reduction in number of ingredients-compared to that used in several recent trials with complex formulas-has been purposefully chosen to simplify the treatment protocol. A few clinical trials rely on one to three herbs. The relatively lower total dosage was deemed likely to be effective as the higher dosage treatments because of the careful selection of ingredients (focused formula design). It should be noted that there is an additional herb extract present in the "vitamin tablet," namely silybum, thus raising the total number of herbs to 8 (the substitute item, Quercenol, contains other herb extracts, including those from green tea, sophora, and grape seed); the dosage of herbs is therefore slightly increased by the inclusion of the vitamin tablet. The additional vitamins and minerals may provide an action in the

current protocol that would otherwise have been obtained from herb ingredients.

RESULTS OF ONE CHINESE CLINICAL TRIAL In a clinical trial carried out at three test sites in China, there were 94 inpatients treated and evaluated, utilizing three therapies (at each site). The main test therapy was the formula now called Salvia/Ligustrum Tablets, taken with the vitamin tablet. The primary control therapy was a tablet of the same size and same dosage made with lentinus extract (shiitake mushroom, used in Japanese treatment of hepatitis B), atractylodes, and schizandra; the control patients also took the vitamin supplement. The third control group took a patent medicine made in China that was understood, by the Chinese researchers, to be the most effective one available. As a result of 12 weeks treatment, in the Salvia/Ligustrum group and the Lentinus group there was marked improvement in symptoms and liver enzymes, more so than with the Chinese patent remedy. Antigen conversion from positive to negative occurred for HBeAg in 2/3 of patients treated by Salvia/Ligustrum or Lentinus Tablets, but in only 1/3 of those receiving the Chinese patent. HBsAg conversion occurred only in a few patients, 2 receiving Salvia/Ligustrum, 1 receiving Lentinus, and none receiving the Chinese patent. Nearly half (9/20) of those tested showed viral DNA conversion from positive to negative in those receiving Salvia/Ligustrum, and in one-third (7/21) of those receiving Lentinus, but only in about one-fourth (6/26) of those receiving the Chinese patent. In sum, the Salvia/Ligustrum formula (used with a nutritional supplement) produced excellent results in treating hepatitis B patients. There were also obvious benefits, though less dramatic, for treatment with lentinus, schizandra, atractylodes, and the nutritional supplement. These treatments were superior to one that had been deemed the best available in China by the researchers. The study was conducted at the Hepo Medical Technical Research Institute in Beijing, the Haixia Hospital in Quanzhou (Fujian Province), and the Henan Medical Science Institute. Testing equipment and reagents were provided by the Tumor Virology Department of the Centers for Disease Control, Atlanta. The original study design called for treatment of 200 patients. New government regulations in China require data on safety (such as laboratory animal tests) in order to carry out clinical trials, unless the herbs are in the form of decoction. This regulation halted (perhaps temporarily) continuation of the trial despite the fact that no significant adverse events were noted for any of the participants enrolled thus far.

REFERENCE SOURCES The Chinese Medicinal Materials Research Centre at the Chinese University of Hong Kong (in Shatin) produced three resources which provided most of the background information about active constituents, pharmacology, and clinical trials used in this article: The two volume book Pharmacology and Application of Chinese Materia Medica, edited by Chang and But, published by World Scientific (Singapore), copyright 1986. The proceedings of a meeting that took place in 1983, Advances in Chinese Medicinal Materials Research, edited by Chang, et al., published by World Scientific (Singapore), copyright 1985. The meeting had a section on liver diseases for which seven papers were presented in the proceedings. The quarterly journal of English language abstracts of Chinese medical journal articles, Abstracts of Chinese Medicine, published continuously since 1986; the 1988 issue (vol. 2. #1) included the review by Han Dewu, et al.: "Chinese medicines for the prevention and treatment of viral hepatitis." Additional information was obtained from the following English language sources: Recent Advances in Chinese Herbal Drugs, Science Press, Beijing, 1991. A news article in Beijing The Illustrated Chinese Materia Medica, by Yen, SMC Publishing, Taipei, 1992. X i n h u a [English version], Oriental Materia Medica by Hsu and Hsu, Oriental Healing Arts Institute, Long Beach, CA 1980. Modern Study and Application of Materia Medica by Dong and Yu, China Ocean Press, Beijing, 1990. December 20, 1993, and reported again in New York Journal of Traditional Chinese Medicine [English], Beijing, published continuously since 1981. Times, Feb. 27, 1994, described plans for eugenics policies in China that included hepatitis B infection. An article, "A historical study of Chinese drugs for the treatment of jaundice," by Saburo Miyasita in American Journal of Chinese Medicine, (4(3), 239; 1976), provides background information on herbs mentioned in early Chinese literature. Formulation of the vitamin supplement was based, in part, on information obtained from: Nutritional Influences on Illness, by Werbach, Third Line Press, Los Angeles, 1993.

May 1997

HEPATITIS C: Update 2001 by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

This report provides additional and new information to the May 2000 article Update on hepatitis C treatment. The year 2000 report includes information about possible drug interactions between Chinese herb formulas and interferon treatment and other important information that is not repeated here.

1. THE DISEASE, ITS PREVALENCE, AND MODERN MEDICAL TREATMENTS Much progress has been made in recent years to understand the nature of hepatitis C infection. It is now possible to determine subtypes of hepatitis C virus that help estimate the risk of disease progression and the likelihood of response to interferon therapy. If a patient undergoes such testing, they can more readily make a decision about whether to try the modern therapy. The number of cases of hepatitis C was reported in the media to be 4 million or more in the U.S. several years ago (which would mean about 5 million cases by now). It is actually now estimated to be about 2.7 million, or about half what was guessed before. The cumulative total number of U.S. cases may be about 4 million, but many people who had carried the infection since it was introduced here about 40 years ago have died, usually of causes other than hepatitis. This same situation-excessive estimates of disease incidenceoccurred with the HIV epidemic in the U.S., where the media reported that there were a million people with the infection in the U.S. at a time when the actual number was far lower. The figure of one million was a high estimate of how many total cases there had ever been, including many who were deceased. Most of the hepatitis C cases in the U.S. are among injection drug users who share used needles (1), with infection rates estimated to be 90% (possibly higher in subgroups that do not attempt drug withdrawal procedures, such as methadone replacement therapy). Those dependent on opioids, mainly heroin, may account for about 2 million of the cases. Only a small fraction of those infected by hepatitis C in the U.S. acquired the virus either by blood transfusions (before 1990, when the prevalence of hepatitis C was still low, perhaps fewer than 1 million in the U.S.) or by other routes of transmission (mainly involving some form of blood to blood contact). It is still estimated that, of those infected by hepatitis C, only 20% will go on to suffer from significant liver disease (cirrhosis, fibrosis, and possible liver cancer); about half of those might require liver transplantation as a therapy due to life-threatening complications. Of those who suffer the adverse developments of hepatitis C, the disease progression may be partly the result of behaviors that contribute to liver damage (such as abuse of alcohol, excessive consumption of fatty foods) or from long-term infection that has not been treated by any effective method. Therefore, persons who get an early diagnosis and take reasonable steps to protect their liver from controllable sources of damage may have far less than a 20% risk of developing severe liver damage. There are new forms of interferon (2, 3) that have been developed that may increase the likelihood of complete viral inhibition by this method of therapy (six month intervention with interferon), which would then reduce the possible need for constant vigilance over lifestyle factors. Even when interferon fails to reduce the viral load, there is evidence that it reduces liver inflammation and may protect against liver cancer developing later.

2. CHINESE MEDICAL THERAPIES The use of salvia to reduce liver fibrosis that can occur as viral hepatitis progresses has been a continuing subject of investigation (4, 5, 6). Attention has focused on one of the active components, salvianolic acid A (also called Tanshinone A). Salvia was reported to reverse fibrosis in test animals that had chemically-induced liver damage. Herb formulas with salvia and other blood-vitalizing herbs have been claimed to halt the development of fibrosis and even reverse it; however, these clinical results need to be confirmed under more stringent conditions. Traditional Chinese medical (TCM) therapies for hepatitis C are mainly derived from those used for hepatitis B, an infection that has received far more research attention. In a summary of Chinese language publications (6), it was reported that an open trial of 2,000 hepatitis (B or C) patients using various TCM methods showed improvement of symptoms in 83% and normalization of serum ALT in 82%. In a controlled study of 107 patients with hepatitis-B related diseases, before and after liver biopsies showed that the fibrosis reversal rate following 6 months treatment with Compound 861 (a formula of ten herbs including salvia as a main ingredient) was 78% in stage 2, 82% in stage 3 (precirrhotic stage) and 75% in Stage 4 (early cirrhosis). A report on hepatitis B treatment administered in Tianjin that was first published at the end of 1996 recently became available in English translation (7). The base formula, prepared as a decoction given daily for three months, was: astragalus 30 grams, tang-kuei 10 grams, red peony 15 grams, salvia 15-30 grams, hu-chang 15 grams, bupleurum 10 grams, polygonum fruit (shui honghua zi) 30 grams, and rubia 15 grams. Notoginseng (tien-chi ginseng; sanqi) powder was also administered (3 grams/day). The decoction formula was modified by adding extra herbs as follows: for qi deficiency for yin deficiency for qi stagnation for spleen qi deficiency for damp heat for yang deficiency

add codonopsis, white atractylodes, polygonatum (huangjing) oyster shell, tortoise shell, raw rehmannia add cyperus, curcuma, chih-ko add white atractylodes, hoelen, codonopsis add abrus, oldenlandia, capillaris add curculigo, morinda

The authors commented on the use of polygonum fruit as follows: Polygonum fruit is said to eliminate stasis, break down masses, build spleen qi, and disinhibit damp. According to traditional texts, it treats enlarged liver and spleen, ascites, stomach pain, poor

appetite, bloating, infected eyes, carbuncles, and lymphatic swelling. The herb can be used in the treatment of chronic hepatitis, liver cirrhosis with ascites, lymph tuberculosis, enlarged spleen, poor digestion, abdominal bloating, stomach pain, food accumulation in children, and conjunctivitis. While the result of the herbal treatment of 264 patients having hepatitis for at least one year was not a cure for the viral infection, fibrotic changes of the liver were reported to be successfully averted or improved while liver inflammation and hepatitis symptoms were alleviated. The treatment is somewhat similar in therapeutic approach to Qing Tui Fang, described as highly effective for hepatitis C in a 1994 report (8). Dr. Zhang Qingcai, working in New York City, has been treating patients with HIV and/or hepatitis C for many years using Chinese herbal materials. He recently published a book, Healing Hepatitis C with Modern Chinese Medicine (9), about the herbs that he uses. The book includes an extensive section on the extracts (e.g., glycyrrhizin capsule, derived from licorice) and formulations (e.g., modified Persica and Achyranthes Combination) he administers to patients, some of which he personally formulated. Based on his experience and understanding of Chinese medicine, he stated that "The realistic aim of Chinese medical treatment for hepatitis C is the arrest and reversal of HCV-related problems, resulting in improved or normal function and a reasonable expectation of an average life span. Following are his views on the situation that currently exists, where most patients can not entirely remove the virus from their systems though they are relieved of their viral symptoms: "Pure water has no fish" Many patients worry that they are carrying a virus and have not been cured. Although their liver functions are normalized and they have a normal or near-normal quality of life, they feel uneasy that they still have HCV in their body. I tell them that everybody carries certain viruses in his or her body. It is abnormal not to have viruses in our bodies. Some viruses have names and can be tested; some have no names and can't be tested. Viruses were the first living things on Earth and are one of the major causes of mutation. Bad mutations die off and good mutations become higher living things. We human beings are the highest living things on Earth-thanks to the virus. In millions of years of evolution, the human body has adopted mechanisms to deal with viruses. Given enough time, it will learn how to coexist with a newly invading virus. Gradually, our immune system can control it, keep it at bay, and prevent if from further harm. No living things are pure. There is a Chinese saying: "Pure water has no fish." Why do we want our bodies to be so pure, without viruses? Worrying can only weaken the immune system and make the virus stronger. From the experiences of many of our HIV patients, we have seen the coexistence with the virus is possible. After coexisting for a sufficiently long time, the virus becomes less harmful and finally becomes harmless, while at the same time our body becomes stronger and can contain the virus better. This description freely intermixes the situation that exists within an individual and what happens over a very long time in relation to the entire population. Yet, it helps to address one of the key problems noted with American patients who seek out Chinese medical therapies for hepatitis C: they are very anxious and worried about having the virus even if it is producing no evident adverse symptoms or notable liver damage. One of Dr. Zhang's formulations is called HC Virostatic Formula, used to suppress the virus and lower the viral load. It contains sophora subprostrata (this is a source of the anti-viral alkaloid oxymatrine), hu-chang (a broad-spectrum anti-viral agent), isatis root and leaf, and houttuynia. It is not always possible to clearly differentiate the use of one formula from another in cases of hepatitis C. However, a patient evaluation should include determination of the extent of liver inflammation (as revealed by liver enzyme levels), to determine the need for liver-protecting substances (such as antioxidants); the viral load (as revealed by PCR test), to determine the need for anti-viral substances; the extent of liver damage (fibrosis and cirrhosis, usually determined by liver biopsy), to determine the need for bloodvitalizing and lipid regulating herbs; and the symptomatic presentation (TCM analysis), to determine the need to treat conditions such as damp-heat and spleen-qi deficiency.

REFERENCES 1. Koch M and Banys P, Liver transplantation and opioid dependence, Journal of the American Medical Association, 2001; 285(8): 1056-1058. 2. Zeuzem S, et al., Peginterferon Alfa-2a in patients with chronic hepatitis C, New England Journal of Medicine, 2000; 343(23): 1666-1672. 3. Heathcote EJ, et al., Peginterferon Alfa-2a in patients with chronic hepatitis C and cirrhosis, New England Journal of Medicine, 2000; 343(23): 1673-1680. 4. Hu YY, et al., Actions of salvianolic acid A on CCl4-poisoned liver injury and fibrosis in rats, Chinese Herb News, 1997 18(5): 478-80. 5. Wasser S, et al., Salvia miltiorrhiza reduces experimentally-induced hepatic fibrosis in rats, Journal of Hepatology 1998; 29(5):760-71. 6. Wang BE, Treatment of chronic liver diseases with traditional Chinese medicine, Journal of Gastroenterology and Hepatology, 2000; 15 Suppl(3): E67-70. 7. Zhang Junfu, Cui Lian, and Yuan Shufang, A clinical analysis of treating 264 cases of chronic hepatitis B with the bloodmoving method, Shanghai Journal of Traditional Chinese Medicine and Pharmacology, 1996. 8. Li Hougen, et al., Qingtui Fang applied in treating 128 cases of chronic hepatitis C, Chinese Journal of Integrated Traditional and Western Medicine for Liver Diseases, 1994; 4(2): 20. 9. Zhang Qingcai, Healing Hepatitis C with Modern Chinese Medicine, 2000 Sino-Med Institute, New York. 10. Dharmananda S, A Bag of Pearls, 2000, Institute for Traditional Medicine, Portland, OR. May 2001

HEPATITIS C: Recent Treatment Strategies by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

VIRAL HEPATITIS BACKGROUND Viral hepatitis has been a major human disease for at least 2,000 years. It is estimated that 15% or more of persons living in Southeast Asia and Japan are infected by hepatitis B, a retrovirus that frequently leads to chronic infection. The high incidence of viral infection is the most likely reason that liver cancer and liver cirrhosis have been two of the leading causes of death in China during recent decades (when records were kept). In Japan, hepatitis is cited as the primary reason that medical doctors prescribe Chinese herbs. Minor Bupleurum Combination (Xiao Chaihu Tang) as well as numerous other traditional prescriptions for treating symptoms characteristic of viral hepatitis have been administered and claimed to alleviate symptoms. When persons who die from liver disease in S.E. Asia are checked for hepatitis B, the virus is found in about 80-85% of cases, indicating that fatal liver diseases mainly arise from chronic infection by hepatotropic viruses. Most of the investigation of hepatitis B has been undertaken for specific research projects, evaluating the role of the disease in China's overall health problems, or the efficacy of various treatments. Until recently, it was relatively rare to test patients for hepatitis B as a matter of course in evaluating health complaints, and it is still not frequent practice. It is only very recently that Chinese doctors began checking patients for hepatitis C, a virus that was isolated only a decade ago. It is now found to be a common viral infection in China, though not as prevalent as hepatitis B. A substantial proportion of patients with chronic liver disease who are tested are found to harbor both hepatitis B and hepatitis C. As with hepatitis B, testing for hepatitis C is mainly undertaken for specific research projects, not general health care. The infection is also fairly common in the United States: hepatitis C is currently estimated to infect at least 3.5 million in the U.S., perhaps having been a factor in the death of 100,000 Americans already (mainly during the past decade). Hepatitis C now accounts for an estimated 150,000 newly diagnosed cases of viral hepatitis each year, while many cases continue to go undiagnosed. Approximately 10,000 people die annually from liver disease that is attributed to hepatitis C (liver diseases of all types kill about 40,000 people per year in the U.S. and much of this is now understood to be due to the presence of chronic viruses). About 1,000 people each year receive a liver transplant because of cirrhosis caused by hepatitis C, and the numbers would be higher if there were more livers made available for transplant.

HIDDEN EPIDEMIC The hepatitis C virus was not detectable until a test for it was developed in 1989. Prior to that, cases of hepatitis that could neither be explained by the then-known viral strains (A and B) nor as an evident result of drug side effects were described as non-A, non-B hepatitis. Hepatitis C (as well as numerous other hepatic viruses) is now known to be the main cause of non-A, non-B hepatitis. This virus has been spread by blood transfusions for at least three decades (see below), persisting in the blood supply for several years after hepatitis B was removed. The hepatitis B test was applied to all collected blood since the 1970's; hepatitis C is no longer in the donated blood supply, having been eliminated by routine testing since 1990. Hepatitis C is thought to be transmitted almost solely by direct blood contact. However, surveys of hepatitis C patients indicate that up to one in six cases might be caused by sexual contact with an infected person, and there appear to be cases where people living in the same home but having no sexual intimacy with an infected person can pick up the disease (accounting for up to one in ten infections). Most of the unexplained cases of hepatitis C transmission might actually involve some kind of less evident blood to blood transmission. It is suspected that blood contacts occur more often than people realize-sexual contact when there are lesions caused by other infections, tattooing or ear piercing under less than sanitary conditions, sharing of razors or toothbrushes, and during treatment of minor wounds. The practice of sharing contaminated needles during illicit IV drug use is presently the main route by which the hepatitis C virus is efficiently spread. There have been three decades of increasing levels of IV drug use in the U.S., mainly in the inner cities, and more heavily among African-Americans. Despite increased attention to the health hazards involved with sharing needles, the practice continues. Recent reports indicate that more than 85% of IV drug users are now infected by hepatitis C. About one-third of all people coming to inner-city hospitals have hepatitis C, though the disease is found to some extent in all social classes, all geographic locations, and in all age groups. From the large pool of infected IV drug users it may be spread by sexual contacts as explained above. It is also transmitted from mother to child. Evidence for hepatitis C infection is not obtained as part of routine medical screening. Even the liver enzyme tests that would indicate some degree of liver inflammation are still not standard in the CBC (complete blood count) ordered by many physicians during medical visits, so asymptomatic patients may go undiagnosed for years. While some people experience an acute hepatitis syndrome upon infection, which might lead one to be tested, that is not the usual situation. Acute hepatitis may manifest as a digestive disturbance that can be taken for "stomach flu," so that testing during the initial phase of disease is still not common. Even when measured, elevated liver enzymes are sometimes attributed to drinking of alcohol, which is a very common practice; in fact, the elevation might be caused by a virus and only exacerbated by the alcohol. Furthermore, some persons with active hepatitis C show only very mild elevations of liver enzymes, at levels for which doctors usually don't express concern. In some cases the disease is not detected until there is need for a liver transplant (a similar situation existed with HIV infection, in which some individuals were unaware of the infection until experiencing a life-threatening case of pneumonia). It is estimated that the interval from time of infection to time of significant liver cirrhosis, if that is to occur at all, is 20 to 30 years. The delayed expression of the disease is one reason why hepatitis C seems to be a sudden epidemic; another reason is the recent introduction of testing and the new awareness by medical doctors of the importance of testing (now that there are treatments available to administer when the virus is detected).

HOW THE EPIDEMIC CAME ABOUT

A likely explanation for the current epidemic of hepatitis C in the U.S. is that the virus was brought to the U.S. primarily from Vietnam, mainly during the period 1964-1973. It may have been brought home by just a few hundred American soldiers (among the hundreds of thousands who served there) and then spread, silently, in the absence of diagnostics and with the normal delay in causing obvious liver disease. A number of Vietnam veterans had blood transfusions during the war, were exposed to blood on the battlefield or at medical stations, had sexual relations with the Vietnamese, and/or used IV drugs (while in Vietnam or with other veterans after returning). Therefore, opportunities for transmission of a virus that existed in Vietnam were certainly present. Once the virus arrived in the U.S., there were opportunities for it to spread to non-veterans. Blood transfusions in standard surgical practice were often administered without the patient ever being aware of the fact, or, at least, concerned about it. Thus, an individual diagnosed today with hepatitis C may not realize that they could have been infected when, for example, they had an operation 20 years ago and received blood from someone who carried the virus. Individuals who experimented with non-IV illicit drugs and tried an IV drug even once long ago may have been infected by the virus then; these individuals do not consider themselves IV drug users and may not regard the old incident as an actual example of IV drug use. During the 1960's and thereafter there was a "sexual revolution" in the United States that led to a large percentage of the teen and adult population having numerous sexual partners within a short period of time. This situation produced waves of STD's, including herpes simplex, gonorrhea, chlamydia (the most frequently reported STD today), and HIV. A person who was infected by hepatitis C virus in the 1960's or 1970's might not easily associate a currently diagnosed case of chronic hepatitis C with sexual behavior of recent memory. Since it appears that sexual transmission of hepatitis C is very inefficient (it does not occur with notable frequency between marriage partners), it is most likely that this virus was only transmitted when there was unrecognized blood transmission, for example if there was an STD that caused lesions, permitting transmission to and from broken blood vessels. Many times, lesions are not obvious (especially in women), but they nonetheless serve to promote viral disease transmission. The rate of hepatitis C among unmarried persons with multiple sexual partners is about twice as high as that of the general population, implying a role for other STD's in hepatitis C transmission via sex, though this increased infection rate may also be due to a higher prevalence of IV drug use among these individuals, with little role of sexual transmission. Unlike HIV infection, which has been spread in the U.S. since 1976, hepatitis C does not appear to occur with much greater frequency in the male homosexual population than among others in the U.S. This surprises some researchers, and is sometimes explained by the low rate of sexual transmission of the virus, but it can be explained by several factors. If hepatitis C was originally acquired by and spread among a mainly heterosexual population (U.S. armed forces) and brought to the U.S. where it was transmitted primarily by blood transfusion, and to a lesser extent by sexual contact (initially being primarily heterosexual) and within households, then the disease would be seen with considerable frequency outside the male homosexual community. Of course, it could spread easily within that community as well, but if it were already in the other population subgroups, then there would be a more even distribution (as occurs with HIV infection in Africa). This distribution would seem reasonable with the relatively higher level of transmission via medical blood transfusion and IV drug use compared to sexual or other routes of transmission. Further, since hepatitis C was not detectable until recently, and since a large portion of the homosexual men who were involved with multiple sexual partners or with IV drug use experienced HIV infection and its symptoms, testing of these individuals for hepatitis C may simply not have occurred. Hepatitis C testing has not been a priority among medical doctors dealing with AIDS. Already, over 350,000 people have died of AIDS, the majority being homosexual men, most of them not tested for hepatitis C because the focus of testing and treatment was elsewhere. Further, HIV infection is often fatal within 15 years; less time than it usually takes for hepatitis C to cause obvious liver disease. It is not yet reported whether hepatitis C is unusually prevalent in Vietnam, but it is known that the prevalence is fairly high in nearby Taiwan, and it is evidently fairly widespread in mainland China. Significantly, hepatitis C is frequently found in Vietnam veterans who visit the VA hospitals (although this high rate could be the result of IV drug use after returning to the U.S.) The rate of hepatitis C infection in France is nearly twice that of the U.S,. or of neighboring Germany and about four times that of Australia: French soldiers fought in Vietnam during the 1950's, just prior to American involvement (giving more time for it to spread), which might explain this apparent anomaly. In a study of stored American blood samples from World War II, hepatitis B-but not hepatitis C-was found. While hepatitis C probably existed at that time (and troops stationed in S.E. Asia may have been exposed), it was probably not as prevalent then and there may have been less chance to either pick it up or to transmit it to others.

VARIABLE MANIFESTATION OF THE DISEASE At this time, little is known about its pathogenesis following initial infection, except that the infection may remain without presenting evident symptoms for many years. The virus may impact quality of life, but the signs are not taken as evidence of a problem of hepatitis. Whether or not hepatitis C leads to significant liver disease in an individual may depend on secondary factors, such as the presence and activation of other viruses, especially herpes viruses (e.g., EBV, CMV, herpes simplex, HHV-6, HHV-7). Also the action of liver stressors, such as exposure to toxic chemicals in the work place, consumption of alcohol and/or drugs (prescribed or otherwise), or emotional disturbance, might stimulate the viral activity. It is known that for HIV infection, activation of a herpes virus can cause the viral load (amount of virus in the blood) to increase by up to five times (and then decline some time after the herpes returns to dormancy); it is possible that hepatitis C viral load (levels under 100,000/ml are considered low at this time) is also affected by transactivation (one virus activating another). Herpes viruses generally influence the retroviruses. In the absence of effective treatments, the number of deaths due to advanced liver disease is likely to increase markedly as a result of the spread of both hepatitis B and hepatitis C viruses during the past couple of decades (as with hepatitis C, there is often a twenty year gap between infection by hepatitis B and manifestation of a life-threatening disease). One reason that there are not more deaths by liver disease is that many of those infected by hepatitis viruses succumb first to cardiovascular diseases or to cancers that start somewhere other than the liver. Much of this death is attributed to such common practices cigarette smoking and consuming high levels of dietary fat. It is possible that, since viral hepatitis can alter blood coagulation properties and reduces immune functions, the viral disease actually enhances the chance of death by these other diseases without being formally recognized as a cause.

It has been suggested that nearly all persons exposed to hepatitis C virus become chronically infected (rather than having an acute disease that resolves entirely) and that up to 60% develop chronic liver disease marked by elevated liver enzyme levels if they live through other hazards long enough. However, there are estimates that as few as 9% of hepatitis C infections will become serious (lifethreatening), taking all factors into account. Liver cirrhosis and liver cancer are two major disease outcomes. Hepatitis B causes premature death in about 20% of those chronically infected and this is probably about the rate at which hepatitis C will prove fatal. For the other 80%, the consequence of infection is either minor or overshadowed by other diseases.

MONITORING TREATMENT OUTCOMES The concept of cure in a case of an infectious disease, like hepatitis C, includes the complete elimination of the virus from the body, not just limitation of its action (remission). For this concept to be applied, one requires the modern knowledge of, and testing for, viral particles, something that has become common place only during the past few years. The PCR (polymerase chain reaction) test for hepatitis C viral RNA is, therefore, the current standard for measuring the status of the disease, and the determination method of a true cure. The test measures the "viral load," or the quantity of virus in the bloodstream. In someone who is cured, the viral load should be undetectable (technically, one cannot measure tiny amounts of virus, so one can only say below the limit of detection) and then continue to remain undetectable in the absence of any virus suppressing therapies for several years. At this time, it is not known whether hepatitis C can be cured according to this strict standard, partly because there hasn't been enough time (since testing was developed) to determine whether any treatment has a long-term successful result. Interferon treatment produces an effective and prolonged response (up to about three years thus far monitored, but not necessarily a cure) in only 20-30% of those who try it, and it causes significant side effects in many. In fact, several participants in interferon studies withdrew during the first month of treatment (usual duration of treatment is six months). Recently, a combination of ribavirin and interferon has been offered; it appears more effective in lowering viral load than interferon alone (40% effective rate, with up to two years remission measured thus far), but the side effects are even greater, as ribavirin can cause significant bone-marrow suppression. Currently, a viral load (before treatment) of below 100,000 is considered on the low side; this level is usually accompanied by few, if any, symptoms. A viral load of several million is possible and is usually found in persons with significant symptoms and signs of the hepatic disease. However, individuals who have undergone various treatments have reported alleviation of symptoms while viral load measurements remain quite high, so the viral load is not necessarily a good correlate to the symptomatology. The immune system responds to viral hepatitis with, among other things, antibodies. These antibodies are generated, usually, when the virus is highly active, but may disappear when the virus is at low levels. Antibody tests are far less expensive than PCR tests, so one may measure whether the antibody test shows positive (indicating active virus with immune response to it) or negative (indicating less activity, with reduced immune response) as a cheaper evaluation tool. Converting from antibody positive to negative has been used in the past as a signal for "cure" of the disease, but we now know that this is not reliable. Elevated liver enzymes, the signifier of liver inflammation, are caused by so many things (including recent use of the over the counter drug acetominophen) that unless the levels are quite high most physicians ignore them. However, given the extent of the viral hepatitis epidemic and its potential harm, it may be prudent to check for viral hepatitis when liver enzymes are found to be elevated. This viral assay can also be used to help confirm or refute the possibility that a drug or herb therapy is causing hepatic inflammation. In persons with viral hepatitis, elevated liver enzymes are usually a signal that the virus is replicating, destroying liver cells, and releasing the liver cell enzymes into the blood stream. The test for the enzymes (usually ALT, AST, and GGT, though other enzymes can be monitored) is less expensive and easier than antibody testing, and is used to monitor the health of the liver. If the liver enzyme levels in the blood are high and then become reduced after a treatment, this is taken as a sign of inhibition of the viral activity; still, the liver may become less inflamed while the virus remains active, so it is not a sure sign of viral inhibition. Normalization of liver enzymes will almost always correlate with freedom from symptoms of viral hepatitis, and may be interpreted as a "cure" only in the sense of freedom from clinical complaints. However, as with the antibody testing, this test only means that the viral activity is reduced, not that the virus is eliminated. Liver biopsies are used to determine the extent of damage to the liver; in particular, this test will reveal the extent of fibrosis and fatty deposits. Such tests do little to indicate specific treatment strategies, with two exceptions: persons who have denied (due to limited health impact of the disease) that hepatitis C needs to be aggressively treated may change their minds if they find that their liver has been significantly damaged, and persons who show very extensive liver damage may be put on the list to receive a liver transplant (which is only warranted when the extent of liver damage is great).

WESTERN MEDICAL INTERVENTIONS The Western medical approach to hepatitis C follows the model used for hepatitis B: the main focus is to avoid infection in the first place, by screening the transfusion blood supply, determining transmission-risk behaviors and warning the population about them, and eventually developing a vaccine for those at risk (e.g., medical workers who may be exposed to blood). Development of a vaccine may be difficult because the hepatitis C virus mutates rapidly; so far, at least six subtypes have been identified. Further, within the blood of an individual patient, several different genome sequences are found, indicating that specific viral inhibitors-as well as vaccines-may be of limited value, similar to the situation with HIV. Post-infection treatment of hepatitis C mainly relies on various types of interferons (alpha interferon derivatives are common), alone or in combination with antiviral drugs (such as ribavirin). New drugs regimens are in various stages of research and development. In advanced cases, liver transplant becomes essential to saving the life of the patient.

CHINESE MEDICAL ANALYSIS OF HEPATITIS C Physicians in China were alerted to hepatitis C mainly through the international medical literature. Due to the lesser availability of funds for testing compared to the situation for American and European doctors, Chinese physicians primarily investigate hepatitis C and its treatment in patients who are notably symptomatic for the disease and are seeking relief of symptoms. By contrast, many tens of thousands of Americans with asymptomatic disease may seek treatment simply because the virus showed up after routine examination indicated mildly elevated liver enzymes. Because Chinese doctors mainly deal with symptomatic patients and because testing of these patients is also limited, the analysis of symptoms and the alleviation of symptoms are a primary concern. For traditional doctors, the fact that the virus now involved is "C" rather than "B" has little significance in relation to treatment. Rather, the important factors are the symptom manifestation and the fact, known from modern science, that a virus is involved.

In an article by Chen Lihua (1), a traditional Chinese medical analysis of hepatitis C was presented. The author makes these three points about the disease characteristics and treatments: 1. Toxic pathogens directly enter the nutritive (ying) and blood (xue) levels: most people are infected via blood or plasma transfusion, and the respective pathogen therefore immediately enters the nutritive layer (rather than slowly making its way through the outer defensive layers of the body). The clinical symptom picture seems to support this traditional way of reasoning, since patients usually exhibit little or no symptoms of disease entering the qi level (typically manifesting in fever, jaundice, and digestive symptoms). In response, one should vitalize the blood and resolve toxin: the author suggests the use of herbs that can both move blood and resolve toxin, such as lithospermum, hu-chang, moutan, red peony, rhubarb, curcuma, and oldenlandia. 2. Toxic stasis accumulates easily, smolders chronically, and is hard to disperse: hepatitis C is different from other types of liver disease in that it does not manifest like a warm disease. Although the pathogen directly enters the blood, there are usually no symptoms of rashes, red tongue, bleeding, loss of consciousness, etc. On the contrary, it can be classified as a yin type disease, a damp toxin, which causes damp stagnation, yin coagulation, toxic accumulation, clogging of the collaterals, and obstruction of yang. In response, one should disperse the liver qi and transform phlegm. Due to the characteristics of toxin, blood stasis, phlegm, and dampness, there is usually a chronic disease process that does not respond well to treatment. The author recommends qi-regulating herbs, such as bupleurum, blue citrus, citrus, cyperus, magnolia bark as well as phlegm-transforming herbs such as kelp, laminaria, fritillaria, pinellia. 3. Kidney deficiency promotes infection, and middle aged and old people are primarily afflicted. Since the distinguishing factor of older people is their declining kidney qi, kidney qi weakness seems to have something to do with being prone to the development (worsening) of the disease. [note: this characteristic of affecting older people is mainly due to the long duration of viral quiescence or slow disease progress before significant liver disease causes one to seek medical testing and treatment. However, the situation is changing: diagnosis is being made earlier; still, it is currently rare to receive a diagnosis of hepatitis C prior to age 40]. In older patients, one should tonify the liver and kidney: since there usually are more symptoms of kidney qi deficiency and kidney yang deficiency involved, some of the following herbs should be added in moderate amounts: morinda, epimedium, curculigo, cuscuta, and fenugreek. At the same time some yin tonics should be added to prevent a overheating effect by the yang tonics, such as rehmannia, lycium fruit, and ho-shou-wu. In a study reported by Jin Shi and Chen Quanliang (2), the researchers examined 85 patients with hepatitis C and 37 patients with hepatitis B and compared their general symptom profile. The differential categories used were the following five that have been standardized for all kinds of hepatitis since 1992 by the Liver Disease Committee of the Chinese Association for Traditional Chinese Medicine and Pharmacology: damp heat obstructing the middle burner; liver qi depression affecting the deficient spleen; yin deficiency of liver and kidney; stagnating blood obstructing the collaterals; yang deficiency of spleen and kidney. A general comparison showed that hepatitis C patients were generally older and had a history of blood transfusion; hepatitis B patients often had a close relative afflicted with the same disorder. At the same time, symptoms were much less severe in patients with hepatitis C. A comparison of TCM symptom complex showed equal distribution between the two types in relation to liver qi stagnation, yin deficiency, and yang deficiency, but a markedly higher incidence of blood stasis among patients with hepatitis C, and a markedly higher incidence of damp-heat among patients with hepatitis B. However, these results may not reflect much on the difference between hepatitis B and C disease. Those with hepatitis C tended to have a higher incidence of blood stasis, but were also older: the elderly tend to have blood stasis. Those with hepatitis B tended to have higher incidence of damp-heat, but damp-heat is probably the main manifestation of more severe hepatitis (see below), which was the condition of those in the study with hepatitis B. In the opinion of the authors of that report, TCM treatment protocols for hepatitis C should focus on the following: 1) clear pathogens and resolve toxins; 2) remove toxins by strengthening the righteous qi; and 3) transform stasis to prevent cancer formation (liver cancer is a major cause of death from chronic hepatitis). These are, in fact, about the same treatment principles as are often applied to hepatitis B. Comparing hepatitis B and C, Hong Huiwen and his colleagues (3) examined 100 chronic hepatitis B patients and 50 chronic hepatitis C patients. As noted previously, the patients with hepatitis B tend to be younger than those with hepatitis C (32.7 vs. 46.1 years, mean values in this study). These authors thought that hepatitis B tended to be transmitted more with "socializing"--indulgence in illicit injected drugs and unsafe sexual activity, among other things-which not only accounts for the younger age, but also the tendency for it to affect males (in their group, 89 males and 11 females had hepatitis B; in China it is primarily young men who partake in high-risk "socializing"). Getting a blood transfusion due to diseases of old age was thought to be the reason that hepatitis C tended to involve older individuals and have less sexual differentiation in incidence rates (35 males, 15 females in the hepatitis C group). As to the categories of disorder: Damp-heat Blood stasis Liver and kidney yin deficiency Liver qi stagnation with spleen qi deficiency Spleen and kidney yang deficiency

Hepatitis B 41% 1% 15% 42% 1%

Hepatitis C 26% 12% 8% 54% 0%

These findings tend to confirm the previous report, which was that there were similarities in frequency of liver and kidney yin deficiency, liver qi stagnation, and spleen/kidney deficiency between the two groups, but that there was more damp-heat with hepatitis B and more blood stasis with hepatitis C. The authors also presented information on the tongue and pulse qualities. Generally, patients with hepatitis B tended to have a pale or dark tongue and a yellow greasy coating and a fine wiry pulse or a wiry slippery pulse; patients with hepatitis C tended to have a dark or dark purple tongue, with a thin white coating, and a fine wiry pulse. These findings lend further support to the contended differentiation into damp-heat and blood stasis categories for hepatitis B and C, respectively. Without giving details of treatment, the authors state that of the recipes that were given to patients with hepatitis B, there was a higher proportion of heat-clearing herbs and dampness eliminating herbs, with the following ingredients being dominant: hu-chang, oldenlandia, wild chrysanthemum, dandelion, and coptis. For hepatitis C, heat-clearing and blood-cooling herbs were relied upon, mainly: lonicera, oldenlandia, hu-chang, dictamnus, duchesnia, solanum, and lithospermum. The formulas for hepatitis B tended to have more ingredients than those for hepatitis C. Some therapies relied on astragalus and other qi-tonic herbs. In general, hepatitis-C patients received larger doses of astragalus when that ingredient was included. In a study reported in the 1998 Journal of Traditional Chinese Medicine (4), 108 patients with hepatitis C were analyzed according to TCM. These patients had not used interferon (or had not had drug treatment for at least 6 months) or Chinese herbs (or had not had herbal treatment for at least 3 months). The proportion of males and females was relatively equal: 65 were male, 43 female, with an age range of 22-71 (average age 55). The high average age of this group, and the relatively more equal distribution among males and females correlates well with the proposal that the main risk factor is blood transfusion rather than "socializing." The patients were then evaluated and assigned into the five categories listed above, revealing: 34 had blood stasis 16 had damp-heat 16 had liver/kidney yin deficiency 12 had spleen/kidney yang deficiency 9 had liver qi stagnation with spleen deficiency 21 were difficult to categorize Those with a diagnosis of damp-heat had highly-elevated liver enzymes, while those in the other diagnostic categories only had moderate elevation. The authors believe that it is likely that the symptoms generated by severe liver inflammation (abdominal bloating, nausea, loss of appetite, yellowing of eyes and skin) fit the damp-heat category. The high incidence of blood-stasis was described by the authors as a possible outcome of the tendency of hepatitis C to cause liver cirrhosis. This condition leads to hardening of the liver (and, sometimes the spleen) and partial blockage of the portal vein. This group had a moderate proportion of cases of spleen/kidney yang deficiency, as might be expected with patients having an average age of 55. In a study of a treatment of hepatitis C (5), the tongue and pulse manifestation of patients with hepatitis C was reported. The distribution of findings were: Dark violet tongue Petechia (red spots) Red tongue Pale tongue Yellow greasy coating Thin yellow coating White greasy coating Fine and wiry pulse Wiry pulse Soft, rapid, floating pulse Fine pulse

52 24 14 10 51 28 21 41 25 20 14

As this analysis reveals, blood stasis, as indicated by the dark violet tongue, is prevalent, as is damp-heat syndrome indicated by the yellow greasy tongue coating. The more prevalent fine and wiry pulse may suggest liver qi stagnation coupled with qi deficiency syndrome; this pulse often accompanies qi and blood stasis. Despite the obvious trends, such as blood stasis and damp-heat syndromes, the accumulated data and traditional analysis seem to support the approach of treatment design according to differential diagnosis even if a standard "anti-hepatitis-C" drug, herb, or herbal formula is administered. It may be possible to address the different patterns with acupuncture while addressing the viral disease with a standard herbal protocol, but some means of focusing on the individual pattern is probably of clinical benefit, since there are clearly a range of disease manifestations. Hepatitis B is treated by herbs for the traditional categories of pathological disturbance labeled: toxin; damp-heat; qi and blood stasis; and qi, blood, and yin deficiency. Herbs are also given according to specific manifestation of the disease and underlying constitutional factors. The treatment of hepatitis C is similar to that of hepatitis B, with the differences noted above. In a report by the Institute for Traditional Medicine (see: Treatment of hepatitis B), important herbs for treating viral hepatitis were described and a formulation was mentioned that was developed by ITM and evaluated in China among in-patients with hepatitis B. The seven herb formula (salvia, ligustrum, curcuma, hu-chang, licorice, schizandra, atractylodes) addresses each of the five categories of concern listed above for hepatitis: salvia and curcuma for blood stasis

hu-chang for damp-heat ligustrum and schizandra for liver/kidney-yin deficiency atractylodes and licorice for spleen deficiency curcuma for liver-qi stagnation

REPORTS OF EFFECTIVE THERAPY FOR HEPATITIS C The medical reporting of treatments for hepatitis C in China has a number of flaws. Sometimes, the therapies (the herbal formulas) are not specified or only partially specified. Other times, the outcomes of treatment are unclear. Therefore, one should interpret the reports with some care. One of the most recent reports of effective therapy (6) describes application of a component of the herb sophora (kushen). This is the alkaloid oxymatrine (see: Sophora). In the report, the purity of the compound used was not described. Oxymatrine is usually isolated from sophora root (either from Sophora flavescens or Sophora subprostrata) along with other alkaloids of similar structure, mainly matrine. It was reported that 200 mg of oxymatrine was present in each 2 ml ampule of injectable liquid, which was given intramuscularly at 600 mg/day. Since placebo controls are not looked upon favorably, the control group was given liver-protecting herbs and vitamins (details not given) taken orally. Patients were randomized into the two different treatment groups. The treatment duration was three months. According to the report, of the 20 patients receiving oxymatrine injections, 17 completed the trial, and of those 17, 8 had their hepatitis-C RNA (measured by PCR) drop below detection. This is a possible cure, assuming that there isn't some small amount of virus left that will activate later, but it certainly counts as a significant remission. The potential "cure rate" may thus be 8/20 or 40% (as good as the interferon plus Ribavirin results), or as high as 8/17 (assuming the drop-outs had equal chance of good results had they remained in the study), or about 47%. The control group had 23 patients, of which 18 completed the trial, with only 1 having a PCR value drop below detection (cure rate of 1/23 to 1/18 or about 5%). The liver-enzyme assays showed improvements in both the control and the treatment groups (if liver enzyme tests are relied on alone, many treatments may indicate benefit, while the PCR test is a more reliable test of affecting the virus). The only adverse effect of the oxymatrine treatment was a near universal complaint of pain at the injection site. One patient experienced apparent allergy reaction after four weeks (skin itching), which was treated so that oxymatrine could be continued. Oxymatrine was selected for study because it had previously been shown to inhibit viruses (including hepatitis B), enhance cellular immune functions, and reduce liver fibrosis. Sophora subprostrata has been an ingredient in many hepatitis B formulas (given orally in decoction form). Sophora-root-extract injection has been used experimentally and clinically for a variety of disorders at least since 1976. Usual dosages are 200-400 mg per day, though up to 800 mg is given by injection in two divided doses. The tablet of sophora extract has also been administered; an example of the dosage used is 1.5 grams each time (presumably about 20% alkaloids, thus 450 mg), three times daily. Oxymatrine injections are not an option for treatment outside China, as this would require medical application of an unapproved drug. However, oxymatrine is available for oral administration. The Institute for Traditional Medicine has begun clinical use of oral oxymatrine in tablet form (sophora root extract, 20% oxymatrine, 2% matrine, 1 gram per tablet; three tablets per day for 600 mg oral oxymatrine) as an herbal supplement, not a drug therapy. Another report of particular interest was published in the Chinese Journal of Integrated Traditional and Western Medicine for Liver Diseases (7), and has been previously described by ITM in several articles since 1994. In the study, there were 128 hepatitis C patients treated, including 31 that also had hepatitis B. The treatment given was claimed to produce remission in 55.4% (alleviation of all symptoms, antibody test turning negative, liver enzymes-ALT and AST-normalized), with most other patients showing improvements following a 3 month treatment period. The original translation of the report had the term "cure," as a result of evidence of the antibody test, but with the new information about viral PCR, this term is now seen as inappropriate. Rather, the improvements noted can only be deemed remission. The basic formula given was: Qing Tui Fang salvia

30 g [vitalize blood and remove heat]

red peony

30 g

crataegus

15 g

moutan

15 g

forsythia

30 g [clean toxin, remove damp-heat]

gardenia

15 g

dandelion

15 g

ho-shouwu

15 g [nourish yin and blood]

astragalus

30 g [tonify qi to dispel the pathogen]

bupleurum

10 g [regulate qi]

The herbs are decocted and the amount indicated here is taken in two divided doses each day. According to the medical report, the formula can be modified to address specific symptoms by adding additional herbs (e.g., for pain in the liver area, add 15 grams peony

and 15 grams curcuma; for loss of appetite, add 10 grams hoelen and 10 grams shen-chu; for abdominal distention, add 10 grams magnolia bark and 10 grams perilla stem). Note that this formula fits the patterns described above of using a high dose of astragalus (30 grams), vitalizing blood and clearing heat from the blood (salvia, red peony, crataegus, moutan; this making up nearly half the dosage of the prescription), and treating heat, toxin, and dampness (forsythia, gardenia, dandelion). It also contains bupleurum to regulate the qi, and ho-shou-wu to nourish kidney/liver yin, thus addressing all the categories of concern. Subjective and clinically observed improvements included alleviation of: lassitude, poor appetite, abdominal distension, liver pain, and hepatic swelling. The Institute for Traditional Medicine has been providing this formulation in the form of dried decoctions (hot water extracts of the individual herbs, spray-dried) to patients at its clinic and to practitioners elsewhere for application to their patients. The recommended dosage is 9 grams of dried decoction each time, three times daily (which corresponds, roughly, to about 130 grams of herbs in decoction, compared to the 200 gram dosage mentioned in the Chinese clinical report), though some patients take only 2/3 this dose. Formal reports of the effects of this formula used here have not been obtained, but informal reporting seems to indicate that patients with substantially elevated liver enzymes experience a marked improvement in those measures, while those who have only slightly elevated liver enzymes experience little or no change. Thus far, no reports of PCR dropping below detection have been received (PCR testing is still limited). In a few cases, persons who were experiencing digestive disturbance as part of the hepatitis syndrome reported that the herbal formula exacerbated that symptom (which could then be alleviated by altering the formulation to include more herbs to benefit the stomach/spleen system). Other studies reported in the Chinese medical literature include these: In a study of integrated Chinese and Western medical treatment (8), 64 patients who had a history of blood transfusion and who tested positive for hepatitis C were divided into two groups of 32 patients each. The control group received alphainterferon and the herb group received alpha-interferon plus herbal decoctions (depending on presenting symptoms and signs); each was treated for three months. As an example, for those classified as presenting liver-qi stagnation and spleen deficiency, the formula has 15 grams bupleurum, 12 grams hoelen, 10 grams atractylodes, 10 grams codonopsis, 10 grams peony, 6 grams chih-ko, 6 grams gardenia, 6 grams curcuma, and 5 grams licorice. For those classified as having accumulated heat toxin, the formula was 15 grams lithospermum, 15 grams hu-chang, 15 grams forsythia, 12 grams scrophularia, 12 grams gardenia, 10 grams raw rehmannia, 10 grams moutan, 10 grams red peony, 6 grams curcuma, and 5 grams licorice. Other herbs might be added to these base formulas for treating specific symptoms. Among the 32 persons treated by herbs, 4 had their antibody tests turn negative, compared to only 2 in the interferon only group. Of the others, 17 in the herb group had major symptoms eliminated and ALT normalized, while 13 in the interferon group attained these results. It appeared that the use of Chinese herbs enhanced the effects of interferon treatment. In this small study (9), the details of the treatment were not specified. Patients were given different formulas according to presentation of constitution and symptoms; typical herbs used included smilax, scute, dictamnus, salvia, epimedium, loranthus, and lycium fruit. Inosine and vitamins were also given orally (dosage and other details were unavailable). It was claimed that 20 of the 33 patients (60.6%) so treated were in remission after 3-6 months, with clinical symptoms alleviated, normal liver enzyme tests, and hepatitis C antibody test turning negative. In their patient group, the largest proportion (onethird) had damp-heat syndrome, while blood stasis was not a common finding. The patients selected for treatment in this study (10) were suffering from aplastic anemia and had probably become infected by hepatitis C as the result of blood transfusions. The patients were treated for the anemia using 2 mg stanozol, three times daily (orally), and some patients received additional drugs for the anemia. Hepatitis C was treated according to differential diagnosis, with high-dosage herb combinations. As an example, for patients with symptoms such as pallor, lassitude, anorexia, nausea, abdominal fullness, and thin stools, the prescription included 25 grams pseudostellaria, 25 grams astragalus, 10 grams citrus, 10 grams tang-kuei, 12 grams cardamon, 20 grams peony, 20 grams bupleurum, 25 grams polygonatum, 20 grams coix, and 20 grams plantago seed. Patients also received intravenous vitamins and other nutrient factors. Among 21 patients with hepatitis C, 17 were reportedly improved by the treatment, but only 4 had their hepatitis C antibody test turn negative. In a report of the clinical study (11) of a new patent remedy, "911 granules," 330 cases of hepatitis C were evaluated, 170 were treated with the product, 160 served as control. Patients were treated for 200 consecutive days, consuming two packets of "911" (each containing 8 g of granules) each day. The authors say that "911" contains bupleurum, tang-kuei, white peony, and 13 other herbs (note: we received information that "911" is primarily a combination of Minor Bupleurum Combination, Cinnamon and Hoelen Formula, and capillaris; accordingly, the formula might include any of the following ingredients: bupleurum, scute, pinellia, ginger, licorice, jujube, ginseng, cinnamon twig, moutan, hoelen, persica, peony, capillaris, as well as tang-kuei, mentioned by the authors). The control group was treated with vitamins and standard liver protectants. Effectiveness was determined by applying the ELISA method to determine HBV and HCV antibodies before treatment and within 3-6 months after treatment. Post-treatment results were: HBsAg negative: 12.4% (control group: 1.9%) HBeAg negative: 76.8% (control group: 19.5%) HBc antibodies negative: 17.5% (control group: 2%) HBV-DNA negative: 52.9% (control group: 16.7%) HCV antibodies negative: 29.4% (control group: 8%) In a report of the Hunan Journal of Traditional Chinese Medicine (12), the results of applying Song Zhi Mixture #2 to 30 patients was described. The mixture is said to contain hoelen, gardenia, pseudostellaria, hypericum, and other undisclosed ingredients. These ingredients were apparently made into an extract that was taken one bag each time, three times daily for three months. The researchers used liver enzymes and antibody testing to evaluate the results. A total of 30 patients were tested, some with acute hepatitis C, others with chronic hepatitis C, the latter group further divided into those with or without accompanying hepatitis B. The rate of turning the antibody test from positive to negative was high. For example, among 12 patients who had chronic hepatitis C (without hepatitis B), 10 became negative; liver enzyme levels normalized for all but one of the patients.

SUMMARY OF CHINESE WORK It has been said that Chinese medical journals only publish positive results. In the case of hepatitis C treatments, that appears to be the case thus far. However, it is clear that the positive results claimed are within the realm of possibility: viral inhibition measured by PCR tests shows results that are comparable to Western medical treatment, and tests showing antibody conversion or liver enzyme normalization are consistent with reports for hepatitis B that have been emerging from the Orient (mainland China, Taiwan, Hong Kong, and Japan) for several years. With the exception of the report about oxymatrine, all of the treatments rely on complex mixtures of herbs, with or without added interferon therapy. The dosages of herbs, when described, tend to be high. The formulations vary considerably not only from one research center to the next, but also, in those studies which depict syndrome differentiation, from one patient to the next. As with treatment of many other diseases, the Chinese clinical reports indicate a wide range of herbs selected for treatment, and there are many ingredients that are not mentioned in the clinical reports (as a means of retaining a sort of "patent" on the formulation). Among the ingredients mentioned with some frequency in the above reports are gardenia, forsythia, curcuma, bupleurum, salvia, astragalus, tangkuei, and various types of peony (white peony, red peony, moutan). Some reports mention, off-handedly, the administration of vitamins, either as an accompaniment to herb therapy or as a part of the control group treatment.

USING THE TREATMENTS IN THE U.S. To avoid the extremely-high dosage requirements that often accompany the large decoction formulas, a prescription containing just a few key ingredients might be recommended. The Institute for Traditional Medicine is providing (in addition to Qing Tui Tang ) the following prescription in the form of dried decoctions and tablets, intended for the case of more severe viral hepatitis involving both blood stasis and damp-heat (but not those of liver/kidney yin deficiency or spleen/stomach weakness), as described in the Chinese literature: bupleurum peony gardenia forsythia astragalus salvia tang-kuei



Bupleurum/Gardenia Formula 15% 15% (5% each of peony, red peony, moutan) 15% 15% 15% 15% 10%

This formula is a derivative of the traditional Chaihu Qinggan Tang (bupleurum formula for cleansing the liver; Bupleurum and Rehmannia Combination) of the Ming Dynasty. That formula includes bupleurum, peony, gardenia, forsythia, and tang-kuei as essential ingredients. Astragalus and salvia are important here to address the common problem of blood stasis associated with hepatitis C. Since herbal teas (either making decoctions, or converting dried decoctions to tea) were utilized in the Chinese clinical trials, a similar form should probably be tried here. Due to the long course of therapy, Westerners may wish to rely on dried extracts (which are swallowed with a glass of water or made into tea) as a more convenient form than the more traditional crude herb decoction. A dose of three teaspoons of dried extracts (about 9 grams), two times daily would be equivalent to a decoction dose of around 100 grams crude herbs daily, the amount intended for the above prescription. A tablet form is in preparation, for which a dose of 8-9 tablets each time, three times daily, is suggested to get this dosage. Some patients may experience loss of appetite, loose stool or diarrhea, or other reactions in response to treatments with bitter cold herbs, thus one may need to adjust the formulation somewhat if this reaction occurs and persists. An example of adjustment is to remove one or two of the toxin and damp-heat clearing herbs and to instead rely on qi-tonic and dampness-clearing herbs such as those found in Six Major Herbs Combination (Liu Junzi Tang) . Another formulation, aside from Salvia/Ligustrum Tablets (mentioned above), is available to address hepatitis: Eclipta Tablets. This formula is suited to those who have liver/kidney yin deficiency complicated by stomach/spleen weakness. Any of these formulas could be taken along with Oxymatrine Tablets. In place of the vitamins given in some of the Chinese clinical trials, ITM has developed two nutritional anti-oxidant preparations that can be utilized: Quercenol (which includes milk thistle extract, several flavonoids, and vitamins C and E) and Alpha Curcumone (which includes alpha-lipoic acid, several antioxidant vitamins, ginseng and curcuma). The dosage is 1 tablet of each, 2-3 times daily, to be taken along with the complex herbal prescription selected for the principal treatment component. These formulas are available by prescription only from practitioners who have access to the ITM literature regarding their ingredients, therapeutic actions, and potential clinical applications. Until more clinical work with hepatitis C and Chinese herbs is carried out in the United States, it may be difficult to convince medical practitioners and patients to try this method. Because the herbs are non-toxic, some patients may wish to utilize this therapy in place of, or in addition to, treatment by interferon. It is reasonable to begin collecting information from such patients to provide case histories in an effort to eventually develop a well-designed clinical trial.

REFERENCES 1. Chen Lihua, Hepatitis C: Characteristics and TCM treatment methods, Journal of Traditional Chinese Medicine 1994; (10). 2. Jin Shi and Chen Quanliang, Clinical manifestations of hepatitis C and hepatitis B: A comparative approach utilizing TCM differential diagnostics, Journal of Traditional Chinese Medicine 1994; (9). 3. Hong Huiwen, et al., Analysis of clinical and therapeutic specificity in treating chronic hepatitis B and C, Journal of Traditional Chinese Medicine 1997; 38(12): 732-734. 4. Jin Shi and Wang Yue, Probing into the relationship between the TCM differentiations of chronic hepatitis C and clinical determination results, Journal of Traditional Chinese Medicine 1998; 39(4): 233-235. 5. You Songxin, et al., Clinical research on hepatitis-C treating oral liquid, Journal of Traditional Chinese Medicine 1996; 37(11): 673-675.

6. Li Jiqiang, et al., A preliminary study on therapeutic effect of oxymatrine in treating patients with chronic hepatitis C, Chinese Journal of Integrated Traditional and Western Medicine, 1998; 18(4): 227-229. 7. Li Hougen, et al., Qingtui Fang applied in treating 128 cases of chronic hepatitis C, Chinese Journal of Integrated Traditional and Western Medicine for Liver Diseases (5) 1994; 4(2): 40. 8. Lu Jiawu, 32 chronic hepatitis C patients treated by integrating Chinese herbs and interferon, Chinese Journal of Integrated Traditional and Western Medicine 1995;15(6): 371. 9. Wu Chunrong, et al., 33 patients with hepatitis C treated by TCM syndrome differentiation, Chinese Journal of Integrated Traditional and Western Medicine for Liver Diseases 1994; 4(1): 44-45. 10. Liu Qingchi, et al., Clinical study of Traditional Chinese Medicine and Western medicine on aplastic anemia complicated with hepatitis C, Chinese Journal of Traditional and Western Medicine 1995; 15(4): 198-201. 11. Yao Zhen, Liu Maocai, and Wang Chaolian, A preliminary report on the affect of 911 Granules on chronic viral hepatitis of the B and C types, Journal of Integrated Traditional and Western Medicine 1995/3. 12. Deng Desheng, 30 cases of hepatitis C treated with Song Zhi Mixture, Hunan Journal of Traditional Chinese Medicine 1997; 13(6): 27-28. September 1998

UPDATE ON HEPATITIS C TREATMENTS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Since publication of the September 1998 START Group manuscript Hepatitis C: recent treatment strategies ( revision and update of a 1996 report), calls for newer information have been one of the dominant themes of practitioner contacts with ITM. This comes about for several reasons: 1. Testing for hepatitis C has been accelerated, and findings of new cases, many of which are entirely asymptomatic or nearly asymptomatic regularly (the main symptom reported is fatigue), are appearing. 2. Modern medical treatments are still far from satisfactory. Side effects deter many people from starting or completing a treatment; and patients question whether the success is permanent given the short time available for follow-up since introduction of the current treatment (Rebetron; interferon plus Ribavirin). Currently, fewer than 50% of patients are expected to have prolonged suppression of the virus as a result of the Rebetron treatment. 3. Failure to educate the public about the disease has led to undue fears. For example, despite the fact that about 80% of those with hepatitis C virus are not expected to suffer from any clinically significant liver damage during their lifetime, virtually all those diagnosed with the disease are in fear of the most serious consequences and doctors are quick to recommend immediate treatment even when there is little evidence of disease progression. 4. Chinese herbal therapies that are reported to alleviate symptoms and reduce liver inflammation (as indicated by serum levels of indicator liver enzymes) are frequently dismissed as worthless because they do not eliminate the virus. Viral load reductions are not usually reported. New ideas for treatments are sought. Virtually all the experience of using Chinese herbs for hepatitis C is in China, where the situation surrounding hepatitis C has the following characteristics that are different from those encountered here: 1. Chinese patients are not routinely screened for the hepatitis C virus. The virus is only discovered in patients who are symptomatic for liver disease who are instructed to go to certain city hospitals for testing. Even then, testing may be limited to general hepatitis indicators (such as elevated liver enzymes), and not for determining the particular virus (i.e., not distinguishing hepatitis B from C). 2. In China, herbal therapies that reduce or remove symptoms and that reduce or remove liver inflammation are considered to be highly effective. If the disease symptoms appear again later, they are simply treated again. Testing for viral load is rarely done (it is very expensive and not readily available in China), and viral load changes are not currently a primary objective of the therapies. 3. The combination of interferon plus Ribavirin used in the West involve drugs that are not readily available to Chinese patients (they are extremely expensive in a limited economy). Therefore, Chinese herbs are a standard method of therapy and, in that setting, the results are not usually compared and contrasted to the unavailable Western medical treatments. When a patient arrives at your office with no significant symptoms of liver disease and with limited elevation of liver enzymes, they are presenting a case that, for all practical purposes, has not been previously subjected to treatment by Chinese herbs. Similarly, when a patient asks you to provide an herbal treatment to reduce viral load or to eliminate the virus, they are asking you to attain a treatment objective that has not been the subject of much clinical evaluation. Further, when a patient asks your advice whether to pursue Chinese herbs or the current standard therapy, or to pursue both, or to do them consecutively, the patient is asking you about a clinical situation that has not been the subject of either extensive prior experience or carefully designed clinical trials. This is a new area that must be considered carefully before proceeding. Following is a summary of new information that has been made available to ITM that may help practitioners better understand the situation. Refer to the original article, Hepatitis C: recent treatment strategies, for further background information on the disease and its treatment in China.

1. THE HERBS TO USE Several herbal formulas were described in Hepatitis C: recent treatment strategies based on an extensive review of Chinese literature. Since that time, only a few additional articles have come to light, but they do not go any further towards answering the question: are there any herbs specific for inhibiting the hepatitis C virus? Instead, the possibility is raised that herb formulas primarily function to help restore and maintain the liver cells without affecting the virus. ITM received a translation of an article on hepatitis C by Chen Liping and colleagues (working in Guangdong) that had been published in 1995 (1). The focus of the article was the role of blood stasis in the progression of hepatitis C. The symptoms of blood stasis in hepatitis C patients were listed as including: Lingering or pricking pain below the axilla (pain is fixed, immovable) Mass below the axilla (fixed, immovable, feels painful to the touch) Purple or dark-coated tongue with plaques or petechia Varicosity and blood stasis beneath the tongue Distention of veins in the abdominal cavity Cinnabar palm (discoloration of the palm, showing dark red) Spider nevus (spider veins) If the disease has one of the chief symptoms of pain or mass below the axilla and one or more of the confirming signs of discoloration and/or venous distention, then the blood-stasis type is deemed present. One can readily see that this indicates an advanced

form of the disease. In the discussion section of the article, the authors state: "Internal retention of blood stasis is the basic pathological change in chronic hepatitis and is also an important mark for the unfavorable turn in the condition of the disease." The formula they recommended was Huoluo Xiaoling Dan (Efficacious Powder for Vitalizing the Luo Vessels; luo vessels correspond to veins). The chief ingredients reported were cinnamon twig, red peony, persica, hoelen, and moutan. This is the traditional Cinnamon and Hoelen Formula (Guizhi Fuling Wan) presented in the Jingui Yaolue that is used for blood-stasis syndromes, especially when there is abdominal pain or mass. Some modifications suggested were oldenlandia and sedum (chuipencao) for damp-heat; buffalo horn and rubia for blood heat; malt and gallus for spleen deficiency (for more information on sedum, see: Tibetan herbal medicine ; sedum is a relative of rhodiola and described in that article). Another report received by ITM was a translation from a study conducted during 1995 in Zhejiang at an infectious diseases hospital (2). The typical symptoms reported were fatigue, lack of appetite, yellow urine, pain in the portal area, dull complexion, dull red tongue, and yellow, sticky, tongue coating. The formula used for treatment was called Jiedu Huoxue Tang (Decoction to Clear Toxins and Vitalize Blood), comprised of 40 grams sedum, 30 grams each of lobelia, oldenlandia, red peony, and salvia, plus 15 grams each of turtle shell, pangolin scale, and hoelen. In addition, herbs could be added for specific symptoms, such as magnolia bark and chih-ko for abdominal distention. Of 18 patients so treated for four months, it was reported that all but 4 cases responded obviously; there were 3 cases (17%) in which it was said that the viral test turned negative (no details of test method given). The authors stated that, in the long run, patients with hepatitis C suffer from "damp-heat accumulating in the spleen, stomach, liver, and gallbladder, blocking the smooth flow of qi and blood; stasis shows up when the chronic illness gets into the luo vessels." The formula ingredients were selected to clear heat and toxin, move blood and break stasis, and soften hardness and disperse accumulation. The authors recommended using high doses for all herbs. In the September 1998 issue of the English language Journal of Traditional Chinese Medicine, an article appeared on treatment of hepatitis C with a self-designed formula (3). According to the authors, their analysis of TCM theory and their experience of patients led to a conclusion that the disease should be interpreted as "stagnation of toxic heat and injuries in the liver and spleen." They paid particular attention to tongue and pulse diagnosis and found that the majority of patients had a dark purple tongue or other signs of blood stasis, a yellowish and greasy tongue coating or other signs of damp-heat, and a thready and taut pulse, characteristic of liver stagnation. The following formula was used as the basis for treatment: buffalo horn, hu-chang, red peony, astragalus, lycium, bupleurum, citrus, hoelen, and abrus (jigucao); the proportions were not stated. The mixture was made as a syrup given in two doses of 60 ml each. The authors reported that 15 of 60 patients (25%) had their viral load dropped to below detection for three consecutive readings as a result of this therapy. Also, another 19 patients (32%) had a negative PCR (Polymerase Chain Reaction) reading after treatment, but some evidence of persistence of the liver disease. At first, this sounds very encouraging, because the results appear to be somewhat similar-in terms of PCR effects-to what is obtained with modern medical therapies, minus the severe side effects. Unfortunately, on closer examination, the reported results of the PCR test are suspect. There is not a single detail of how the PCR test was conducted in order to give one any sense of whether the testing was done properly. There were no statements of the lowest viral load able to be detected. As important, there were no statements of duration of therapy or duration of follow-up with the PCR tests. Another report from China that described PCR tests, with results turning negative after treatment, that described the use of oxymatrine (major alkaloid component of sophora root), had already been relayed in the ITM article (see also: Sophora). In that case, the rate of effectiveness for getting the viral load to decline below detection was about 40% (comparable to the modern drug therapies). Unfortunately, that initial report (which was published a second time in English in the Journal of Integrated Chinese and Western Medicine) has not been followed up with reports of any larger study with this substance (only 17 patients had completed the original trial). The item used, injectable oxymatrine, is not available for use in the West, but ITM was able to acquire oral oxymatrine and make it available to practitioners since 1998. At this time, ITM has received no reports of hepatitis C viral load dropping below detection in patients taking this oral form. It is possible that the injectable form, by yielding a higher blood level, is more effective than the oral form, but it is also possible that the tests for PCR used in the published Chinese report were not reliable ones. In the article, this is the total information about the PCR test methods presented: "Serum HCV-RNA were determined by reverse transcription polymerase chain reaction." Therefore, at this time, the question of whether the Chinese have succeeded in reducing or eliminating (temporarily or permanently) the hepatitis C virus remains unresolved. The herbal therapies for hepatitis C used in China have been devised on the basis of traditional considerations: certain herbs are used if the syndrome involves damp-heat, others for blood stasis, yet others for spleen-qi deficiency, etc. Of all the herbs available for treating each of these syndromes, only a few are mentioned frequently. These herbs are chosen on the basis of prior experience treating hepatitis (mostly hepatitis A and hepatitis B) as well as some influence of modern research studies (finding active constituents that reduce liver enzymes in laboratory animal experiments in which the animals are subjected to toxic chemicals as an inducer of liver damage). Among the most frequently-used herbs (considering all the reports) are those included in a prescription designed at ITM called Bupleurum-Gardenia Tablets, which contains bupleurum, red peony, astragalus, oldenlandia, gardenia, and forsythia. No studies have come to the ITM office that would suggest that an individual herb or active constituent is a specific or general inhibitor of hepatitis C viral replication. Red peony and oldenlandia appear to be the herbs that are more commonly used for hepatitis C than for other hepatitis types. A traditional-style diagnosis followed by the corresponding herbal therapy remains the standard method of treatment in China. When differential diagnosis and treatment is not practical, complex formulas based on addressing the most commonly-manifest symptoms and signs may be used. Patients with no symptoms and only a diagnosis of having a virus infecting their liver do not have a clear recourse at this time. There is no viable evidence that formulas designed for highly-symptomatic patients will have an impact on those without symptoms. In Japan, glycyrrhizin (from licorice) and ursodeoxycholic acid (from bile) have been tested individually, together, and in combination with interferon therapy for hepatitis C (see Appendix 1). These active ingredients derived from traditional medicines were able to lower liver enzymes, but not viral load.

2. EFFECTS OF THE HERBS DESCRIBED OUTSIDE OF CHINA

In addition to the clinical reports from China indicating reduction of symptoms and reduction of liver enzymes, ITM has received a number of informal case reports, either verbally or in writing, from American practitioners who have given Chinese herbs to their hepatitis C patients. In general, patients who have significantly elevated liver enzymes prior to the Chinese herb treatment are reported to show a decline of liver enzymes over a period of several weeks. As an example, ITM was recently sent the following data (5) on a patient who was taking Salvia-Ligustrum Tablets (Seven Forests; made with salvia, ligustrum, licorice, hu-chang, curcuma, atractylodes, and schizandra) at the recommended therapeutic dosage used in a Chinese clinical evaluation (9 tablets, three times daily): Date of Test

AST

ALT

1/12/00

379

538

2/03/00

159

279

2/29/00

138

167

The patient had begun taking herbs just a few days after the first test (1/12/00), and one can see significant improvements in the values after about 2 weeks, with further improvement over the next 4 weeks. In this case, the patient has significant liver inflammation. According to reports received at ITM, it is common for the laboratory test results to indicate marked improvement in liver enzymes over a similar time course when the patient is regularly using the Chinese herbs. Among the reports are cases of liver enzymes returning to the normal range (for the above test lab, the normal range is less than 32), usually after a few months of therapy. A practitioner who has consulted frequently with ITM regarding hepatitis C treatment published two cases from her practice in 1997 (6). The liver enzyme results were reported as follows: Patient 1

Patient 2

Date of Test

AST

ALT

Date of Test

AST

ALT

8/95

50

81

12/94

223

185

12/95

39

65

9/95

132

86

4/96

34

52

5/96

98

89

9/96

33

56

-

-

-

The first test reports in each of the two cases are from before treatment and the following ones are during treatment; the duration of the treatment here (13-18 months) is longer than reported above (6 weeks). The very dramatic effects seen with the higher initial levels of liver enzymes have been relayed to ITM by several other practitioners. Some patients are said to have a dramatic improvement of liver-enzyme levels even if their viral load goes up rather than down. Reports of dramatic decline in viral load have been rare. In the START report: Two case histories of hepatitis C treatment (based on treatments at the ITM clinics), one example was given of a patient who had an extremely-high viral load (13 million) that reduced markedly (below 2 million) during a few months of treatment. According to the clinician making that report, the patient has continued to maintain the relatively lower viral load ever since, even without substantial herbal therapy (a course of low-dosage constitutional herb therapy is all that is said to be used). The initial viral load was much higher than typical for patients being seen in Chinese medical practices. Dr. Qingcai Zhang, working in New York City, has been providing herbal formulas for patients with hepatitis C for several years. The materials administered include herbal formulas in capsules (containing dried extracts), glycyrrhizin tablets, and oleanolic acid tablets. Zhang has distributed background information (received by ITM in a fax message of 1998), including four successful case studies. Among the reported effects of treatment were decline of liver enzymes, reduction of symptoms, and reduction of fibrosis (compared to earlier biopsy). In one case in which viral load was said to be reduced, he reported that the initial viral load was 14 million, and that this was reduced to 500,000 after treatment. As with the other case of viral-load decline mentioned above, the initial level is extremely high; the reduced viral load after treatment in both those cases was still quite high compared to typical patients, despite the marked change. Dr. Zhang claims that "Using this protocol, above 80% of the patients will see their liver enzyme levels normalized within about two to three months. If there was jaundice, the yellow color can be cleared within three weeks. Subjective symptoms, such as fatigue, nausea, and poor appetite, can be improved within three to four weeks. The dull pain in the liver area will be relieved within a few weeks. After two to three months taking the herbs, biopsy will show reduction of inflammation. In many patients, the viral load will be reduced." Although the effects are noted within a few weeks or months, he recommends that treatment proceed for at least two years in an attempt to clear the liver of the virus via the normal turnover of liver cells (with lifespan of about 18 months). A small double-blind clinical trial of a Chinese herb formula for hepatitis C was carried out in Australia and published as a preliminary report (7). Forty patients were divided equally into two groups: one receiving herb tablets (5 tablets three times daily) and the other receiving placebo. It was found that those taking the herbs had a significant reduction in ALT (the enzyme most commonly used as a reference for hepatitis C since it is the one most significantly affected by the disease), but not in viral load. The author concluded that "Chinese herbal medication was associated with a significant reduction in alanine aminotransferase (ALT) levels over the 6 month study period. No patient cleared the virus, but four normalized their ALT on treatment. Appropriately prescribed Chinese herbal medicine may have a role in the management of chronic hepatitis C and further controlled studies are indicated." The formula used included salvia, red peony, and tien-chi ginseng (sanqi).

In Japan, the use of injectable glycyrrhizin for treatment of chronic hepatitis C reportedly reduces the progression of this liver disease to hepatocellular carcinoma (see Appendix 1). A study was conducted in the Netherlands (8) to evaluate the effect of glycyrrhizin on ALT and hepatitis C viral load. Fifty-seven patients with chronic hepatitis C, non-responders or unlikely to respond to interferon therapy, were randomized to one of the four dose groups of glycyrrhizin: 240, 160, 80 mg, or 0 mg (placebo). The herbal drug was given intravenously 3 days per week for 4 weeks; follow up also lasted for 4 weeks. It was reported that within 2 days of start of therapy, serum ALT had dropped 15% in the three non-placebo dosage groups. The mean ALT decrease at the end of active treatment was 26%, significantly higher than the placebo group (6%). A dose-response effect was not observed, however, indicating that the low-dosage treatment worked about the same as the higher-dosage treatments. Normalization of ALT at the end of treatment occurred in 10% (4 of 41) of patients receiving glycyrrhizin. The effect on ALT disappeared after cessation of therapy. The duration of therapy was relatively short compared to most standard hepatitis C treatments of 3-6 months, and the frequency of treatment was half that usually used in Japan, where the drug is given 6 times per week. During treatment, viral clearance was not observed; there was a slight but non-significant decline in the active treatment group. No major side effects were noted. None of the patients withdrew from the study because of intolerance. In the U.S., a small trial was conducted in California in which patients received a complex herbal mixture for six months. The formula was designed on the basis of a prescription being used by a Chinese doctor in California who claimed success in treating the disease, as well as on the basis of formulas described in the Chinese literature. ITM acquired the herbal extracts and prepared the tablets for the study; patient treatment began in September 1999, with continued enrollment for some months afterward. Although the clinical trial results have not yet been fully tabulated and reported, the lead investigator (E. Stern, who published the two case studies in reference 6) relayed the fact that liver enzyme improvements were noted but that the PCR tests did not show an improvement. This is consistent with all other reports ITM has received from practitioners using a variety of herbal combinations for hepatitis C. Another trial of Chinese herbal therapies for hepatitis C is being carried out in Minnesota, with the help of an acupuncturist who had previously observed the treatment of hepatitis C patients in Guangdong, China (9). The double-blind, placebo-controlled evaluation of an herbal extract formula (ingredients list to be released when the trial is completed) is funded by the National Institutes of Health (NIH), as part of their evolving alternative medicines program. Thus far, only 2 patients (out of a total of at least 40 to be enrolled) have completed treatment and another 8 are taking the herbs (or placebo) at the time of this writing. Enrollment has been slow, partly because the protocol requires patients to delete use of potentially confounding substances, such as milk thistle extract (silymarin; see Appendix 2). Use of such substances is common among those who are interested in taking herbal formulas for the disease. Treatment time in this study is just 3 months and the researchers hope to complete the treatments and report results by the end of 2001. Liver Enzymes Versus Viral Load Assays The ability of herbal therapies to reduce liver enzymes while having the viral load remain essentially the same, as appears to occur in most instances, may seem contradictory. Viral load is a measure of hepatitis C virus that has been released into the blood stream. In order to be released, the virus must reproduce (usually many millions of copies within a single cell) and then burst the liver cell, destroying it and releasing its enzymes into the blood along with the virus. One might expect that the liver-enzyme level would remain somewhat proportional to the viral load. However, it is possible that in the untreated patient the viral reproduction is resulting in what might be termed collateral damage: destroying liver cells that are not currently yielding the virus. For example, the enzyme nitric oxide (NO) synthetase is stimulated in persons with hepatitis C, and the increased output of NO may be causing the collateral damage. If the herbs protect these other cells from the secondary damage by squelching the NO effect, then the marker liver enzymes will be reduced, even cells with active virus continue to pour out their enzymes when they break down to release the viral particles. Patients who experience a lowering of liver-enzyme levels are usually encouraged by the fact that the improved levels are close to, or within, the laboratory "normal" range. However, at close examination, it is realized that the test results in these patients are usually near the upper part of the range. (e.g., in the patient depicted above who had AST decline to 33, the laboratory normal range was 0-37; at the same time, the ALT remained just above the upper normal level of 40, being last reported at 56). Thus, while the enzyme levels after treatment may be deemed normal or near normal, the figures are usually consistent with there being a certain level of liver inflammation or damage still occurring. A hepatitis C viral load of many thousands might involve destruction of a small enough number of cells that the liver enzyme levels will be near the top of the "normal" range. These cells are dumping huge amounts of virus into the blood stream, just as they were before. Consistently, it is found in laboratory animals that Chinese herbs that are clinically useful for treating viral hepatitis protect liver cells from damage due to chemicals. This kind of testing was done, for example, with the previously-mentioned hepatitis C treatment in syrup form (3). There is no evidence, as yet, that these herbs halt the virus from reproducing. Chinese reports, from laboratory animal experiments and limited work with humans, suggest that some herbs, such as salvia (used for vitalizing blood) can limit liver fibrosis, a condition that leads to permanent damage. At this time, it cannot be confirmed whether or not this takes place; most patients in the U.S. who come to acupuncturists for treatment have early-stage hepatitis C and do not have before and after biopsies to prove the condition of their livers. However, interferon-alpha therapy is reported to reduce liver fibrosis, even in patients who do not have clearance of the virus as a result of the treatment, so reduction of fibrosis is a reasonable objective of therapies that are not able to clear the virus or reduce viral load. According to liver biopsy specialists, liver enzyme levels in hepatitis C patients have relatively little correlation with the extent of liver damage. Thus, whether the ALT levels are high or low does not inform a patient about the condition of their liver. This does not mean that lowering the liver enzymes by use of herbs or drugs is not protective, but only that the enzyme level cannot be counted on to accurately reflect the changes that may occur in the liver.

3. DOSAGE ISSUES Chinese clinical reports frequently describe marked therapeutic outcomes from treatments that utilize high doses of herbs. More-limited clinical effects may result from a similar herbal formula given at the lower dosages commonly applied in the West. If the Chinese reports of the viral load falling below detection reflects a true result rather than poor methodology, then the apparent failure of most

Western patients to attain the same results might be due to inadequate dosing. In the case of oxymatrine, the Chinese method of therapy involves injections of the herb alkaloid. This method of application is not available here, and would not be used due to the unknown level of risk. The dosage of oral oxymatrine that ITM recommends is the same as that used in the injection form (total daily dose: 600 mg). Higher oral doses, as might be needed to attain the same blood levels as with the injection, are not recommended due to concerns about potential side effects or toxicity. Although the Chinese reports of the injection treatment do not include serious adverse effects, the number of patients is small, and infrequent problems are easily missed. Alkaloids have the potential for serious reactions if the dosage is high enough. No evident adverse responses have been reported to ITM for use of oral oxymatrine in the dose of 3-4 tablets daily, taken one tablet at a time (as recommended), and the beneficial effects on liver enzymes appear to be attainable. In the case of the glycyrrhizin treatment, Japanese clinicians reported a persisting effect of the treatment, but the Netherlands study did not find that (8); the liver enzymes rebounded shortly after discontinuing the herb drug injections. However, the Japanese doctors applied the treatment twice as often as the European doctors who conducted the study, which may explain the discrepancy. Glycyrrhizin can accumulate with frequent administration to yield a higher blood level. A formula described in the earlier ITM publications is Qing Tui Fang, one of the first herbal prescriptions reported in the Chinese literature to successfully treat hepatitis C patients. This formula has been made available by ITM as granules (dried decoctions that are reconstituted to an instant tea preparation) and recommended at a dosage of 18-27 grams/day. This is the highest dosage level recommended by ITM for this form of herb preparation. Typical dosing of such dried decoctions in Japan and Taiwan where they are commonly used is 6-9 grams, which is a low dosage form. ITM recommends up to a maximum of 3 times this amount for treatment of some diseases, if the Chinese literature indicates that application of the high dosage yields desired effects but few or no side effects. The Chinese report on which this treatment method is based indicated the following dosages for the formula ingredients: Qing Tui Fang salvia red peony astragalus forsythia gardenia crataegus moutan dandelion ho-shou-wu bupleurum

30 g 30 g 30 g 30 g 15 g 15 g 15 g 15 g 15 g 10 g

The total dosage is 205 grams, a relatively high amount, though not inconsistent with other preparations recommended in China. According to suppliers of the dried extracts, the typical herb extract is a 5:1 concentration, which means that 5 grams of crude herbs yields 1 gram of the dried extract. The amount of extract corresponding to 205 grams would then be 41 grams, or about 50% more than the highest dose recommended for the granule preparation by ITM (27 grams). At 41 grams, the cost and inconvenience would probably render the treatment unusable. Although adverse reactions were not reported in the Chinese medical journal article on Qing Tui Fang, Americans frequently report discomforts or adverse reactions to the high dosage decoctions, regardless of formula composition. ITM has received a small number of reports of adverse reactions from taking the Qing Tui Fang at the dosage of 18-27 grams per day in patients with "spleen deficiency". For example (10), one patient reported feeling "wiped out" (fatigued) from taking the formula; she was then switched to a formula that treats spleen-qi deficiency and accumulation of dampness (the formula was not aimed at treating hepatitis C, but only at her constitutional syndrome), which gave the opposite effect: she felt energized. While this experience emphasizes the importance of checking the patient's total syndrome before prescribing a set formula, it also points to the fact that adverse responses may be experienced and caution must be used in administering large amounts of herbs.

4. PROPOSED GUIDELINES Patients with hepatitis C usually approach practitioners of Chinese herbal medicine with the hope of finding an alternative to the standard medical treatments. In addition, they usually hope to cure the disease. The standard medical treatment currently recommended is particularly unattractive to many people. Both drugs in use at the time of this report produce side effects in many patients, including some potentially serious long-term effects for a few patients. The chances of removing the virus entirely or putting it into remission for many months or years is limited. Therefore, the medical treatment might be regarded as a resort for those who cannot easily put the disease into at least a partial remission by other means. Many new drugs are in development for treatment of hepatitis C, including new varieties of interferon that yield better results and fewer side effects. A curative method (or one that puts the disease into remission for many years) with an acceptable level of side effects may become available within the next few years. For example, enzymes involved in the production of the hepatitis C virus are being identified and there may be a means of blocking their action without producing significant side effects. Therefore, except in those patients with evident progressive liver disease uncontrollable by other means, it may be best to wait for the next generation of medical therapies. In order to wait for the potentially curative drug therapy, one must feel confident that adequate liver protection is being attained. While freedom from symptoms and low liver-enzyme levels cannot guarantee absence of slowly progressing liver damage, at present, these indicators are the only means of evaluating success short of getting regular liver biopsies (which virtually all patients will decline,

despite physician recommendations). Patients who have little or no symptoms and who already have relatively low liver enzymes might undertake a conservative treatment of using antioxidants (these are liver protective in almost all cases) and being careful to minimize use of substances that can potentially accelerate liver damage (e.g., alcohol and acetominophen). Good diet, moderate exercise, and other healthy living patterns may help keep the liver in the best possible condition while affording a minimum of chance for the virus to become more active and damaging. Coactivation of the hepatitic virus by other viruses, such as herpes, may occur. Therefore, efforts should be made to avoid viral infections and such infections should be treated promptly and effectively (whether with herbs or drugs) to minimize coactivation. Patients who have symptoms and/or elevated liver enzymes can be additionally treated with herbal formulas that are similar to those evaluated in Chinese clinical studies. There appears to be no need to match any one of the study formulas exactly, as there is no evidence to suggest that one formula is superior to another; but it is reasonable to gain guidance from the tested formulas: the selection of ingredients for those formulas was based on considerable efforts by experienced physicians. Those with some obvious degree of liver disease may need to use a combination of the standard medical therapy and the approaches outlined above. It is recommended that during the six-month course (sometimes longer) of standard medical therapy, the Chinese herb formulas should not be used (to avoid any concerns about interactions; see below). However, most antioxidant and nutritional strategies will prove compatible with the drug therapies, based on experience with treatment of other diseases. The herbal formulas (usually given in high dosage) can be utilized before and after the standard medical treatment.

5. HERB-DRUG INTERACTIONS In 1999, several informal Chinese medicine publications in the U.S. relayed a report from Japan claiming adverse reactions, even deaths, from combining a traditional Chinese herb formula with interferon therapy for hepatitis C. A sample newsletter report ITM received from a practitioner read as follows: Combining Xiao Chai Hu Tang with Interferon Proves Fatal The CAAOM has recently heard from several different Japanese sources that over sixteen people have died in Japan from taking the herbal formula Xiao Chai Hu Tang (Minor Bupleurum) with interferon for the treatment of hepatitis. According to Dr. Hirohisa Oda, a licensed pharmacist with a doctorate of Medical Science from Japan and president of the Meiji College of Oriental Medicine [California], all product containers of Xiao Chai Hu Tang are labeled [in Japan] with a warning that this formula should not be taken with interferon. Japanese researchers suspect the culprit may be a saikosaponin chemical found in Chai Hu (bupleurum). Please don't give your patients this formula when they are taking interferon. The Oriental Healing Arts Institute (Long Beach, California) was requested by ITM to try and find an original Japanese article and provide a partial translation to English. In addition, an extensive MedLine (National Library of Medicine) search was performed that yielded most of the information provided below, and a Japanese web site was accessed (www.nihs.go.jp/dig/infodrug) thanks to a notice from an acupuncturist (9). The adverse effect attributed to the herb formula was interstitial pneumonia, also called pneumonitis; it manifests as an acute disorder impairing breathing and oxygenation of the blood, sometimes with high fever. The traditional formula in question is Minor Bupleurum Combination (Xiao Chaihu Tang; in Japanese: sho-saiko-to; SST), comprised of bupleurum, scute, pinellia, ginger, ginseng, jujube, and licorice. This formula is perhaps the most commonly-used herbal prescription in Japan (and extensively used in China). It is frequently employed in the treatment of liver disorders, including both the traditional patterns of liver disharmony and the specific liver diseases as described in modern medical terminology, including viral hepatitis. Numerous reports from Japan during the 1970's and 1980's mentioned use of this prescription for hepatitis, used mainly for hepatitis B, the most common form of the disease. It was then adopted for use in treating hepatitis C. In 1989, the first case report of interstitial pneumonitis attributed to use of SST was published (11). The patient, a 71-year-old woman, agreed to a challenge test, that is, repeating exposure to the formula. On two trials with just 2.5 grams of the extract granules (usual daily dosage for this preparation is 7.5 grams, taken in three divided doses of 2.5 grams each), she developed the clear signs of pneumonitis (high fever, dyspnea, X-ray evidence of infiltrative shadows in the lungs). The reaction to the formula was described as pulmonary hypersensitivity, which seems appropriate given the dramatic response to such a low dosage. Additional case reports appeared in the literature in subsequent years, such as a report of pneumonitis in a 66-year-old man who had been taking SST for just 20 days (12). The doctors found an elevated level of lymphocytes and eosinophils in the lung fluid, indicating an immunological type of response. The authors stated that 13 cases of Chinese-herb-induced pneumonitis had appeared in the literature up to that time (1993). Interstitial pneumonia is also a side effect of interferon therapy (13). Interferon is known to cause a number of pulmonary disorders in susceptible patients, including sarcoidosis, an immune-based disorder (14). In 1995, the Department of Respiratory Medicine at Tokyo General Hospital reported five cases of pneumonitis that was attributed to "sho-saiko-to or interferon-alpha or both" during treatment of hepatitis C (15). One of the patients took interferon-alpha alone (no SST), two patients took SST alone (no interferon), and one patient took both. Lymphocyte stimulation tests were conducted to reveal that there was sensitivity to both SST and interferon. According to an analysis done by the authors, the incidence of pneumonitis in patients with chronic hepatitis or liver cirrhosis was 0.5% for alpha interferon and 0.7% for sho-saiko-to, thus indicating a nearly identical risk of this side effect; however, they reported that the risk rose to 4.0% in those given both, suggesting that there might be a synergistic action. A possible explanation for the problem with the herb formula and interferon was proposed by members of the Kumamoto University Medical School (16). They stated that it is well known that activated neutrophils are important mediators of pulmonary fibrosis, and that these neutrophils damage lung tissue when activated by cytokines such as tumor necrosis factor (TNF) or interleukin-1 (IL-1). The mechanism by which a synergistic action could be produced by SST and interferon was revealed by their laboratory test results: interferon causes neutrophils to accumulate in the lungs and SST increases the production of TNF. In general practice SST may not cause any lung damage, but it increases the effect of either interferon treatment or the immunological consequences of a predisposing disease condition in relation to neutrophilic damage of the lungs. The cascade of events may be triggered if some antigen is present.

A treatment for the pneumonitis was described in a report from the Fukui Medical School (17). They described four cases of acute pneumonitis with symptoms of fever, dry cough, dyspnea, hypoxemia, and diffuse infiltrates in chest scans. The patients with the disorder had taken either interferon, SST, or both. A lymphocyte stimulation test in two patients showed one responded to interferon and the other to SST. Oral prednisolone therapy was successful in all four cases, and there were no recurrences during a follow-up of 1-3 years. The authors concluded that the mechanism of action by which interferon and SST induced pneumonitis was an allergicimmunological mechanism and not a toxicity problem. The level of the cytokine interleukin-2 (IL-2) in peripheral blood was reported to be a marker of the pneumonitis severity. One of the reported antiviral actions of glycyrrhizin in licorice, which is used as a single active ingredient in the treatment of viral hepatitis and which is an ingredient of SST, is stimulation of IL-2 production. Based on the accumulating evidence, a formal warning about the association between use of SST and pneumonitis in patients with chronic hepatitis was issued in Japan by the Ministry of Health in March 1996. A death associated with interstitial pneumonia attributed to SST was first described in 1996 (18). The patient had taken the herb formula for about 50 days and then reported symptoms of fever, diarrhea, progressive dyspnea. After six weeks of follow-up treatments, he died from a combination of respiratory distress and gastrointestinal bleeding (the latter probably due to high-dose steroids aimed at alleviating the pneumonia). The government warning about use of SST in patients with liver cirrhosis was issued again, in revised form in December of 1997. An evaluation of reported cases of SST reactions was undertaken at the Hamamatsu University School of Medicine (19). They concluded that of 94 cases of pneumonitis reported to the manufacturer of the herb formula, 72 appeared to be actually related to the herb use (average age of patient: 64 years). Most of the cases were patients having chronic hepatitis C. The mean duration of taking the herbs before the pneumonitis symptoms arose was 50 days. Typical symptoms were coughing, dyspnea, and fever with acute onset. X-rays showed diffuse "ground-glass" shadows and infiltration. Abnormally high levels of C-reactive protein and lactate dehydrogenase were common. The bronchoalveolar fluid revealed abnormally high percentages of lymphocytes and neutrophils and a low CD4/CD8 ratio. Of the 72 cases, 64 survived after discontinuing SST, with some patients receiving high-dose steroid therapy; 8 patients, including the one described above, died. The patients that died were said to have had an underlying lung disorder, had taken the herbs for a longer time, and had more severe hypoxemia. In a case of pneumonitis attributed to sho-saiko-to that occurred recently (20), it was reported that the patient, a 71-year-old women, had been treated with SST for 14 days until the symptoms arose. Her bronchial fluid was tested for sensitivity to both the entire formula and to two of its ingredients, scute and pinellia, and was found to be sensitive to all of them. The authors also suggested that her liver had developed autoimmune hepatitis in reaction to the herbs. In another report (21), a 62-year-old man with pneumonitis attributed to herbs was taking both SST and Coptis and Scute Combination (Huanglian Jiedu Tang; Japanese: oren-gedoku-to) for two months. Challenge tests with both formulas applied separately were positive. The authors suggested that scute, the ingredient common to both formulas, might be of concern; this ingredient was also reactive in the previously described case. Nearly all the cases of the pneomonitis induced by interferon alpha or SST were in patients with advanced liver disease associated with hepatitis C. It is possible that the virus might yield immunological stimulation and dysfunction that makes these treatments more likely to cause a reaction. Hepatitis C has numerous secondary effects including (22): glomerulonephritis, thyroiditis, and possibly Sjogren's syndrome, IgA deficiency, Mooren's corneal ulcers, Behcet's syndrome, polyarthritis, Guillain-Barre syndrome, and ITP (Idiopathic Thrombocytopenic Purpura). Hepatitis C, without treatment by interferon or SST, may cause idiopathic pulmonary fibrosis. In the Japanese government warnings (24), the main concern expressed is for patients with advanced liver cirrhosis or advanced liver cancer and especially those who have low platelet counts (ITP). In these patients, various autoimmune processes may be stimulated, and the use of interferon or the immunologically-active SST in such circumstances may lead to a further immunological development that causes a severe reaction even after a few days. In response to interferon therapy, one patient was reported (24) to develop not only interstitial pneumonia, but also hemolytic anemia, implying an immunological sensitization. Hemolytic anemia is similar to ITP in nature and mechanism; a different blood cell line, red blood cells rather than platelets, is the target of the autoimmune response. Despite several investigations of sensitivity to ingredients within SST as relayed above, it is not known which herbal components might be yielding an adverse effect. The pneumonitis may not be the result of reaction to any individual herb, but to the immunological effects of the entire formula. The two main therapeutic compounds in Minor Bupleurum Combination are triterpene saponins, referred to as "saiko-saponin chemical" in the newsletter warning about the formula (see: Platycodon and other herbs with triterpene glycosides ), and flavonoids. Generally, these compounds appear harmless in the dosage used and may require some rare combination of predisposing factors to produce the adverse effects. One of the primary product manufacturers (Tsumura Juntendo) recently investigated the mechanism by which SST might be causing pneumonitis; it was shown that the formula stimulates interleukin-6 (IL-6, a pro-inflammatory cytokine) in laboratory mouse models of lung injury (25). When active fractions of SST were analyzed, it was found that multiple ingredients had the IL-6 stimulating capability, and the authors cited liquiritin, a component of licorice, as an example. Liquiritin is a flavonoid; the active constituents of scute, suggested to be implicated in a prior evaluation, are flavonoids. However, both bupleurum and pinellia have been potentially implicated as well, and these have triterpene saponins and alkaloids, respectively, for their main active ingredients. SST is used for treatment of many inflammatory disorders, lung diseases, and viral infections. One would expect from such uses that it has the capability to promote antiinflammatory cytokines and reduce pro-inflammatory cytokines (such as IL-1 and IL-6). However, the hepatitis C virus, interferon, and/or other things influencing the patients who develop pneumonitis, may alter the immune system in such a way that it responds adversely to the otherwise beneficial action of the herb formula. SST is extensively used in the treatment of hepatitis and, as a result, there have been opportunities for rare adverse reactions. It is possible that other herb formulas would also produce this result, but their less frequent use has either led to no cases or to not enough reproducible results to raise a concern about the specific formulation. Particular caution should be used in patients who are taking multiple drug therapies. The Japanese government has released (via a web site) three sample cases of deaths attributed to sho-saiko-to, which may help illustrate ways to avoid problems: Case 1: the 61-year-old female patient had experienced interstitial pneumonia from interferon therapy for chronic hepatitis C; therefore, she was withdrawn from the drug therapy and placed, instead, on SST. She took the formula for nearly three years, and then developed

interstitial pneumonia again. She had also been taking glycyrrhizin, as well as drugs, such as troxipide. Case 2: a 68-year-old female with Alzheimer's disease and hepatitis C was treated with SST for just 5 days before developing interstitial pneumonia. The patient was taking numerous drugs, including aniracetam, famotidin, indeloxazine, sparfloxacine, cefotiam, and teprenone. Case 3: a 68-year-old female with chronic hepatitis, gastritis, post-stroke syndrome, and insomnia, took SST for more than three months and developed interstitial pneumonia. She was taking glycyrrhizin and several drugs, including cisapride, ticlopidine, and rilmazafone. These patients were all elderly and were taking either numerous drugs or glycyrrhizin or both. They had advanced liver disease in which the metabolism of herbs and drugs is impaired. It has been found that patients with liver cirrhosis have higher levels of glycyrrhizin in their blood than others receiving the same glycyrrhizin treatment (26). If glycyrrhizin can contribute to the development of pneumonitis, then the presence of liver cirrhosis would increase the risk. Practitioners in the U.S. are advised that patients with advanced liver disease, and especially those manifesting secondary immunological disorders (such as ITP), as well as those taking multiple drug therapies, should probably avoid all herbal therapies during treatment with interferon until more is known. In fact, because of the severity of the reactions to interferon and/or SST, it is best to not take chances with mixing interferon with Chinese herbs until a better understanding of the situation arises. Later, it may be possible to identify specific circumstances where the combination could be recommended and others where it must be avoided. Since Minor Bupleurum Combination (SST) alone had some potential for causing interstitial pneumonia in some of the patients described in the literature, herbal formulas, particularly SST, should be used cautiously in elderly patients who have both hepatitis C and any signs of autoimmune disorders or who are relying on multiple drug therapies. If a patient reports symptoms of acute onset fever, dyspnea, or coughing, they should immediately discontinue use of the herbs in case it is a rare instance of herb-induced pneumonitis. In Japan, doctors are cautioned to monitor the platelet levels of patients with advanced hepatic cirrhosis and to discontinue use of Minor Bupleurum Combination if the platelets are dropping.

REFERENCES 1. Chen Liping, et al., The relationship between the blood stasis of hepatitis C and the serum HA and HPC III and the effect of herbal medicine, Tribune on Traditional Chinese Medicine 1995; (1): 30. 2. Zhenghua Le and Xier Tang, Jiedu Huoxie Tang in treating hepatitis C-18 cases, translation of unpublished clinic report. 3. You Songxin, et al., A clinical study Bing Gan Ling Oral Liquid for treatment of hepatitis C, Journal of Traditional Chinese Medicine 1998; 18(3): 209-214. 4. Tall J, personal communication, April 2000. 5. Grubb G, personal communication, March 2000. 6. Stern E, Two cases of hepatitis C treated with herbs and supplements, Journal of Alternative and Complementary Medicine 1997; 3(1): 77-82. 7. Batey RG et al., Preliminary report of a randomized, double-blind, placebo-controlled trial of a Chinese herbal medicine preparation CH-100, in the treatment of chronic hepatitis C, Journal of Gastroenterology and Hepatology; 1998; 13(3): 2447. 8. van Rossum TG, et al., Intravenous glycyrrhizin for the treatment of chronic hepatitis C: a double-blind, randomized, placebo-controlled phase I/II trial, Journal of Gastroenterology and Hepatology 1999, 14(11):1093-1099. 9. Beyendorff U, personal communication, May 2000. 10. Nepstead G, personal communication, March 1995. 11. Tsukiyama K, et al., A case of pneumonitis due to sho-saiko-to, Nihon Kyobu Shikkan Gakkai Zasshi 1989; 27(12): 15561561. 12. Takada N, et al., A case of sho-saiko-to induced pneumonitis, diagnosed by lymphocyte stimulation test using bronchoalveolar lavage fluid, Nihon Kyobu Shikkan Gakkai Zasshi 1993; 31(9): 1163-1169. 13. Okanoue T, et al., Side effects of high-dose interferon therapy for chronic hepatitis C, Journal of Hepatology 1996; 25(3): 283-291. 14. Hoffman RM, et al., Sarcoidosis associated with interferon-alpha therapy for chronic hepatitis C , Journal of Hepatology 1998; 28(6): 1058-1063. 15. Nakagawa A, et al., Five cases of drug-induced pneumonitis due to sho-saiko-to or interferon alpha or both, Nihon Kyobu Shikkan Gakkai Zasshi 1995; 33 (12): 1361-1366. 16. Murakami K, et al., A possible mechanism of interstitial pneumonia during interferon therapy with sho-saiko-to, Nihon Kyobu Shikkan Gakkai Zasshi 1995; 33 (4): 389-394. 17. Ishizaki T, et al., Pneumonitis during interferon and/or herbal drug therapy in patients with chronic active hepatitis, European Respiration Journal 1996; 9(12): 2691-2696. 18. Tojima H, et al., Two cases of pneumonia caused by sho-saiko-to, Nihon Kyobu Shikkan Gakkai Zasshi 1996; 34(8): 904910. 19. Sato A, Pneumonitis induced by the herbal medicine sho-saiko-to in Japan, Nihon Kyobu Shikkan Gakkai Zasshi 1989; 35(4): 391-395. 20. Katou K and Mori K, Autoimmune hepatitis with drug-induced pneumonia due to sho-saiko-to, Nihon Kyobu Shikkan Gakkai Zasshi 1999; 37(8): 641-646. 21. Nishimori F, et al., Pneumonitis induced by the drug ougon, Nihon Kyobu Shikkan Gakkai Zasshi 1999; 37(5): 396-400. 22. Gordon SC, Extrahepatic manifestations of hepatitis C, Digestive Diseases 1996; 14(3): 157-168.

23. Japanese Ministry of Health and Welfare, 1999 Drug and Medical Device Safety Information, Volume 158. 24. Hizawa N, et al., A patient with chronic hepatitic C who simultaneously developed interstitial pneumonia, hemolytic anemia, and cholestatic liver dysfunction after alpha-interferon administration, Internal Medicine 1994; 33(6): 337-341. 25. Ohtake N, et al., Modulation of lung local immune responses by oral administration of a herbal medicine sho-saiko-to, International Journal of Immunopharmacology 2000; 22(6): 419-430. 26. Takahashi M, et al., The pharmacokinetics of the glycyrrhizin and glycyrrhetic acid after intravenous administration of glycyrrhizin for the patients with chronic liver disease caused by type C hepatitis virus, Nippon Shokakibyo Gakkai Zasshi 1995; 92(12): 1929-1936. 27. Tsubota A, et al., Combined ursodeoxycholic acid and glycyrrhizin therapy for chronic hepatitis C virus infection: a randomized controlled trial in 170 patients, European Journal of Gastroenterology and Hepatology 1999; 1077-1083. 28. Schalm SW, et al., New treatment strategies in non-responder patients with chronic hepatitis C, Journal of Hepatology 1999; 31(supplement 1): 184-148. 29. Abe Y, et al., Effectiveness of interferon-glycyrrhizin combination therapy in patients with chronic hepatitis C, Nippon Rinsho 1994; 52(7): 1817-1822. 30. Clerci C, et al., Interferon plus ursodeoxycholic acid versus interferon in the treatment of chronic C viral hepatitis, Minerva Medicine 1997; 88(5): 219-225. 31. Senturk H, et al., Long-term efficacy of interferon-alpha and ursodeoxycholic acid in treatment of chronic type C hepatitis, Digestive Disease Science 1997; 42(7): 1438-1444. 32. Lirussi F, et al., Long-term treatment of chronic hepatitis C with ursodeoxycholic acid: influence of HCV genotypes and severity of liver disease, Liver 1999; 19(5): 381-388. 33. Flora K, et al., Milk thistle (Silybum marianum) for the therapy of liver disease, American Journal of Gastroenterology 1998; 93(2): 139-143. 34. Berkson BM, A conservative triple antioxidant approach to the treatment of hepatitis C, Medical Clinic, 1999; 94 Supplement 3: 84-89. 35. Garcia-Monzon C, et al., Intrahepatic accumulation of nitrotyrosine in chronic viral hepatitis is associated with histological seveerity of liver disease, Journal of Hepatology, 2000; 32(2): 331-338. 36. Soliman KF and Mazzio EA, In vitro attenuation of nitric oxide production in C6 astrocyte cell culture by various dietary compounds, Proceedings of the Society for Experimental Biology and Medicine, 1998; 218(4): 390-397. 37. Sharara AI, et al., Inteferon alpha activation of human blood mononuclear cells in vitro and in vivo for nitric oxide synthetase type 2 mRNA and protein expression, Journal of Experimental Medicine 1997; 186(9): 1495-1502.

APPENDIX 1: Glycyrrhizin and Bile Licorice has been found to have potent antiviral action and it is especially suited to inhibiting retroviruses. In Japan, a special glycyrrhizin preparation for treating viral infections has been available for more than 20 years and has been tried for HIV, hepatitis B, and hepatitis C. The product is called stronger neominophagen (SNMC), and is mainly comprised of glycyrrhizin with cysteine (an amino acid used to protect against the undesired effects of glycyrrhizin on the sodium-potassium balance). It is often given by injection, but is also available as a pill and a syrup. Bile products (whole gallbladders or isolated bile) have long been used in traditional medicine to treat liver and gallbladder diseases. For example, the patent formula Li Gan Pian (Liver Normalizing Tablets) indicated for chronic hepatitis, is comprised of lysimachia (jinqiancao) and ox bile (niudan) ; Jigucao Wan (Abrus Pills), also indicated for chronic hepatitis, contains abrus, tang-kuei, lycium, salvia, and ox bile (listed as ox gallstone) as the main ingredients. Cholic acid is the base compound in bile salt (cholic = bile-derived), and a variant, deoxycholic acid, is the most common form. Ursodeoxycholic acid, a specific bile salt, has been adopted into modern drug therapy and is used in treatment of hepatitis. This bile salt is the main one found in bear bile (urso = bear), but it is also found in other bile products and can now be produced synthetically, making it a practical source for drug therapy. Both of these substances have been reported helpful in lowering liver enzymes in patients with hepatitis C. Recently, a large clinical study (170 patients) compared use of glycyrrhizin alone or with ursodeoxycholic acid (27). It was found that glycyrrhizin alone could markedly lower AST and ALT levels, but only by adding ursodeoxycholic acid (600 mg/day), could the GGT level also be markedly reduced. The level of hepatitis C virus was not affected by the treatment. The authors of the study concluded that: "The combined therapy with ursodeoxycholic acid and glycyrrhizin is safe and effective in improving liver-specific enzyme abnormalities, and may be an alternative to interferon in chronic hepatitis C virus infection, especially for interferon-resistant or unstable patients." The possibility of using such liver-stabilizing therapies in place of interferon was suggested for non-responders to interferon therapy in a review article on the subject (28). The authors stated that "For the many patients who still do not respond with viral clearance despite these new approaches [using interferon in differing dosages and with ribavirin], the goal of therapy might be shifted towards persistent ALT normalization in order to reduce the progression of liver disease." In a small study (28 patients), SNMC was combined with interferon for 15 patients and the 13 others were given interferon alone (29). It was reported that the serum viral clearance was higher (but not with statistical significance) in the group receiving the combined therapy, and that there was a higher rate of improvement in liver condition as observed by biopsy in the combined therapy group. This study was too small to reveal whether there might be side effects, such as pneumonitis, from the combination therapy that otherwise appears quite favorable. Another small study (41 patients), compared treatment of interferon alone (20 patients) with interferon plus ursodeoxycholic acid (21 patients). It was reported (30) that decline in liver enzymes was faster in the combined therapy group than in the interferon-only group; further, there were greater improvements in the liver condition as revealed by biopsy in the combination therapy group. A second study for long-term response compared use of either ursodeoxycholic acid or interferon alone and in combination (31). The ursodeoxycholic acid alone was said to be ineffective; the combination increased the interferon response rates, but the difference was not

deemed significant nor sustained. In another study comparing use of interferon alone or with ursodeoxycholic acid (31), it was reported that the combination was not significantly more effective than interferon alone except that the response to interferon (e.g., lowering liver enzyme levels) was prolonged in some patients receiving the combination. A situation where ursodeoxycholic acid appears to be effective, even if given alone, is autoimmune-associated chronic hepatitis C (32). This is a liver disease in which hepatitis C induces a secondary autoimmune process (interferon therapy may also induce this process). According to the report, patients with the autoimmune component responded to a one year treatment with ursodeoxycholic acid by having significantly lowered liver enzyme levels.

APPENDIX 2: Silymarin Silymarin, the active fraction from milk thistle (Silybum marianum) has become a well-known agent for treatment of liver disease. In a review of its application and efficacy (33), doctors at the Division of Gastroenterology at the Oregon Health Sciences University stated that: In a recent poll of patients attending our hepatology clinic, we found that 31% were using over-the-counter alternative agents for the therapy of their liver diseases. The most commonly-used nontraditional therapy was milk thistle (silymarin)....Most of the clinical trials designed to assess the efficacy of silymarin are difficult to interpret, as they are flawed by the small numbers of subjects, variability in etiologies, and severity of the liver diseases studied, as well as inconsistencies in alcohol usage by patients, heterogeneous dosing, inconsistent use of control groups, and inadequately defined endpoints. Clinical trials with silymarin and hepatitis C have not been reported up to now. During acute viral hepatitis A or B, silymarin has been reported to hasten recovery and shorten hospital stays, consistent with an anti-inflammatory activity that is supported by laboratory animal studies with chemical-induced hepatitis. A report on three patients with advanced liver disease associated with hepatitis C treated by the antioxidant approach was presented by a doctor at the Integrative Medical Center of New Mexico (34). Patients received a combination of silymarin, alpha-lipoic acid, and selenium and were said to have a quick alleviation of major symptoms and an improvement in liver enzyme levels. In Spain, liver biopsies of hepatitis C patients were conducted to evaluate the extent to which inflammatory nitrogen compounds influence liver damage (35). It was reported that the severity of liver disease seen in the tissue samples was correlated with the content of the damaging nitrogen compounds, nitric oxide and nitrotyrosine. The possibility that silymarin and other antioxidants, such as green tea extract and quercetin, might help protect against these effects is raised by preliminary work reported at the College of Pharmacy at Florida A and M University (36). Using in vitro assays, they noted that silymarin, green tea, quercetin, curcumin and a variety of flavonoid compounds could inhibit nitric oxide by stimulated cells. Nitric oxide production is stimulated by interferon alpha in patients with hepatitis C according to researchers at the Duke University Medical Centers in North Carolina (37). These researchers proposed that nitric oxide stimulated by interferon may contribute to the antiviral action, though it is also possible that such stimulus is merely a reflection of enhanced antiviral action from other components of immune cells. The use of antioxidants during interferon therapy for hepatitis C might be questioned, if it reduces a nitric oxide mediated attack against the virus. At this time, there is no evidence to support use of silymarin during the time of interferon treatment. As with the recommendation above for other herbal therapies, the best use of silymarin and other antioxidant therapies (as supplements taken in larger than normal dietary levels) might be before or after interferon therapy. In Appendix 1, examples of natural products that have been tested along with interferon are described. The usual dose of silymarin used in clinical trials is reported to be 140 mg each time, three times daily. However, this amount usually refers to the crude preparation that is 70% silymarin, which means the actual dose of the compound is about 100 mg each time, for a total daily dose of 300 mg. May 2000

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HIV DRUGS AND HERB INTERACTIONS essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Since the initial reports of HIV infection in the U.S. in the early 1980s, a large number of people with this disease have pursued herbal remedies. Prior to the development of highly effective anti-HIV drug combinations, thousands of HIV infected people tried a variety of herbal therapies to boost their immune systems, inhibit opportunistic infections, alleviate symptoms, and inhibit HIV itself. Due to the deadliness of the disease, preliminary studies, many of them in vitro only, were grasped at as hope for a cure or effective limitation of the disease, and a variety of natural substances were tried, including roots of leguminous plants, such as licorice and astragalus, Oriental medicinal mushrooms, and ordinary garlic. From about 1983, when the viral nature of the disease was established, until 1995, when the drug cocktails became available, a culture of using herbs for people with HIV had developed. This occurred especially in large cities, and with an emphasis on Chinese herbs, since the main licensed health profession in the U.S. involving herb prescribing is acupuncture (licensing in a few states has been granted for naturopaths, who also prescribe herbs). During that time, none of the herbs had been shown to be substantially effective for inhibiting HIV, but many people were convinced that they helped, some to the point that they considered herbal supplements to be life-saving. It is not surprising, then, that even after highly active drug therapies were developed many of those with HIV infection continued to use herbs. The drug therapies did not cure the disease, so herbs were sought to provide additional protection from the virus and to restore the damaged immune functions. Herbs were also considered a possible means to minimize drug side effects. The situation surrounding HIV infection appeared brighter in the late 1990s, with the virus better controlled and with herbs apparently able to help alleviate a variety of symptoms as well as reducing the anxiety that accompanies taking drugs that are, in the view of many, toxic substances. What did come as a surprise was news-emerging first in 1999 and formally published in 2000-that a very popular herb, St. John's Wort, appeared to lower indinavir blood levels significantly. This herb, Hypericum perforatum, had been used primarily for its antidepressant actions, but it also had been shown in laboratory tests to possess HIV-inhibiting action, which attracted HIV-infected patients to the herb even more. The reports of indinavir interaction were soon accompanied by other reports suggesting that this herb interacted with a very wide range of drugs, from birth control pills to warfarin, with the same potential adverse consequence: lowering the drug dosage to an ineffective level. The growth in popularity of St. John's Wort had been driven by a number of published controlled clinical studies of its effectiveness as an antidepressant beginning in 1993, and it rapidly became one of the top selling herbs. From 1997-2000, for example, it was the 5th largest selling herb in the U.S., with retail sales of about $48 million dollars. The news about herb-drug interactions triggered a retreat from reliance on this herb, a change that was intensified when some new clinical reports, beginning with one published in JAMA in 2001, questioned its efficacy for depression. Then the drop-off began: by 2002, the sales of St. John's Wort were cut in half compared to their peak levels, and by 2003 they had declined by another 40%. The herb in no longer extensively used, although it is still available and some consumers remain unaware of its effects on drug levels. The mechanism of herb-drug interaction with St. John's Wort has been elucidated, and the greatest concern is focused on medications that are substrates on CYP3A4; this enzyme degrades many drugs. St. John's Wort induces production of the enzyme, hence the drugs are degraded faster. This is the same enzyme that is inhibited by grapefruit juice, which has the opposite effect of increasing drug levels in the blood. Both St. John's Wort and grapefruit juice are among the strongest of the known natural substances that affect drug levels when consumed at ordinary doses. In addition to CYP3A4, St. John's Wort affects phosphorylated glycoprotein (Pglycoprotein or Pgp), which also metabolizes drugs. Aside from indinavir, the metabolism of other protease inhibitor anti-HIV drugs are also affected by St. John's Wort. The question then arises: how many other herbs might have this effect on the drugs of concern for people with HIV? Fortunately, it appears that few other commonly used herb materials have such a dramatic effect. Just as fruits other than grapefruit have minimal impact on drug metabolism, so too, herbs other than St. John's Wort appear to have limited effect. St. John's Wort has an unusual ingredient, hypericin (pictured below), that confers the high level of activity.

Chemical structure of hypericin As mentioned, many people with HIV use herbs routinely; they usually have their viral load tests done at intervals (typically six months to a year) to monitor continuing efficacy of their drug treatment. Thus far, St. John's Wort is the only herb that has been demonstrated to actually affect blood levels of HIV drugs in people. However, induction of CYP3A4 does occur to some extent with several herbs and components isolated from herbs, such as kaempherol and quercetin (which are also found in ordinary foods, such as fruits, vegetables, and tea) and allicin (in garlic). High doses of quercetin may be given as an antioxidant and even higher doses are recommended to inhibit allergies. The antioxidant levels of quercetin (typically less than 1 gram) have been used by thousands of HIV infected individuals while utilizing the drug cocktails, seemingly without adverse consequence; the higher doses (up to 2 grams per day)

are used less frequently and the effects may remain unknown. A difficulty with detecting actual herb-drug interactions is the complexity of individual cases where the interaction may occur, as well as the problem of poor reporting. One can easily get the sense from reading medical literature that herb-drug interactions are a rampant problem. However, a review of that literature, based on an intensive search for and evaluation of herb-drug interaction reports, yielded the following: "108 cases of suspected interactions were found: 68.5% were classified as 'unable to be evaluated,' 13% as 'welldocumented' and 18.5% as 'possible' interactions. Warfarin was the most common drug (18 cases) and St. John's Wort the most common herb (54 cases) involved." In another evaluation of the literature published two years later, it was observed that there were very few wellsupported interactions detected: namely 22 that involved more than an individual report, or a simple pharmacology study, or a mere suggestion of potential interaction. The main drug of concern again was Warfarin and the primary herb was St. John's Wort. In all, it appeared that the rate of well-documented herb-drug interactions has been about 4 per year. No doubt, many more instances occurred and were not reported, perhaps due to their minor nature or uncertainty in attributing the cause. Even so, the numbers should be kept in perspective: the nutriceutical industry estimated (for 1999) that 21 million adults are regular users of herbal remedies, so the rate of serious herb-drug interactions appears to be quite small given the high level of prescription and OTC drug use in this country. There are a number of steps to take in order to avoid herb-drug interactions, of which avoiding St. John's Wort is the most important. Caution should be taken when consuming herbs in large doses, since the higher dose provides an opportunity for affecting drug metabolizing enzymes. Before embarking on use of any herb at high dosage, it is important to check the current literature, which is done quite effectively by using the free PubMed website (http://www.ncbi.nlm.nih.gov/entrez/). For example, if one types into the search box "Indinavir, herb-drug interactions," several article abstracts will be made available (14 of them as of January 2005). The articles mostly focus on St. John's Wort, but some abstracts mention numerous other herbs that show some effect on the same enzyme systems in laboratory experiments. Those who wish to be maximally cautious about the interactions may wish to avoid the mentioned herbs altogether, while others might simply avoid high dosage preparations that include them. Since 1992, The Institute for Traditional Medicine has operated a clinic in Portland, Oregon that has provided Chinese medicine to patients with HIV and has provided support to similar clinics in San Francisco and elsewhere. Patients at these facilities take their prescribed drug cocktails and also utilize high-dosage protocols involving herbs (St. John's Wort is not among them) and have not reported increases in viral load or suspicion of herb-drug interactions. While such informal monitoring does not provide clear evidence for the absence of such interactions, the apparent lack of adverse effects is entirely consistent with the findings mentioned above for formal medical reports: that herb-drug interaction incidents are infrequent.

February 2005

NATURAL THERAPIES FOR HIV/AIDS IN THE AGE OF DRUG COCKTAILS essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The situation with HIV/AIDS changed dramatically in 1996 with the widespread introduction of protease inhibitors used in polydrug therapy (“drug cocktails,” combinations of three or more HIV-inhibiting drugs). Many persons with AIDS who were experiencing wasting syndrome and numerous opportunistic infections suddenly began to gain weight and experience improvements in general health. The death rate from HIV/AIDS dropped significantly by 1997, partly because of the success of these drug therapies. Thus far, only onethird of persons infected by HIV have been treated by this new method, and it has been proposed that the drug cocktails be made available to everyone who is able to take them regularly. New drugs that go into the mix are being introduced annually. This should help reduce side effects and improve efficacy for those who are resistant to the earlier drugs (usually as a result of using them in monotherapy, as had been the previous practice). Of course, the battle is not quite over. There are some persons who do not tolerate the drugs, others who are irregular in their use (which makes the drugs essentially ineffective), and others who inadvertently defeat their drug therapy by ingesting other drugs, or even foods, that reduce their effectiveness. In a recent study in San Francisco, about half those using the drug cocktails showed some degree of failure, i.e., rising viral load. It is not yet known if this virus that can grow in the presence of the drugs is particularly virulent: however, rising viral load can trigger immune responses that generate some characteristic symptoms of HIV infection. If the virus growing under these conditions is problematic, a new three drug cocktail (new drugs are already available) or a four drug cocktail may be necessary. Aside from cases of treatment failure, there are others who choose not to use drug therapies, and those who, despite the drug benefits, still display immunological disturbances that lead to opportunistic infections. Further, persons who have regained health to a certain extent by effective inhibition of HIV may still experience other health problems, such as cardiovascular disease and cancer, that affect the general population, as well as residual disorders from the lengthy experience of rampant HIV infection. No one yet knows the consequence of taking the anti-HIV drugs for several years and it remains unknown how far the immune system can recover. Some physicians have expressed optimism that successful long-term inhibition of HIV infection by the drugs may lead to a cure in some individuals, especially those who were infected relatively recently and treated immediately. Following is a review of some natural therapeutic approaches that address the current issues. These are divided into sections: 1. Vitamins/Minerals 2. Proteins/Fats 3. Antioxidants 4. Chinese Herbs The methods to be described are being utilized at the Institute’s Immune Enhancement Project (IEP, in Portland, Oregon), which has over 100 patients with HIV infection. The clinic has been providing these types of services for the past five years at the current location. The specific treatment options mentioned here were selected from the broader approach used at the clinic, in consideration of proposed application to clinical situations likely to be encountered elsewhere. For example, at ITM’s clinic, patients usually receive weekly acupuncture and moxibustion therapy, bimonthly Oriental massage therapy, and a wider range of Chinese herbs than is described here (prescribed on the basis of the individual patient presentation). For most people, such services are frequently unavailable (mainly to be found in large cities) or are too expensive to be convenient. For example about 75% of our clients receive financial assistance (from Ryan White funds and from ITM) and the remaining 25% participate at the program’s standard fees that are below average cost of delivery.

1. VITAMINS AND MINERALS It has been known for many years that when persons with HIV/AIDS are tested for serum nutrient levels a high percentage reveal significantly low levels of one or more nutrients. In fact, for virtually every nutrient tested, serum levels appear low in a substantial proportion of HIV infected individuals (the exception is copper levels, which have an inverse relationship with the very low zinc levels). The severity of nutrient deficiency increases with AIDS, compared to that observed in early stages of HIV infection. There are several books that can be consulted for a summary of earlier data, including: Nutrition and AIDS (Watson, CRC Press, 1994), Nutrition and HIV (Romeyn, Jossey-Bass Publishers, 1995), and Nutrition and HIV Infection (FASEB, 1990). To access the latest information about the deficiencies, one can retrieve abstracts from AIDSLINE (a subdirectory of the National Library of Medicine at: http://www.nlm.nih.gov/nlmhome.html) checking each individual nutrient of interest. The causes of the nutritional deficiencies are not fully established. Certainly, in later stages of the disease, malabsorption, diarrhea, and hypermetabolism have been suggested as contributors. In addition, cytokine imbalances may stimulate some mechanisms that more rapidly clear nutrients from the serum. As a further complication to this problem, a higher than usual amount of certain nutrients might be needed by the individual because of the hyperactivation of the immune system and the occasional (or continual) need to repair damage due to infection and inflammation. Some drug therapies affect nutrient levels or require high levels of nutrients to minimize the incidence and severity of side effects. Currently, the demographics of HIV infection are shifting. A larger proportion of infections are experienced by persons who have difficulty maintaining a healthy lifestyle because of drug addiction, homelessness, mental illness, poor education, and other problems. Among this group may be found an even higher proportion of persons with a diet that is lacking in many important nutrients. While the finding of nutrient deficiencies has been a major area of research, the effect of the obvious treatment—administering extra nutrients in order to overcome lower absorption and higher utilization rates—has been less studied. Nonetheless, in several published reports the impact of short-term (6 weeks to 6 months) nutrient administration has been shown to produce symptomatic and immunological improvements. The evidence that is accumulating for supplementing in cases of deficiency is compelling. The question arises as to what is prudent practice while awaiting results of further clinical trials. What are the benefits, risks, and costs associated with nutritional supplementation?

The process of monitoring nutrient status can be quite expensive. There are a large number of nutrients that could be measured. One service, a lymphocyte nutrient status test, is provided by SpectraCell in Houston, Texas. A typical analysis of nutrients (which does not include all the nutrients of potential interest, but, rather, a sampling of vitamins, minerals, and amino acids) has a cost of about $400. Can one give nutrients in the absence of testing for deficiencies? The answer to that question revolves around the issue of safety, since the cost of administering nutrients is not especially high and even having potential benefits can be of interest within the current state of disease management. Administration of nutrients, even in fairly high quantities, has been undertaken for several decades by people having a wide range of ailments, and quite a large number of persons with HIV infection have either self-administered or have been prescribed nutritional supplements. Except in cases of extreme high dosage, adverse reactions are not obvious. A substantial body of evidence has been accumulated regarding the range of dosages that are safe to administer. An excellent compilation of research reports has been gathered by Melvyn Werbach, M.D. and published in his book Nutritional Influences on Illness (Third Line Press, 1993). Since vitamins and minerals provided in nutritional supplements are also found in dietary sources, it is reasonable to expect that they are safe to administer so long as the dosage is not excessive. Those working with natural healing are convinced that if the overall evidence shows a tendency to having a deficiency in nutrients, and if nutrients can be easily and inexpensively provided, and if there is some evidence showing benefit, then one might as well administer them while awaiting proof of effectiveness. If this step turns out to have little or no clinical benefit, there will not be much loss; if there is a benefit, it will likely prove to be a cost-effective intervention. It is also thought that negative impacts that have at times been suggested as a result of using high doses of individual nutrients can be avoided by relying on combination therapies at moderate dosage. The supplements should also be taken with a healthful diet whenever possible. Instead of using the RDA (recommended daily allowance) of nutrients as a guide to a reasonable level, the amounts to be used are a reflection of the current state of knowledge derived from studies of nutrient administration to resolve symptoms and diseases. These levels are sometimes considerably higher than the RDA, but not near a toxic level. At IEP, nutrient substances have been provided to patients over a period of four years in response to the growing body of evidence suggesting that it would be a safe and effective intervention, and as an attempt to improve upon the self-administration regimens adopted by individuals not trained in nutrition. A broad spectrum of substances have been provided. Lack of funds has prevented the monitoring of serum levels of individual nutrients to determine whether deficiencies existed and were alleviated by the treatment when they did exist. Evident adverse reactions have not been observed, and long-term monitoring of the patients has suggested (but not proven) that the patients enrolled in this program have fared well. Though obvious benefits (such as dramatic symptom improvement) have also not been observed, individual participants report that they believe the use of the supplements is helpful. The actual cost of nutritional supplementation will depend on what nutrients are delivered, but for the standard vitamins and minerals, the cost is about 80 cents per day. In Portland, nutritional supplements are provided at no extra cost at IEP, and they may be obtained at no cost by using Ryan White Vouchers (available to persons who have an income less than twice the federally defined poverty level; the supplements must be prescribed by a health professional).

PROTEINS AND FATS Protein and calorie deficiency frequently occurs during AIDS and is part of the cause of AIDS-related weight loss. A good review of the subject is by S.J. Bell, et al., Nutrition support and the human immunodeficiency virus (Parasitology 1993; 107:S53–S67). At IEP, body weight monitoring revealed that HIV positive persons who are not classified as having AIDS had an average 20 pound higher body weight than those with AIDS who were not suffering from an acute wasting syndrome. Studies have suggested that persons with AIDS may have a daily caloric need of up to 2,700 kcal compared to a pre-AIDS level of about 2,200 kcal, and may have a protein need of 1.2 grams/kg compared to a pre-AIDS level of 0.8 grams/kg (see, for example, the publication by C.M. Derek, et al., Energy expenditure and wasting in HIV infection, New England Journal of Medicine 1995; 333(2): 83–88). Those patients who undertake muscle-building exercise programs, as is recommended to help prevent lean mass wasting, may have even higher protein requirements. Albumin levels in persons with AIDS frequently fall below 4.0, and it has been shown that survival time has a strong relationship with albumin levels, with a high probability of death among persons with albumin at or below 3.0. Glutamine, the main amino acid in the body with reserves stored in the muscle, is often depleted. Glutamine has important functions for the immune system and is needed for gastro-intestinal health. In the absence of adequate protein intake, muscle mass is gradually wasted. As glutamine stores and albumin levels drop, the ability to carry on normal physiological processes is inhibited and the individual becomes highly susceptible to a catastrophic illness. It is not so easy for persons with AIDS to get the protein they need, especially if appetite is reduced as the result of loss of taste for food, feeling bloated soon after beginning to eat, or as a reaction to infections or drug therapies. Protein-wasting diarrhea may also occur as a result of HIV enteropathy. Here is a protein level analysis of several foods considered to be high in protein: two eggs: 12 grams eight ounces white chicken meat: 12 grams four ounces halibut or shrimp: 24 grams one cup of yogurt: 8 grams one-half cup of cottage cheese: 13 grams one ounce typical hard cheese: 7 grams two ounces of peanuts: 14 grams one-half cup of cooked lentils: 8 grams If all these items were consumed in one day—which would be quite a task—the total protein from them would be 88 grams, about the amount needed by a 160 pound man that required 1.2 grams/kg. Of course, there is some protein in the other foods that might be consumed along with these things, but relatively little. Two methods of protein supplementation that are sometimes suggested are nutrition drinks (e.g., Ensure, Advera, Sustacal, Boost, Peptamen), which provide 10–15 grams of protein per can (and about 250 kcal), or protein powders, which can be added to foods or blender drinks, and which provide about 5 grams per scoop (adding only about 22 kcal to the liquid base).

At IEP, it is recommended to AIDS patients that they try eating more than three meals per day, focusing especially on high protein foods, such as fish, chicken, eggs, and Japanese style tofu (which has lower fat than Chinese style), and to supplement with protein powder, bee pollen (has 28% protein), and nutrition drinks (up to two cans per day to get the extra 500 calories needed). In addition, glutamine powder (which is tasteless), in the amount of 10–30 grams per day is recommended to patients if they have wasting, intestinal distress, or low body weight. The orally-ingested glutamine spares body stores of this amino acid, helps replenish glutathione (an antioxidant that may reduce HIV activation rates), and helps repair damaged intestinal cells (in some cases relieving diarrhea). There is a vast body of literature on glutamine and its potential benefits for persons with bowel disorders; up to 40 grams per day is given by IV drip to persons who have undergone bowel surgery, but oral administration is best for those who are able. Based on the results of a review of patient files at IEP, patients are now instructed to begin special protein-enhancing diet when the albumin level drops below 4.0 (even though “normal” values are listed as being 3.5 and above). Several studies have shown that low albumin is associated with poor outcomes in recovery from diseases, surgery, and trauma. For further information see “Malnutrition,” a compilation of abstracts provided by Abbott Laboratories (Ross Products Division), and see “Effect of malnutrition on the progression of AIDS,” by Donald Kotler, HIV 1994; 3(3): 17–23. Dr. Kotler has produced several other excellent reviews on the relationship of nutrition to HIV/AIDS. Fat malabsorption and futile lipid cycling result in abnormal fat levels, which can affect body warmth, fluidity of membranes, and can cause dryness and itching of the skin. In a study carried out at IEP, it was found that while lean mass levels were declining rapidly after onset of AIDS, body fat percentage was also declining. Fat malabsorption reduces the ability to gain necessary calories (as the caloric content of fats is twice that of carbohydrates and proteins), reduces access to fat soluble vitamins, and it can also lead to bloating and diarrhea. Many high protein foods, such as meats and nuts, are high in fat, and may thus prove to be poor dietary sources of protein (fish and chicken are relatively low in fat). It has been shown that medium chain triglycerides (MCT) are an easily absorbed fat. In a study of Ross Nutrition products in persons with AIDS, it was found that persons who regularly used Ensure (which is relatively high in long-chain fat and has some fiber) lost weight, while persons who used Advera (which is high in MCT and has no fiber) gained weight. In order to get the needed lipids and calories, it is important to have meals that contain some fat, but a small enough amount that does not cause adverse reactions due to the unabsorbed component. It may also be valuable to consume products that contain MCT (MeadJohnson provides an MCT liquid product that can be used as a substitute for other fats in the diet). Small amounts of omega-3 and omega-6 fatty acids have been suggested to be helpful to immune regulation, and are readily available in soft-gel capsules, with the oil derived from borage and flax seeds. Fish oils may also be helpful and are best obtained by eating fish to provide high protein at the same time (though capsules are available for persons who do not like to eat fish). Nutrition drinks with high MCT are suggested to be used only can per day mainly because of high cost, unless there is significant bowel disorder, in which case more may need to be used to assure adequate fats and calories). The protease inhibitors Saquinavir and Ritonavir are to be taken with relatively high-fat meals to enhance absorption. While some recommend hamburgers, pizza, sausages, or cream sauce, a more healthful approach would be to use olive oil, fatty fish (e.g., tuna or salmon), eggs, walnuts, and peanuts.

ANTIOXIDANTS Antioxidants are compounds that help reduce the damage caused by oxygen. The body naturally relies on multiple antioxidant systems, to prevent cellular dysfunction and death, including glutathione, vitamins and minerals, and superoxide dysmutase. Several antioxidants are obtained from the diet, especially from consuming fruits and vegetables, which are rich in vitamins and minerals and which may also contain the natural antioxidant compounds called flavonoids. Lipid peroxidation, which is prevented or reversed by antioxidant systems, is believed to be responsible for a number of pathological conditions, including many cases of cardiovascular disease and cancer. For this reason, it is believed that maintaining a high antioxidant level can have life-prolonging and so-called anti-aging effects. When tested in vitro, virtually every antioxidant inhibits HIV replication. It has been suggested that the mechanism of action includes halting the stimulation of DNA by the nuclear factor NF-kB, which is, in turn, activated by oxidation and inflammation byproducts. There have been relatively few clinical tests of antioxidants in persons with HIV infection. The results of the small trials that have been conducted thus far have been positive, but modest. Besides the obvious interest in using such agents to reduce HIV replication rates, antioxidants are attractive because persons with HIV infection are usually in a state of “oxidative stress,” which means that the existing antioxidant systems are inadequate to meet physiological needs. One of the apparently promising antioxidants tested early on was NAC (N-acetyl-cysteine), which is the active component of the drug Mucomyst (used to thin mucus and to counteract the toxicity of Tylenol). NAC contributes to building up glutathione, one of the key antioxidant systems. The clinical problem with NAC is that it is poorly absorbed, so that to get adequate blood levels, one must consume several grams of the substance; unfortunately, that dosage often causes nausea. Since the original work with NAC, several other antioxidants have shown potential benefit, notably the mineral selenium, vitamin C, the thiol alpha-lipoic acid, and the coenzyme called CoQ10. Each of these has shown some positive benefits in small clinical evaluations. As an example, in Germany, alpha-lipoic acid given to 10 HIV infected patients showed that it could (in the majority of patients) increase plasma ascorbate, total glutathione, total plasma thiol groups, T-helper lymphocytes and helper/suppressor ratio, and reduce the levels of lipid peroxidation products. Another German group reported that “First virological data from patients treated with alpha-lipoic acid indicate that antiviral effects are also seen in vivo. A reduction of infectious viral titers was observed as predicted from the in vitro experiments.” For more information about alpha-lipoic acid, conduct a search on AIDSLINE, using the common name for the compound, thiotic acid. Naturally-occurring antioxidants are non-toxic and they do not cause side effects when used in modest dosage (in high dosage, several of them can cause digestive disturbance). Their effects are not dramatic (for example, they do not cause decreases in viral load or increases in CD4 levels as much as do combination anti-HIV drug therapies), but appear consistently positive. Antioxidants might be prescribed as a follow-up to oxidative stress measurement that reveals a high level. SpectraCell Laboratories in Houston, Texas offers an oxidative stress evaluation for lymphocytes. However, even if one does not pursue this testing, antioxidants might be given when a person is not tolerating standard anti-HIV drug therapy or the therapy is not having an adequate benefit in terms

of viral load, CD4, or clinical outcome. One can try antioxidants as a replacement or supplemental therapy. Antioxidants are probably best applied when the viral load is not extreme (so that their impact might have some evident clinical benefit) and when an individual’s digestive functions are not too greatly impaired (otherwise, the absorption is likely to be too low). Antioxidant therapy is the main non-drug method of dealing with HIV replication other than herbal compounds. Because of limited clinical testing, it is not well-established which antioxidants function best in relation to HIV infection. For this reason, a broad mixture of the components are offered in the hope of providing a synergistic antioxidant activity. To quote from Suzuki and Packer (Molecular aspects of medicine, 1993; 14(3): 229–239), “We have examined the effects of vitamin E and alpha-lipoate derivatives on NF-kappa B activation, and have observed that each of these antioxidants behave differently.” At the International Conference on AIDS (August 1994), these researchers pointed out that “NF-kappa B transcription factor regulates HIV activation. Natural and safe compounds which target NF-kappa B action may, therefore, be useful in AIDS therapy to support the action of antiviral agents.”

CHINESE HERBS The chronic viral infection that has plagued the Orient is hepatitis B. In some areas, 15 to 20 percent of the population is infected. Treatment of hepatitis B is one of the major reasons why individuals in China and Japan visit practitioners that prescribe Chinese herbs. The course of hepatitis B disease is variable, but it frequently manifests as a relatively brief acute illness followed by an extended period of seropositive status but little or no symptoms; then, at some point many years later, a chronic active phase begins, which eventually leads to degeneration of the liver and, not infrequently, liver cancer. This description is not entirely unlike that of HIV infection, except that the liver is not necessarily the organ that experiences the degeneration and neoplasm. Like HIV, hepatitis B virus is a retrovirus. Unlike HIV infection, there are treatments that can cure the disease in about half of those infected: those treatments are herbs and herbal derivatives given orally or by intravenous route. Not surprisingly, when Chinese and Japanese researchers and doctors who had extensive experience with treating hepatitis B learned about HIV, they endeavored to try the same herbs to see if they could get similar results. Ten years ago, Americans infected by HIV who were tuned into the HIV/AIDS treatment news read that Japanese doctors had treated patients, yielding some significant improvements, with the polysaccharide-rich extract (called lentinin) of Lentinus edodes (the shiitake mushroom) and with glycyrrhizin, one of many active components of licorice. Both of these substances had already proven effective for treating hepatitis B. In addition, many Japanese doctors that prescribe traditional Chinese herbal medicines had experience with using a complex formula (with seven herb ingredients) for persons with hepatitis B and also for persons with several other health problems. The formula is known in Japanese as Sho Saiko To (in Chinese: Xiao Chaihu Tang), and it was tested in vitro against HIV, found to be inhibitory, and then further studied to reveal that a major active constituent was the flavonoid baicalin, which proved to be a reverse transcriptase inhibitor. The formula also contains licorice, with its component glycyrrhizin. Follow-up studies with Sho Saiko To have been conducted in France. Lentinin, glycyrrhizin, and Sho Saiko To have all been subjects of small U.S. studies, usually applied in combination with zidovudine. A polysaccharide produced in the U.S. with properties similar to lentinin, called acemannan, has also been the subject of several clinical trials in persons with HIV infection. While Japanese doctors were trying their remedies, researchers from mainland China submitted a list of 27 herbs to test against HIV, mainly from their list of anti-hepatitis B remedies; these were tested in the U.S. at the University of California (Davis). Eleven of the herb extracts showed inhibitory action, and the mechanism of action was mainly to inhibit uptake of the virus by cells. Although these herbs are not practical to use in HIV therapy (the dosage that would be needed to accomplish the task in persons, as opposed to cell culture, is quite high), this work stimulated interest in the potential value of herbal compounds. An advantage of these herbs is their very low toxicity and lack of side effects (gastro-intestinal disturbances can occur in some individuals, however); unlike some of the anti-HIV drugs now in use, they do not cause bone marrow suppression (to the contrary, several are known to counteract bone marrow suppression), and they do not cause damage to the pancreas, liver, kidneys, or nerves. One strategy for treatment has been to take several of these anti-viral herb materials and administer them to persons with HIV infection. The reason for using several is that it is presumed that none will individually shut-down HIV replication or infection of new cells, but together they may greatly inhibit the progression of HIV disease by reducing several aspects of the HIV life cycle, an approach similar to using a drug cocktail. Most times the dosage given to persons with HIV infection has been too low to have the desired effect. This is mainly because the cost of the herbs is usually not covered by research grants or insurance and only relatively crude preparations have been readily available, so that the amount of material that needs to be consumed is high. Also, few persons who prescribe Chinese herbs in the U.S. are familiar with the dosage levels used for treating hepatitis B in China and Japan. At this time, the effectiveness of the herbs is not established, but adverse reactions have been very few, and the clinical studies (usually with few patients) have produced positive outcomes. Along another line of inquiry, specialists in Chinese herbs have sought to treat problems characteristic of HIV disease, such as wasting, night sweating, diarrhea, and fatigue, by using herbs that have successfully treated similar symptoms in patients suffering from other diseases, such as tuberculosis (another major health problem in the Orient). Further, herbs that counteract the bone marrow suppressive effects of cancer therapies are considered potentially valuable for those using anti-HIV drug therapies. The herbs selected according to this way of thinking may not inhibit HIV, but it might ward off some of the difficulties encountered secondary to the HIV infection and drug therapies. Chinese doctors working in Los Angeles, New York, Africa, Thailand, and other places have reported favorable outcomes from the use of Chinese herbs. One doctor in Los Angeles, Jin Lin Wang, has been collecting data about his patients for several years and his herbal treatment was recently subject of a double-blind study at the Pacific Oaks Medical Center (where it was shown that P24 antigen levels were significantly reduced in the Chinese herbs group). The Institute for Traditional Medicine (ITM, Portland, Oregon) has compiled a partial listing of journal references related to the application of Chinese herbs to HIV/AIDS, with mention of both clinical and pharmacological investigations. ITM has produced a listing of major HIV treatment centers that provide Chinese herb formulas (as well as acupuncture and other services), and also maintains Practitioner Reference Guide to assist interested persons in finding private practitioners in the U.S. that have access to the information and herbal materials needed to provide Chinese formulas. It is estimated that about 6,000 individuals in the U.S. are receiving professional Chinese medical services in relation to HIV disease, about half of them at the major clinics that serve

12 or more patients (up to 400 at one site). The Institute for Traditional Medicine and the Centers for Disease Control (Tumor Virology Laboratory) worked together to test the effectiveness of Chinese herbs for the treatment of hepatitis B. A formulation similar to Baicalcumin (with licorice, salvia, curcuma, and hu-chang in common) was being used in a double-blind trial (patients are treated in China) against a lentinus-based treatment (representing the earlier standard therapy) and a well-recognized anti-hepatitis preparation currently used in China. The outcomes from the first group of patients revealed substantial inhibition of hepatitis B viral activity and improvement in liver function in those taking the test substance as well as the lentinus preparation. The dosage of dried herb extracts in tablet form administered daily is 23.5 grams. The decision to use this amount was based on information obtained from several previous clinical trials with Chinese herbs in decoction form. COUNTERACTING DRUG SIDE EFFECTS Experience at IEP supports the contention that ordinary tea (black or green; most people use black tea) taken with the dose of protease inhibitors can reduce or eliminate symptoms of nausea and/or diarrhea. This suggestion originally derived from the descriptions of protease inhibitor side effects and problems: they tend to cause nausea and diarrhea, should be taken with, or away from, foods to assure absorption (with fatty food being the biggest concern), and tend to cause kidney stones (made up of the drugs). This picture is parallel to what one can find with ingestion of heavy fatty materials. From the traditional Chinese perspective, this can be resolved by taking certain herbs, of which ordinary tea is the most readily available. Translations of Chinese medical literature have been used as the basis of additional steps applied to dealing with drug side effects. A Chinese laboratory animal study indicated that the bone marrow suppressive action of AZT (zidovudine) could be counteracted by epimedium polysaccharides (a preparation of epimedium and lycium fruit extracts is used for this purpose at IEP; the dosage is 3 grams twice daily of dried hot water extract of the two herbs in equal proportions). In a clinical study, herbal treatment was shown to reduce the bone marrow suppressive action of cancer drugs; results of this work might also be applicable to the effects of nucleoside HIVinhibitors. The herbal therapy was based mainly on use of astragalus, which contains polysaccharides similar to those found in epimedium (the formula is 100 grams astragalus, 20 grams tang-kuei, 15 grams atractylodes, and 15 grams siler). The ototoxicity of antibiotics has been reportedly counteracted by ingestion of drynaria (a kidney tonic herb) and liver toxicity of several drugs was reported to be counteracted by a combination of herbs including scute and hu-chang, two of the herbs frequently recommended for persons with HIV infection. Licorice, another herb often prescribed to persons with HIV infection, was reported by the Chinese to counteract the toxicity of adriamycin. The potential of Chinese herbs, as well as nutrient supplements and antioxidants, to protect against adverse effects of various chemotherapeutic agents, is a relatively new area of research. Since about 1976 in China, numerous attempts have been made to counter the side effects of cancer drugs. Two anti-HIV drugs, AZT and hydroxyurea, have been used for treating cancer (AZT was withdrawn from consideration, but hydroxyurea is still used). But, even in cases where the new drugs differ from those that have been tested in the past, the protective action of the Chinese herbs might still apply. This is because the activity of the Chinese herbs may not be specific for the drug, but rather for the target cellular components. In fact, the original development of Chinese herbal formulas, such as Composition-A, for treating HIV, was based on the immune-restoring aspects of herbs that were being used in China to counter side effects of cancer drugs. October 1997

ACUPUNCTURE AND HERBS FOR MIND AND BRAIN DISORDERS II. Herbs by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

In many cases, disorders that involve a defect in brain function require continuous therapy. In modern medical practice, patients with mind-brain disorders may be given drugs that are taken for years or for life. It is rarely practical to utilize acupuncture over such an extended period of time, so herbal therapies become an important consideration. Since some people live far from a site where acupuncture is offered, herbal remedies may be the only viable method of traditional medicine to be prescribed, other than simple exercises that can be done daily, such as those derived from the practices of taiji and qigong. BASIC THERAPEUTIC APPROACHES The Chinese literature includes numerous reports about the treatment of mind and brain disorders with herbs, the most common subject by far being the treatment of senile dementia. This will be the focus of the current presentation (see also: Alzheimer’s disease: treatment with Chinese herbs). For mind/brain disorders that occur earlier in life, the treatment method for attention deficit disorder serves as a model (see: Chinese herbal treatment for attention deficit disorder ); also, the book Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs (1) provides information on herbal therapy for schizophrenia and several other mental disorders. In general, it can be said that there are three component therapeutic approaches that have long been relied upon in traditional Chinese medicine to address the problems characteristic of senile dementia: 1. Tonification therapy. The brain is described as an extension of the marrow which belongs to the kidney system, so herbs that nourish the kidney are understood to nourish the brain. Lack of nourishment of any organ can lead to mental distress, due to the fact that the internal spirits cannot rest if their associated internal organs are “empty,” that is, deficient in essential fluids. In particular, deficiency of liver and heart can easily cause disturbance of the mind. Weakness of spleen qi is often ultimately responsible for lack of nourishment; the spleen must also promote upward circulation of qi to reach the brain. 2. Clearing orifices of phlegm-mist. The connection between the heart and mind (or body and brain) is made by channels (orifices) that can become obstructed; the source of obstruction may be weak stomach/spleen function leading to accumulation of phlegm or fire syndrome damaging fluids and transforming them to pathological phlegm. Aromatic and penetrating herbs can clear the obstruction and phlegm-resolving herbs can help prevent the orifices from becoming obstructed again. 3. Calming agitation. Aside from the problem of deficiency that leads to unsettling of the spirit, the mind can be agitated as a result of heat, wind, or uprushing qi and yang, disorders that may be secondary to deficiency (e.g., yin deficiency of the liver yields liver fire and internal wind) or may be an excess pattern. Herbs are used to clear the heat, sedate the wind, and settle the upward rising of qi and yang. It is common to combine all these therapies in a single formulation because each of the pathological conditions will often be present to a certain extent in elderly patients. Throughout the history of Chinese medicine, several mental disorders, including loss of consciousness, mania, and emotional agitation, were understood to occur as the direct result of feverish diseases. Thus, herbs that purge fire, including rhino horn, raw rehmannia, coptis, gardenia, and scute, were sometimes key ingredients in the prescriptions. In modern times, most of these feverish conditions can be controlled with antibiotics, antipyretic drugs, and other modern therapies so that the mind and brain disorders that are the subject of potential Chinese-herbal treatment today are rarely associated with febrile disease. While these same fire-purging herbs have some sedative effects, it is clear from the ancient formula descriptions that they were included mainly for their role in treating a febrile condition. This fire-purging aspect of treatment is not discussed further in this article. As is the case with many other diseases, modern Chinese practitioners have added to the traditionally employed methods the principle of treating blood stasis as a means of resolving mind-brain disorders. Frequently used herbs, such as red peony, cnidium, persica, carthamus, and salvia are the most frequent additions for this purpose. Since blood-vitalizing therapy is a new method for treating mental disorders (except in the syndrome xue dao zheng, see: Complex disease patterns), it will only be noted later in this article in the section devoted to modern journal reports. A Chinese herb adopted into the practice of Western herbal medicine, ginkgo leaf, has become well-known for promoting circulation to the brain. The circulation improvement may restore some of the affected mental functions (see: Ginkgo). Presumably, the blood vitalizing herbs have a similar action. Tables 1–3 list some sample herbs in each of the three therapeutic areas of primary concern. The herbs were selected for inclusion on the basis of high frequency of use in treating mind and brain disorders as described in both the traditional and modern literature. Within each category, the herbs are listed alphabetically by common name (followed by pinyin for clear identification). In the section of “main actions,” the information is derived from Oriental Materia Medica (2), with only those actions that are somewhat relevant to treatment of mental disorders included in the table. Table 1: Tonic Therapies Frequently Used for Mind and Brain Disorders. Herb Alpinia yizhiren

Main Actions supplements spleen, warms the kidney, astringes essence, strengthens the stomach, fortifies qi

Asparagus tianmendong

nourishes yin, moistens dryness

Astragalus huangqi

supplements qi, increases yang

Comments The Chinese name for the herb means to enhance the disposition of the individual (increase wisdom, is one translation). It is thought to improve the thinking function associated with the spleen and the will associated with the kidney. Asparagus is considered similar in nature, taste, and function to ophiopogon and is commonly used in combination with it to nourish the yin. Astragalus helps the spleen generate a pure and clear qi that rises upward to nourish the heart and brain

Herb Atractylodes baizhu Cistanche roucongrong Codonopsis dangshen

Main Actions supplements spleen, tonifies qi

Comments This aromatic tonic for the spleen disperses stagnated fluids that can obscure the heart orifices.

nourishes kidney essence, supplements yang

The soft, black, salty herb is thought to quickly nourish the deficient kidney essence.

invigorates the spleen and stomach, replenishes qi

Cornus wuzhuyu Cuscuta tusizi

supplements liver and kidney, astringes essence

In China, codonopsis is almost always used as a substitute for ginseng in modern practice; its action is more focused on rectifying stomach/spleen weakness, but it lacks the sedative qualities of ginseng. The sour fruit is frequently used to astringe the essence and help prevent deterioration of health.

supplements kidney essence, clears vision

The seed is thought to help prevent leakage of essence (like the astringent herbs), therefore it is used to prevent deterioration.

Dioscorea shanyao

supplements spleen and stomach, tonifies lungs and kidneys, astringes essence

Ginseng renshen

replenishes and supplements original qi, benefits the five viscera, pacifies the spirit, soothes the soul, increases wisdom, opens the cleverness of the heart, clears vision

Ho-shou-wu heshouwu

nourishes yin, replenishes essence and blood, tonifies liver and kidneys strengthens spleen, harmonizes middle warmer, tranquilizes the heart, soothes the nerves, and pacifies the spirit supplements the heart, stabilizes the spirit, tonifies spleen, nourishes blood supplements liver and kidneys, promotes production of jing and blood nourishes yin, moistens dryness, removes heat, resolves phlegm

Dioscorea is used in many treatments for weakening of the kidney essence; its ability to benefit the spleen at the same time is unusual among the Chinese herbs used for that purpose. Ginseng is one of the original remedies for mental disorders used in Chinese medicine; it has a calming nature and replenishes all deficiencies. In the West, ginseng has taken on the connotation of an energy stimulant, partly due to the erroneous translation of qi as energy. As a result, practitioners and patients often worry about the stimulant action of this herb. Ho-shou-wu is a famous “anti-aging” herb that is reputed to keep the body and mind young and active. By nourishing the kidney and liver, it nourishes the brain. Hoelen is favored as a sedative, especially when there is weakness of the stomach/spleen system. It has a mild action.

Hoelen fuling Longan longyanrou

This sedative tonic has properties that imitate the actions of ginseng plus tang-kuei. It is primarily used in Ginseng and Longan Combination (Guipi Tang). Lycium Lycium is commonly used in cases of jing deficiency and is considered especially useful because of its mild nature, not gouqizi producing any adverse effects even in large dosage. Ophiopogon This yin-nourishing herb is especially relied upon when there is phlegm accumulation and heart agitation, as it has maimendong both phlegm-resolving and calming properties; sometimes asparagus is added to enhance the heat clearing action. Peony supplements blood Peony is frequently used in formulas that tonify spleen qi and nourish liver blood; it has an affinity for the spleen and baishao liver, where it can enhance the action of the other herbs. Rehmannia nourishes blood and essence, This rich, black processed root is considered one of the most supplements kidney and liver important herbs to nourish the liver and kidney. It is used to shoudihuang prevent and even reverse the deterioration associated with aging. Schizandra nourishes the kidneys, astringes Like cornus, it is relied upon to astringe essence and prevent essence deterioration of health; modern research has shown that it wuweizi normalizes cerebral electrical discharges and is thus used in treatments for brain disorders, especially those involving insomnia and poor memory. Tang-kuei supplements and moves blood This herb is used for nourishing the blood of the liver and heart, which has the effects of controlling emotional distress danggui and relieving spasms. Table 2: Sedative Herbs Commonly Used for Mind and Brain Disorders. For a more comprehensive list of herbs that calm mental agitation see: Emotions and health. Polygala, listed in the Materia Medica among the heart-nourishing herbs, has been moved to the category of herbs to help resolve phlegm mist, because of its well-known phlegm-resolving action (see Table 3). Herbs (Pinyin) Biota baiziren

Main Actions nourishes heart and calms mind

Comments This seed is very oily, so it is used only moderately or left out if there is a spleen-damp syndrome, but is favored for constipation and dryness.

Herbs (Pinyin) Cinnabar zhusha Dragon bone longgu Dragon teeth longchi Fu-shen fushen Oyster shell muli Succinum hupo Zizyphus suanzaoren

Main Actions sedates the heart and calms the mind

Comments

This is the premier sedative of the Chinese tradition and mentioned in numerous ancient and modern formulas; however, it is avoided in the West due to its content of mercury, the active constituent. pacifies the liver, restrains These are fossilized bones, comprised mainly of soluble floating yang, sedates and minerals, such as calcium carbonate. It has a nutritive and calms the mind calming action. sedates and calms the Like dragon bones, dragon teeth are fossilized; they are the spirit huge teeth of mastodons and other creatures that have long since disappeared. Chinese doctors regard them as especially useful for fright-induced mental disorders. sedative Fu-shen is mostly the same material as hoelen (see Tonics) but includes portions of pine root; the pine confers a sedative effect. pacifies the liver and Oyster shell is the principal ocean shell used in Chinese restrains the floating yang medicine, though several others are also used and have similar actions; they contain calcium carbonates and are used to calm agitation. They also are used to reduce excess stomach acid. sedates and calms spirit This is the aged resin of pine; the Chinese say that this material is actually the soul of tigers that have died, and it has a sedating quality that still imparts the tiger’s power. nourishes heart and calms The most commonly-used liver-nourishing sedative in Chinese spirit medicine, it treats most mental disorders characterized by insomnia and agitation.

Table 3. Herbs that Clear Phlegm Mist and Open the Orifices. This table includes herbs found in the Materia Medica categories of opening orifices and of resolving phlegm. One herb, curcuma, is usually categorized as vitalizing blood, but it is included in formulas for brain disorders because of a cooling, phlegm-resolving action. Herb (Pinyin) Acorus changpu Arisaema tiannanxing

Bamboo zhuru, zhuli, tianzhuhuang Borneol longnao

Main Actions

Comments

opens orifices, expels phlegm This is the most commonly-used Chinese herb (of plant and turbidity, replenishes origin) for treatment of mental disorders. It was listed in the intelligence Shennong Bencao Jing as a superior herb and it also has symbolic value as a dispeller of evil spirits. dispels wind to relieve Arisaema is described as having the power to vaporize convulsions, dries dampness phlegm accumulations; it is mainly used when the herbal to resolve phlegm, disperses formula is aimed at treating phlegm obstruction of the lumps and accumulations orifices. The bile processed arisaema, known as dannanxing, has a cooling rather than warming nature. removes heat, transforms Bamboo leaves, juice, or dried secretion are all used to treat phlegm, calms fright irritability, fidgets, and convulsions. They are particularly favored in treatment of children’s disorders. opens orifices, moves qi, clears vision

Curcuma yujin

regulates flow of qi, dissolves qi stagnation, disperses stagnant blood

Musk shexiang

opens orifices

Ox gallstone niuhuang

opens orifices, transforms phlegm, clears heat, removes toxin, calms fright

Pinellia banxia

harmonizes stomach, dries dampness, removes phlegm, disperses accumulation

Platycodon jiegeng

resolves phlegm

Polygala yuanzhi

stabilize the heart and calm the mind

Borneol is usually used as an adjunct ingredient in formulas for resolving phlegm that causes brain disorders; it is often combined with musk and/or acorus to open orifices. Although curcuma is best known for its ability to vitalize circulation of qi and blood, it enters into several formulas for brain disorders because it is also considered useful in treating phlegm accumulation disorders, especially when there is a heat syndrome. Musk, with its penetrating aroma and stimulating quality, is mostly used for the very severe cases of brain disorder, especially when the person is losing consciousness or suffering from severe delirium. Ox gallstone is utilized to correct gallbladder disorders that result in hot phlegm moving upward to cloud the consciousness. A mixture of bile acids and minerals is used today to make synthetic ox gallstone to replace the extremely rare and expensive original compound. Pinellia is the most commonly-used phlegm-resolving herb in Chinese medicine and it enters into formulas for treating brain and mind disorders that involve phlegm accumulation due to stomach/spleen weakness. Platycodon is thought to direct the action of other herbs to the upper body, and it is, therefore, useful in treating brain disorders; in addition, it helps to resolve phlegm accumulation that is often associated with diseases of the brain. Polygala is often used as an adjunct to acorus for resolving phlegm that obstructs the orifices of the heart. In addition, it is used as a sedative, often along with zizyphus.

SAMPLE FORMULAS: TRADITIONAL PRESCRIPTIONS AND PATENT REMEDIES The formulas described below were designed for mind and brain disorders that arise from a nutritional and functional deficiency of the internal organs. The herb ingredients are divided according to the three categories of therapy outlined above; most of the formulas have additional ingredients that do not fit into these categories and are not listed here. For complete ingredients listings, please see the reference texts (3, 4). Descriptions of modern patents may involve partial ingredients lists and should be interpreted with some reservations. After each presentation of the formula ingredients by therapeutic category, there is a very brief description of the formula. For problems in mind/brain function that are associated with imbalances in the seven emotions, stagnation of qi and blood, and accumulation of moisture, see the article: Complex disease patterns, which presents a different selection of herbal formulas. Niuhuang Qingxin Wan (Bos and Musk Formula) Tonics Sedatives Orifice-clearing Herbs Atractylodes Cinnabar Musk Tang-kuei Borneol Peony Ox gallstone Ginseng Platycodon Hoelen Curcuma Dioscorea Ophiopogon





Bos and Musk Formula is used for loss of consciousness, stroke, extreme emotions (anxiety, fright, grief), irritability, insomnia,

abnormal mood swings, and mental confusion. An older version of this formula has a large number of tonic herbs, probably to help restore fluids damaged by a prolonged febrile disease (treated by ingredients such as coptis, scute, and gardenia). Tianwang Buxin Dan (Ginseng and Zizyphus Formula) Tonics Sedatives Orifice-clearing Herbs Schizandra Zizyphus Platycodon Tang-kuei Biota Polygala Rehmannia Cinnabar Ophiopogon Asparagus Ginseng Hoelen Ginseng and Zizyphus Formula, probably the best known of the prescriptions in this group, is used for poor memory and insomnia. Cinnabar is used only to coat the outside of the traditional pills. This prescription is commonly prescribed in the West (cinnabar is usually deleted). It is considered suitable for long-term therapy in treating chronic brain disorders, such as occur with aging. The main emphasis of this formula is tonification of yin and blood. A formula originally developed to tonify the spleen, Guipi Tang (Ginseng and Longan Combination), has been adopted to a similar application. It has ginseng, hoelen, tang-kuei, zizyphus, and polygala in common, but includes several other qi tonics (astragalus, jujube, atractylodes, licorice) in place of the yin-nourishing herbs of Ginseng and Zizyphus Formula. Tonics Schizandra Tang-kuei Cistanche Lycium

Bu Nao Wan (Cerebral Tonic Pills) Sedatives Orifice-clearing Herbs Zizyphus Acorus Biota Arisaema Succinum Polygala Dragon teeth

Cerebral Tonic Pills is a modern patent remedy indicated mainly for poor memory and insomnia. The emphasis of this formula is sedative effects, useful for anxiety, heart palpitations, and being easily frightened.

Tonics Schizandra Tang-kuei Cistanche Ginseng Alpinia Lycium Dioscorea

Jian Nao Wan (Healthy Brain Pills) Sedatives Orifice-clearing Herbs Zizyphus Acorus Biota Bamboo Cinnabar Polygala Succinum Dragon teeth

Healthy Brain Pills is a modern patent designed along the same lines as Cerebral Tonic Pills, and for the same indications. The acorus used is known as altaica (jiujie changpu), from a different plant. This formula includes gastrodia (see section on gastrodia below). Baizi Yangxin Wan (Biota Heart Nourishing Pills) Tonics Sedatives Orifice-clearing Herbs Schizandra Zizyphus Pinellia Tang-kuei Biota Polygala Hoelen Cinnabar Biota Heart Nourishing Pills is a patent remedy that represents a variation of the traditional Ginseng and Zizyphus Formula (Tiawang Buxin Dan); numerous factories produce sedative formulas in which they attempt to improve on this widely-used prescription. The ingredients list is probably incomplete.

Tonics Ginseng Hoelen

Sedatives Dragon’s teeth Fu-shen

Orifice-clearing Herbs Acorus Polygala

There are several traditional formulas similar to Anshen Yuangzhi Wan , including Yuanzhi Wan (Polygala Pills; slightly different proportions of same ingredients) and Dingzhi Wan (Emotion Controlling Pills; cinnabar replaces dragon’s teeth), all of which have the same indications: to calm mental agitation. Ping Bu Zhenxin Dan (Calming and Sedating the Heart Pill) Tonics Sedatives Orifice-clearing Herbs Ginseng Dragon’s teeth Polygala Ophiopogon Fu-shen Schizandra Zizyphus Dioscorea Cinnabar Asparagus Rehmannia Hoelen The Calming and Sedating Pill, with its large group of tonic herbs, is mainly used in cases of essence deficiency, where the person is easily frightened, has heart palpitations, and fatigue. Yangxin Tang (Heart Supporting Decoction) Tonics Sedatives Orifice-clearing Herbs Ginseng Zizyphus Polygala Hoelen Fu-shen Pinellia Schizandra Biota Astragalus Tang-kuei Yangxin Tang is an example of a formula that is virtually all tonic in nature. Each of the herbs, despite the category listed, has a nourishing action affecting one or more of the zang organs. Therefore, it is used in persons who are weak and thin and have trouble getting adequate nutrition. Sheng Tie Luo Yin (Iron Filings Decoction) Tonics Sedatives Orifice-clearing Herbs Hoelen Fu-shen Acorus Ophiopogon Cinnabar Polygala Asparagus Arisaema This formula is aimed at the treatment of upflaring phlegm-fire, in which the fire is secondary to yin deficiency. The imbalance often gives rise to a variable mental condition, such as manic-depressive disorder. When the fire dominates, a manic condition is present; when the phlegm dominates, a depressive condition arises. REVIEW ARTICLES ON HERBAL THERAPIES FOR SENILE DEMENTIA Two review articles published in the Journal of Traditional Chinese Medicine are elaborated here in order to summarize a broad range of Chinese medical literature. Due to the length of the review articles and diversity of therapeutic categories and formulas offered, certain portions were selected for presentation. In a 1996 review of Chinese herbal therapies for senile dementia (5), doctors at the Chengdu University of Traditional Chinese Medicine and Pharmacy presented the following summary (Table 4) of syndromes and key herbs that reveal the current therapeutic approaches. Table 4: Modern Differential Diagnosis and Treatment for Senile Dementia. Syndrome

Main Symptoms

Key Herbs

Deficiency of kidney essence

Stagnation of phlegm

Deficiency of qi and blood

Cerebral blood stasis

progressive dementia, dizziness, tinnitus, insomnia, poor memory, difficulties in speech, dull eyes, and slow responses dull expressions, vague mind, depression, poor memory, abnormal behavior, involuntary crying or laughing, dizziness, heavy sensation of the head or limbs, chest distress, poor appetite, sleepiness dizziness, poor memory, indifferent expression, dreaminess and light sleep, susceptible to fright, pale complexion and listlessness, unable to participate in normal daily activities dizziness, headache, poor memory, dementia, stiff tongue and incapability of uttering a sound, history of apoplexy, facial hemiparalysis, hemeplegia

rehmannia, cornus, dioscorea, hoshou-wu, lycium, eucommia, tangkuei, zizyphus, polygala pinellia, hoelen, acorus, polygala, citrus, curcuma, bamboo, bamboo sap, chih-ko, angelica

ginseng (or codonopsis or pseudostellaria), astragalus, tangkuei, atractylodes, fu-shen, rehmannia, ho-shou-wu, polygala, peony, zizyphus salvia, carthamus, persica, cnidium, astragalus, angelica, musk, tang-kuei, red peony

The authors suggested that there are two main actions of the herbs that are used in the formulas: to replenish the kidney, and to supplement and invigorate qi and blood. They translated the means by which these actions affect dementia to a Western idiom as follows: 1. To supply substances needed by the brain and nerve cells to carry out normal metabolism and regulate cerebral activities; and 2. To invigorate the following activities: blood supply to the heart, immunologic functions, detoxification of the liver, nutrient absorption of the alimentary system, and utilization of energy by the body to improve the nutritional and metabolic state, or, in other words, to regulate the vitality of the whole body to improve mental function and combat senility. The overall effects of the herbal therapies, they claimed, were: “strengthening the body activities to combat or retard senility of organs in the body, and to facilitate elimination of pathological products resulting from the hypofunction of an organism.” The authors also suggested that if blood-vitalizing herbs are included with the tonic therapies that the results will be even better than using tonics alone, mainly because of the improved microcirculation. Two case examples were presented, in which patients over 80-years-old were given decoctions to take for about one month in order to get substantial improvements in mental and physical conditions. In a 1999 review from the Ningjin County Hospital of Traditional Chinese Medicine (6) journal reports were divided into four groups: treatment based on general differentiation; treatment based on differentiation of regulating and nourishing the kidney and heart; treatment based on differentiation of blood stasis and phlegm obstruction; and treatments based on specific formulas. In this presentation, a number of the prescriptions are designated by their traditional name (see the Appendix for ingredients lists for most of the formulas) and many were said to be “modified” without specifying the alterations made. 1. Treatment Based on General Differentiation Several examples of this approach were offered, the one attributed to a 1994 article by Dr. Wang Hengsong is as follows, giving the diagnostic category and recommended formula for treatment: · Deficiency of brain and spinal cord: Modified Bushen Yisui Tang (Decoction for Tonifying the Kidney and Rectifying the Marrow); · Deficiency of heart and spleen: Guipi Tang (Ginseng and Longan Combination); · Hyperactivity of heart fire and liver fire: Modified Tianma Gouteng Yin (Gastrodia and Uncaria Formula) plus Huanglian Xiexin Tang (Coptis Combination); · Yin deficiency of liver and kidney: Modified Qi Ju Dihuang Tang (Lycium, Chrysanthemum, and Rehmannia Formula) plus Dingzhi Tang (Emotion-calming Decoction); · Stagnation and obstruction by phlegm and blood stasis: Modified Banxia Baizhu Tianma Tang (Pinellia and Gastrodia Combination); and · Stagnation of qi and blood: Modified Xiaoyao San (Bupleurum and Tang-kuei Formula) plus Tongqiao Huoxue Tang (Decoction for Activating Blood Circulation). In the other approaches to general differentiation of syndromes by various authors, the categories differed somewhat (usually, there were 4–6 categories) and the specific formulas used also varied. Here are two sets of recommendations, the first attributed to a 1995 article by Xu Shizhen, the second attributed to a 1994 article by Dr. Zhao Xiangjun: Category Liver/Kidney Yin Deficiency Spleen/Kidney Yang Deficiency Accumulation/Obstruction by Phlegm Interior Obstruction by Blood Stasis Category

Xu Shizhen’s Recommendations Modified Bushen Yinao Tang Modified Yougui Wan Modified Erchen Tang Modified Fuyuan Huoxue Tang Zhao Xiangjun’s recommendations

Failure of Kidney Essence

Modified Yougui Wan

Liver/Kidney Yin Deficiency Heart/Spleen Deficiency Obstruction by Phlegm and Blood Stasis

Modified Zuogui Wan Modified Guipi Tang Mengshi Guntan Wan plus Xuefu Zhuyu Tang

2. Treatment by Regulating and Nourishing Heart and Kidney The following self-designed base formulas were offered in a 1995 article by Lin Changxing and colleagues: · Insufficiency of heart qi: codonopsis, hoelen, licorice, acorus, polygala; and · Deficiency of kidney yin: asparagus, ophiopogon, rehmannia (cooked and raw), cornus. Dr. Yao Peifa, in a 1992 article, offered these therapeutic categories and formulas: · Reinforcing kidney and replenishing essence: rehmannia, lycium, ho-shou-wu, curculigo, epimedium, acorus, polygala; · Nourishing kidney and eliminating phlegm: Modified Dingzhi Wan and Yougui Wan; · Nourishing the kidney, removing blood stasis: rehmannia, ho-shou-wu, lycium, cyathula, persica, carthamus, cnidium, earthworm, cyperus, acorus, polygala; and · Nourishing yin and eliminating phlegm: rehmannia, ho-shou-wu, ophiopogon, forsythia, bamboo, coptis, pinellia, curcuma, acorus, polygala, salvia. 3. Treatment Based on Differentiation of Blood Stasis and Phlegm Accumulation Two articles were described in this section of the review, one was a 1995 publication of Yan Qianlin that focused on blood stasis, and the other a 1995 article by Zhang Jueren focused on phlegm obstruction: Category Obstruction of phlegm and blood stasis Stagnation of qi and blood stasis Qi deficiency and blood stasis Marrow deficiency and blood stasis Category Upward attack of wind-phlegm Phlegm preventing lucid yang to rise Phlegm and blood stasis obstructing collaterals Phlegm due to deficiency

Yan Qianlin’s Recommendations modified Huanglian Wendan Tang and Tongqiao Huoxue Tang modified Dian Kuang Mengxing Tang modified Yiqi Congming Tang plus Tao Hong Siwu Tang Xingnao Yizhi Tang Zhang Jueren’s Recommendations Banxia Baizhu Tianma Tang plus Changpu Yujin Tang Banxia Baizhu Tianma Tang plus acorus, kao-pen, angelica Banxia Baizhu Tianma Tang plus acorus, kao-pen, angelica, plus modified Buyang Huanwu Tang modified Banxia Baizhu Tianma Tang plus modified Changpu Yujin Tang

4. Treatment by Specific Prescriptions The following information is based on reports in which a single base formula was utilized for cases of senile dementia, rather than relying on differential diagnosis. The formulas are presented here according to the therapeutic approach that was utilized for the patients. In many cases, the formula was then modified slightly to address the unique symptoms of the patients: Therapeutic Category Supplementing qi and activating blood circulation to remove stasis Nourishing the kidney and brain Nourishing the kidney and brain Tonifying the kidney, supplementing qi, and activating blood circulation Tonifying the kidney, supplementing qi, and activating blood circulation Tonifying the kidney and activating blood circulation to remove stasis Tonifying the kidney and activating blood circulation to remove stasis Dispelling phlegm and removing blood stasis Dispelling phlegm and removing blood stasis

Formula Ingredients astragalus, cnidium, red peony, peony, persica, pueraria, millettia, codonopsis, acorus, curcuma, alpinia, polygala modified Dihuang Yinzi ho-shou-wu, cornus, dioscorea, lycium, cuscuta, red peony, salvia, curcuma astragalus, codonopsis, pueraria, salvia, crataegus, lycium, polygonatum, cornus, tang-kuei, gastrodia, acorus astragalus, salvia, codonopsis, alpinia, acorus, lycium, ho-shou-wu, polygala, red peony, cnidium cornus, cuscuta, alpinia, curcuma, arisaema, polygala, acorus, placenta, leech, crataegus rehmannia, cistanche, tortoise shell, cornus, polygonatum, curcuma, tribulus, silkworm, gastrodia, astragalus, acorus, arisaema, carthamus Wendan Tang plus acorus, curcuma, silkworm, arisaema, gastrodia, salvia astragalus, red peony, cnidium, persica, earthworm, curcuma, acorus, polygala, bamboo, aurantium, pinellia, carthamus, gastrodia, silkworm, scorpion, leech, centipede

The authors of the review commented: TCM holds that while the location of the disease is in the brain, its root cause is insufficiency of vital essence and energy of various zangfu organs in addition to obstruction by stagnation of phlegm and blood stasis. The weak constitution due to old age often leads to weakness and failure of the zangfu organs and deficiency of qi and blood and deficiency of yin and yang. This weakness and failure may give rise to stagnation of qi, causing blood stasis, which, in turn, leads to accumulation of qi to form phlegm that may retain in the five zang organs and obstruct collaterals of the brain to confuse the mind, hence the occurrence of dementia. Its pathogenesis is deficiency in origin and excess in superficiality. EFFECTS OF TREATMENT Chinese clinical reports depict reasonably-high success rates (describing some patients as markedly improved, others as improved), but what is the specific expectation? A recent clinical trial carried out at the TCM Hospital of the Luzhou Medical College (7) is indicative and will be used here as an example in which there is more detailed reporting by the researchers than is usually found. The disorder category under consideration was senile dementia in patients over age 60. Criteria for inclusion were symptoms such as disturbances in memory; difficulty making calculations or getting oriented to surroundings; marked emotional or personality changes; and a slow or progressive course of the symptoms lasting more than six months. From the TCM viewpoint, participants had to fit into the deficiency (consumptive) type of disorder. Thus, all patients suffered from a deteriorating physical and mental health for at least six months. The patients were sub-grouped by symptom patterns according to three TCM categories of yang deficiency of spleen and kidney; deficiency of qi and blood; or deficiency of yin and yang. The patients were randomized to Chinese herbal or Western medical treatments and the patients were equally represented within the diagnostic groupings for both treatment methods. In general, patients with the spleen- and kidney-yang deficiency or deficiency of qi and blood had mild to moderate dementia, while those with deficiency of yin and yang had more severe dementia. The patients treated by Western medicine (31 patients) received centrofenoxine, gamma-aminobutyric acid, and folic acid. The patients treated by herbs (34 patients) received Yu Cong Tang , a decoction of the following: astragalus, codonopsis, atractylodes, rehmannia, drynaria, cistanche, aconite, epimedium, cnidium, cyathula, pinellia, arisaema, and acorus. The treatment time for the study was 30 days. This short treatment time is not deemed sufficient for evaluating therapies by Western standards: drug evaluations for senile dementia usually involve a minimum treatment time of six months, and to make a decision about suitability of the treatment method, administration for one to two years is often required. Nonetheless, when patients seek help with Chinese medical techniques in the West, a prompt response, within one month, is usually important in order to decide whether to continue the therapy. In this study, a six-month follow-up after completion of the treatment was made for patients who opted to continue taking the herbs or drugs. The physicians tested the patients for remote and recent memory, understanding, orientation of time and space, calculation ability, and compliance. They performed CT scans of the brain, as well as EEG and REG tests (detecting brain waves and blood flow, respectively). They also took blood samples to evaluate blood oxygenation, hemoglobin, and other parameters. For the performance tests, the report indicated no differences between the two treatment groups prior to treatment, and no improvement in the Western medicine group after treatment. A statistically significant improvement in all five performance tests were claimed for the Chinese herb group. The same result was claimed for the CAT scans, EEG, and REG, though the most significant improvement was in the blood flow measurement. Among the blood factors assayed, the most significant improvement was in hemoglobin levels, which increased markedly in the Chinese herb group, but decreased slightly in the Western medicine group. Summarizing the results of one month of treatment with herbs, the authors indicated that in mild and moderate cases of the disease, all the patients showed improvement, while in severe cases only 40% showed improvement with herbal therapy. During follow-up, it was reported that “25 cases in the TCM group persisting in taking Yu Cong Tang were spiritually good, could take care of daily life, and the scores of tests on remote and recent memory, orientation, calculation and understanding kept in the range of being markedly effective. Brain CT was performed in 13 cases and only a mild degree of brain atrophy was found. Of the 9 cases who did not continue the therapy, 3 died of secondary infection, 2 could not take care of their daily life, and 4 became worse.” The authors concluded: “In clinical practice, it is essential to prevent and treat deficiency of the organism because the severity of dementia is proportional to the deficient state of the organism.” USE OF GASTRODIA IN BRAIN DISORDERS One of the ingredients frequently mentioned in the treatments for senile dementia that does not quite fit the therapeutic patterns usually mentioned is gastrodia (see: Gastrodia). The reason for its inclusion is its strong reputation for ability to treat a wind-phlegm disorder. This disorder usually causes symptoms of muscular incoordination, with spasms, convulsions, or repetitive movements. The spasms can manifest as headaches and hypertension, the convulsions can manifest as epileptic seizures or irregular movements, and the repetitive movements can manifest as Parkinsonism. To treat wind-phlegm, Chinese herbalists usually tonify the spleen (e.g., with ginseng and atractylodes), resolve phlegm (e.g., with pinellia and citrus), and settle wind (e.g., with gastrodia and uncaria; sometimes adding herbs to nourish the liver, see below). Silkworm is also used in severe cases of wind-phlegm. Many patients with senile dementia have neurological problems that correspond to the wind-phlegm syndrome. However, gastrodia is sometimes used in formulas for senile dementia based on the theory that internal wind agitates the mental functions even if there is no physical manifestation of wind as movement. The consideration is described by Peng Jin at the Institute of TCM Basic Theories (8): The liver responds to moistness and is averse to dryness. Moistness makes the liver soft which ensures a normal mental activity. The aged people with prolonged illness are susceptible to deficiency with consumption of the yin essence. Deficiency of the liver yin may result in restlessness of the mind due to stirring-up of the endogenous wind, hence the appearance of unconscious shaking of the head, foreign body sensation in the eye, tinnitus, sleeplessness, and irritability. In such cases, the liver is nourished with herbs such as rehmannia, cornus, ho-shou-wu, and lycium, while gastrodia is added to calm the wind. Gastrodia is also used in the context of modern theories that atherosclerosis, a syndrome of blood stasis and phlegm accumulation, leads to hypertension and mental deficits from poor blood circulation. Gastrodia helps alleviate the hypertension while

other herbs used along with it address the blood stasis syndrome (e.g., salvia, red peony, cnidium) and the phlegm accumulation syndrome (e.g., pinellia, citrus, arisaema, bamboo). SUMMARY OF THE MODERN MEDICAL REPORTS The approach of differential diagnosis and corresponding treatment is a dominant theme in Chinese publications about resolving senile dementia. This is because the disease is thought to arise gradually from constitutional disorders rather than from some specific dysfunction in the brain. This interpretation differs markedly from the modern medical approach to Alzheimer’s disease, a main cause of senile dementia, in which researchers examine specific proteins that are accumulating in the brain and deficits in specific neurotransmitter substances in hopes of finding a successful treatment that is not dependent on the whole body functions. In virtually all Chinese reports, the importance of tonification therapy was emphasized. Despite the stated reliance on differential diagnosis, almost every modern herbal prescription designed specifically for treating senile dementia (or other brain/mind disorders that have overlapping characteristics) includes one or more of the following limited list of herbal ingredients: acorus, polygala, curcuma, arisaema. These are all herbs that treat the “phlegm-mist” disorder. It can be implied that the basic Chinese approach is comprised of these methods: · Treat the constitutional organ-system disorders, mainly deficiencies, that can cause numerous symptoms and diseases; · Add the herbs that are specific for brain disorders, which are a small number of phlegm-mist resolving agents; and · Incorporate a blood-stasis treatment relying primarily on this short list: salvia, red peony, pueraria (this indication based on modern research), persica, carthamus, and cnidium. REFERENCES 1. Fruehauf H, Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 Institute for Traditional Medicine, Portland, OR. 2. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 3. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. 4. Chun-Han Zhu, Clinical Handbook of Chinese Prepared Medicines, 1989 Paradigm Publications, Brookline, MA. 5. Wang Xiaoping and Zhai Mudong, Experience in TCM treatment of senile dementia, Journal of Traditional Chinese Medicine 1996; 16(4): 299–303. 6. Sun Guanlan, Ren Jianlin, and Sun Qingjun, Advances in TCM treatment of senile dementia, Journal of Traditional Chinese Medicine 1999; 19(4): 304–312. 7. Wang Dehua, Huang Xia, and Du Shuhua, A clinical trial on Yu Cong Tang in treatment of senile dementia , Journal of Traditional Chinese Medicine 1999; 19(1): 32–38. 8. Peng Jin, Professor Kong Lingxu’s experience in TCM treatment of insomnia , Journal of Traditional Chinese Medicine 1999; 19(3): 175–181.

APPENDIX: Reference Formulas In the two review articles about treating dementia (5, 6), several traditional formulas were mentioned that are commonly used; the ingredients are presented here for easy reference. A few formulas are not included here because they are well known (e.g., Xiaoyao San, Guipi Tang) or because they are not described in any of the standard literature sources devoted to Chinese herbal formulas. Kidney-nourishing Formulas A pair of formulas that are used by some doctors are the Zuogui Wan (Left Returning Pill) and Yougui Wan (Right Returning Pill). The formula names refer to the idea that the left kidney houses the yin and the right kidney houses the yang. The formulas have five herbs in common, and these five ingredients mainly nourish the yin and restrain the essence. A formula similar to Yougui Wan , Dihuang Yinzi, includes altaica (used as a type of acorus) and polygala (not listed below); the formula is often prescribed for neurological disorders. Zuogui Wan Rehmannia Dioscorea Cornus Lycium Cuscuta Antler gelatin Cyathula

Yougui Wan Rehmannia Dioscorea Cornus Lycium Cuscuta Aconite Cinnamon bark Tang-kuei Deer antler Eucommia

Dihuang Yinzi Rehmannia Hoelen Cornus Ophiopogon Morinda Aconite Cinnamon bark Cistanche Schizandra Dendrobium

Phlegm-resolving Formulas Erchen Tang is the base formula for the warm the gallbladder (wendan) formulas; it improves the function of the stomach and spleen to prevent accumulation of phlegm and helps dry most phlegm. By adding the cooling herbs bamboo and chih-shih, the formula drains hot phlegm. Coptis can be added to further clear heat and also to dry dampness. Although the formula names indicate a warming action for the gallbladder, the meaning is that the prescription aids the gallbladder in discharging bile. The bile carries out heat and phlegm, with its downward purging action. Erchen Tang Pinellia Citrus Hoelen Licorice

Wendan Tang Pinellia Citrus Hoelen Licorice Bamboo Chih-shih

Huanglian Wendan Tang Pinellia Citrus Hoelen Licorice Bamboo Chih-shih Coptis

Gastrodia Formulas There are two commonly-mentioned gastrodia formulas, one for treating a wind-phlegm disorder originating with spleen-qi deficiency (Banxia Baizhu Tianma Tang), and the other for treating a wind-fire disorder that arises from liver-yin deficiency (Tianma Gouteng Yin). Banxia Baizhu Tianma Tang Pinellia Citrus Atractylodes Hoelen Licorice Gastrodia

Tianma Gouteng Yin Gardenia Scute Cyathula Eucommia Leonurus Loranthus Polygonum stem Hoelen Haliotis Uncaria Gastrodia

Blood-vitalizing Formulas There are numerous traditional blood-vitalizing prescriptions to choose from, all of them having similar constituents and actions. In modern practice, salvia is often added. Tongqiao Huoxue Tang Persica Carthamus Red peony Cnidium Allium Jujube Musk

Fuyuan Huoxue Tang Persica Carthamus Rhubarb Trichosanthes root Tang-kuei Pangolin scale Bupleurum Licorice

Tao Hong Siwu Tang Persica Carthamus Peony Cnidium Tang-kuei Rehmannia

May 2000

Buyang Huanwu Tang Persica Carthamus Red peony Cnidium Tang-kuei Astragalus Earthworm

Xuefu Zhuyu Tang Persica Carthamus Red peony Cnidium Tang-kuei Rehmannia Bupleurum Licorice Chih-ko Achyranthes Platycodon

TREATMENT OF IRRITABLE BOWEL SYNDROME WITH CHINESE HERBS By Subhuti Dharmananda, Ph.D., Director, Institute For Traditional Medicine, Portland, Oregon

BACKGROUND Irritable bowel syndrome is one of the most common intestinal complaints presented to medical doctors (1). Direct intestinal examinations (e.g., endoscopy) usually show no obvious abnormality inside the intestine. Other tests show no significant changes in absorption of nutrients or nutritional status. A characteristic of the disorder is spasm of the intestinal muscles, which produces discomfort, including pain, bloated feeling, and urgency; defecation usually provides temporary relief of the symptoms. The disorder has been called spastic colon, as a reflection of the apparent underlying problem. Frequent bowel movements, sometimes described as a case of diarrhea, occur during certain phases of the disorder; at other times, there is constipation. The constipation may be the combined result of several factors, such as a low fiber diet, inadequate fluid intake, and the after-effect of having several bowel movements on one or more previous days; in addition, if the intestinal musculature is in a tonic condition (a continuing contraction without the pulsation of spasms or normal peristalsis), that will tend to cause constipation. It is generally believed that nervousness contributes to irritable bowel syndrome. The disorder is sometimes called intestinal neurosis to reflect this. Bowel problems are amplified during times of emotional distress. However, the irritability of the nerves affecting the intestinal muscles may be brought on by other factors as yet undetermined. Although dietary constituents have been suggested to be a problem, the results of investigations have been mixed. Certainly, food allergens may trigger bouts of spasm and diarrhea. A high fat meal induces discharge of bile from the gallbladder, which stimulates intestinal peristalsis: in persons who tend to get intestinal spasms, this might be enough to trigger the response.

TRADITIONAL CHINESE MEDICAL APPROACH A condition corresponding to irritable bowel syndrome was described in early Chinese literature, with a specific formula recommended: Bai Zhu Shao Yao San (Atractylodes and Peony Powder), later named Tong Xie Yao Fang (Formula for Painful Diarrhea). According to Formulas and Strategies (2), the first mention of the formula was in a 15 th Century text, but the official recognition of it comes from Jing Yue Quan Shu , published in 1624; the indications for the formula are "recurrent problems of borborygmos, abdominal pain, diarrhea with pain (which starts with the urge to defecate and subsides after completion)." The simple four herb formula-peony, atractylodes, citrus, siler-has been classified as one of the important harmonizing prescriptions (see Exploring Yin/Yang #7 ), having the property of regulating the functions of the liver and spleen. It is related to the famous harmonizing prescription from the Shang Han Lun: Bupleurum and Chih-shih Formula (Si Ni San), which also has four herbs-peony, licorice, chih-shih, and bupleurum. In this newer formula, bupleurum is replaced by siler, chih-shih is replaced by citrus, and licorice is replaced by atractylodes. In Tong Xie Yao Fang , siler is utilized to spread the liver qi in the same manner that bupleurum does; it also causes the qi to rise (as does bupleurum), but it differs from bupleurum in that it is more supportive of the spleen functions. Chih-shih also spreads liver qi, but it tends to help the downward draining of accumulation. Chih-shih is often used to treat constipation, as in the Minor and Major Rhubarb Combinations (Xiao Zheng Qi Tang and Da Zheng Qi Tang ) and it is used to treat abdominal pain in combination with peony (as in the formula Zhishi Shaoyao San, made of just those two herbs). However, when the main focus of the treatment is diarrhea, chih-shih (which is an immature citrus fruit) is usually replaced by citrus; chih-ko or fu-shou would also do and are sometimes substituted or added in modern versions of Tong Xie Yao Fang . Licorice is replaced by atractylodes in this formula because atractylodes is better at calming diarrhea; both serve as qi tonics that benefit the spleen. Still, with all the replacements, the basic functions of these two formulas remain the same: to enhance the spleen function and spread the liver qi. Both formulas are indicated for abdominal pain and diarrhea; Tong Xie Yao Fang focuses on problems of painful diarrhea, while Si Ni San focuses on other problems of liver disharmony, such as cold limbs. In the majority of modern clinical applications for irritable bowel syndrome, Tong Xie Yao Fang , applied as a basic harmonizing formula, is often the prescription of choice, to be modified according to the herbalist's own perception of what works best for this disorder, and also according to what is needed for specific cases. However, some physicians pursue a course of fuller differential diagnosis and use alternative prescriptions for the minority of cases that are not deemed to be due to the liver/spleen disharmony.

SAMPLE CLINICAL TRIALS IN CHINA The Chinese literature does not contain many references to irritable bowel syndrome. However, there are a few reports that include this syndrome; three examples are described here. In 1985, Li Yujun and Zhou Xitin reported (3) on treatment of 45 cases of patients suffering from recurrent diarrhea. The patients were subdivided into four groups according to differential presentation, with two groups representing an irritable bowel syndrome (based on symptoms, such as abdominal pain alleviated with bowel movement). One group was treated with herbs to harmonize liver and spleen, using the following combination derived from Tong Xie Yao Fang : peony, atractylodes, siler, citrus, saussurea, polyporus, hoelen, chih-ko, rose fruit, and licorice. In this case, polyporus and hoelen are added to remove dampness and rose fruit to astringe the intestines to treat diarrhea. The other group was treated with herbs to harmonize cold and heat. The combination, derived from Mume Formula (Wumei Wan), was: asarum, zanthoxylum, aconite, roasted ginger, coptis, phellodendron, codonopsis, atractylodes, hoelen, licorice, and mume. Here, coptis and phellodendron-bitter fire-purging herbs-stand in stark contrast to aconite, zanthoxylum, asarum, and aconite-strongly spicy and heating herbs. Codonopsis, atractylodes, hoelen, and licorice comprise the Four Major Herbs Combination (Si Junzi Tang ), strengthening the spleen. Mume serves as an intestinal astringent. The traditional Wumei Wan is usually described as a treatment for intestinal parasites, though only two of its ingredients are recognized antiparasitic herbs: zanthoxylum and mume. The traditional formula has been adopted for use in treating indigestion, gastritis, intestinal spasms, chronic diarrhea, and other gastrointestinal disorders. The rate of effectiveness of the formulas for patients with irritable bowel syndrome could not be extracted from the generalized data

on treatment of all the groups that suffered from some type of diarrhea, but the approach to treatment is clear from the formula selections. The mean course of treatment was one month. In another study published in 1985, Zheng Xian also reported (4) on differential treatment of several types of intestinal dysfunction, including a group corresponding to irritable bowel syndrome. Those individuals were treated with the following derivative of Tong Xie Yao Fang : peony, atractylodes, siler, citrus, fu-shou, chih-ko, magnolia bark, hoelen, pogostemon, cyperus, saussurea, codonopsis, and licorice. In this case, additional herbs for regulating qi and moisture were added to the base formula. In particular, three types of citrus (chenpi, fushou, and zhiqiao) were included; these benefit the spleen, disperse stagnant qi, and calm the intestinal muscles. As with the previous study, results for the irritable bowel subgroup could not be extracted from the general data; the treatment time for this subgroup was given as 15 days. In 1988, Guo Zongmeng reported (5) on treatment of "gastrointestinal dysfunction," in a large number of patients: Air Force pilots, who, he reported, have a high tendency to get this disorder. The basic condition described appears to be irritable bowel syndrome. Several different treatments were offered, including decoctions of Tong Xie Yao Fang and other traditional formulas indicated for diarrhea; some patent medicines (mainly Fuzi Lizhong Wan and Renshen Jianpi Wan), and the author's own formula for this disorder, made as an extract and then formed into pills. The latter contained: red peony, atractylodes (half white, half red), citrus, siler, codonopsis, ginger, cinnamon bark, hoelen, psoralea, galanga, piper, nutmeg, coptis, and evodia. This formula is based on Tong Xie Yao Fang, but red peony replaces white peony, white atractylodes is joined by red atractylodes, and there is a group of warm spicy herbs added (cinnamon bark, ginger, psoralea, galanga, piper, nutmeg, and evodia) with only a very small amount of bitter-cold coptis. Some patients received two of the above types of treatment together (e.g., decoction plus pills). Overall, the treatment time was an average of 20 days and the "markedly effective group," those who responded best to the treatment, comprised about 40% of the patients (only 11% were described in terms of ineffective treatment, the rest showed some degree of improvement). One of the few studies found in the literature that was aimed specifically at irritable bowel syndrome was a 1990 report by Huang Suiping (6). He used a modified Tong Xie Yao Fang , which he called Tiao Gan Fang. It is comprised of peony, atractylodes, chih-ko, siler, saussurea, and a rarely-used species of ilex (Ilex rotunda; jiubiying, it is bitter and cold, clears heat and toxins, promotes diuresis and eliminates wetness, and alleviates pain). The formula could be modified for cases of notable spleen deficiency by adding astragalus and codonopsis, or for cases of dampness, by adding coptis. The study was relatively small (30 patients), making it somewhat difficult to evaluate the results. It was a placebo-controlled cross-over study, with half the patients receiving the pilled Tiao Gan Fang or a matched placebo pill; then, after a two week period, reversing the treatments. Treatment time was 21 days. Unfortunately, full data for the two treatment periods were not detailed, but, the overall data suggested that about 72% of those showing IBS symptoms at the start had the symptoms alleviated after three weeks of the herb formula, while only 14% of those in the placebo group had the same result. These published studies indicate that Tong Xie Yao Fang remains the basis for traditional herbal treatment of irritable bowel syndrome, though modifications are made and other formulas are also used at times. The typical treatment time, in these clinical trials, was 15-30 days.

REFERENCES 1. Clayman CB (ed.), Encyclopedia of Medicine, 1989 Random House, New York. 2. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. 3. Li Yujun and Zhou Xitin, Observation on comparative treatment of 45 cases of functional diarrhea by traditional Chinese and western medical therapies, Journal of Traditional Chinese Medicine 1985; 26(5): 27-28. 4. Zheng Xian, Observation of 42 cases of entero-susceptible syndrome treated by traditional Chinese medicine differentiation of symptoms and signs, Journal of Traditional Chinese Medicine 1985; 26(2): 36-37. 5. Guo Zongmeng, An analysis of 883 cases of gastrointestinal dysfunction, Journal of Traditional Chinese Medicine (English); 1988; 8(2): 94-96. 6. Huang Suiping, Treatment of irritable bowel syndrome according to the condition of the liver, Journal of Traditional Chinese Medicine 1990; 31(3): 31-33.

APPENDIX 1. OTHER CONSIDERATIONS Constipation associated with irritable bowel syndrome is to be treated by consuming more fiber in the diet and consuming more water. It has been reported in European medical journals that peppermint oil can help treat irritable bowel syndrome via an antispasmodic action on the intestinal nerves (enteric coated soft gelatin capsules are sometimes used for this purpose). This same action is likely to occur from the essential oil ingredients of herbs such as atractylodes, pogostemon, nutmeg, saussurea, cyperus, and other aromatic herbs used in the Chinese treatment of irritable bowel syndrome.

September 1997

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CANCER TREATMENT STRATEGIES AT IEP essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine (ITM), Portland, Oregon

The Immune Enhancement Program (IEP) is a clinical facility of ITM, established in 1992 in Portland, Oregon, but based on projects in the San Francisco area initiated as early as 1985. At the Portland facility, several acupuncturists and massage therapists provide treatments to patients, including about 60 persons with various types of cancer. The primary purpose of the IEP clinic, in relation to cancer patients, is to offer a means of responding to a diagnosis of cancer that supports the essential standard cancer therapies and is satisfying to the patient. There is an opportunity to address certain symptoms that arise without relying on additional drugs (a desire expressed by many patients), to limit the adverse effects of cancer therapies (particularly nausea, fatigue, and immune suppression), and to establish a pattern of therapeutics and lifestyle changes that are aimed at health promotion, not just disease control. Patients are able to participate more fully in the treatments at IEP, compared to at the standard medical facilities, interacting with the practitioners frequently to manage the ever-changing course of bodily sensations, functional disorders, and mental distress. Many patients pursue this therapy for months, or even years, because of the perceived benefits.

BACKGROUND In most instances, patients receive standard medical therapies for cancer as soon as possible after diagnosis. No effort is made at IEP to suggest that there is an alternative method of treatment; in fact, if persons are seeking alternatives to the standard therapies, they are encouraged to return to their oncologists for treatments and rely on the IEP for supportive care. The medical therapies (surgery, radiation, chemotherapy) are aggressive in inhibiting cancer growth, far more so than any of the natural therapies; in most cases, time is of the essence. Treatment delays may lead to metastasis of cancer that could otherwise have been prevented, or may lead to irreversible or difficult-to-reverse health problems that are secondary to the advancing cancer cell reproduction. These medical interventions, which have the quality of emergency care, are undertaken because of the great difficulty involved in controlling cancer by any other means and the rapidity with which cancer can cause debility, pain, and death. Their ultimate aim, in some cases, is eliminating the cancer. When this outcome is unlikely, however, they may be utilized to provide increased survival duration and/or fewer symptoms of the cancer. There are a few patients who attend the clinic that are not receiving standard medical therapies: those with cancers that are beyond medical treatment because of their stage, location, or resistance to available treatments, and patients who have completed the entire course of cancer therapy but cannot know if they are truly cancer free. Aside from surgery, which is undertaken to remove cancerous tissue (sometimes with nearby lymph nodes to try and prevent spread of migrating cells), a major problem with cancer therapies-radiation and drugs-is that they have adverse effects related to their potent inhibition of cancer cell growth. Thus, for example, radiation destroys tumor cells by breaking up molecules in the cells. It does this also, to a certain extent, to otherwise healthy cells surrounding the cancer, including those of the skin, muscles, and bones in the radiation beam pathway, and to cells in the blood stream traveling through the area being irradiated, including critical immune cells. Chemotherapy often has the effect of halting the reproduction of cells that have a rapid reproduction rate, as do cancer cells. The drugs may inhibit cells of the stomach lining, bone marrow, and hair follicles, yielding the characteristic symptoms of nausea, blood cell deficiency (and accompanying fatigue when red blood cell numbers fall), and loss of hair. A concern that has been raised about applying various techniques to protect healthy cells from the adverse consequences of medical therapies is that they could theoretically also protect the cancer cells; however, there is little evidence to support fear of this result. To the contrary, most evidence upholds the benefit of natural therapies in maintaining the strength of patients while they are proceeding through the course of medical anticancer strategies. There are some relatively non-toxic anti-cancer drugs in development, such as vaccine-based immunological treatment, that promise to reduce these side effects. However, the majority of research is currently aimed at utilizing existing surgical, radiation, and chemotherapy techniques with new combinations and delivery methods and, when available, with newly developed drugs. The research focus is required to assure the best possible treatment of current patients while more easily tolerated therapeutic methods are in various stages of development: it can take many years of research to bring significantly different approaches into clinical practice. Against this background, Chinese medicine, and other types of natural healing or complementary health care (e.g., nutritional supplements) are applied in an attempt to minimize the injury caused by the standard methods and, hopefully, to improve the overall effect, including faster shrinkage of tumors, more complete elimination of cancer cells, and longer patient survival. Some clinical trials with natural therapies have been conducted that indicate that these desired outcomes are possible. Few such trials are deemed to be adequately conducted, reported, and interpreted to lead to incorporation of the method into standard oncology practices. This is why these treatment methods remain a complementary approach usually administered by non-M.D. health professionals, or involve over-thecounter products found in health food stores. I have reviewed some, but certainly only a small portion, of the literature on these complementary methods (mainly involving Chinese medicine) and produced a number of articles based on my findings: Oriental perspectives on cancer and its treatment The treatment of gastro-intestinal cancers with Chinese medicine Treatment of leukemia using integrated Chinese and Western medicine Chinese medical treatment of brain tumor Prognosis after diagnosis of liver cancer Counteracting the side effects of Western medical therapies The physiological responses to immunologically-active polysaccharides Estrogen-dependent tumors and herbs Soybeans for cancer patients How emotions may contribute to cancer [appendix to Emotions and Health] Do herbs, vitamins, and antioxidants adversely affect cancer therapies?

Questionable cancer therapies In addition, there are articles about certain herbs often used by Chinese doctors in treating cancer patients, including these titles: Sophora Matrine and oxymatrine: subjects of Chinese research [these are active ingredients of sophora] Sparganium & zedoaria Oldenlandia and scutellaria Astragalus/Oldenlandia Tea Soybeans for cancer patients Update on soy products: are they appropriate for women concerned about breast cancer? Articles cautioning about claimed remedies include those about PC-SPES (a product now off the market after discovery of included drugs), and about IP-6 and cat's claw (both likely to be ineffective). The purpose of the current article is to outline some treatment approaches that are either not covered in the reviews about cancer treatment or are insufficiently described elsewhere in relation to clinical practice. Also, the items of the ITM formulary, described in the book A Bag of Pearls (2004 edition), will be mentioned.

ACUPUNCTURE While there is little, if any, evidence that acupuncture therapy can control cancer growth or disease progression in cancer patients, there is evidence that acupuncture can alleviate side effects of cancer treatments (some studies demonstrating this are reviewed in the article, Zusanli). Patients at IEP specifically mention benefits of acupuncture in terms or alleviation of pain, digestive distress, mental agitation, insomnia; and experience improvement in their general sense of well being. The perception of direct relief of these and other symptoms as a result of acupuncture therapy is one of the main reasons cited by patients for continuing participation at IEP. A unique feature of the IEP clinic is making it easier (or even possible) for patients to obtain acupuncture treatments 2 or more times per week. This is accomplished by several measures: having a set, low monthly fee for IEP services, so that additional visits during the month do not entail additional costs; by having an extended clinic schedule that allows patients to find relatively convenient times for treatment; by limiting the duration of each visit to half an hour (thus making it less of an obstacle to the daily schedule of activities); and by having treatment administered by the practitioner available at the time of visit, rather than having a patient rely solely on a single practitioner. The value of this approach is described in my article "Restructuring American acupuncture practices," and the basic considerations are re-iterated below. I have noted that Chinese medical journal reports almost always indicate the use of acupuncture on a daily basis or, at the least, every other day. This applies to a wide range of diseases and disorders, including side effects of cancer therapies and cancer pain. I have likened this daily treatment approach to the way in which herbs, nutritional supplements, and drugs are utilized: normally, the patient takes these every day until they are no longer appropriate to use (some drugs are given by IV administration or injection only once per week, but those are exceptional). The common practice in America, of administering acupuncture once per week (or less frequently), does not seem to have much correlation with what is done in China. In discussing this matter with acupuncturists, the general impression I have obtained is that the frequency of acupuncture is reduced to once per week because of the high cost of acupuncture services and the difficulty most patients would have in coming to the clinic regularly, as well as the part-time nature of most acupuncture practices (practitioners are usually available 2-4 days per week). It has often been reported that more frequent acupuncture, such as twice per week, does yield better results when it is utilized. If the benefits of acupuncture last for one day or less, then daily acupuncture is indicated. If they last for two days or more, then somewhat lower frequency of acupuncture treatments is indicated. The duration of effect can change as the situation for the patient changes over time. For example, the immediate cause of symptoms may be removed (for example when the cancer treatment is completed and the cancer is either highly restricted or apparently gone), thus making frequent treatments no longer necessary. One of the measures of the success of acupuncture and other therapies may be an increase in the duration of beneficial effects from each individual treatment, allowing less frequent treatments to maintain the benefits. Based on these observations and concepts, we encourage patients who are highly symptomatic to visit the clinic frequently, at least 2-3 times per week. There is some limitation to our ability to provide daily acupuncture to any large number of patients (not enough scheduled treatment opportunities), so daily acupuncture is usually not suggested except in the most critical cases. Acupuncture sessions are set at 30 minutes. Because the patient comes to the clinic frequently, there is no need for any lengthy "intake" period, except for the initial appointment, so that almost the time can be used for administering treatment. In the Chinese medical literature, needle retention for 20 minutes is common, and this duration fits easily into the schedule. However, needling front and back points in one session becomes difficult. According to Chinese medical literature, a useful procedure is to stimulate one set of points one day, with another set of points stimulated the next day, alternating the two basic sets day-by-day. This approach is workable for those who come in frequently (at least twice per week), but probably has little benefit if the patient comes infrequently. Greater effects of treatment are reported in the Chinese medical literature if additional stimulus to the needles is given (compared to briefly manually stimulating at time of insertion, as is common practice in the West). This includes manually stimulating the needles for about 1 minute at intervals of 5-10 minutes and applying moxibustion or cupping. Practitioners are encouraged to actively work with patients during the 20 minute needling period, rather than just inserting the needles and going away until the treatment is over, though some patients prefer not having the interruptions. An assistant is available to help with these activities, such as checking on patients and applying non-needle stimulus (e.g., moxibustion). The patients should experience some periods of uninterrupted rest, with duration of 4-8 minutes, during which they may experience the mind-body effects of the stimulus; continually working on the patient with different stimuli may not be advantageous. For situations where more stimulus is needed or where continued stimulus is considered beneficialparticularly for pain syndromes-electroacupuncture may be used (see the article: Electro-acupuncture).

In the application of acupuncture, a basic treatment plan that is repeated frequently is likely to yield better results than a series of unrelated treatments that vary markedly from one visit to another. This concern about consistency may again be likened to the practice of prescribing herbs and drugs. If you were to give patients a different herbal prescription each day, you would not expect to get the same good results that you would if you had the consistent effect of repeated application of the same prescription. At IEP, different practitioners will treat the patient on different days. Therefore, it is important to observe the treatment pattern administered each time and to make an effort to coordinate the treatments, rather than simply provide a personalized prescription that is unrelated to the previous personalized prescription. While altering between two set patterns from one day to the next during administration of frequent acupuncture is described in the Chinese literature, changing patterns entirely from day to day just to meet a practitioner's favored style is never mentioned. Any treatment failure should be carefully evaluated to determine whether or not the acupuncture therapy that has been administered is the best choice and has been used consistently. If it appears that a different strategy is called for, the adjustment should be made. It does not make sense to continue providing ineffective therapy without evaluation and redirection. One must distinguish between symptoms and conditions that are expected to be resistant to treatment and require prolonged therapy and those which ought to respond promptly; lack of obvious effect in the former case is not a good indication that the therapy needs to be changed, but it is in the latter case.

IMMUNE ENHANCEMENT The complex interaction between cancer and the immune system remains a mystery. Cancers develop in persons who appear to have normal immunological condition as well as in those with debilitated immunity. Immune-based cancer therapies (whether utilizing herbs or drugs) sometimes work very well in laboratory animal models of cancer treatment, but may have disappointing effects in humans. This is because many of the laboratory studies involve transplanted tumors and the stimulation of a host reaction to the foreign cells. By contrast, human cancers develop from the body cells and are detected only after they have defeated any immune attack that might have taken place to eliminate them. In other cases, the control over laboratory conditions and the means of inducing a cancer in laboratory animals fails to provide a good model for what takes place in humans. The immunological impact of chemotherapy and radiation are better known than that of the cancer itself. These treatments impair the bone marrow production of blood cells, particularly white blood cells (leukocytes) and, to a lesser extent, red blood cells, and they can also impair the functional quality of the immune cells circulating in the plasma. Immune suppression by cancer therapies can lead to flare up of chronic viral infections and can also make a patient susceptible to serious bacterial infections. In order to avoid these problems, chemotherapy and radiation are interrupted if the immune parameters drop too low. Additionally or alternatively, stem cell stimulants, such as Nupagen (for white blood cells) and Epogen (for red blood cells), can be administered by injection as part of the standard medical therapy, usually once per week until recovery. In the Chinese medical literature some evidence is presented that acupuncture, moxibustion, and herbal therapies can counteract some of this immune suppression. The largest body of evidence is for herbs, with considerably less information about acupuncture and moxibustion effects (immune effects of moxibustion have been a significant area of research; see the article: Moxibustion). The strongest clinical evidence of immune restoration is for complex herb mixtures comprised primarily of herbs classified as tonics, and for polysaccharides derived from herbs. The effect of herbs is not to eliminate immune suppression entirely, but to reduce its severity. Two tableted formulas are routinely offered at IEP to protect the immune system and aid immune recovery from the effects of chemotherapy and radiation. One is Gynostemma Tablets (Seven Forests), which is structured similar to the complex formulas used in Chinese clinical trials, and the other is Coricepium (White Tiger), which is a concentrated extract rich in polysaccharides from several mushrooms and two herbs (lycium and astragalus). Composition-A may be used in place of Gynostemma Tablets if the latter is not available. These remedies contribute significantly to the cost of operating IEP. Gynostemma Tablets is made of concentrated extracts and usually administered in doses of 4-6 tablets each time, three times daily; Coricepium includes three mushroom extracts; it is administered in doses of 2-3 tablets each time, three times daily. The expense for these supplements is justified in cases where the remedies are clearly indicated; their use should be continued only where they appear to be showing positive effects. The principal use is protecting the immune system from cancer therapies and aiding the recovery of the immune system from damage caused by such therapies that have just been discontinued. Generally, these formulas are applied from the start of the cancer therapies and continued until the end of the cancer therapies, plus a few weeks afterwards (typically 2-6 weeks). In elderly persons with a localized cancer (e.g., lung cancer) who are unable to use Western medical therapies (or where the effectiveness is questioned even by the oncologist), Coricepium may be of some benefit, as the immune system in these patients may already be severely compromised and that could be responsible for the tumor growth in these cases. The complex herb formulas administered in China are often given in doses that are higher than can be attained with Gynostemma Tablets. At 15 tablets per day (750 mg each), the tablets provide the dried decoction from about 60 grams of dried crude herbs. By contrast, the herbal decoctions in China are made from 2-3 times that dosage. The use of the polysaccharide tablets (Coricepium) boosts up the dosage considerably: at 6 tablets per day (1 gram of herb extracts per tablets), they provide the equivalent of an extract of more about 90 grams of dried herb material, thus bringing the total between the two formulas to about 150 grams. Generally, there is no need to use additional herbal prescriptions along with these two formulas. Gynostemma Tablets includes herbs that benefit digestion, promote circulation, tonify the qi, blood, yin, and yang, and calm the spirit. Asking cancer patients to take more, especially if they are already taking supplements related to nutrition, is probably asking too much and threatening to disturb their digestive functions. In addition, the costs become prohibitive. Still, if other Chinese herbal formulas are clearly indicated and the patient is willing and able to take them and tolerates them well, then an additional formula might be used. Certainly, the dosage of herbs attained by adding another formula is within the quantities used in Chinese clinical practice. As mentioned in the review article on medicinally active polysaccharides, it may be possible to administer the polysaccharide remedies (such as Coricepium) on an every-other day basis. Such application would permit a lower cost as well as a reduction in tablets ingested, or allow for use of a different formula on the alternate days (something like the acupuncture protocol using two sets of points on alternating days). As a substitute for the Gynostemma Tablets, ITM provides a packet of crude herbs: Astragalus/Oldenlandia Tea. This tea is a

different formula, though the principles of therapy are similar. The tea can have two purposes: one is in place of using tablets for a patient who does not feel comfortable taking a large number of tablets (or simply can't swallow tablets), and the other is to initiate therapy with a tea that can be followed up by tablets later. Granule formulas, administered by adding the granules to hot water to make a tea, might be useful in the course of therapy and they become a more acceptable option for those who have gotten used to consuming a tea in the first place. Astragalus/Oldenlandia Tea provides a dosage of herbs somewhat higher than that of Gynostemma Tablets, has a taste that some patients come to appreciate, and has been favorably received (i.e., good reports about its effects). The packet of herbs comes with instructions to make up a batch of tea on one day and then another batch using the herb dregs the next day. To boost the dosage, as may be needed in cases of strongly immuno-suppressive chemotherapy, the second batch should be taken on the same day rather than the next day. An ingredient of some Chinese herb therapies for immune enhancement and bone marrow protection is deer antler, which is usually not provided in the form of tea or extracts, but as a powder (loose or in pills). Antler 8 (Seven Forests) and Pantosterone (White Tiger) both provide a significant amount of deer antler in a small number of tablets. A daily dose of 1.0-1.5 grams of deer antler powder is often sufficient (recommended doses of Antler 8 are up to 6 tablets per day and for Pantosterone are just 2-4 tablets per day). These remedies are especially given to aid in boosting red blood cell production. In addition to strict tonification therapy, bone marrow function is sometimes addressed using blood vitalizing herbs that have a tonic nature. The formula Millettia 9 (Seven Forests) is based on prescriptions used in China for this purpose. However, it needs to be used at a higher dosage than the antler formulas: about 4-5 tablets three times daily. These herbs might be used if Epogen is not giving adequate results or is not prescribed despite low red blood cell levels.

ANTI-CANCER HERBS There are numerous herbal materials from around the world that have been claimed to have cancer-inhibiting effects. In America, it is common for people interested in alternative cancer therapies to take herbal formulas such as Essiac Tea, Hoxey Formula, and other preparations that have been heavily promoted. Thus far, little evidence has been accumulated that would support an anti-cancer action of these herbs. Several organizations, including the National Cancer Institute (NCI) in the U.S., have screened thousands of herbs for potential anticancer activity. When herbs are found to have such activity, they are entered into various trials (usually starting with cell cultures, then animal studies, followed by a series of clinical evaluations leading either to rejection of the compound or to development of a new drug). Some Chinese herbs already have been developed into anti-cancer drugs in China and some of these are under advanced levels of examination by NCI. Most of the ones that make it through the process of drug development, like the other chemotherapy drugs already in use, are quite toxic. A recently developed anti-cancer drug derived from a plant is Taxol, from the yew tree. Due to the small amounts of this compound in the trees, it had to be synthesized to prevent complete destruction of the yew populations. Taxol is now quite widely used, but is not thought of as an herbal drug and is known to have significant side effects, not unlike those experienced with other chemotherapy agents. Herbs of low toxicity that are claimed to inhibit cancer have not been developed into drugs and their effectiveness remains undetermined. In China, the herbs oldenlandia and scutellaria are repeatedly included in herb formulas for cancer patients. These two herbs have low toxicity and are used in high dosages. A third herb, solanum, is also widely used in Chinese anti-cancer formulations and is regarded in China as having very low toxicity (Westerner's know the herb as "nightshade," for which the leaves are deemed highly toxic; the Chinese use the roots). A granule formulation with these three herbs plus others is made available to clients and is described in the article on oldenlandia and scutellaria (other versions of the formula can be made for specific needs). A combination of "anti-cancer" herbs is prepared by ITM as Paris 7, and includes oldenlandia and scutellaria. One of its ingredients, subprostrata (Sophora subprostrata) has been further developed in China into an anti-viral and anti-cancer drug, namely oxymatrine. This compound has low toxicity and is reported additionally to have immunological benefits similar to the herbs described in the previous section. ITM has obtained oxymatrine to make a tablet by the same name (White Tiger). A compound prescription, Ping Xiao Dan, is reported in the Chinese literature to have good effects on shrinking tumors. An herbalist in China, Jia Kun, has used this formula in pill form, accompanied by decoctions of herbs, to treat a wide range of cancers. Ping Xiao Dan (which is not a single formula, but is a name applied to several similar formulations) contains some toxic ingredients that are not acceptable for use in the West. A formulation that is of similar nature that includes some of the herbs found in the decoctions used by Jia Kun is Chih-ko/Curcuma (Seven Forests). The three tablet formulas, Chih-ko/Curcuma, Paris 7, and Oxymatrine, and the granule preparation with oldenlandia, scutellaria, and solanum, are the main "anti-cancer" compounds provided by ITM. There is some question as to their value when standard medical therapies are being used at the same time, since those therapies accomplish the same goal: shrinking tumors and inhibiting cancer cells. Their role at IEP is mainly in treating patients who have failed to respond to standard medical therapies. However, Oxymatrine can be used for its roles as immune protector and sedative. It is usually difficult to administer both the "anti-cancer" formulas and the immune enhancing formulas at the same time, so one generally has to choose one herbal strategy at a time and follow it. Paris 7 is made from a highly concentrated extract of the herbs, but to get into the range of a potentially effective dosage one must prescribe 5-6 tablets, three times daily, and higher doses may be acceptable. Chih-ko/Curcuma (herb powders to which some concentrates have been added) is used in doses of 4-5 tablets three times daily. Oxymatrine, being an alkaloid fraction derived from an herb, is used in doses of just 1 tablet each time, 3-4 times per day.

NUTRITIONAL STATUS There is a vast medical literature on nutrition research. Overall, this research shows that well-nourished people do better than malnourished people in virtually every area with regard to health. In relation to cancer therapy, well-nourished people survive and recover better from surgery than do those who are malnourished. There is also some evidence to imply that well-nourished people do better with radiation, chemotherapy, and other injurious experiences.

Analyzing foods in terms of nutrients is not always the first priority (see: The ideal meal), but it can prove helpful in understanding certain aspects of diet and the use of supplements. Nourishment can be described in terms of three categories of substances: 1. major nutrients: protein, fat, carbohydrate; 2. trace nutrients: vitamins, minerals; and 3. "non-essential" nutrients and food components: coenzymes, flavonoids, fiber, etc. With regard to major nutrients, protein intake is most often the one that is deficient, and this may be the result of limited appetite, limited ability to prepare meals, or lack of knowledge regarding dietary protein. However, some natural health care proponents may intentionally or inadvertently recommend a low protein diet as a "cleansing" one, not realizing that the resulting protein deficiency can have adverse consequences for the cancer patient. As a general rule of thumb to use in estimating protein needs, a low-body-weight individual who does little physical exercise has a daily requirement on the order of 50 grams, while a high-body-weight individual who does a lot of physical exercise has a daily requirement on the order of 100 grams (with others falling somewhere in between, based on body weight and physical activity). IEP makes available Narula-Soy powder as an easy-to-digest soy protein powder that provides 13 grams of protein per ounce (one serving is one ounce) in a pleasantly flavored form. High protein foods include egg whites and seafood, as well as most meats; the main vegetable sources are legumes (including soy beans, peanuts, and lentils). Fat consumption is usually adequate and sometimes excessive, especially if processed foods and restaurant foods are consumed. Fats rich in omega-3 fatty acids are considered potentially beneficial and are obtained mainly from fish and from seeds (notably, flax seeds). Those who cannot obtain significant levels of omega-3 fatty acids can take supplemental capsules that contain these oils (usual dosing recommendations are 3 grams of encapsulated oil per day). There are frequent literature recommendations to utilize olive oil over other vegetable oils in food preparation; olive oil contains some compounds, such as oleanolic acid, that may be beneficial for cancer patients and others. Foods that have been stored for too long may contain rancid fats which are considered potentially harmful and should be avoided. Carbohydrates are usually adequate in the diet and sometimes excessive. Carbohydrates are present in substantial quantities in fruits and vegetables, the foods that are deemed to be of particular benefit because of their trace and non-nutrient components, such as vitamins, flavonoids, and fiber. Starch, as obtained from grains, is rapidly converted to sugar: a high grain diet (which may include bread, pasta, rice, etc.) corresponds to a high carbohydrate diet. In my article, The role of dietary and herbal flavonoids on gastro-intestinal health, I present a modified food pyramid that places more emphasis on fruits, vegetables, and proteins, and somewhat less emphasis on grains than the highly publicized food pyramid of the U.S. Department of Agriculture. This dietary approach may be useful for cancer patients. Some poorly supported dietary recommendations, such as strictly avoiding carbohydrates either to aid weight loss or to "starve" the cancer of needed sugars (which can not actually work), simply force the patient into unnecessary dietary restrictions when, in fact, good nutritional status should be the focus. There may be some benefit to providing vitamins and minerals in quantities that significantly exceed usual dietary intake. For example, some research indicates a potential benefit for cancer patients by consuming selenium in amounts on the order of 100-300 micrograms per day, while dietary intakes are usually less than 50 micrograms per day. Antioxidants, which include vitamins C and E, may have a role in protecting the non-cancer cells from damage due to cancer therapies and do not appear to interfere with the potent cancer-killing effects of chemotherapy or radiation. Patients undergoing cancer therapies may have restricted exercise routines (due to fatigue or other factors), which contributes to osteoporosis, so increased calcium and magnesium intake may be helpful. B-vitamins may aid the nervous system to help with anxiety and nervous agitation, as well as to help alleviate fatigue that occurs during cancer therapies (vitamin B12 and folic acid contribute to red blood cell production). IEP provides most patients with a comprehensive vitamin/mineral mixture called Calmagnium (White Tiger). This formula also helps new patients replace a "shopping bag" full of individual nutrition supplements with a single one, which can improve compliance with taking needed supplements, such as the herb tablets previously described. Non-nutrient components of natural foods and beverages include some substances that are ingested in the diet but are also manufactured by the body as well as other substances that have a role in health but are not immediately required for survival. As examples, coenzyme Q10 is an essential compound that is found in the diet but is also manufactured by the body (so, if dietary sources were excluded, there would still be enough to live on). Fiber is a component of food that is not manufactured by the body, but is important to maintaining good health: it does not provide a substance that is of immediate need for survival. Long-term deficits in these two non-nutrient substances are associated with increased risk of cardiovascular disease and cancer. Several non-nutrient substances have been implicated in preventing the development of cancer when ingested with some frequency over many years. The list of protective compounds includes flavonoids (including isoflavones, flavonols, anthocyanidins, and polyphenols), fiber (and accompanying phytic acid), coenzyme Q10, and sulfur compounds (found in garlic, broccoli, cabbage, brussel sprouts, etc.). At high doses, these same substances may have direct anti-cancer activity, though their effects are far weaker than those of standard oncology therapies (chemotherapy, radiation, surgery). A diet rich in natural foods from several categories, including fruits, vegetables, legumes, meat, fish, dairy products, and grains, can provide considerable quantities of the desirable nutrient and non-nutrient substances. Certain foods are especially noteworthy for their content of substances that may prevent the occurrence of cancer, including apples and onions (quercetin and related compounds), soy beans (genistein and daidzein), tea (especially green tea, for its polyphenols), broccoli (sulforaphane), tomatoes (lycopene and other carotenoids), etc. These foods can be suggested for inclusion in the diet. Some of the compounds in these foods have been isolated and provided as supplements. For example, soy isoflavones are available in Narula-Soy (mentioned above) and in the tablet Genistemma (White Tiger). Tea polyphenols are present in the tablet formula Quercenol (White Tiger) along with quercetin, carotenoids, and other antioxidants; the same polyphenols are also present in Genistemma. A number of substances found in plants have been found to protect cardiac cells and bone marrow from adverse effects of chemotherapy. Among the substances of interest are coenzyme Q10 (derived from bovine cardiac muscle, though now produced

synthetically), theanine (an alkaloid from tea, now derived enzymatically from other sources), polysaccharides from mushrooms (and a few flowering plants), matrine and oxymatrine (alkaloids from Sophora species), and withanolides (from the Indian herb ashwaganda). Coenzyme Q10 is commonly available as an over the counter health care product and it is an ingredient of the circulatory formula Cartaequin (White Tiger); theanine is included in the sedative formula Nardova (White Tiger); matrine and oxymatrine are available together in tablet form, called Oxymatrine (White Tiger); and withanolides are present in Ashwador (Herbs from India), an immune enhancing and adaptogenic formula. Overall, these nutrient and non-nutrient substances can be considered as helpful in stabilizing the cancer patient, improving general health conditions, and, possibly, improving the effects of standard medical therapies while reducing the adverse effects. Their impact may be subtle and largely unnoticed; in fact, a sudden and dramatic change in health and an improvement in cancer status should not be expected by adding these to the therapeutic regimen. Some care must be taken in having patients alter their dietary practices or having them take large amounts of dietary supplements: there are a number of factors that influence the ability and willingness of patients to comply. If this nutrition information is provided to patients, most will learn something about nutrition that they didn't know before and they may opt to adjust their diet accordingly-if they are in a position to do so. By contrast, demanding a restrictive diet that is based solely on consuming "favored" ingredients and avoiding unfavorable ingredients can be counterproductive. Similarly, expensive and complex supplement regimens may also provide minimal benefits while being disruptive to the pursuit of more important therapies. The ability of patients to take supplements-whether powder, liquid, capsule, or tablet form-may be limited as a result of the effects of cancer or its treatment. Therefore, careful judgment must be used in giving dietary recommendations and determining whether or not to prescribe additional nutrient or non-nutrient materials. Digestive system disturbances, including poor appetite, weak digestion, and abdominal distress, can sometimes be addressed by dietary changes and acupuncture without resorting to herbs or other supplements. Some cases of digestive system disturbance, such as those caused by a tumor or ascites pressing against the stomach, may not be benefited by giving supplements that are intended to increase the production of gastric juices and promote digestive functions, even if they would be effective in other situations. Indeed, adding more volume of material to the digestive system in such cases could be counterproductive by limiting the intake of essential nutrients via food. Therefore, before prescribing herbs and supplements to aid in treatment of digestive system disturbance, one should carefully consider what may be the root cause of the problem. If a supplement is administered, the anticipated beneficial effects ought to be noted with the use of a single bottle in most cases when the correct dosage is taken, and sometimes with a slightly longer period. Examples of formulas aimed at promoting digestion and alleviating digestive distress are Gallus-Malt Tablets (Seven Forests), Shen-chu 16 (Seven Forests), Kang Ning Pian (Pine Mountain), Bao He Wan (Pine Mountain), Hingwastaka (Herbs from India), and Galletaine (White Tiger). In addition to herbs given to improve the digestive functions, a potentially valuable supplement is glutamine powder (bulk powder to be added to water or juice; especially useful for post-surgical intestinal inflammation), which has been described in a separate article (see: Amino acids I: glutamine). Briefly, glutamine is the dominant amino acid in the body, it is stored in the muscles, may contribute to immune functions, and is important in repair of damage to the intestinal tract. Glutamine levels may fall with low food intake and with muscular wasting. Dosage of glutamine to get beneficial effects is on the order of 10-30 grams per day (an amount that can not be attained when purchasing encapsulated glutamine). However, glutamine is not known to have any benefits for simple gastric distress, diarrhea due to infections, and other situations where there is not intestinal damage. Some chemotherapy agents are harmful to the intestinal tract; surgery for colon cancer is a situation where glutamine is recommended to be provided as part of the hospital follow-up.

SYMPTOM RELIEF It is common for patients to present symptoms that are not only those physically related to the cancer and the cancer therapies, but also associated with other factors, such as mental distress and disorders that exist separate from the cancer, such as injuries, chronic illnesses, etc. While herbs are available to address each of the symptoms that might be presented, it is quite difficult to add anything to the herbal protocol already outlined. One should, to the extent possible, rely on herbs that have dual effects. As an example, Oxymatrine has a sedative effect and could substitute for use of an additional remedy aimed at treating insomnia and nervous agitation; Nardova (White Tiger) has a sedative effect (see: Valerian and nardostachys ) and provides the protective agent theanine (see: Amino acid supplements IV: theanine). Symptom relief should be addressed as much as possible by frequent acupuncture, as described previously. In addition, IEP offers its patients a form of shiatsu (see: Zen shiatsu) that can aid in providing symptom relief. Although such massage sessions cannot be offered frequently enough or of long enough duration to have the full effect that they might otherwise have, when used in conjunction with acupuncture therapy (either on the same day or as alternative sessions during the treatment period), the massage sessions can provide substantial symptom relief. I have focused on Zen shiatsu because I believe it is one of the few massage therapy techniques that integrates very well with acupuncture and, therefore, can contribute complementary and additive effects. Other massage techniques may be beneficial for the patients, but are not offered at IEP. Sometimes the use of herbs for alleviating individual symptoms can be futile (i.e., they may have minimal impact on the severity) and the additional materials may disrupt compliance with the efforts to counteract side effects of cancer therapies. As an example, bone pain due to cancer metastasis in unlikely to respond to common blood vitalizing and pain relieving herbs unless the dosage is increased to the level that causes side effects and toxicity. It may be much better to have that pain managed by proper use of morphine (in China, the opium poppy is an herb that is available for treatment of pain; in addition, the toxic herb datura is used for pain). According to Chinese reports (see: Prognosis after diagnosis of liver cancer), the constipating side effect of morphine can be overcome by a rhubarb-based laxative therapy (at high dose) which may help the patient use this drug effectively. Also, severe ascites due to advanced liver cancer or other cancer, usually will not respond to common herbal diuretic formulas. Although ascites is reported to be alleviated in some Chinese medical reports, this is often accomplished with very high dosage decoctions which our patients seem unable to consume if they have this symptom. In China, patients who have difficulty consuming herbs may obtain herb extracts by IV administration or other methods that are not suitable for use here.

PREVENTING CANCER RECURRENCE Some patients at IEP learn from their oncologists that they no longer show signs of having cancer, as a result of successful therapy; they

usually wish to make a strong effort to avoid recurrence of cancer. There is an extensive literature on risk factors for getting cancer. This literature points to certain things one can do to minimize experiencing a first diagnosis of cancer, including: 1. Avoid exposure to carcinogens, such as tobacco products (chewed or smoked), excessive alcohol, estrogen (in women), industrial chemicals (e.g., benzene), radiation (e.g., radon), niter-compounds in food (e.g., in preserved meats), hepatic infections (viruses), etc. 2. Have a high intake of fruits and vegetables which contain cancer-protective substances including fiber and non-nutrient substances (e.g., flavonoids and other antioxidants) and drink healthful teas. 3. Avoid repeated irritation and inflammation, such as sun burns, repeated rubbing against a part of the skin, chronic inflammatory disease. There is much less known about preventing cancer recurrence. The vast majority of cases of recurrence involve the cells of the initial cancer, though they may grow at a different site. This means that some cancer cells were not eliminated in the otherwise successful therapy, and they begin to multiply later. The recurrence of cancer most often arises within 5 years, which is why many doctors do not consider their patients to be cured of cancer who otherwise appear cancer free until they have lived for 5 years without recurrence. It is certainly possible that many of the same factors that lead to the initial cancer (or that reduce risk of getting such a cancer) influence the dormant cancer cells that were left behind after the initial therapy. Therefore, many of the strategies used to lower cancer risk for an initial diagnosis of cancer may help prevent cancer recurrence. On the other hand, the strategies that lower cancer risk are usually followed for decades, whereas the time available to prevent recurrence is relatively short, so their effect may be more limited. For substances that are ingested to protect against cancer, a higher dosage may be needed to inhibit recurrence. Working with the limited knowledge of how to prevent recurrence, the following strategies may be suggested: 1. Work towards optimum health. A healthy body is more likely to control residual cancer cells if they can be controlled at all. This means proper diet, exercise, regulating work and rest, and control of emotions (see the article: Disease prevention and harmony: control the emotions). Although the effect may not be well documented, recurrence of cancer appears to arise frequently in persons who are emotionally distressed or who suffer from depression. Putting in place a procedure for responding to stress would be of potential benefit; antidepressant drug therapy may prove helpful in some cases where natural approaches are inadequate. 2. Take antioxidants and substances that are considered cancer-protective in quantities somewhat higher than available through the diet. IEP provides supplements such as Quercenol (a mixture of antioxidants) and Genistemma (a mixture of flavonoids) that may be of benefit. A combination of herbs that include several of those recommended in Chinese medical literature for preventing cancer or its recurrence are in Baicalcumin (White Tiger). 3. Promptly address any health problems that arise, including infections, inflammatory diseases, and mental disorders. At IEP, these may be addressed by undertaking a series of acupuncture treatments and taking herbs specific for the disorder; standard medical therapies may need to be pursued as well. Some of these procedures suggest a more active role for the person who wishes to prevent cancer, rather than a passive role of taking some prescribed pills and expecting the supplements to take on the full burden of inhibiting cancer growth. Many cancer patients are above age 40, and the majority of patients are above age 50. In these patients, the Chinese diagnostic category of yin deficiency syndrome may be present, following the classical theory that yin deficiency develops with aging. Chinese researchers and doctors have proposed the Rehmannia Six Formula, the classic yin nourishing prescription, and similar formulations may help prevent cancer development and recurrence, especially in this age group. Formulas of this nature are available at IEP, including: 1. Seven Forests: Rehmannia 16, Restorative Tablets, Tremella 14 2. Pine Mountain: Rehmannia Six Formula, Rehmannia Eight Formula 3. White Tiger: Iridoid Complex (iridoids are one of the main active components in Rehmannia Six Formula) In Korea, the daily use of ginseng is thought to be cancer preventive, and there is some laboratory evidence supportive of this view. Gynostemma is an herb that has active ingredients that overlap with those found in ginseng. Ganoderma and cordyceps are famous mushrooms that are thought to confer similar benefits. Eleuthero is a popular herb reputed to have effects similar to those of ginseng, and ashwaganda is a traditional herb from India said to have similar properties. All of these herbs are known as adaptogens; substances that help the body adapt to stresses and, thereby, prevent diseases. Ginseng, and these substitutes, may be obtained in the following materials available at IEP: 1. Seven Forests: Ginseng 6, Eleuthero 10+, Ganoderma 18 2. Pine Mountain: Ginseng-Royal Jelly, Cordyceps Tablets 3. White Tiger: Genistemma Tablets, Pantosterone 4. Herbs from India: Ashwador In Japan, soy products are thought to be cancer preventive. There are numerous soy foods available and IEP can provide the active constituents, soy isoflavones, in Narula-Soy and Genistemma Tablets. Whenever possible, practitioners should help patients select the smallest number of supplements to take that would be consistent with their constitution and what they may already get from their diet.

THERAPIES AND SUPPLEMENTS SUMMARY The following table summarizes some of the therapeutic interventions used at IEP for various conditions presented by cancer patients. Condition to Treat Anxiety, nervousness, stress

Therapies acupuncture, massage, meditation, exercise; Nardova, Oxymatrine

Immune suppression

Gynostemma Tablets, Astragalus-Oldenlandia Tea, Coricepium, Ashwador, Oxymatrine

Cardiac protection

coenzyme Q10, Cartaequin

Nutritional deficiency

dietary adjustments, Narula-Soy, Calmagnium, Quercenol, glutamine

Anticancer effects

Oldenlandia-Scutellaria granules, Paris 7, Chih-ko/Curcuma, Oxymatrine

Digestive distress

acupuncture, massage, dietary adjustments, Gallus-Malt Tablets, Shen-chu 16, Kang Ning Pian, Bao He Wan, Hingwastaka, Galletaine, glutamine

Low Red Blood Cells

Antler 8, Pantosterone, Millettia 9

Preventing Recurrence

exercise, good diet (fruits, vegetables, etc.), acupuncture, stress-reduction, Quercenol, Genistemma, Baicalcumin, Rehmannia Six Formula, Ginseng-Royal Jelly Tablets, Ashwador, Ganoderma 18, green tea, etc.

October 2004

IMPETIGO AND ITS TREATMENT Inhibitors of Staphylococcus by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Impetigo is a bacterial skin infection caused mainly by Staphylococcus aureus (in more than 90% of cases) but sometimes by group A Streptococcus, both pathogens leading to formation of pustules. The disorder primarily affects children, particularly before age 12; it can rarely occur in adults. The infection is experienced more often in warm weather and it is spread around the body from an initial localization by scratching the sores and then infecting other parts of the skin. The disease is usually treated with antibiotics, which are usually effective for an outbreak, but the condition can occur again upon exposure to the bacteria. The majority of cases occur where children are living in unclean conditions, and among those who with weakened immune function as the result of inadequate diet. The disease is related to folliculitis, boils, carbuncles, and cellulitis, all caused by Staphylococcus, and to erysipelas, caused by Streptococcus. In addition, sore, cracked nipples in breastfeeding mothers are often a type of impetigo caused by Staphylococcus aureus. Staphylococcus has also been implicated in some cases of acute dermatitis and chronic eczema.

WESTERN MEDICINE Antibiotics and antiseptics are applied topically and/or antibiotics are given internally. For localized lesions, topical mupirocin ointment applied three times daily for ten days is the usual treatment. For more widespread infections, oral therapy with cephalexin, erythromycin, or dicloxacillin may be used. Alternative treatments are being investigated to maximize response and minimize the chances of drug side effects (mainly from oral therapies) and avoid problems of drug resistance. In a recent study (1), a topical application of fusidic acid (an antibiotic) with povidone-iodine (iodine complexed with the polymer povidone that releases the iodine gradually) was tried. This treatment was deemed effective in attaining clinical cure of impetigo after just one week, but in only 55% of children so treated. The researcher in charge of the project was mainly interested in the use of fusidic acid as a treatment; the povidone-iodine combination is sometimes irritating and is a standard topical therapy for the disease that served as the control treatment. Fusidic acid, a steroid like molecule which does not, however, have steroid-like activity, is used for mild to moderately severe skin and soft-tissue infections, including impetigo, folicullitis, erythrasma, furunculosis, abscesses, and infected traumatic wounds. The topical combination of fusidic acid with a steroid (e.g., betamethasone or hydrocortisone) is very useful in the treatment of atopic dermatitis and eczema when staphylococcal secondary infection or staphylococcal antigen is suspected to be a contributor (5). In most cases of skin staphylococcal infection, when topical and oral routes of treatment have been studied individually and compared, the oral route has had a higher level of effectiveness and lower rate of recurrence. Pharmaceutical researchers, especially those working in countries where herbal medicine remains of interest, have begun evaluating the potential use of herbs and their active components in the treatment of impetigo, with special emphasis on treating drug resistant strains of the bacteria that cause this disease. For example, in a clinical study of topical impetigo treatment, extract of black tea was reported to be effective for more than 80% of children treated, being as valuable as using topical framycetin and gramicidin, or oral cephalexin (2). The main active component of tea, epigallocatechin, was tested in combination with antibiotics to treat resistant strains of Staphylococcus aureus in vitro, showing good effects (6, 7). Other herb components found useful against antibiotic resistant S. aureus include carvone from star anise and benzyl benzoate from Acorus graminaeus; these compounds were tested in conjunction with antibiotics (e.g., ampicillin or chloramphenicol) to overcome the resistant strains (8). Licorice has been shown to inhibit S aureus, and its flavone components appear to be particularly active, usable against drug resistant strains (10). Staphylococcus becomes easily resistant to gentamicin and erythromycin, and, to a lesser extent, methicillin.

CHINESE MEDICINE In China, impetigo is known as huangshi chuang (yellow-discharge sore). The disease is thought to be produced by the combination of internal damp-heat and external toxic-evil (3). Damp-heat arising internally is usually understood to be due to dietary factors, especially when the stomach/spleen function is weak and unable to distribute moisture. The accumulated dampness from fatty, moist, and salty foods, and from food residue that remains too long as a result of weak stomach function, transforms into heat, yielding the internal dampheat condition. The external toxic-evil corresponds to the contact with the bacterial pathogen. The primary therapy is to clear heat and toxin and eliminate dampness. An example of a formula is Qinlian Pingwei Tang (Scute and Coptis Stomach Benefiting Decoction): Scute Coptis Lonicera Forsythia Gardenia Chiang-huo Alisma Hoelen Red Atractylodes Dandelion Patrinia

10 grams 10 grams 10 grams 10 grams 10 grams 10 grams 12 grams 15 grams 10 grams 12 grams 15 grams

This is taken orally as a decoction. Topically, a powder of rhubarb, phellodendron, scute, and sophora is applied with enough water to moisten it (or a skin wash can be prepared with the herbs). A similar treatment recommendation is found in the Encyclopedia of Practical Traditional Chinese Medicine (4), deleting the herbs for dampness: Scute Coptis

9 grams 9 grams

Lonicera Chrysanthemum Gardenia Phellodendron Viola Semiaquilegia Dandelion

15 grams 15 grams 9 grams 9 grams 15 grams 9 grams 15 grams

The chrysanthemum to be used is wild chrysanthemum (yejuhua) and the formula is prepared as a decoction with the amounts indicated forming a one day dose. For topical therapy, a combination of lonicera, chrysanthemum, phellodendron, sophora, and alum is recommended. Chinese reports of successful treatment of infant eczema with topical phellodendron-based treatments (11) may, in fact, represent therapy for atopic dermatitis associated with Staphylococcus. The alkaloids of phellodendron, such as berberine and palmatine (see Figure 1), have antiseptic action against Staphylococcus and Streptococcus. Coptis (see Figure 2), another source of berberine and palmatine, was shown to inhibit S. aureus, while the combination of coptis, scute, and licorice had an even stronger effect (9). The Chinese herbs recommended for internal use are mainly those used for damp-heat (e.g., coptis, scute, phellodendron, and gardenia, the components of the well-known Coptis and Scute Combination, Huanglian Jiedu Tang) and those used for toxic heat (e.g., forsythia, lonicera, dandelion, viola, semiaquilegia, patrinia). The dosage of herbs taken internally in one day is about 100-120 grams. Topical therapies often rely on sophora and phellodendron, two herbs with broad-spectrum antibacterial properties.

REFERENCES 1. Koning S, et al., Fusidic acid cream in the treatment of impetigo in general practice: double blind randomised placebo controlled trial, British Medical Journal, 2002; 324(7331): 203. 2. Sharquie KE, et al., The antibacterial activity of tea in vitro and in vivo in patients with impetigo contagiosa, Journal of Dermatology 2000; 27(11): 706-710. 3. Li Lin, Practical Traditional Chinese Dermatology, 1995 Hai Feng Publishing Company, Hong Kong. 4. Xu Xiangcai (chief editor), English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (v. 16, Dermatology), 1990 Higher Education Press, Beijing. 5. Wilkinson JD, Fusidic acid in dermatology, British Journal of Dermatology 1998; 139 (supplement 53): 37-40. 6. Hu ZQ, et al. Epigallocatechin gallate synergy with ampicillin/sulbactam against 28 clinical isolates of methicillin-resistant Staphylococcus aureus, Journal of Antimicrobial Agents and Chemotherapy 2001; 48(3): 361-364. 7. Hu ZQ, et al., Epigallocatechin gallate synergistically enhances the activity of carbapenems against methicillin-resistant Staphylococcus aureus , Antimicrobial Agents and Chemotherapy 2002; 46 (2): 558-60. 8. Kim H, et al., Screening and isolation of antibiotic resistance inhibitors from herb materials IV-resistance inhibitors from Anetheum graveolens and Acorus gramineus, Archives of Pharmaceutical Research 1998 Dec; 21(6): 734-7. 9. Yan M, et al., Observation on inhibitory effect of coptis alone and its combination with scute and licorice on the growth of Staphylococcus aureus, Journal of Chinese Herbs 1998; 23(6): 375-377. 10. Hatano T. et al., Phenolic constituents of licorice. VIII. Structures of glicophenone and glicoisoflavanone, and effects of licorice phenolics on methicillin-resistant Staphylococcus aureus, Chemical and Pharmaceutical Bulletin 2000; 48(9): 12861292. 11. Chang HM and But PPH (editors), Pharmacology and Applications of Chinese Materia Medica, 1986 World Scientific, Singapore.

March 2002

Figure 1: Berberine and palmatine.

Figure 2:Coptis chinensis.

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John Paul II's Theology of the Body (online text and published book with review) Popular presentations on JPII's Theology of the Body (links to resources for further study)

This site is devoted to Christian theology of the body for subjects other than those that were the focus of John Paul II's series of talks titled Theology of the Body that dealt with sexuality and marriage (see valuable links to that topic, lower left). There are other important subjects related to the body, including those listed to the left, which are presented in articles posted here and through links to other articles. At the heart of this site is the matter of health, sickness, and healing. Among the primary tenets to be described in relation to healing are: Prayer is a central focus of healing. Prayer, an expression of faith, is a means of healing presented in the Gospels. Prayer does not replace medical help, and there is no conflict between prayer and medical therapy. Turning to prayer as a last resort, when medical therapies have failed, misses the value of prayer in healing; it serves as an integral part of healing. We are commanded to help heal others. This does not mean that everyone needs to become a medical practitioner, though being a physician is a noble profession which may be likened to a religious vocation. There are many ways to help others in healing aside from technical medical interventions. Self-help, although of a distinct value, should not be the primary center of attention in the concept of healing. We are to maintain the health of our bodies in order to serve others. Living in a healthy way can be a model for all. Health is a goal, but is not the only satisfactory condition in life; suffering and debility can be seen as having their own value. Effective health maintenance is important for reducing waste of medical resources better reserved for treating unavoidable sickness and injury.

Vatican texts, especially the writings of John Paul II and Benedict XVI, will form a central reference point for several of the presentations. "Do you not know that your body is a temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore honor God with your body." -1 Corinthians 6:19-20 translation | exegesis | styles | author | contact *The icons at the top of this home page are available from Monastery Icons: http://www.monasteryicons.com/

May the content of this site help the process of unification of the Christian Church, particularly towards the goal expressed by Pope Benedict XVI when he said: "I ask you all to set out with determination on the path of that spiritual ecumenism which, through prayer, opens the doors to the Holy Spirit, who alone can create unity." at Bari, Italy; May 29, 2005

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IRON DEFICIENCY ANEMIA by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The traditional Chinese medicine view of blood deficiency (xuexu) doesn't correspond completely to the modern medical concept of anemia. This divergence in interpretation often leads to difficulty in discussing the matter with patients. Although there are many types of anemia described in modern medicine (some of them related to rare deficiencies of blood cell production or altered hemoglobin formation), by far the most common type-and the one that might come closest to the usual description of blood deficiency in Chinese medicine-is iron deficiency anemia. The causes, such as excessive menstrual bleeding, are the same in the two systems. Iron deficiency is easily measured by taking a blood sample and evaluating its iron constituents, such as hematocrit (red blood cell proportion), hemoglobin (iron-based blood component), and serum ferritin (iron storage protein). From a symptomatic point of view, there are typical indicators of blood deficiency, which sometimes overlap and sometimes differ in the two medical systems, as shown in Table 1. TABLE 1: Iron Deficiency Symptoms. Symptoms that have some overlap or similarity are listed in the same row, those which differ are in separate rows. The modern medicine indications are taken from University of Maryland Medicine (1) and MedLine Plus (2); Chinese indications are from the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (3) and New Practical Syndrome Differentiation of TCM (4). Modern Medicine

Traditional Chinese Medicine

abnormal paleness or lack of color of the skin

pallor or sallow complexion, pale lips and nails

lack of energy or tiring easily (fatigue)

weak and thready pulse

increased heart rate (tachycardia)

palpitation

sore or swollen tongue

pale tongue

dizziness

dizziness

shortness of breath



headache



irritability



desire to eat peculiar substances (e.g., dirt, ice)





blurring of vision



insomnia



numbness of the limbs



hypomenorrhea, delayed menstruation, or amenorrhea

The primary overlap is in the pale complexion. Easy fatigue is attributed to qi deficiency in the Chinese medicine texts referenced here, and a swollen tongue and shortness of breath may also correspond to qi deficiency. It should be noted that tachycardia is not the same as palpitation, the latter referring to the experience of feeling the heart beat, which seems fast; speeded up heart rate may occur with palpitation. Irritability is sometimes associated in Chinese medicine with a liver qi stagnation syndrome, which, according to doctrine, can arise with liver blood deficiency, but irritability is not considered a typical symptom within the general blood deficiency pattern. Potentially, iron deficiency anemia might correspond to a diagnosis of deficiency of qi and blood in the Chinese system. While blood deficiency is a commonly treated syndrome in traditional Chinese medicine, few texts devote much space to discussing the basic concept of blood deficiency. In a compilation of information from four Chinese language sources, an article in the Journal of the American College of Traditional Chinese Medicine laid out some of the basic dogma (5). Blood deficiency is described as occurring from excessive blood loss (with insufficient replacement) and by "inadequacy of the blood factors and components required in blood formation due to spleen and stomach dysfunction." It was also pointed out that blood deficiency could arise secondary to blood stasis. This problem is usually attributed to the idea that generation of new blood requires getting rid of old blood, and blood stasis indicates old blood that is retained. In addition to the signs of systemic blood deficiency as outlined in Table 1, blood deficiency syndromes can be elaborated as belonging to one or more of the major organs, adding certain symptoms, specifically: heart blood deficiency, add symptoms of restlessness, agitation, disturbing dreams, and forgetfulness; spleen blood deficiency, add anorexia and mental fatigue; and liver blood deficiency, add spasms, dry and withering nails. According to the central doctrine, blood is governed by the heart, stored by the liver, and generated and controlled by the spleen. Modern medical treatment of iron deficiency anemia is straightforward and easy: the main thrust is to recommend a diet rich in iron. Then, if necessary, iron supplements can be administered (many of these are available over-the-counter). The Chinese treatment of anemia most often revolves around the use of a small number of herbs, with tang-kuei (see Figure 1, last page) as the central one. This herb is an ingredient in the principal blood nourishing formulas of Chinese medicine, such as Siwu Tang, Danggui Buxue Tang , Guipi Tang, and Bazhen Tang. Tang-kuei is not particularly rich in iron, nor are these formulas.

Iron compounds, primarily hematite, pyrite, and magnetite, are used in Chinese medicine, yet these mineral ingredients do not appear in any of the commonly-used blood nourishing prescriptions. However, an important aspect of traditional Chinese medicine in China is combining herbs with food therapies or directly with foods. For example, tang-kuei (or the full formula Siwu Tang) is often administered in a base of chicken soup, providing some iron from the chicken (if the chicken liver is included, that is the source of most of the iron). Siwu Tang, and its expanded form Bazhen Tang (which adds tonics for spleen qi), are usually recommended for recovery from blood loss due to menstruation; for most women, this blood loss is limited. The main formula recommended for treating severe blood loss is Danggui Buxue Tang , comprised of two herbs: a high dose of astragalus (30 g), with a standard dose of tang-kuei (6 g), a formula made without any iron compounds. Another prescription, made with just fresh ginger (15 grams) and a high dose of tang-kuei (9 grams), is cooked with mutton (48 g), a red meat that is high in iron, though not quite as much as in beef. That formula is used for the blood loss associated with childbirth, which can be significant. Evidently, Chinese herbs prescribed for blood loss are not good sources of iron even when treating severe blood loss, though when prepared with chicken or mutton or other meat products, the combination becomes at least a moderate source of iron. It is possible that the herbs promote some aspect of red blood cell production or iron metabolism leading to better retention of iron in the blood; this interpretation remains to be evaluated. Therefore, within the realm of standard herbal practice, given the ready availability of iron compounds used in making formulas and their absence in blood tonic formulas, one may suspect that iron deficiency anemia is not a significant target of Chinese medicine therapy for blood deficiency. With our modern knowledge of the blood and its constituents and functions, practitioners may wish to find out about the patient's blood test results regarding iron to determine whether iron deficiency is a part of a broader diagnosis of blood deficiency. If it is, dietary recommendations related to adequate iron consumption and consideration of iron supplements might be appropriate, since most patients will not be cooking their herbs with meats in order to get additional iron. The issue of dietary and supplemental iron may be an important one for practitioners who prescribe herbs. It is common for patients who seek herb therapies to pursue vegetarian or near-vegetarian (e.g., no red meat) diets that are low in iron. Further, excessive menstrual bleeding due to fibroids is a frequently presented disorder for treatment by herbs therapies.

GETTING IRON FROM THE DIET It has been determined that most adults can maintain a healthy level of iron in the blood by consuming a total of about 10 mg of iron each day, with 15 mg per day for menstruating women. According to USDA recommendations, the allowances of dietary iron intake are as follows: Young children - male and female: 6 months to 10 years: 10 mg Males: 11 to 18 years: 12 mg; 19 and older: 10 mg Females: 11 to 50 [menstruating]: 15 mg; 51 and older [non-menstruating]: 10 mg; Pregnant: 30 mg; Lactating: 15 mg There are three primary dietary sources for iron (see Tables 2 and 3, for specific examples and quantities): consumption of meat, usually providing 1-5 mg in a modest serving of about 3 ounces (an amount currently recommended for a single meal portion to minimize consumption of saturated fats); dried fruits, fruit juices, vegetables, legumes, and certain nuts usually providing 1-3 mg per serving of about half a cup (these are items that are encouraged to be consumed with higher frequency to assure adequate intake of vitamins, flavonoids, and other beneficial plant components); and wheat products, which are usually made with iron-fortified flour, providing, for example, 1-2 mg of iron in two sandwich slices or a cup of pasta. In a typical diet of three meals per day, one needs about 3-4 mg of iron per meal, which is easily obtained by most people. Some individuals, particularly women, suffer from low iron levels in the blood as a result of: low intake of foods (e.g., low calorie diets); losses of iron from bleeding (e.g., menstrual bleeding; see appendix for further details); and problems with iron uptake or distribution to iron carriers and reservoirs. TABLE 2: Iron-rich foods arranged from largest to least amount of iron in a typical serving size (1). The quantities of iron may differ slightly from those in the table below based on different samples of the foods (variation is usually not more than 25%). Iron-Rich Foods

Serving Size

Iron (mg)

Oysters

3 ounces

13.2

Beef liver

3 ounces

7.5

Prune juice

1/2 cup

5.2

Clams

2 ounces

4.2

Walnuts

1/2 cup

3.75

Ground beef

3 ounces

3.0

Chickpeas

1/2 cup

3.0

Bran flakes

1/2 cup

2.8

Pork roast

3 ounces

2.7

Cashew nuts

1/2 cup

2.65

Shrimp

3 ounces

2.6

Raisins

1/2 cup

2.55

Sardines

3 ounces

2.5

Spinach

1/2 cup

2.4

Lima beans

1/2 cup

2.3

Kidney beans

1/2 cup

2.2

Turkey, dark meat

3 ounces

2.0

Prunes

1/2 cup

1.9

Roast beef

3 ounces

1.8

Green peas

1/2 cup

1.5

Peanuts

1/2 cup

1.5

Potato

1

1.1

Sweet potato

1/2 cup

1.0

Green beans

1/2 cup

1.0

1

1.0

Egg

TABLE 3: Iron content of some common foods rich in iron, divided by heme-iron (more easily absorbed) and non-heme iron (less easily absorbed, by a factor of about 10). These are also grouped according to type of source; note the variation in iron content among different varieties of a food type (6). Serving Size

Iron (mg)

Beef, corned

Heme-iron Food Source

3.0 ounces

2.5

Beef, lean ground; 10% fat

3.0 ounces

3.9

Beef, round

3.0 ounces

4.6

Beef, chuck

3.0 ounces

3.2

Beef, flank

3.0 ounces

4.3

Chicken, breast w/out bone

3.0 ounces

0.9

Chicken, leg w/bone

2.0 ounces

0.7

Chicken, liver

3.0 ounces

7.3

Chicken, thigh w/ bone

2.3 ounces

1.2

Fish, cod, broiled

3.0 ounces

0.8

Fish, flounder, baked

3.0 ounces

1.2

Fish, salmon, pink canned

3.0 ounces

0.7

Fish, shrimp, 2 1/2 inch

1.1 ounces

0.5

Fish, tuna, canned in water

3.5 ounces

1.0

Pork, lean ham

3.0 ounces

1.9

Pork, loin chop

3.0 ounces

3.5

Turkey, dark meat

3.0 ounces

2.0

Turkey, white meat

3.0 ounces

1.2

Serving Size

Iron (mg)

10-12 each

0.7

Beans, baked, canned

1/2 cup

2.0

Beans, kidney

1/2 cup

3.0

Beans, lima

1/2 cup

1.8

Fruit, apricots, dried

10 each

1.7

Fruit, dates

10 each

1.6

Fruit, prune juice

1/2 cup

1.5

1/4 cup

1.0

Rice, brown

1 cup*

1.0

Rice, white enriched

1 cup*

1.8

Vegetables, broccoli, raw

1 stalk

1.1

Vegetables, peas, frozen

1/2 cup*

1.3

Vegetables, spinach

1/2 cup*

2.0

Wheat, bagel

1 whole

1.5

Non-iron Food Source Almonds, raw

Fruit, raisins, not packed

Wheat, bread, white

2 slices

1.4

Wheat, bread, whole wheat

2 slices

1.7

Wheat, macaroni, enriched

1 cup*

1.9

Wheat, spaghetti, enriched

1 cup*

1.6

*serving size and iron content is for cooked food

IRON SUPPLEMENTS Iron supplements are readily available, and can provide quantities of iron that range from 10 to 40 mg per daily dose. There are potential problems with some iron supplements, of which the greatest is getting too much iron. Excess intake of iron can cause constipation, impair the uptake of essential trace minerals, and contribute to a higher state of oxidative stress (iron is one of nature's most potent oxidants). Children who accidentally consume large amounts of iron are most susceptible to the adverse effects and the single most commonly reported poisoning from supplements is due to children getting into packages of iron supplements (all supplements providing iron are now required to have child-proof caps). In 2001, the Institute of Medicine set a tolerable upper intake level of 40 mg per day for infants and children through age 13 and 45 mg per day for ages 14 and over. Generally, supplement recommendations, even for severe iron deficiency anemia, are for less than 40 mg/day, because at that level people can experience nausea and other immediate reactions. In an attempt to maximize iron supplementation without evident side effects, many suppliers of supplements for prescription by nutritionists provide 27 mg/day, the highest amount that is associated with a low incidence of complaints. In addition to maximizing iron levels in the supplements, the manufacturers also attempt to maximize its absorption by using iron glycinate and by including vitamins (mainly vitamin C and several B vitamins) that enhance the absorption of iron. Maximizing iron dosage and promoting efficient absorption together may not be ideal because it involves adding as much iron as possible to the system. An alternative is to provide a more modest amount of iron within a blood nourishing herb formulation that may have other benefits to the blood system.

APPENDIX. THERAPIES FOR EXCESSIVE MENSTRUAL BLEEDING The base RDA for iron is set at 10 mg, but rises to 15 mg (some suggest 18 mg) for menstruating women to compensate for the monthly blood loss. Dietary sources may prove inadequate to attain this level, especially for those who rely on non-heme sources. A supplement is often indicated, particularly for women who have heavy blood flow during menstruation. By adding about 10 mg of supplemental iron to the daily diet that should already provide 10 mg, a sufficient level (e.g., about 20 mg/day) is attained for most women. There appears to be some correlation between low iron levels and increased blood flow during menstruation, so that a low iron state can end up being maintained easily: the low iron promotes more bleeding, while the bleeding keeps the iron levels low. This situation may be remedied in some cases by the addition of iron supplements to the dietary intake. Increased menstrual blood flow is a common result of uterine fibroids, a condition that brings many women to seek natural health care alternatives to surgery. Herbs used to reduce uterine bleeding from various causes include tien-chi ginseng (sanqi); lotus (seed, node, and other parts); gelatins (deer antler, tortoise shell, donkey skin); and certain traditional formulas, mainly Guipi Tang (Ginseng and Longan Combination) and Bazhen Tang (Tang-kuei and Ginseng Eight Formula), and patent medicines (mainly Yunnan Bai Yao and Wu Ji Bai Feng Wan). The low point of blood iron levels occurs as the menstrual period is completed, with maximum cumulative blood loss. Thus, Chinese herbalists emphasize the use of tonic formulas to begin immediately following cessation of menstrual bleeding, and continuing for several days afterward. In some cases, the blood tonics are continued throughout the month, rather than used for just a few days. The decision to purse this routine use of tonics is based on the constitutional analysis, to determine whether tonification is the most appropriate therapy during the rest of the menstrual cycle, as opposed to a possible alternative therapy, such as regulating liver qi. Similarly, the decision to continue iron supplementation throughout the month, or only during the days following menstruation (and during menstruation, to help control excessive blood flow), would depend primarily on blood tests showing low levels of iron.

REFERENCES 1. University of Maryland Medicine, Iron-deficiency Anemia, 2003 University of Maryland Medical System, http://www.umm.edu/blood/aneiron.htm 2. Medline Plus, Iron in diet, 2003 U.S. National Library of Medicine and National Institutes of Health http://www.nlm.nih.gov/medlineplus/ency/article/002422.htm 3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (vol. 1) 1995-6 New World Press, Beijing 4. Wang Qi and Dong Zhi Lin, New Practical Syndrome Differentiation of T.C.M., 1992 China Ocean Press, Beijing. 5. Cheung CS and Belluomini J, Blood, Journal of the American College of Traditional Chinese Medicine 1982 (2): 48-54. 6. McKinley Health Center, Dietary Sources of Iron, 2001 University of Illinois; http://www.mckinley.uiuc.edu/handouts/dietiron.html 7. Dharmananda S, Bag of Pearls, 2002/2003 Institute for Traditional Medicine, Portland, OR.

Figure 1. Tang-kuei (danggui) pressed slices as found in Hong Kong pharmacies. These are made by slicing the roots, putting several root slices next to each other, and then pressing them, to make one large "palm" slice. They are usually soaked in Chinese wine, which makes the active constituents more mobile when cooking as a decoction or when using consuming the ground herb powder.

May 2003

TREATMENT OF ITP WITH CHINESE MEDICINE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Idiopathic Thrombocytopenic Purpura (ITP) is a somewhat archaic term for a condition of low platelets (thrombocytes). Idiopathic means that the cause is unknown; with advances in modern technology, a substantial amount has been learned about the causes. While one may not be able to definitively point to all the causative factors and agents involved in any one patient, as is the case with many diseases, now it is often possible to describe much of the etiology and pathology of ITP quite accurately. Purpura refers to the splotches seen on the skin where capillaries have leaked blood to yield a bruise or many red or purple petechia (flat, pin-head sized spots). However, with careful monitoring of the platelet counts and appropriate treatment when the platelets approach a low level, people with this disease may rarely show any such symptom. Nonetheless the moniker ITP has stuck in the medical literature and will, as a result, continue to be used here. The deficiency of platelets has two basic origins: autoimmune attack against platelets (primary ITP) and bone marrow disorder (usually: secondary ITP). In primary ITP, the bone marrow produces platelets as fast as usual (at least in the early stages of the disease), but even before they have a chance to mature, they are taken out of circulation. An antibody of the G series (the type involved in several autoimmune diseases), IgG, attaches to the platelets and marks them to be removed from circulation. It is likely that individuals who suffer this disease have a genetic propensity to get it, and that a viral disease triggers it. Many autoimmune disorders have this characteristic. In such cases, treatment is often aimed at inhibiting the immune system with corticosteroids (e.g., prednisone). If necessary, the spleen is removed (splenectomy) in order to both reduce the production of anti-platelet antibodies and to slow the clearance of the platelets from the system (the spleen filters out the platelet-immune complex). A suitable name for this disease is autoimmune thrombocytopenia. Autoimmune thrombocytopenia occurs mostly in children and young adults (typically before age 30), though it can rarely occur later in life. Many times, it manifests as an acute disease, lasting a few weeks and then clearing up completely. It might recur again later after another viral infection or with reactivation of a chronic virus, but eventually it ceases to be a problem in the majority of children who experience it. The acute manifestation can usually be controlled by a course of therapy using steroids to inhibit the immune response for a period of several weeks. Chronic autoimmune thrombocytopenia develops in a small percentage of patients. In that case, steroid therapy eventually fails (due to the side effects from prolonged administration). Until recently, the main therapy for chronic autoimmune thrombocytopenia has been splenectomy, which is sometimes curative, but at least reduces the disease severity. More recently, intravenous (IV) infusion of normal IgG (hence the treatment initials: IVIG) to replace the body’s anti-platelet IgG has been tried with some success and may replace splenectomy for some patients. IVIG has also been proposed as an alternative to the initial therapy with prednisone. Other therapies are also being developed. Medical opinion appears to be leaning towards finding an alternative to splenectomy. A defect in the production of platelets by the bone marrow, resulting in ITP, can occur as part of a general bone marrow dysfunction, in which both red and white blood cells are also produced insufficiently. Or, it can occur secondary to leukemia, in which the stem cells that yield white blood cells proliferate and crowd out the stem cells that produce platelets and red blood cells (yielding high white cell count and low RBC and platelet counts). Low platelets can also occur as the result of certain medical treatments, such as chemotherapy for cancer. Some chronic diseases that affect the immune system, such as HIV, hepatitis C, and systemic lupus, may yield a combination of inhibited platelet production and shortened time that platelets persist in the blood, with resulting ITP. For these situations, the platelet deficiency is called secondary ITP, because there is something else going on first or at the same time that yields the clinical result. The platelet disorder that may be resolved if the other disease process or medical treatment is removed. CHINESE HERB THERAPY In China, both primary and secondary ITP are noted in the medical literature, though primary ITP is the main subject of the reports and is the object of the current article. Treatment, other than Western medical therapies, is based on using Chinese herbs: reports of acupuncture therapy are rare or non-existent. The Chinese herbal therapies vary markedly from one physician to the next and sometimes among different patients, depending on the differential diagnosis. The general theory of treating primary ITP, at least as it occurs in children and young adults, is that there is a heat syndrome causing the blood to escape the vessels. Therefore, clearing heat is the primary concern. Also, since bleeding is the symptom, treatment with hemostatic herbs, especially those which are also cooling, is standard procedure. There are two major causes of the blood heat, one being an excess heat syndrome that might be associated with a viral infection and the other is a yin deficiency syndrome, which may arise from nutritional deficits, prior diseases, or inherent factors. In the case of the yin deficiency syndrome, nourishing yin (tonification) is deemed the most important aspect of therapy. Except in the cases of dominant excess syndrome, there are usually some herbs included in the ITP treatment to tonify the spleen, owing to the concept that the spleen restrains the blood within the vessels and the spleen helps produce new blood and replenishes the yin. In patients who show an evident spleen qi deficiency syndrome, the qi tonics may become a major part of the therapy, with less emphasis on clearing heat or nourishing yin. In cases where there is prolonged disease, the deficiency of qi often extends to a deficiency of the kidney and additional tonic therapies may be added. For most cases of secondary ITP, the theory is that the bone marrow is inadequate to produce the cells and this is addressed by tonifying the kidney (to invigorate marrow), nourish the liver (to increase the blood storage), and tonify the qi to help produce blood and essence. Within the theoretical framework, a number of different herbs are selected. Among the most commonly used herbs for primary ITP are the ones listed in Table 1. Table 1: Herbs Commonly Used in the Treatment of Primary ITP in Four Categories. Note that some of the herbs are classified differently than the standard Materia Medica categories. Heat Clearing rehmannia, raw gardenia

Hemostatic agrimony imperata

Qi Tonifying astragalus licorice

Liver Nourishing tang-kuei gelatin

moutan red peony salvia lithospermum isatis leaf

eclipta rubia san-chi biota tops sanguisorba

codonopsis hoelen atractylodes jujube dioscorea

tortoise shell ho-shou-wu lycium millettia cuscuta

Within these four groups are herbs that vitalize blood circulation (red peony, moutan, salvia, san-chi, tang-kuei, millettia), which is another method of therapy that has been proposed, to be described later in this article. According to the Chinese medical reports, administration of decoctions made with the above-mentioned herbs in appropriate combinations will raise the platelet levels in patients with persistent ITP, often to an acceptable level, though only rarely will they return to the normal range. Normal platelet levels are usually defined as 150 or above (billions of platelets per liter of blood). According to the clinical reports, the use of herbs will often raise the platelets from the unacceptable level (below 50, at which bleeding that is difficult to stop may occur) to an average of about 75–85. Some patients described in the literature had their platelet levels reach over 100 and very few attained a completely normal level. Primary ITP spontaneously resolves at a rate that is better with younger age; overall only about 20% of cases are persistent and refractory to standard treatments. If the Chinese herb therapy can raise the platelets to an acceptable level, the condition may stabilize for most individuals within a few days or weeks; if there is a relapse, then the same kind of treatment might be applied again. For persisting ITP, which is a greater concern because of the difficulty of finding suitable modern medical therapy, Chinese herbal treatment will usually be administered for several weeks or months. In the Chinese clinical evaluations, the success of the therapy for the chronic disease is often monitored in terms of the relapse rate after the herbs have been stopped. Herbal therapy is reported to be of some benefit to nearly all patients, though the degree of improvement varies markedly and the relapse rate (within a year, if monitored that long) is often high. Virtually all studies of ITP treatment include a control group that receives steroids, usually at high doses (about 45 mg/day). The Chinese herbal therapies are claimed to be superior in their results and lacking in the characteristic side effects of the drugs. Because the randomization and matching of patients in the herb treatment and control groups is usually not clear in the Chinese reports, the value of the comparisons can be questioned. Further, it is unclear in the reports to what extent the corticosteroid dosage is manipulated according to methods commonly recommended in modern clinical practice. Therefore, in the summaries of the medical journal articles presented here, the results for the control group are usually not indicated. The main purpose of conveying the information presented in the Chinese journal articles is to illustrate the selection of herbs, the dosage (described in a separate section of this article), duration of therapy, time to obtain changes in platelets, and the claimed results of therapy. Much of the work done on ITP in China has been carried out at the Shanghai College of Traditional Chinese Medicine. This very large college has a number of affiliated hospitals where studies can be carried out. There are also other medical universities in Shanghai that cooperate with the TCM College in conducting some of the studies. CLINICAL REPORTS INVOLVING DIFFERENTIAL DIAGNOSIS The majority of the recent Chinese clinical reports describe trials involving a single herb formula that may be modified slightly according to presenting conditions. However, outside of the trial setting, differential diagnosis is the rule, so this aspect is presented first. A study of patients with ITP according to their traditional Chinese diagnostic category was carried out by the Shanghai College of Traditional Chinese Medicine and published in 1991 (1). It involved 103 patients (75 female) with an age range of 12–58 years. The differentiation went this way: Table 2: Division of 103 Patients with ITP into Four Diagnostic Categories with Group Characteristics: Age, Disease Duration (years), IgG Levels, and Platelet Counts. Differentiation Group Qi Deficiency Blood heat Yin deficiency Yang deficiency

Number of Patients 20 22 43 18

Mean Age (Mean Duration of Disease) 24 (3) 26 (4) 36 (7) 40 (12)

IgG (Control: 18) 115 63 80 112

Platelets (Control: 122) 29 44 39 34

The qi-deficiency group was described as a spleen-deficiency type; the blood-heat type was described as an excess syndrome, the yin-deficiency type was described as a syndrome secondary to chronic spleen deficiency; and the yang-deficiency type was said to be a deficiency of spleen and kidney. The control group of non-ITP patients involved 20 individuals with a similar ratio of the two sexes, mean age of 30, and similar range of ages as the differentiation group. The control group was included for obtaining relative blood values. Looking at the mean values for patient age and disease duration only, it can be seen that the disease generally started before age 30 and falls in the category of chronic ITP. According to the analysis, the most common type of the disease is a yin-deficiency syndrome. Both the blood-heat and yin-deficiency syndromes can be described as being of the general heat-type of ITP, accounting for 2/3 of the cases. The deficiency of qi and of yang correlated with the most dramatic elevation of IgG. In the report, there were also slight elevations noted in IgA and IgM for all the ITP patients, but not sufficient to explain the disease manifestation. The platelet numbers did not vary much from one group to the next (the control group level is quite low to begin with, suggesting that these numbers are not directly comparable to those from other laboratories). The report also presented information on T-cell subsets, but there were no significant differences in their numbers or ratios among the different groups, including the controls. In 1991, a research team at the Shanghai College of TCM presented a formula for ITP (2) with the following ingredients: astragalus,

codonopsis, tang-kuei, moutan, agrimony, isatis leaf, perilla stem, licorice, raw rehmannia, cooked rehmannia, and eclipta. The trial group of 36 patients receiving this formula ranged in age from 13–60 years. Treatment time was at least three months (average 110 days) and it was reported that all but 3 of the patients had improvement of symptoms. The average increase of platelets was from 38 to 79, and the average decrease in IgG was from 74 to 32. The formula included herbs for tonifying qi (astragalus, codonopsis, licorice), nourishing yin (rehmannia and eclipta), clearing heat (moutan, isatis leaf, raw rehmannia), and inhibiting bleeding (agrimony and eclipta). The use of perilla stem (zisugeng) is unique; it is not found in other formulations for ITP (see key herbs section, below). This basic formula was later adopted by another group at the same college using differential diagnosis and treatment (3). According to their report, there were four categories of disorder and treatments, but the data for all the patients were then pooled for analysis rather than divided by group. The above-mentioned formula was adopted for the yin-deficiency group and modifications of it were used for the other groups as shown in Table 3. Table 3: Differential Therapy for ITP at the Shanghai College of Traditional Chinese Medicine. Differentiation Group (Number of Patients) Qi Deficiency (30) Blood heat (24) Yin deficiency (76) Yang deficiency (24)

Herb Formula astragalus, codonopsis, tang-kuei, moutan, agrimony, isatis leaf, perilla stem, licorice, etc. buffalo horn, raw rehmannia, red peony, moutan, eclipta, trachycarpus, rubia, isatis leaf, perilla stem, licorice, etc. astragalus, codonopsis, tang-kuei, moutan, agrimony, perilla stem, licorice, raw rehmannia, cooked rehmannia, eclipta, etc. astragalus, codonopsis, tang-kuei, moutan, agrimony, perilla stem, licorice, raw rehmannia, cooked rehmannia, eclipta, epimedium, cuscuta seed, etc.

As in the previous report on differentiation of the syndrome, the most common form was the yin deficiency type and the combined heat syndromes (yin deficiency and excess heat as blood heat) comprised 2/3 of the cases. All of the formulas included moutan, perilla stem, and licorice, and all but the qi-deficiency formula included raw rehmannia, while all but the blood-heat formula included astragalus, codonopsis, tang-kuei, and agrimony. For the kidney-deficiency cases, the formulas included cooked rehmannia and eclipta. The herb formulas were prepared as a liquid syrup and consumed three times per day. A control group was given prednisone; treatment time was at least three months. Side effects of the herb therapy were limited to a few cases of loss of appetite and thin stools. The prednisone group presented side effects in half the patients including the typical increase of body weight and upset stomach. Mean values for platelets in the herb group rose from 38 before treatment to 68 after treatment. The control group had nearly identical mean values. Some patients were treated for six months to a year, and the platelet values continued to rise slowly in the herb treatment group, reaching 75 at six months and 88 at one year. The IgG values in the herb treatment group declined from 99 at the beginning of treament to 41 at the end of treatment (three months); the values for the control group were similar. The authors claimed that the best therapeutic responses were among the patients suffering from qi deficiency and yin-deficiency syndromes. In a more recent study (4) conducted Shenyang (rather than Shanghai), patients were simply divided into two groups, one being the common yin-deficiency type with heat symptoms (30 patients), and a spleen-kidney deficiency group, involving spleen qi deficiency and kidney/liver yin deficiency (31 patients) with pallor signs The treatments were: · Yin deficiency type: codonopsis, cuttlebone, rehmannia, moutan, artemisia, gelatin · Kidney/Spleen deficiency type: ho-shou-wu, lycium, ginseng, astragalus, tang-kuei, san-chi. The herbs for the yin deficiency type were made as a decoction with 10–15 grams of each herb (except cuttlebone at 25 grams). The herbs for the kidney/spleen type were made into tablets, given 4–6 each time, three times daily, with 380 mg/tablet. A control group was treated with prednisone. At the end of four weeks, 35 of the herb treated patients had some level of improvement; after one year, 56 of the 61 herb treated patients had some degree of improvement. According to the report, the time from starting herb therapy until the platelet counts started to rise was, on average, 24 days (compared to 8 days for the prednisone group), and it took three months for the herb treated group to reach its maximum level of platelets, compared to 22 days for the prednisone group. After one year of therapy, the herbs were stopped. The relapse rate for the patients who did best in the herb treatment group (in terms of platelet improvements and corresponding improvements in symptoms), of which there were 24, was examined. There were 11 patients that remained stable (no relapse), while 13 patients had a relapse (between 3.5 and 11 months after stopping the herbs). A similar pair of differential groups was described in an earlier study (1987) with the following formulas (5): · Yin-deficiency type: tortoise shell, oyster shell, phellodendron, imperata, biota tops, sanguisorba, lycium, eucommia, scute, lycium bark, gardenia, san-chi. · Kidney/Spleen-deficiency type: astragalus, imperata, schizandra, codonopsis, hoelen, tang-kuei, atractylodes, lycium gelatin, san-chi. These formulas were ground into powder, made into pills and taken in the amount of 5 grams of herb powder twice per day. The patients had been treated with Western medicine without success. The results from the two groups were pooled, and it was claimed that all patients showed some improvement. These studies that involve differential diagnosis do not clearly demonstrate that such differentiation is essential to the outcomes. All of the formulas include herbs that clear heat, inhibit bleeding, and nourish yin. While kidney deficiency is mentioned in the reports, there is very little reliance on kidney-yang tonic herbs in the prescriptions. Even when kidney-tonic herbs are included (such as the yinnourishing rehmannia and eclipta or the yang tonics eucommia, cuscuta, and epimedium), the ones selected are also traditionally classified as nourishing the liver, so that a liver-nourishing principle would describe the basis of treatment equally well. CHINESE CLINICAL REPORTS WITH BASE FORMULAS THAT MAY BE MODIFIED There are a substantial number of reports in the Chinese medical literature published during the 1980’s and early 1990’s describing

treatments for ITP. They usually present a basic formula that can be modified slightly for individual presentation of symptoms; the modifications may not be directly relevant to the experience of ITP. Due to concerns about the quality of clinical testing and reporting, and due to the fact that most of these reports are available only in summary or abstract form, only the most basic information is presented here in table format to illustrate the nature of the prescriptions used. Table 4: Clinical Reports on Herbal Therapy for ITP. The majority of these reports were summarized in The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs (5), translated from Compendium of Secret Chinese TCM Formulas, a three-volume book of medical report summaries first published in 1989. In a few cases, the study reported here was available only as an abstract in Abstracts of Chinese Medicine (a quarterly journal) or other source. A total of 600 patients were involved in the herbal treatments; most studies also had a control group of about 20 patients using steroids. Author (Citation) [No. Of Patients] Sha Bingyi (5) [22] Yang Jin (5) [50]

Su Eryun (5) [33]

Zhang Yisheng (5) [80]

Deng Youan, et al. (5) [31]

Liu Shaoxiang (5) [62]

Han Weigang and Qi Rongfang (6) [27]

Gao Xiang, et al. (7) [35]

Cui Shuzhen, et al. (8) [100]

Peng Xiang, et al. (9) [24]

Formula Ingredients; Modifications

Comments

agrimony, jujube, oyster shell, licorice, forsythia, Symptom improvement reported salvia after 5 days, substantial platelet increase after 10 days. agrimony, sanguisorba, codonopsis, atractylodes, All but 2 patients improved; after cornus, salvia, astragalus, shou-wu, rehmannia, treament was concluded there was scrophularia, licorice, phytolacca (this herb is no relapse during a six month boiled a long time to reduce toxicity); for yin follow-up. deficiency, remove codonopsis and atractylodes, add phellodendron, anemarrhena, moutan, tortoise shell; for qi deficiency, add hoelen, jujube millettia, agrimony, licorice, tang-kuei, ixeris, Improvements claimed for 25 of the biota tops, astragalus, raw rehmannia; for yin 33 patients. deficiency, increase rehmannia, decrease astragalus; for blood stasis, double the millettia dose gardenia, raw rehmannia, red peony, moutan, Bleeding brought under control in tang-kuei, astragalus; for heavy bleeding, add all cases. lithospermum, rubia, agrimony; for anemia, add gelatin, millettia, ho-shou-wu; for yin deficiency add yu-chu, glehnia, ophiopogon, imperata; for qi deficiency, add codonopsis, atractylodes, hoelen, dioscorea cnidium, salvia, tang-kuei, carthamus, millettia, red peony, leonurus; for qi deficiency add codonopsis, astragalus, dioscorea; for weak digestion, add atractylodes, hoelen, crataegus, malt, citrus, magnolia bark; for kidney yang deficiency, add morinda, cuscuta; for kidney yin deficiency add ligustrum, lycium

For treatment of chronic platelet deficiency but not for use when the platelets are very low, causing purpura. Average treatment time was one month. IgG was greatly decreased after treatment. A few patients had no relapse for at least 6 months. agrimony, rumex, millettia; for qi deficiency add Secondary ITP was mainly treated, astragalus and codonopsis; for blood deficiency with chemotherapy and radiation the add tang-kuei and gelatin; for weak digestion, cause. Reported platelet restoring add atractylodes effect took place in 5 days on average. buffalo horn, raw rehmannia, moutan, red peony, 24 of 27 patients reported to respond isatis leaf, paris, agrimony, lithospermum; for well with 12 days treatment. blood heat, add fresh lotus node; for qi deficiency, add astragalus; for yin deficiency, add ho-shou-wu astragalus, codonopsis, hoelen, atractylodes, 30 day treatment course (could be rehmannia, tang-kuei, psoralea, drynaria, extended), 31 of 35 patients showed cuscuta; for nose bleed add agrimony; for purple some improvement. Platelet counts petechia, add salvia; for poor appetite, add red increased from average of 52 to 79. atractylodes and citrus cnidium, salvia, red peony, millettia, leonurus; See Dong Youan study above, with digestive disturbance, add crataegus, malt, citrus, nearly identical in treatment. This atractylodes, malt; serious bleeding, add raw study involved children 6 months to rehmannia, moutan, and cirsium 13 years with persistent ITP. One month treatment course; platelet increased from 26 to 109. All patients “improved.” astragalus, codonopsis, atractylodes, licorice, Improvements noted in 20 of 24 rumex, scute, coptis, frankincense, myrrh, patients. tribulus

Author (Citation) [No. Of Patients] He Guoxing and Wang Xiuhua (10) [52] Zhang Gaochen and Mao Yuwen (11) [55] Li Zhiyuan (12) [23] Duan Yu, et al. (13) [10]

Xiang Renpu (14) [26]

Formula Ingredients; Modifications

Comments

rehmannia, deer antler gelatin, tortoise shell gelatin, ho-shou-wu, codonopsis, tang-kuei, astragalus, epimedium, salvia, rubia, ligustrum, licorice tang-kuei, agrimony, moutan, gardenia, san-chi, biota tops

Improvements noted in 50 of 52 patients.

astragalus, codonopsis, tang-kuei, nutmeg, rehmannia, cinnamon bark, aconite, dioscorea, agrimony, gelatin bupleurum, codonopsis, scute, licorice, jujube, equisetum, pyrrosia, verbena, rehmannia

20 of 23 patients improved. No relapse during 3–6 month follow-up.

raw rehmannia, agrimony, ho-shou-wu, lycium, psoralea, cistanche, salvia, red peony, rubia, tang-kuei, moutan, cornus

Treatment time was 9–36 days, and mean platelet count rose from 58 to 78; 2/3 of patients improved.

Average treatment time was 4 weeks; an IV drip of hemostatic drugs and vitamins was given for an average of 3 day. Mean platelets increased from 19 to 121. All but 1 patient has some improvement, but relapse was common. Platelet count increased by an average of 32.

BLOOD STASIS HYPOTHESIS FOR CHRONIC AUTOIMMUNE THROMBOCYTOPENIA It has been proposed by some authors that the symptomatic manifestation of purpura signifies a blood stasis syndrome and that the chronic disease, in particular, should be treated mainly by vitalizing blood circulation. One of the first descriptions of this approach was from the Heilongjiang College of Traditional Chinese Medicine, published in 1981 and then republished in English in 1983 (15). The authors reported that in a group of 200 ITP patients, there were 46 who had chronic cases and, of these, 30 had “varying degrees of blood stasis.” The remaining 16 chronic cases had varying degrees of spleen qi deficiency with inability to restrain the blood and yin deficiency with glowing fire. The symptoms of blood stasis were: bruising and petechia; dry, lusterless hair; dark facial color; purplish congestion in the eye vessels; lower eyelid shows purplish dark case; pulse was thready and/or astringent. Two or more of these signs were needed to place an ITP patient in the diagnostic category of blood stasis. Since the purpura signs are to be expected in chronic cases of ITP in those seeking treatment, only one other sign would be necessary to yield the diagnosis. The proposed formula was: millettia, red peony, san-chi flowers, rubia, tang-kuei, salvia, codonopsis, jujube, eclipta, rehmannia. If there was a high level of bleeding, the formula could be modified by temporarily removing red peony and salvia and adding agrimony, lotus node, charred hair, and trachycarpus. Additional anti-hemorrhage herbs might be added according to their reputation for treating a specific site of bleeding. The authors claimed that improvements occurred in all but 3 of the 30 cases of blood stasis that were so treated. The average duration of therapy was 85 days (about three months) and the platelet levels increased from 41 before treatment to 85 after treatment. The authors of this report quoted earlier physicians as stating that one should not just attempt to stop bleeding, but should move or circulate the blood. This should be done whether the blood is fresh or black, and whether the condition is associated with cold or heat. The authors then relayed their own experience: In the beginning stage [of treatment] if we use the principle of following the etiology (e.g., kidney yin deficiency with uprising and flaming of deficiency fire; spleen deficiency with loss of control and blood not returning to the vessels), we will have some patients respond poorly to this treatment. These patients will present the signs of blood stasis....Chinese researchers using animal experiments found that the treament method of vitalizing blood and dissolving blood stasis inhibit the formation of IgG and regulates the T-cell balance....The treatment of vitalizing blood and dissolving blood stasis lowers capillary fragility and decreases the permeability of vessels and, in this way, resistance to bleeding is increased. In two of the studies cited in Table 4, the base formula that is applied is: cnidium, salvia, tang-kuei, carthamus, millettia, red peony, leonurus. The ingredients in common here are salvia, red peony, millettia, and tang-kuei. The principle of using a blood-vitalizing therapy for ITP, incorporating many of the same herbs, was mentioned recently in a reported clinical trial 16). The herb therapy was comprised of astragalus, atractylodes, polygonatum, tang-kuei, millettia, red peony, moutan, carthamus. According to the authors, 2/3 of the patients showed improvements, and the average platelet count for the whole group increased from 34 to 57, while the IgG level decreased from 195 to 122. In addition, the researchers measured hepatoglobin, a substance produced by the liver that is elevated in patients with ITP; this substance declined by 1/3 following the herb treatment. The authors expressed the view that ITP had the characteristic of a dysfunctional immune system which could be corrected by tonifying the qi (with astragalus, polygonatum, and atractylodes; this method of therapy promotes the correct qi and reduces the pathological qi) and invigorating blood circulation (which inhibits autoimmune attacks). A disorder similar in symptoms to primary ITP, idiopathic multifocal bleeding and platelet aggregation defect (IMBPAC), was addressed with a blood-vitalizing therapy by physicians working at the Tongji Medical University in Wuhan (17). They used Xiaoyu Zhixue Pian (Reduce Stagnation, Regulate Blood Tablets) made with astragalus, codonopsis, licorice, peony, tang-kuei, and persica. The herbal material, corresponding to 1.2 grams crude herb per tablet, was administered 5–8 tablets each time, 2–3 times daily. They reported a hemostatic effect in most patients in 5–7 days (total treatment time was four months). Instead of relying on hemostatic herbs, the formula boosts the qi and vitalizes blood circulation NORMALIZING PLATELET FUNCTIONS

There is considerable concern raised in modern medical practice about altering platelet functions. During the 20th century, the primary cause of premature death in the Western world was a blood clot that either caused a heart attack or stroke. As a result, the stickiness of platelets, which contributes to forming the blood clot, has been deemed one of the most serious pathological problems. Patients who experienced a non-fatal blood clot event would often be placed on life-long therapy to inhibit platelet sticking, so as to avoid a second event. The ease with which a clot could form in the population (especially those past 45 years of age) appears to be due to several factors, including excess blood sugars and lipids, high oxidation status (lipid peroxidation products in the membranes), and the influence of smoking, excessive alcohol consumption, use of exogenous estrogens (menopause treatment), and the effects of sedentary lifestyle. These factors help explain why there was such a dramatic increase in fatality due to blood clots during the 20th century compared to the 19th century, and also why there were declines in incidence of these problems in the latter part of the 20th century after recommendations were made for adjusting life style and using drugs to inhibit clotting. However, one effect of the high incidence of clotting and the corresponding medical attention to the clotting problem is to generate an image of platelets as being inherently harmful and to view substances that alter bleeding and clotting to be something that must be strictly controlled medically. In relation to herbal medicine, this has meant serious concerns about using herbs that influence clotting (many of them do if the dosage is high enough), and especially using these herbs along with medical therapies that influence clotting. Chinese physicians have emphasized the use of blood-vitalizing herbs ever since Wang Qingren, in the first half of the 19th century, proposed that blood stasis was a major factor in several serious diseases. His blood-vitalizing formulas had dramatic effects in many cases, and were widely adopted for use during the 20th century when the cardiovascular diseases became prominent. One of the issues that was raised was whether or not blood-vitalizing herbs might worsen, or even induce, bleeding; the other was whether or not hemostatic herbs might worsen or induce undesired blood clotting. A traditional theory, that some bleeding disorders are due to blood stasis, meant that Chinese doctors would sometimes treat bleeding with herbs that had a reputation for getting rid of clotted blood (e.g., bruising as occurs with injuries). Those herbs were shown in some pharmacology experiments to reduce platelet aggregation, which, one would think, would worsen rather than aid bleeding. An explanation for the apparent contradiction between clinical observations and the laboratory experiments is that at low dosage the herbs can regulate platelet function and stop bleeding when the function is deficient, while at very high doses (as used in laboratory experiments and some decoctions), the herbs specifically reduce platelet sticking. One of the apparent paradoxes of modern Chinese herbal medicine is the use of san-chi ( Panax notoginseng) to treat bleeding and also to help resolve blood clots and vitalize blood circulation. Other herbs that might have this effect are agrimony, rubia, and leonurus. While this diversity of actions may appear contradictory, it is not inherently so. For example, if the dietary and other lifestyle factors yield platelets which function abnormally, then lifestyle changes and herbs that help normalize their functions can have several beneficial effects. Normal-acting platelets will not be likely to spontaneously clot in the blood vessels, but they will clot promptly when there is a damaged vessel causing leakage of blood. Herbs that regulate blood circulation might normalize platelet functions and, at the same time, influence blood vessel dilation, vessel wall integrity, and other factors. The idea that the Chinese herbs will have a normalizing function, rather than causing an adverse effect, is one which is difficult to prove, leaving some question in the minds of concerned practitioners and patients. Chinese physicians, for the most part, have adopted the view that the use of the herbs to regulate blood conditions is safe. KEY HERBS FOR REGULATING BLOOD Table 5 presents hemostatic herbs that are included in several of the formulas for treating ITP. There are a wide range of botanical sources represented here (each herb being from a different plant family) and wide range of active constituents that might ultimately contribute to hemostatic action, including essential oils, flavonoids, saponins, and alkaloids. Other herbs that are used to treat bleeding, such as fried schizonepeta, typha, and the thistles (breea and cirsium), are not commonly used for ITP, suggesting that the physicians have focused on a small group of herbs that may be more suited to treating this particular disorder. The possible mechanisms of action of the hemostatic herbs include: · increasing the production of platelets · promoting the ability of platelets to aggregate when there is blood leakage · decreasing capillary permeability · contracting peripheral blood vessels · inhibiting autoimmune attack against platelets These effects should be expected to be observed within a few days of administering the herbs. In most of the Chinese medical reports, improvement in symptoms (such as spontaneous bleeding and petechia) were observed within about 10 days. Changes in bonemarrow functions and autoimmune processes may require somewhat longer therapy, at least several weeks (typically one to three months treatment time), with increasing effect in responsive patients. The reported changes include higher platelet counts and lower IgG levels. Three groups of active constituents are known to have some hemostatic effects and may influence autoimmune processes: · anthraquinones, found in rubia and rumex and also an ingredient of rhubarb root (which has hemostatic effects, but is not included in the ITP formulas) · flavonoids, found in eclipta and agrimony, and also in scute (used to inhibit bleeding but rarely in the ITP formulas) · alkaloids, found in lotus (all plant parts), eclipta, and san-chi The role of essential oils (which usually dilate vessels; some might increase bleeding), triterpenes, and saponins found in several of the herbs remains unknown. One of the most frequently-used herbs in the formulas, raw rehmannia, contains iridoid glycosides that have hemostatic effects (see: Rehmannia). The same active constituents are found in gardenia, which is mentioned in a few of the ITP treatments, as well as in scrophularia and cornus (only rarely mentioned in the ITP formulas). Table 5: Hemostatic Herbs Used for ITP. All of the herbs listed here are reported to shorten bleeding time in laboratory testing.

Common Name Pinyin Agrimony xianhecao Biota tops ceboye Eclipta hanliancao

Botanical Name Active Constituents Agrimonia pilosa; agrimonin (essential oil); agriminolide (flavonoid) Biota orientalis essential oils: juniperic acid, thujone Eclipta prostrata (ecliptine, wedelolactone)

Imperata maogen

Imperata cylindrica triterpenes: simiarenol, fernenol

Lotus node oujie

Nelumbo nucifera alkaloids: nuciferine, liriodenine Rubia cordifolia alizarin, purpurin anthraquinones Rumex spp. anthraquinones: emodin

Rubia qiancaogen Rumex (yangdi; suanmo) San-chi sanqi Sanguisorba diyu

Panax notoginseng dencichine Sanguisorba officinalis saponins: sanguisorbin

Comments Agrimonin has been developed into a hemostatic drug in China, but pharmacology studies give conflicting results. The clinical effectiveness is not confirmed. Biota leaves are frequently used (applied topically and taken internally) to treat alopecia, which is thought to involve an autoimmune disorder. Though classified as a yin tonic, it is often used to control bleeding. The flavonoids may reduce capillary permeability. The triterpenes reduce inflammation; there may be flavonoids in the flower that reduce capillary permeability. The alkaloids shorten bleeding time. The herb extract dilates vessels and shortens bleeding time. Although not frequently mentioned in the Chinese literature, the rumex plants are recommended for bleeding in association with blood stasis. This is the key ingredient in the popular hemostatic remedy Yunnan Baiyao. Sanguisorba is especially used in cases of rectal bleeding.

In development of herbal formulas for ITP, there may be some influence of what has been called the “doctrine of signatures” in selecting some of the herbs. The hallmark of the disease, as seen from the traditional viewpoint without laboratory tests, is the petechia with a red to purple color. Several of the herbs recommended for the treatments also have a red to purple color. Examples are the purple-colored (zi) lithospermum (zicao) and perilla stem (zisugeng), the cinnabar-colored (dan) salvia (danshen) and moutan (mudanpi), and the red-colored (chi or hong) herbs red peony (chishao) and carthamus (honghua). The herb jujube used in the treatments may have been the red one (hongzao), rather than the more common black one (dazao), though the variety was not clearly specified in the literature. Similarly, there is the blood-colored millettia (jixueteng; xue = blood), and the reddish herbs which are noted for their color in their botanical names (Sanguisorba; sangui = blood; Rubia; rubi = red). Isatis leaf, used in some formulas, is the source of the purple dye indigo. The yin-tonic lycium fruit, which is used in some formulas, is a bright-red colored fruit, while the astringent cornus fruit has a purplish color. It is not clear to what extent the red to purple color of the herbs has influenced their selection for treatment of ITP by modern practitioners, but the color of herbs is known to have been a factor in the early development of the Chinese herbal medical system. DOSAGE Information about herb dosage was not available for all the studies, but in many cases doses of herbs used in decoction were given. The description for most of the treatments is use of “heavy dosage” of the individual herbs, with amounts of 9–15 grams per day of each ingredient, sometimes more. Typically, the herbal formulas (or at least, the portion described) would contain 8–10 ingredients, with possible additions (for particular symptoms or disease manifestation) of 1–3 other ingredients. As a result, the decoctions would be made from a minimum of about 100 grams to a maximum of about 150 grams, with 125 grams being typical. In the West, it is common to use dried extracts in place of decoctions; these dosages correspond to about 18–27 grams per day. In most of the reports, the decoctions were divided into two doses per day. It is understood that children receive lower doses, based on their age. In the Pharmacopoeia of China, a dosage schedule relating children’s dosage to adult dosage is presented as follows: Age Dosage Range 1–2 years 1/5–/14 of the dose for adult 2–4 years 1/4–1/3 of the dose for adult 4–6 years 1/3–2/5 of the dose for adult 6–9 years 2/5–1/2 of the dose for adult 9–14 years 1/2–2/3 of the dose for adult 14–18 years 2/3 to full dose for adult A good example of dosing for adults and for children is offered by examining two studies published in 1991, one (7) aimed at treating adults (ages 18–53) and the other (8) aimed at treating children (ages 6 months to 13 years). Both studies involved decoctions that had a basic formula which could be modified for the individual cases. The adult formula was based on tonifying the spleen and kidney yang and was comprised of 12 grams each of psoralea, drynaria, cuscuta, atractylodes, and hoelen; 15 grams of tang-kuei; and 20 grams each of astragalus, codonopsis, and rehmannia. The total dosage of the base formula was 135 grams. Modifications to the formula involved adding from 10–30 grams of one or two herbs, such as agrimony or salvia. For the children’s study, the formula was based on vitalizing blood circulation and the formula was: 15 grams of leonurus; 10 grams each of salvia, red peony, and millettia; and 5 grams of cnidium. The base formula dosage was 50 grams. Modifications involved adding from 1 to 6 herbs, with dosages of 5–15 grams each. In this case, the dosage was about one-third the adult dosage, which corresponds to the Pharmacopoeia dosing for ages 2–6

years of age. These two formulas also illustrate a difference in therapeutic approach; the young children generally suffer from the early stage of an acute ITP which is treated here by the principle of invigorating blood circulation while the older patients, many of whom suffered the disease chronically and therefore suffer the effects of the persistent disease and the medical treatments (including steroids used before) were treated with herbs that tonify the liver, kidney, and spleen. In one study (5) of acute ITP (treatment time 10 days), a very large dose of agrimony root (whole herb is more commonly used) is given. The dosing of this ingredient in decoction form is described as follows: 100 grams for adults, 50 grams for 7–12 years, 30 grams for 5–6 years, 20 grams for 2–4 years, 10 grams for infants. In two of the ITP reports (and the one report on IMBPAD), pills and tablets were used rather than decoctions. The pills for ITP were made from powdered herbs, consumed in the amount of 5 grams each time, twice daily; the tablets for ITP were poorly described; they contained 380 mg per tablet, with a dosage of 12–18 tablets per day, for a daily intake of about 5–7 grams per day. It is common practice to use about 5–10 times as much herb to make a decoction as to make a pill when treating the same disorder, so these dosages fit the usual pattern. For IMBPAD, the dosages reported for the tablets corresponded to 12–29 grams per day of crude herbs, but the processing to yield the tableted material was not specified. The limited reporting of using non-decoction forms such as these makes it difficult to know if they are as effective as the high dosage decoctions.

REFERENCES 1.

Huang Zhengqiao, et al., Study on the relationship between TCM differentiation of primary thrombocytopenic purpura and immunology, Journal of Traditional Chinese Medicine 1991; 32(10): 607–609. 2. Zhou Yongming, et al., Clinical observation on the principle of strengthening spleen, tonifying kidney, and purging fire for primary thrombocytopenic purpura, Shanghai Journal of Traditional Chinese Medicine 1991; (3): 1–3. 3. Huang Zhengziao, et al., Clinical study on initial thrombocytopenic purpura, China Journal of Traditional Chinese Medicine and Pharmacy, 1993; 8(2): 11–14. 4. Zeng Fanchang, et al., Clinical study of Zhinu-1 and Zhinu-2 in treating 61 patients with ITP , Chinese Journal of Integrated Chinese and Western Medicine 1996; 16(4): 207–209. 5. Fruehauf H, The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 ITM, Portland, OR. 6. Han Weigang and Qi Rongfang, 27 cases of primary thrombocytopenic purpura treated by traditional Chinese medicine, Gansu Journal of Traditional Chinese Medicine 1995; 8(4): 11–12. 7. Gao Xiang, et al., Treatment of chronic primary thrombocytopenic purpura with Chinese herbs , Journal of Traditional Chinese Medicine 1991; 32(3): 24. 8. Cui Shuzhen, et al., Treatment of infant persistent thrombocytopenic purpura with Chinese herbs, Jilin Journal of Traditional Chinese Medicine 1991; (3): 25. 9. Peng Xiang, et al., Treatment of 24 cases of primary thrombocytopenic purpura with Shenqi Sanhuang Tang , Journal of Norman Bethune University of Medical Sciences 1989; 15(5): 538–539. 10. He Guoxing and Wang Xiuhua, Treatment of 52 patients with thrombocytopenic purpura with Bushen Shenxue Tang , Shanxi Journal of Traditional Chinese Medicine 1991; 7(6): 23–24. 11. Zhang Gaochen and Mao Yuwen, Treatment of thrombocytopenia with Weixueling Gao , Jiangsu Journal of Traditional Chinese Medicine 1985; 6(7): 312–313, 315. 12. Li Zhiyuan, Treatment of 23 cases of primary thrombocytopenic purpura mainly by warming and tonifying the spleen and kidney , Hubei Journal of Traditional Chinese Medicine 1987; (3): 24–25. 13. Duan Yu, et al., Treatment of primary thrombocytopenic purpura by modified Minor Decoction of Bupleurum, Journal of Traditional Chinese Medicine 1995; 13(2): 96–98. 14. Xiang Renpu, Treatment of 26 cases of primary thrombopenic purpura by tonifying the kidney and activating the blood , Zhejiang Journal of Traditional Chinese Medicine 1988; 23(2): 79. 15. San Weisheng and Ren Qifang, Chronic idiopathic thrombocytopenic purpura: 46 cases with differentiation of symptom-sign complex, Journal of the American College of Traditional Chinese Medicine 1983; (2): 25–29. 16. Yang Jingming, et al., Invigorating qi and promoting blood circulation in the treatment of chronic idiopathic thrompocytopenic purpura, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(1): 12–14. 17. Shen Di, et al., Clinical observation on effect of Xiaoyu Zhixue Tablet on 104 patients with idiopathic multifocal bleeding and platelet aggregation defect, Chinese Journal of Integrated Traditional and Western Medicine, 1998; 4(4): 247–250. May 2000

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THE USE OF JIANPILING IN TREATING ULCERATIVE COLITIS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Background: Ulcerative Colitis and Crohn's Disease Ulcerative colitis and Crohn's Disease are chronic inflammatory diseases of the intestines that may have similar causes. Crohn's disease produces the main ulcerative sites in the ileum, especially in young people, while ulcerative colitis is mainly confined to the rectal area. Both diseases may cause abdominal pain and diarrhea, but Crohn's is more often characterized by spasms and loss of appetite, while ulcerative colitis is more often characterized by bloody diarrhea. Ulcerative colitis occurs about ten times more frequently than Crohn's, and is, for that reason, more often the subject of clinical study. The causes are not firmly established, but may include chronic infection, allergy responses, autoimmune disease, and genetic predisposition; the condition worsening with emotional stress and poor dietary habits. Western medical treatments usually focus on steroidal drugs to reduce the inflammation. In severe cases, intestinal portions that are unremittingly inflamed may be surgically removed. It has been noted that nicotine controls ulcerative colitis (the disease flares up when a smoker quits using tobacco), and it has been suggested, though not proven, that the new and safer nicotine delivery systems, such as nicotine patch or nicotine chewing gum, may help manage the disease. In Chinese medical terms, most ulcerative intestinal disease is classified as spleen deficiency type, because it is believed that the spleen qi is necessary to maintain the health of the intestines. During the Yuan Dynasty, Li Gao developed the "stomach/spleen" school, treating most diseases by administering herbs benefiting these organs. One of his most lasting contributions to Chinese medicine was the prescription Ginseng and Astragalus Combination (Buzhong Yiqi Tang; literally: decoction to tonify the center and regulate the qi), which forms the basis for the majority of therapies for ulcerative colitis and Crohn's disease. The most extensively studied version of this basic formula is the prescription called Jianpiling.

A Proven Formula: Jianpiling Jianpiling (literally: the effective remedy for supporting the function of the spleen), is a modern prescription for treatment of ulcerative colitis. Its ingredients are: Astragalus Astragalus membranaceous) Codonopsis (Codonopsis pilosula) Atractylodes (Atractylodes macrocephala) Tang-kuei (Angelica sinensis) Ginger, roasted (Zingiberis officinalis) Licorice (Glycyrrhiza uralensis) Peony (Paeonia lactiflora) Saussurea (Jurinea souliei) Mume (Prunus mume) Catechu (Acacia catechu) Corydalis (Corydalis bulbosa) It is prepared as a tablet. The herbs are decocted, dried, and made into tablets of about 0.5 grams each, equivalent to 0.75 grams of crude dried herbs. The formula is a slightly modified version of Ginseng and Astragalus Combination, with codonopsis replacing ginseng (as is standard practice for virtually all such prescriptions in modern China); the first six ingredients are from the original formulation, with roasted ginger replacing fresh ginger, as is often done when there is diarrhea as a symptom. There are added ingredients for treating diarrhea (peony, saussurea, mume), pain (corydalis), and bleeding (catechu). These ingredients replace four items in the original prescription: bupleurum and cimicifuga for raising qi, citrus for drying dampness, and tang-kuei for nourishing blood. The dosages of the Jianpiling ingredients were indicated in a 1991 report (7), with equal amounts of each ingredient, except 2/3 as much saussurea and 1/3 as much licorice as the other ingredients. After the first report of the use of this formula, two additional ingredients, rubus (Rubus parvifolius) and coptis (Coptis chinensis), that were included the first time, were no longer mentioned. The designer and principle researcher of this formulation is Chen Zhishui, at the Department of Traditional Chinese Medicine, No. 211 Hospital of the Chinese People's Liberation Army (PLA). He reported in 1987 (1, 2, 3) that 60 patients were treated by this formula in tablet form for 40-60 days. He claimed that by endoscopic examination 2/3 of the cases were cured, and nearly all others showed some degree of clinical improvement (only 2 cases failing to show positive response). The dosage given was 8 tablets three times daily (total 24 tablets per day), for a total dosage of 12 grams of herb materials per day, derived from 18 grams of crude materials. A control group of 26 patients was treated with salicylazosulfapyridine at 1 gram, four times per day, and some patients received other drugs (e.g., diphenoxylate and other spasmolytics). In the control group, 8 patients were reported cured (about one-third the group), while the others showed some degree of improvement (except 3 cases failing to show positive response). Additional testing, including erythrocyte count, hemoglobin, serum albumin, D-xylose excretion rate, and cellular immunity (E-rosette formation rate, lymphocyte transformation rate, etc.), were said to reveal that the Chinese herb group benefited significantly but the control group did not. Further, the one year recurrence rate for those treated by Jianpiling was 10% while for the drug group it was 57%. There was a third group of 31 cases treated by herbal decoctions prescribed according to traditional means, and their results were intermediate between the drug and Jianpiling groups. In a laboratory study of the effects of the formula on rabbit small intestine, the formula, applied in the form of a decoction, apparently inhibited peristalsis, antagonized stimulation by acetylcholine and barium chloride (preventing tonic seizure), directly inhibited smooth muscle contraction, and had transient antagonism to epinephrine (4).

In a follow-up study reported in 1989 (5, 6), 268 patients (176 with chronic colitis, 92 with atypical ulcerative colitis) were treated with the same protocol. It was reported that 170 were cured (63%) and that almost all others showed some degree of improvement (only 4 cases not responding favorably). D-xylose testing suggested that there was enhanced small intestine functioning in patients who had diarrhea. Another report by Chen in 1991 (7) describes treatment of 596 cases, all diagnosed by colonoscopy. The mean duration of disease was 8.7 years. Of these, 370 cases (62%) were said to be cured (with no relapse during a six month follow-up), and nearly all patients showed some improvement (6 patients failed to respond favorably) by taking Jianpiling. Colonoscopy revealed that congestion, edema, and granule alteration were eliminated in more than 70% of the cases, and erosion, mucus accumulations, and bleeding spots were eliminated in over 90% of the cases. In 1994, Chen (8) reported on a double blind trial of Jianpiling, with 153 cases of intractable ulcerative colitis. A retention enema was added to the protocol, comprised of sophora root and flower (S. flavascentis). One control group received salicylazosulfapyridine (which had previously been shown by Chen to be less effective) and a second control group received a placebo. After three months treatment time, the results were 53% of the Jianpiling group was deemed cured, but only 28% of the sulfapyridine group and only 19% of the placebo group. Although the cure rate was lower than with a more generalized group of colitis sufferers (as had been tested previously), this level for "intractable" colitis is impressive, and the 2:1 efficacy ratio of Jianpiling to sulfapyridine that was found before was replicated. In addition, it was shown that IgG, IgM, and C3 (third complement protein) were elevated in patients at the beginning of the trial and lowered by treatment with Jianpiling. Thus, according to the claims of Chen Zhishui, administration of a modest dosage of herbs for about two months can lead to a cure of colitis (symptoms and signs disappear, colonoscopy reveals normal mucosal membrane) in nearly 2/3 of cases, with a very low rate of recurrence, and in three months it can cure about half of intractable cases. He has stated that there is greater safety, less toxicity, and fewer adverse side-effects when using Jianpiling Tablets than when using drug therapies. These findings should be further evaluated by additional clinical testing, though the research center where Chen Zhishui works reported in 1997 that altogether about 10,000 patients have been treated with this formula (9).

Other Formulations and Differential Approach A similar approach was mentioned in a report from the Shanghai College of Traditional Chinese Medicine, published in the Journal of Traditional Chinese Medicine (1985). A decoction made with codonopsis, atractylodes, hoelen, ginger, saussurea, citrus, fraxinus, and sanguisorba (fraxinus relieves inflammation of the intestines and sanguisorba inhibits intestinal bleeding) was given. For severe cases of the disease, another mixture, made with a decoction of gall (wubeizi) and portulacca (machixian), into which the powder of indigo (qingdai) and sanqi were suspended, was additionally administered as a retention enema. This combination treatment was reported to be effective in 2/3 of the severe cases treated. The use of herb enemas for treatment of intestinal diseases is a common practice in China: in one study, reported in the Beijing Journal of Traditional Chinese Medicine (1991), 93% of 184 patients with ulcerative colitis were reported cured as the result of 40 days treatment with herbs given by rectal infusion alone. In the Journal of Traditional Chinese Medicine (1986), a treatment protocol for chronic colitis began with the division of patients into four categories, all of them involving stomach/spleen deficiency, for which four different formulas were administered accordingly: 1. Stomach/Spleen Deficiency Type: astragalus, codonopsis, atractylodes, saussurea, peony, licorice, citrus, bupleurum, cimicifuga, lotus seed, oldenlandia, and pulsatilla. The first six ingredients are in common with Jianpiling, and the citrus, bupleurum, and cimicifuga are ingredients of the original Ginseng and Astragalus Combination. Lotus seed is an astringent for diarrhea, and oldenlandia plus pulsatilla treat infection. 2. Deficiency Complicated by Cold: the same formula as above, but add the warming herbs aconite and ginger, delete the cooling herb bupleurum. 3. Deficiency Complicated by Damp Heat: astragalus, lotus seed, bupleurum, chih-shih, peony, coptis, pulsatilla, artemisia, sanguisorba. In this case, the base formula is Bupleurum and Chih-shih Formula (Si Ni San), with artemisia and sanguisorba to control bleeding. 4. Qi and Yin Deficiency: astragalus, lotus seed, atractylodes, tang-kuei, rehmannia, ophiopogon, melia, cimicifuga, pulsatilla, artemisia, sanguisorba, and rubia. In this case, tang-kuei, rehmannia, and ophiopogon nourish the yin and blood, while artemisia, sanguisorba, and rubia control bleeding. The formulas were modified for certain symptoms: with incontinence of feces, add schizandra, kaolin, and pomegranate; for mucus in the feces, add pinellia, atractylodes (cangzhu), and bakeri; for sharp pain, add peony and corydalis; for bleeding, use the patent formula Yunnan Pai Yao . For severe cases, a retention enema with hemostatic herbs was used additionally. It was claimed that 84% of patients had notable improvements after using this treatment for three months. In another study relying on modified Ginseng and Astragalus Combination, reported in the Hubei Journal of Traditional Chinese Medicine (1991), 12 patients, some with Crohn's disease and some with other chronic colitis disorders, were treated with a decoction of astragalus, codonopsis, atractylodes, citrus, cimicifuga, bupleurum, licorice, dolichos, and chih-ko for 24 to 120 days. Five patients were cured and there was no recurrence within a follow-up period of six months. In the Jiangxi Journal of Traditional Chinese Medicine (1985) a variation of Pinellia Combination (Banxia Xiexin Tang) was mentioned as a treatment for chronic colitis. The ingredients were pinellia, coptis, scute, ginger, ginseng, licorice, jujube, pueraria, smilax, oldenlandia, and dandelion. Pueraria is often used in cases where diarrhea is accompanied by intestinal irritation: it is a source of soothing starch and anti-inflammatory flavonoids. Smilax, oldenlandia, and dandelion inhibit infection and inflammation. Twelve of fifteen patients were reported cured by this method, using a one to four month treatment time. In the Compendium of Secret Chinese Traditional Formulas, several studies relying on spleen-tonifying methods are mentioned under the heading ulcerative colitis. Among the main formulas are: Bupi Tongyong Fang: astragalus, codonopsis, atractylodes, licorice, saussurea, dioscorea, hoelen, crataegus, and cardamon.

Manxing Jie Changyan Fang: codonopsis, atractylodes, lotus seed, hoelen, plantago seed, purslane, malt, and oryza. Bao Yuan Zhong Ji: astragalus, codonopsis, atractylodes (cangzhu), licorice, bletilla, agastache, zanthoxylum, cinnamon bark, sanqi, and terminallia. Jianpi Lizhong Fang: astragalus, codonopsis, atractylodes, ginger, peony, tang-kuei, corydalis, chih-shih, catechu ( ercha), cinnamon bark, mume, rubus, and cimicifuga. These prescriptions were given to nearly 300 patients, and 77% were rated as cured. Treatment time was typically three months, though some patients were able to discontinue treatment before then due to good therapeutic results and some patients required four months of therapy. Sanqi vitalizes blood circulation and stops bleeding and it also has qi and blood nourishing actions. It is one of the main ingredients of Yunnan Pai Yao, and it has been used successfully in treating ulcerative colitis in combination with pearl powder, as reported in the Chinese Journal of Integrated Traditional and Western Medicine (1990). The effects of such Chinese formulas given for a few months is usually lasting. In a study reported in Henan Traditional Chinese Medicine (1987), 21 cases of chronic ulcerative colitis were treated with a decoction taken orally (including codonopsis, atractylodes, raw rehmannia, tang-kuei, cnidium, red peony, and licorice) and a retention enema made with borneol, borax, sanqi, and other herbs. 21 of the 31 patients so treated were cured, and followup of the cured cases 30 months later showed no relapse. Chinese medical texts rarely differentiate Crohn's disease, ulcerative colitis, or other chronic inflammatory intestinal disorders. In the book Clinic of Traditional Chinese Medicine, in the section on non-specific chronic colitis, several approaches to treatment are mentioned. Under the heading of treating spleen/stomach deficiency, the symptom picture presented is quite similar to that for Crohn's disease, and the formula recommended is a modification of the Ginseng and Atractylodes Combination. In the book Formulas and Strategies, three formulas, Zhen Ren Yang Zang Tang , Tao Hua Tang , and Jian Pi Wan are each recommended for ulcerative colitis, Crohn's disease, and chronic dysentery. These formulas all warm the stomach and spleen; the first two intensely astringe the intestines and the latter stops diarrhea by removing food stagnation and accumulated fluids in the intestinal tract.

References 1. Chen Zhishui, Treatment of 60 cases of chronic ulcerative colitis with Jianpiling Tablet, Shanghai Journal of Traditional Chinese Medicine 1987; (5): 21-22. 2. Chen Zhishui, et al., Treatment of 60 cases of chronic ulcerative colitis with Jianpiling Tablet, Journal of Traditional Chinese Medicine 1987; 28 (10):748-750. 3. Chen Zhishui, A clinical study on Jianpiling Tablet in treatment of chronic ulcerative colitis, International Conference on Traditional Chinese Medicine and Pharmacology Proceedings, 1987 China Academic Publishers, Shanghai. 4. Chen Zhishui, Jia Danbing, and Zhang Zhiqing, Inhibitory effect of Jianpiling Decoction on isolated rabbit small intestine, Liaoning Journal of Traditional Chinese Medicine 1988; 12 (11): 36-37. 5. Chen Zhishui and Jia Danbing, Treatment of diarrhea due to spleen deficiency with Jianpiling, Chinese Journal of Integrated Traditional and Western Medicine 1989; 9(6):345-347. 6. Chen Zhishui, Gao Ping, and Wei Jianjun, Clinical and pharmacological effects of Jianpiling Tablet, Chinese Traditional and Herbal Drugs 1989; 20(1): 29-30, 24. 7. Chen Zhishui, et al., 596 cases of chronic colitis treated with Jianpiling Tablet, Shenxi Journal of Traditional Chinese Medicine 1991; 12(9): 406. 8. Chen Zhishui, Nie ZW, and Sun QL, Clinical study in treating intractable ulcerative colitis with traditional Chinese medicine, Journal of Integrated Chinese and Western Medicine 1994; 14(7):400-402. 9. Fu Kezhi, Personal Communication, 1997 ITM China Office, Harbin, China.

May 1997

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TREATMENT OF LEUKEMIA USING INTEGRATED CHINESE AND WESTERN MEDICINE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The Nature of Leukemia Leukemia is the term applied to cancers in which one line of bone marrow stem cells that produce white blood cells (leukocytes, the immune system cells) undergo neoplasia. The transformed cells uncontrollably yield an abnormally large amount of the corresponding white blood cells, mainly in an immature form. Also, by proliferating in numbers, the neoplastic stem cells crowd out the other stems cells in the marrow, so that there are fewer of the red cells and platelets, as well as other lines of white blood cells able to be produced. The destructive aspect of the disease is often manifest first by the lack of these other cell types, producing anemia and spontaneous hemorrhage. Eventually, the internal organs (initially the liver and spleen) swell up with the excess white cells, causing further problems. In addition, the leukemic cells usually have substantially reduced immune functions, leading to high incidence of infections (1). Different types of leukemia are identified by the stem cell line involved. There are two major categories: lymphocytic and myelogenous; the latter is sometimes divided into myelocytic, monocytic, and granulocytic leukemias, depending on the analysis used. Two somewhat similar bone marrow diseases are polycythemia (with excessive production of red blood cells) and thrombocythemia (with excessive production of platelets). Depending on the severity with which the leukemia manifests, it may be classified as acute or chronic; despite these names, acute leukemia does not have the meaning of a self-limiting temporary disease: without treatment it can be fatal within 2-4 months. Generally, acute leukemia is characterized by very large numbers of immature lymphocytes (known as lymphoblasts) or large numbers of myeloblasts (the "blasts" are immature cells; this leukemic condition is sometimes called myeloblastic leukemia). Chronic leukemias can flare up with an acute phase, producing a huge production of blast cells, yielding a "blast crisis" that is often the fatal phase of the disease. It is common practice to label the leukemias by initials for easy reference: ALL (acute lymphocytic leukemia), CLL (chronic lymphocytic leukemia), AML (acute myelocytic or myeloblastic leukemia), and CML (chronic myelocytic leukemia). The leukemias are further subdivided according to the patterns of cells seen by microscopic examination of the blood, revealing different cell sizes, degrees of maturation of the cells, cell surface markers (especially immunological components), and proportions of different cell types. These divisions may be of importance, in that the treatment strategies can vary according to the observed condition; the results of these tests can also help the oncologist advise the patient regarding prognosis. The possible causes of leukemia include exposure to ionizing radiation, exposure to some chemicals (benzene is an established example), and the action of viruses (e.g., HTLV, human T-cell leukemia virus, a type of retrovirus). Genetic factors play a role in susceptibility, especially for the childhood leukemias. Except for the possibility of attempting an antiviral treatment for virus-induced leukemias, the causes of the disease do not shed much light on the treatment to be given. Even in the case of a viral causation, if suppression or elimination of the virus could be accomplished, that might not cure the disease; the cellular transformation that occurred may no longer reversible. Some cases of chronic leukemia, notably CLL, are sufficiently innocuous that they are left without treatment for a time because the degree of imbalance in blood cell production is within tolerable limits; in most other cases, anticancer drugs are used in an effort to slow its progress. Some new techniques of treating leukemia have been developed, include destroying the cancerous bone marrow (thus eliminating the neoplastic cells) and transplanting healthy bone marrow (grown in the laboratory from donated marrow cells). Substantial success has been attained in treating acute childhood leukemia, especially ALL, which was, until recently, a major cause of childhood deaths (with peak incidence around 4 years of age). This positive outcome may be the result of two factors: in acute leukemia, the chemotherapeutic drugs have a much stronger effect on the highly active abnormal cells than on the normal cells; and in children the ability to recover normality is better than in older persons. Up to 90% of cases of childhood acute lymphocytic leukemia go into remission with treatment, with about 70% of treated cases gaining long-term survival (2). AML tends to strike in the age range of 15-39 years and has a moderately good response to treatment by bone marrow transplant, though long-term outcomes are not yet known. Cases of chronic leukemia are poorly managed by modern chemotherapy: the disabling effects of the therapy on the entire physiological function are often as strong as they are on the cancerous cells. Often, the individual must undergo multiple types of interventions, including blood transfusions, antibiotics, and other "supportive therapies." Progress towards a cure has been difficult. The age of diagnosis for chronic leukemia is typically between 40 and 60 years. Without treatment, chronic leukemia patients are expected to live for 2-6 years from onset of the disease; CML tends to progress more rapidly than CLL. However, about half of the patients with chronic leukemia die within two years of their diagnosis even with treatment. Slightly increased survival time after diagnosis in recent years may be the result of earlier detection more so than successful treatment. Busulfan (a.k.a. Myleran), a drug that has been frequently used for one type of chronic leukemia (granulocytic), commonly produces mean survival times of about 3-4 years. For leukemia in adults, it is reasonable to pursue Chinese medical therapies in an attempt to improve the outcomes.

Chinese Medical Approaches The ability to diagnose leukemia, which requires assay of blood cells, came to China with Western medicine, and was attained there about 60 years ago. Prior to that, leukemia patients must have presented a difficult challenge to traditional practitioners. A patient might show severe anemia and easy tendency to bleed, the results of insufficient production of red blood cells and platelets. The high metabolism of the leukemic cells caused fever and fatigue. The patient might show swelling of internal organs as they are impacted by the large numbers of circulating white blood cells. The disorder would thus appear as a complex combination of deficiency and excess. The primary disease, buried in the bone marrow, might not have been easy to trace.

Along with Western diagnostics came the limited methods of therapy then available in the West; these included toxic treatments with arsenic compounds and, later, the introduction of some chemical agents, such as busulfan, which was, until recently, the standard treatment for myelogenous leukemia (it is of no value in other leukemias). The Western drugs that have been used for leukemia (including hydroxyurea, chlorambucil, and prednisone) appear in the modern Chinese medical literature as treatments given to control groups when evaluating Chinese therapies or used in integrated therapies. Once the efforts of traditional Chinese doctors were turned to the problem of treating leukemia, it did not take long for certain antileukemic remedies to arise. According to Chang Zhinan of the Hematology Division of Capital Hospital in Beijing (3), leukemia (of modern diagnosis) has been subjected to various attempts at using Chinese materia medica items since about 1953. He reported that herbs have been applied for four purposes: reducing complications of leukemia, such as bleeding and infection; reducing adverse reactions to chemotherapy or increasing resistance of the body to adverse impact of leukemia; promoting the body's natural healing ability to reduce the impact and spread of the neoplastic process; and eradicating the leukemia cells. Today, there are basically three treatment methods: inhibit leukemia cells; promote the body function and protect it from leukemia and side effects of toxic treatments; and treat specific symptoms. These three will be analyzed below.

1. Inhibiting leukemia cells. The primary traditional Materia Medica items for inhibiting leukemic cells have been indigo (qingdai) and realgar (xionghuang). Indigo is the purple dye obtained from certain plants, mainly Isatis tinctoria and Baphicacanthus cusia, but also from other Isatis species and from certain species of Clerodendron and Polygonum. This variability in source means that the market products can also have variable constituents and effects. The principal active constituent of indigo, in relation to leukemia, is indirubin, which was isolated and experimented with first by Western scientists and later investigated by Chinese researchers. Indirubin is a substance found in humans as well as in plants, possibly a metabolite of tryptophan. Indirubin levels in the urine are found to be increased in persons with various pathological conditions, including sprue, disturbed protein metabolism, renal diseases, myelocytic leukemia and other neoplasms (4). Isolated indirubin is a drug product used in China. It is given in tablet form in dosages of just 150-200 mg each time (some patients receive a double dose), three times daily, for treatment of chronic granulocytic leukemia. It is reported that indirubin has better therapeutic effects, faster onset of effects, lower dosage requirements, and milder side effects than indigo. Side effects of indigo include abdominal pain, diarrhea, nausea, vomiting, and mushy stool. Almost all of these effects appear to be the consequence of an irritant action of the crude material and are dose dependent, though sensitivity to the irritant action varies widely among individuals. While indirubin has a good effect on chronic granulocytic leukemia (this is the same type of leukemia that busulfan treats), it has a lesser effect on the non-granulocytic myelogenous leukemia and is not known to be effective for lymphocytic leukemia. Like other chemotherapeutic agents, indirubin has general bone-marrow suppressing action, but it is less than some antileukemia drugs, including busulfan. Indirubin is not available in the West. However, Chinese immigrants to the U.S. have prescribed indigo (qingdai) in capsules to Western patients with leukemia who visit them. This herbal extract is not especially toxic, but, as mentioned above, it does easily produce gastric irritation that can limit the dosage to ineffective levels in some individuals. According to the author of Anticancer Medicinal Herbs (5) "Indigo really has an anticancer effect. The daily dose is 2-4 grams usually, but sometimes can be increased to 6-10 grams." Realgar is a mineral compound that is mainly arsenic sulfide with some impurities. Arsenic inhibits leukemic cells. The use of arsenic in medicine was not limited to the Chinese, who have used it since ancient times to "cure debility and impotence and disperse accumulations." A drug dubbed "the first wonder drug of the twentieth century (6)," was Salvarsan, an arsenic compound that was found effective for treating syphilis (a disease previously treated by mercury compounds). Arsenic compounds are also used in Ayurvedic medicine. Realgar is listed in the modern Chinese Pharmacopoeia and is suggested to be used by making pills or powders, taken at a dosage of 150-300 mg each time, avoiding long-term administration. Realgar is sufficiently toxic that its use by Western practitioners is all but precluded; in fact, concerns for heavy metal contamination of Chinese herbs, especially with arsenic and mercury (mainly from realgar and cinnabar, included in many formulas) are so great that it would probably cause significant legal problems if someone were to knowingly prescribe this as a medicinal agent. Other anticancer materials that the Chinese have used for leukemia include strychnos, camptotheca, cephalotaxus, celastrus, catharanthus, and toad secretion. These are all somewhat toxic and not used by Western practitioners. Cephalotaxus is related to the yew tree that yields the modern anticancer drug taxol; cephalotaxus has yielded the antileukemia drug harringtonine, which is extensively used in China, but not in the U.S. It is a treatment for acute monocytic leukemia (a type of AML). Camptotheca has been intensively studied in both the U.S. and China and yields the drug hydroxycamptothecin (used for acute myelocytic and lymphocytic leukemias), also not approved in the U.S. Strychnos, which contains strychnine, has anticancer properties but is not licensed for use here (it is an ingredient of the Chinese formula Ping Xiao Dan, used for many types of cancer). Celastrus contains dibromodulcitol, which is used to treat chronic granulocytic leukemia (same application as indigo). Catharanthus is the source of the standard chemotherapeutic agents vinblastine and leurocristine; these are used in treatment of ALL and AML. Toad secretion contains bufotoxin, which is highly irritating and not permitted for use in the U.S. (one case of bufotoxin fatal poisoning was recorded in the U.S. recently when an herbalist accidentally filled a prescription incorrectly and substituted this item, it was present at a dosage much higher than would normally be used). Toad secretion also contains bufotenine, a compound similar in structure to indirubin. A well-known, but somewhat toxic patent medicine, Liu Shen Wan, is sometimes recommended by Chinese doctors for leukemia: it includes toad secretion and realgar. A toad secretion prescription, originally applied topically for treatment of lip cancer, was later used to treat ALL, with some success. It also includes realgar, as well as other toxic materials, such as cinnabar and calomel (both contain mercury). These Chinese leukemia remedies have the same function as modern pharmacological interventions that we call chemotherapy. In fact, Chinese chemotherapy is sometimes simply derived from herbal active constituents, including harringtonine, indirubin, and hydroxycamptothecin. The purpose is to inhibit the abnormal bone marrow cells, so as to permit the growth and function of the normal cells. In China, there are more of these drugs available than in the U.S. as the result of fewer restrictions on drug licensing.

Anti-CML Pill The discovery that indigo was clinically effective for leukemia was made in the early 1960's, when researchers at the Institute of Hematology, Chinese Academy of Sciences (Beijing) noted that an herbal formula prescribed by Chinese doctors appeared to be producing good results in many patients. The formula, Danggui Luhui Wan, included indigo as an ingredient and had prominent action in cases of chronic myelocytic leukemia (CML). The formula also contains tang-kuei, gentiana, coptis, phellodendron, scute, rhubarb, aloe, saussurea, and musk, and was traditionally used for reducing fever, purging intense heat, and removing toxin. A modified version of the traditional formula, which includes both indigo and realgar, was developed at this Institute, and reported to be even more effective than the original: it was called the anti-CML pill. It contains indigo, realgar, ranunculus, sophora, scute, phellodendron, tang-kuei, terminalia, leech, and eupolyphaga. The basis for adding realgar to the indigo was that potassium arsenite, a related compound, had previously been used for treating CML by Western-style practitioners (in the 1940s), but had been abandoned due to toxicity problems. The lower toxicity of realgar may be due solely to differences in rates of absorption from the intestinal tract. Realgar was substituted for potassium arsenite and reported effective in 1960 by a hospital in Shanghai. It was found in one small study in 1970 that complete remission could be attained in some leukemia patients by administering 9-18 grams of realgar per day (by decocting it, where only a fraction is solubilized; usual dosages of orally ingested powder are less than 2 grams per day). The adverse effects were less than those of potassium arsenite. Another toxic arsenic compound formula, made with arsenic oxide, was reported by a group in Harbin to be reasonably effective for acute myelocytic leukemia. According to the author of Anticancer Medicinal Plants, realgar is also single remedy for chronic granulocytic leukemia, taken at a dose of 0.3-0.9 grams each time, one or two times daily. Indigo had been tested as a single herb remedy for CML in the 1970s. A dose of 6-12 grams per day was reported to achieve complete or partial remission. The remission rate increased when realgar was added as 11% of the formula (for example: 1 gram realgar mixed with 8 grams indigo). Recent treatments in China continued to rely on the crude material for some time, even though indirubin is available. As an example, Qinghuang Powder, prescribed at the Xiyuan Hospital for treating chronic granulocytic leukemia, is made of a 9:1 ratio of indigo and realgar, given in capsule form, with a daily dosage of 6-14 grams, divided into three doses; a maintenance dosage, after improvement is attained, is 3-6 grams per day. The anti-CML pill is reported, by the group that worked with it, to be more effective than indigo-realgar treatment alone. The reason for this is not yet established. Other ingredients in the pill include sophora root (which contains the anticancer ingredient matrine) and tang-kuei, which may serve in a protective role. Arsenic levels of patients taking this pill were monitored by urine analysis. Chronic arsenic intoxication produces changes in the skin, with pruritis, skin pigmentation, and keratodermia, and it may cause mild peripheral neuritis. If such occurred, arsenic was cleared from the system using sodium dimercaptopropan sulfonate or sodium dimercaptosuccinate. By simply stopping the use of the anti-CML pill, urinary excretion of arsenic would reduce over a period of 1-6 months. The researchers working with the anti-CML pill felt that the problem of arsenic toxicity was manageable. In the U.S., the only one of the specific anti-leukemic substances that can be reasonably prescribed is indigo (qingdai) . When Chinese immigrant doctors have prescribed encapsulated indigo to their patients it is usually administered at doses far lower than the 612 grams reported above (typical amounts are 1-3 grams).

Patient Improvements with Treatment Remission rates described in the clinical reports from China may be easily misinterpreted. A remission in the case of leukemia means that there is a dramatic reduction in the levels of the affected white cell line, accompanied by improvements in the impaired cell lines and in symptoms. Complete remission means normalization of the blood picture, while partial remission means improvement without attaining normal condition of blood cells. However, some time after this remission has been observed, the disease usually recurs. For example, in a study of bufotoxin treatment of acute leukemia, it was reported that partial remission was attained in 50% of patients and full remission was attained in 25% of patients. The longest remission period was 6 years. In a study of 6 patients treated with realgar plus indigo, it was reported that complete remissions occurred in 3 patients; and 2 of those patients lived more than four years. Remission usually results in a period of a few months or years free of the cancer; when the leukemic condition returns, one must start treatment again, usually in the midst of a blast crisis. Producing a remission and then extending the remission period is the goal of current treatments. In one study comparing busulfan with alternating busulfan and anti-CML pill, mean survival time was reportedly increased from 40 months to 61 months. The same results were reported in another comparative trial with busulfan alone versus alternating treatment with busulfan and an herbal pill, similar to the anti-CML pill, called Manli Wan (composed of ranunculus, sophora, scute, phellodendron, tang-kuei, terminalia, indigo, eupolyphaga, and leech). These alternating strategies are deemed interesting to Western-trained Chinese doctors because the busulfan is so toxic. In a long-term study of indirubin treatment for CML, it was reported that "maintenance therapy [with indirubin] was necessary for CML patients after achieving complete remission and there was no obvious side effects over long-term administration of the drug. Unfortunately, indirubin could not suspend or postpone development of blastic crisis (7)." Median survival time in this study of 57 cases of CML treated with the simple protocol of indirubin administration was 31.5 months. Put simply, remission of leukemia is usually a temporary condition. Improvement in the quality of life of patients is also a major factor, despite any changes in blood picture or duration of life. The proponents of Chinese medicine suggest that rates of complete and partial remission and quality of life are improved by using Chinese medicine, but the duration of survival may increase only slightly (by a few months), if at all. About 20% of chronic leukemia patients can attain survival times of 10 years or more.

2. Complementary medical approach Chinese doctors have worked out strategies of complementing the basic anti-leukemic approach, whether the modern chemotherapy or the traditional style (e.g., realgar and indigo) are used. These complementary approaches often involve non-toxic herbs that could be prescribed by practitioners in the West; but there are also toxic substances mentioned in the literature for this purpose. For example, in the book Anticancer Medicinal Herbs, it is reported that the toxic insect mylabris, when accompanied by chemotherapy, can control leukopenia in patients with leukemia. Since a major problem with mylabris is its irritant effect, the Chinese pharmaceutical factories

have added mung bean flour to the preparation of tablets, which protects the gastro-intestinal tract from irritation. In the book Treatment of Cancer with Fu Zheng Pei Ben Principle (8), this is said: Leukemia is a disease of constitutional dimensions and, as such, its treatment should be comprehensive: eliminate and inhibit the hyperplastic leukemia cells, and at the same time protect the integrity of the normal tissues. The crucial point when treating this disease is a comprehensive therapeutic approach which can deal properly with the delicate relationship between dispelling pathogenic factors, while restoring normal functions of the body....A very large number of clinic experiences and recordings show conclusively that a course of treatment combining the principles of TCM and western medicine is always better than either one applied alone. Effectiveness of chemotherapy can be greatly enhanced when supplemented by TCM based on principles of syndrome differentiation. The regulatory and stabilizing effect of TCM administered during respite between chemotherapy cycles helps maintain the efficacy of the original treatment and prolongs the period of remission. A sample treatment for acute leukemia (AML) presented in this book is a modified Rhino and Rehmannia Decoction (Xijiao Dihuang Tang ), which includes raw rehmannia, moutan, rhino horn (substituted by water buffalo horn), lithospermum, lonicera, isatis leaf, indigo (12 grams), scrophularia, gypsum, and lycium bark to clear heat and toxin, with turtle, tortoise shell, and pseudostellaria to nourish yin. It also contains some blood-vitalizing herbs (red peony, agrimony, and carthamus). This treatment is to be applied to cases of high fever and sweating, spontaneous bleeding, and other symptoms that are characteristic of uncontrolled leukemia. The ingredients can be understood in terms of presenting symptoms: lithospermum, raw, rehmannia, and rhino horn, for example, are used for high fever and spontaneous bleeding; turtle shell and tortoise shell not only nourish the blood and yin, but also prevent hemorrhage. The anti-leukemic substance, indigo, is provided in the highest quantity usually recommended. The difficulty with this approach is that the very high dosage decoction (over 200 grams per day) would have an extremely bitter taste and would likely have an irritating and even an inhibiting effect on the digestive system (which is probably already weakened by the disease and prior treatments). Therefore, one would hope to use a different prescription, such as the others offered in that book and described below. A common complaint of leukemia patients is chronic low grade fever and fatigue. This is the combined result of deficient blood status, side effects of cancer therapies, and secondary effects of continuing leukemia (especially the high metabolic status of the white blood cells). A recommended treatment is to use 24 grams of salvia, 20 grams millettia, 20 grams agrimony and 6-15 grams each of the following: ginseng, red peony, tang-kuei, cnidium, persica, astragalus, hoelen, atractylodes, licorice, and pseudostellaria. This formula nourishes qi and blood and vitalizes blood circulation. It is to be used in conjunction with chemotherapy to enhance its effects and alleviate the characteristic symptoms the patient faces. This formulation, although high in dosage, has a tolerable taste and is unlikely to cause gastro-intestinal irritation; to the contrary, it has herbs that may improve the condition of the gastro-intestinal system. Other complementary formulas for leukemia recommended in this book focus more on tonic actions, by combining yin tonics (for those showing more evident signs of yin deficiency) or tonics for the qi and essence (for those showing overall deficiency syndrome). The formulas for leukemia patients do not differ significantly from those that might be used in various types of cancers in which the patient is receiving chemotherapy. That is, the fact that leukemia is being treated does not strongly influence the selection of herbs or formulations. The patient ought to be evaluated for evidence of the common problems of blood stasis, yin deficiency, qi deficiency, essence deficiency, organ swelling, etc., and treated accordingly. In each case, a total daily dosage of about 200 grams is recommended in this book. These dosages are impractical for American patients, who are not used to taking such decoctions. Even when using dried decoctions, a total daily dosage of 30 grams of the powders (corresponding to about 150 grams of crude herbs in decoction) is usually deemed too much. However, a lower total dosage might be successfully used if a smaller number of herbs are selected and if they closely match the Oriental diagnosis of patient requirements. In some of the Chinese reports on treating leukemia patients, general anticancer herbs that are non-toxic or of low toxicity, such as scutellaria, oldenlandia, solanum (lyratum or nigrum), and paris, are included in the formulas. It is not known at this time whether these have a specific antileukemic effect.

3. Treating specific symptoms of leukemia Chinese physicians apply herbs according to traditional principles to treat certain characteristic symptoms of leukemia. These include (9): 1. Anemia: treated with herbs that nourish the blood, including marrow-nourishing agents. Examples are tang-kuei, cnidium, peony, rehmannia, lycium fruit, deer antler, epimedium, codonopsis. 2. Hemorrhage: treated with hemostatic herbs. Examples are raw tien-chi ginseng, agrimony, and cirsium. 3. Fever: treated with herbs that cool heat and nourish yin. Examples are raw rehmannia, moutan, scrophularia. 4. Swelling of the liver, spleen, lymph nodes, etc.: treated with herbs that resolve masses. Examples are laminaria, sargassum, oyster shell, curcuma, chih-ko (or other citrus materials), pangolin scales. 5. Ulceration and swelling of the gums, tongue, and oral cavity: treated with herbs that alleviate aphthae, such as fire-purging agents. Examples are coptis, gardenia, raw licorice, borneol. 6. Skin eruptions and purple maculae: treated with herbs that promote blood circulation and clean toxins. Examples are red peony, dandelion, carthamus, salvia, lonicera. 7. Aching: treated by herbs that regulate qi and blood and analgesic herbs. Examples are corydalis, pteropus, typha, cyperus, lindera, sandalwood. In each of the cases, these agents are selected according to standard principles of Oriental diagnostics and prescribing, with no special reference to the source of the symptoms as being leukemia. One can see from untreated cases that this disease would be diagnosed as a syndrome involving pathogenic heat in the blood. Such a

condition would help to explain several symptoms, such as fevers, bleeding (and appearance of purple maculae), skin eruptions, and ulceration and swelling in the oral cavity. Not surprisingly, the traditional remedies are often based on formulas for such symptoms that might arise as well from other causes. The Rhino and Rehmannia Combination is one such formula. The traditional formulas can be modified by adding one or more blood tonics to address the anemia, and one or more herbs for dispersing accumulations to treat the organ swelling and accompanying aching. The Danggui Luhui Wan formula, that includes indigo and was at the basis of the anti-CML pill, is an example; it contains saussurea, rhubarb, aloe, and musk to help get rid of accumulations.

Examples of Current Chinese Treatment Strategy for Chronic Leukemia In a recently published clinical trial (13), patients with chronic granulocytic leukemia (a type of CML) were treated with herbs according to syndrome differentiation, mainly in the categories of qi/blood deficiency, liver/kidney deficiency, or blood stasis. Details given were sketchy, but all patients received the anticancer herbs scutellaria, oldenlandia, and lasiosphera (puff-ball mushroom, most often used to treat lung ailments), and the tonic herbs codonopsis and peony, along with herbs that were specific for the syndrome (examples: tangkuei and astragalus for qi/blood deficiency; rehmannia and ophiopogon for liver/kidney deficiency; sparganium and zedoaria for blood stasis). If the pathological condition became serious during the treatment period (or was quite serious at the outset), chemotherapy was also used. Either busulfan or hydroxyurea was given for this purpose. Other herbs or drugs could be given to treat specific symptoms, such as infections, bleeding, or severe anemia. The short term results indicated that after six months of treatment, 69% of patients had complete remission, 25% had partial remission, and only 6% did not respond. Treatment continued beyond six months. The ultimate results of therapy were measured in terms of survival time from initial diagnosis. Of 80 patients, 37 lived less than 3 years, 16 lived 3-4 years, and the remaining 27 patients lived for 5 or more years. The median survival time was 3.8 years. While the remission rates reported in this article are quite good, the survival rates are not significantly better than those reported in the U.S. where indirubin and complementary Chinese herb therapies have not been used. However, it is possible that the clinic was presented with more severe cases of leukemia to treat. In some earlier studies, median survival times of 5 years were reported. In another trial of indirubin plus herbs for chronic granulocytic leukemia (14), patients were treated by indirubin, 50 mg each time, 3 times daily. Herbs given according to syndrome differentiation: 1. Qi Stagnation with Liver/Spleen Enlargement: ching-hao, lycium bark, red peony, moutan, sparganium, zedoaria, salvia, solanum lyratum, oldenlandia, cremastra, turtle shell, tortoise shell, gardenia, chih-ko, rhubarb, licorice (each item, 9-15 grams, except 30 grams oldenlandia). Note that solanum, oldenlandia, and cremastra are general anti-cancer herbs. 2. Qi and Yin Deficiency: pseudostellaria, asparagus, rehmannia, ching-hao, lycium bark, oldenlandia, solanum nigrum, scutellaria, eclipta, lycium fruit, turtle shell, sophora subprostrata, forsythia, lonicera stem, gallus, baked licorice (each item, 9-15 grams, except 30 grams oldenlandia). In this formula, oldenlandia, solanum, scutellaria, and sophora subprostrata are general anti-cancer herbs. Complete remission was attained in 40% of the patients, partial remission in 50%, no benefit in 10%. About 15 days of treatment were required to reduce spleen enlargement, with normalization after about 40 days. Leukocyte levels began to show decline after about 10 days, with 60 days treatment required to get to the normal range in responsive patients. Long-term results were not reported. This study reveals that one can monitor the effectiveness of the treatment by checking leukocyte levels over a two month period.

Recommendations for Western Practitioners Patients with leukemia, especially with chronic leukemia that is the most likely syndrome to be presented to practitioners of Chinese medicine, are often depressed and debilitated when they present themselves for treatment. The depression may result from having a diagnosis of cancer, especially with a poor prognosis, and from any failures up to this point in gaining an adequate resolution. The debility may result from the effects of the disease and/or treatments that have been tried thus far; also, chronic leukemia is usually seen in older individuals, who may experience debility from poor nutritional habits, lack of exercise, and other characteristics common to elderly persons with chronic disease. Leukemia may arise at this time of life from insufficient immune functions, lack of antioxidant activity, and stresses that permit chronic viruses to activate. The first thing a practitioner can do is assure the patient that the poor prognosis of the disease may be improved by nutrition and herbal therapy. Although there are a number of clinical reports from China that describe disease remission (and improved rates of remission compared to using chemotherapy alone), one should be cautious about promising too much from the treatments to be offered. There is reasonable evidence from China that leukemia patients can get symptomatic relief and may have prolonged life span (perhaps 50% longer than that normally expected with standard chemotherapy) by the use of herbs and improved nutrition. Patients should be directed to consult with their oncologist(s) to get a clear picture of the prognosis that is expected with a chemotherapeutic or other intervention that is currently being undertaken or might be pursued. Both the risks and benefits of the chemotherapy course should be weighed. If the prognosis is not very good and the adverse effects are troubling, then one might pursue a course of natural therapies only, with the knowledge that the prognosis (in terms of survival time) is not necessarily improved but the adverse effects of chemotherapy might be avoided. If the prognosis is good, then a combined therapy, using Chinese herbs and nutrition in a supportive role might be a valuable course of action. Some oncologists might even be willing to entertain a program of alternating chemotherapy and herbal therapy for patients who are not open to using the standard chemotherapy. When there has been chemotherapy failure or when there is refusal to use chemotherapy, a treatment similar to the anti-CML pill may be of value for myologenous leukemias. This approach usually relies on the use of indigo as the primary therapy, with various supporting herbs to be included in the treatment, probably in the form of dried decoctions (formula designed by the practitioner), or, if the patient is unwilling to use that method, tableted formulas (in large quantities). A monthly blood draw can be used to monitor the progress of the treatment, along with the standard examination of symptom changes.

Indigo can be provided in capsules, starting at a dose of about 1 gram per day and working up to 6 grams per day, or up to tolerance levels. Once the maximum level has been determined, herbal combinations should likewise be administered starting at a modest dosage and working up to a maximum possible dosage. For example: using decoctions, begin at 30 grams per day; using dried decoctions, start at 6 grams per day, using tableted formulas, start at 9 tablets per day. Let the patient know about the high dosage form of natural materials. The ability to ingest and tolerate large amounts of herbs (and, possibly, nutritional supplements) may be a key to success with this natural approach. It has been reported that indirubin used for an extended period of time may cause pulmonary hypertension and cardiac insufficiency in some patients (10). This effect, which occurred in persons treated for 9 months to 3 years, was slowly reversed when the indirubin was removed. Presumably, this adverse reaction could occur with administration of the higher doses of natural indigo, as it contains indirubin. Therefore, any patients who are to be treated for 9 months or longer should have their cardiac function monitored. While specific nutritional approaches have not been developed for leukemia, certain general methods can be applied: 1. Make sure the individual is receiving adequate basic dietary nutrients, such as proteins, fats (preferably unsaturated), and carbohydrates. Monitor body weight and muscle strength, and take further action if there is not improvement, including recommending easy-to-use concentrated nutrition sources. 2. Provide additional nutrients and a high level of antioxidants using supplements (11). General anticancer substances may be tried, including flavonoids (quercetin, genestein, tea polyphenols), minerals (selenium), and vitamins (high dose vitamins A, C, and E). Even if these fail to produce a cancer-inhibiting action, they may provide other benefits for persons in the age group that suffers from chronic leukemia. 3. When possible, use Oriental dietary techniques to match the dietary components to the symptom/sign pattern (12). For example, use cooling foods for fevers, astringent foods for sweating, yin-nourishing foods for yin deficiency patterns, etc. Make sure the suggestions include using foods that can reasonably be obtained and prepared. The relative deficiency of reports in the Chinese literature regarding treatment of chronic lymphocytic leukemia (CLL) with herbs is mainly due to the fact that CLL is very rare in the Orient, due to genetic factors. Although a few recipes for treatment (based on traditional principles for treating the symptom presentation) have been published, evidence for their effectiveness is lacking because of insufficient case studies. The approach to be taken would be to treat according to the traditional syndrome differentiation, in combination with standard chemotherapy when possible. Chronic granulocytic leukemia appears to be the type of leukemia most intensively investigated, no doubt as a response to early findings of benefit from using traditional Chinese herbal materials coupled with a relatively high frequency of incidence in China. Acute leukemia is always treated with a chemotherapy, with reported improvements attained by adding Chinese herbal therapies.

APPENDIX: Treatment Strategies for Acute Leukemia In the book An Illustrated Guide to Antineoplastic Chinese Herbal Medicine (18), the following formulas for acute leukemias are relayed from the medical literature during the period 1981-1985: Toad Skin Wine: 1.8 kg toad, with viscera discarded, in 1.5 liters wine; dosage of 15-30 ml three times per day after meals, for various kinds of leukemia, especially ALL. An Lu San: made of centipede, scorpion, silkworm, and eupolyphaga (in equal amounts, ground to powder, administer 0.3-1.0 grams each time, three times daily) for all acute leukemias. Anti-leukemic mixture: with lonicera, rhaponticum, scutellaria, dandelion, viola, millettia, cuscuta, salvia, epimedium, coptis, prepared as a decoction 6-10 grams of each herb (except coptis, 3 grams), administer 25 ml each time, twice daily. When acute crisis is relieved, make a pill using deer antler as the main ingredient, plus ginseng, peony, rehmannia, ho-shou-wu, lycium fruit, zizyphus, salvia, epimedium schizandra, tang-kuei, astragalus, sesame oil, carthamus, cnidium, and a small amount of realgar (1.5%). Administer the pill (with about 130 mg herb ingredients) twice daily for maintenance. This treatment is indicated for acute leukemia in children (probably for ALL). Oldenlandia Decoction: with oldenlandia, isatis root, solanum lyratum, trichosanthes fruit, paris, lithospermum, and belamcanda. Each ingredient is 15-30 grams, except belamcanda 9 grams. Used for acute leukemias. Acute Leukemia Decoction: with rehmannia, hoelen, astragalus, oldenlandia, solanum nigrum, sophora subprostrata, lithospermum, dioscorea, cornus, cistanche, morinda, psoralea, ginseng, ophiopogon, schizandra, tang-kuei (each ingredient 10-30 grams, except tangkuei, 6 grams), indicated for non-lymphocytic leukemia, as an adjunct to chemotherapy. Anti-Cancer Formula 7: with oldenlandia (75 grams), solanum nigrum (60 grams), coix (60 grams), san-chi (9 grams), dioscorea bulbifera (6 grams), and mume (6 grams), indicated for acute granulocytic leukemia. Toad Skin and Scutellaria Decoction: with toad skin, scutellaria, isatis root, rhubarb, solanum lyratum, paris, lithospermum, and belamcanda; all ingredients 15-30 grams, except toad skin (9-12 grams, and belamcanda 9 grams). Indicated for acute granulocytic leukemia as a supplement to chemotherapy. In a study of acute leukemia patients (15), 18 cases were treated with Chinese herbs plus chemotherapy and 21 cases were treated with chemotherapy alone. The herbal therapy, in the form of decoction, was comprised mainly of tang-kuei, cnidium, millettia, red peony, carthamus, and san-chi. The treatment group had a higher percentage of cases gaining remission (89% vs. 57%) and a longer mean survival time (13 months vs. 7 months). Another study (16) involved 70 acute leukemia patients divided randomly into two groups, one receiving chemotherapy alone and the other receiving chemotherapy plus herbs in decoction. Those receiving herbs were divided into three groups according to syndrome: 1. Excess heat type: lonicera, forsythia, isatis leaf, dandelion, oldenlandia, scutellaria, sophora subprostrata, isatis root, buffalo horn, scrophularia, rehmannia, red peony, lithospermum, and imperata, all herbs in heavy dosage (15-30 grams); if there was liver spleen enlargement, there was also added 15 grams each of salvia, sparganium, and zedoaria. 2. Qi and yin deficiency type: pseudostellaria, astragalus, atractylodes, lycium fruit, hoelen, polygonatum, asparagus,

ophiopogon, scrophularia, ligustrum, eclipta, dandelion, scutellaria, oldenlandia, and cirsium, all in heavy dosage of 10-30 grams. 3. Qi and blood deficiency type: astragalus, codonopsis, atractylodes, hoelen, tang-kuei, gelatin, lycium fruit, psoralea, hoshou-wu, oldenlandia, cirsium, salvia, and millettia, all in heavy dosage of 15-30 grams. The Western medical treatments were also differentiated according to whether the disease was the acute lymphocytic type, acute non-lymphocytic type, or acute granulocytic type. Of 35 patients in the integrated therapy group, 69% had complete remission and 20% had partial remission, with 11% not improved; of 35 patients in the Western medicine group 43% had complete remission, and 20% had partial remission, with 37% not improved. Survival time was reported to be longer in the integrated group than the partial remission group, but the details in the report were unclear. An article (17) describing treatment of a small number of patients with refractory recurrent acute leukemia, indicated that those who failed to attain remission by chemotherapy alone could sometimes gain benefit from combined therapy with Chinese herbs. Sixteen patients were treated according to syndrome differentiation, all having internal pathogenic heat, with four subtypes: qi and yin deficiency; damp-heat plus blood stasis; phlegm nodules; blood stasis with movable mass. In each case, a decoction was given to address the syndrome. It was reported that 10 of the patients had complete remission, and 2 patients had partial remission as a result of using 1-4 months of therapy, an average of 3 months.

References 1. Robbins SL, Cotran RS, and Kumar V, Pathologic Basis of Disease (3rd Ed.), 1984 W.B. Saunders Company, Philadelphia, PA. 2. Boik J, Cancer and Natural Medicine, 1995 Oregon Medical Press, Princeton, MN. 3. Hson-Mou Chang, et al., Advances in Chinese Medicinal Materials Research, 1985 World Scientific, Singapore. 4. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore. 5. Chang Minyi, Anticancer Medicinal Herbs, 1992 Hunan Science and Technology Publishing House, Changsha. 6. Leake CD, Historical Account of Pharmacology to the Twentieth Century, 1975 Charles C Thomas, Springfield, IL. 7. Qian Linsheng, et al., " Observation on the long period effect of indirubin in the treatment of 57 cases of chronic myelogenous leukemia," Chinese Journal of Hematology 1991; 12(3): 125-127. 8. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing House, Fujian. 9. Sun Chiyuan, A Probing into the Treatment of Leukemia with Traditional Chinese Medicine, 1990 Hai Feng Publishing Company, Hong Kong. 10. Jiang Shuzhen, Yu Gong, and Cao Jinni, " Adverse effect of indirubin on the cardiovascular system, a report of 3 cases," Chinese Journal of Hematology 1986; 7(1): 30. 11. Werbach M, Nutritional Influences on Illness, 1993 Third Line Press, Tarzana, CA. 12. Lu HC, Chinese System of Food Cures, 1986 Sterling Publishing Co. Inc., New York, NY. 13. Tao Shuchun, "Observation on clinical effect of 80 cases of chronic granulocytic leukemia treated with Chinese medicine mainly," Journal of Traditional Chinese Medicine, 1997 38(6): 349-350. 14. Yin Pingping, "Observation on clinical effect of 20 cases of chronic granulocytic leukemia," Shanghai Journal of Traditional Chinese Medicine 1997; (6): 31. 15. Deng Youan, et al., " Additional use of blood-activating Chinese herbs in chemotherapy of acute leukemia," Sanxi Medical Journal 1988; 17(2): 79-81. 16. Yan Yi, "Analysis of therapeutic effectiveness in 35 cases of acute leukemia with therapy by Chinese integrated medicine ," Chinese Journal of Integrated Traditional Chinese and Western Medicine 1995; 15 (1): 643-645. 17. Wang Jiliang, "Clinical research on treatment of 16 patients with refractory recurrent acute leukemia," Practical Journal Integrating Chinese and Modern Medicine 1996; 9(3): 138. 18. Ou Ming, et al., An Illustrated Guide to Antineoplastic Chinese Herbal Medicine, 1990 Commercial Press, Hong Kong.

Bibliography for Further Examples of Herb Therapies Used for Leukemia Cheung CS, et al., translators, " Leukemia-Understanding and treatments in traditional Chinese medicine," Journal of the American College of Traditional Chinese Medicine 1982; (1): 73-85. [translation of Chinese report by the Hematology Group of Xiyuan Hospital in Beijing, originally published 1976, just prior to introduction of indigo-based treatments for leukemia] Jia Kun, Prevention and Treatment of Carcinoma with Traditional Chinese Medicine , 1985 Commercial Press, Hong Kong. [includes a chapter about using Ping Xiao Dan plus other therapies to treat leukemia]. Shi Lanling and Shi Peiquan, Experience in Treating Carcinomas with Traditional Chinese Medicine , 1992 Shandong Science and Technology Press, Shandong. [this book has a section on leukemia that simply lists several "proved recipes," that is, formulas that appeared in journal articles or books with case presentations illustrating positive results]

December 1997

PROGNOSIS AFTER DIAGNOSIS OF LIVER CANCER: The Influence of Chinese Herbs by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Reports about treatment of liver cancer have often included a statement that the disease has a "poor prognosis." Sometimes, this is more specifically stated, such as in a 1994 pathology textbook: "The outlook for hepatocellular carcinoma is not good, with death occurring within six months of diagnosis." Patients diagnosed with cancer generally expect their physicians to provide them with a prognosis, an educated guess about what will happen to them. In the case of liver cancer, which has generally been associated with a poor outcome, the patients may want to know how long they have to live. While it is impossible to know the lifespan of any individual, the chances (probability) of passing a certain survival time can often be given. Factors that can alter this survival, including treatments with standard, experimental, and complementary therapies, can be taken into account, but also introduce uncertainty into the determination. Currently, prognosis for life-expectancy is based on statistical data for prior cases that have been documented, analyzed, and summarized. In the case of cancer, survival time after the initial diagnosis is measured in median duration to death or in rate of survival past certain marker points, usually 1, 3, and 5 years. Median duration to death is the time at which 50% of patients have died; survival rate indicates the percent of patients surviving at a given time point after diagnosis of the disease. Data used for survival rates do not take into account the actual cause of death, which can include adverse effects of attempted treatments and death due to other diseases. Sometimes, prognosis is also given in terms of improvements versus disease progression within a limited treatment period without reference to survival duration. Improvements in the accuracy of prognosis occur as a disease category (e.g., liver cancer) is subdivided according to parameters that affect overall outcomes. Liver cancer may be divided first into two broad categories: primary (hepatocellular carcinoma) and secondary (metastases from other cancers, such as colorectal carcinoma). The cancers are then staged (I through IV) based on tumor size, tumor number, and invasiveness into the organ's vascular system, with decreasing survival as the stage of disease progresses. Recent research, described below, provides a number of other determinants for survival.

PROGNOSIS WITH NO TREATMENT OR INEFFECTIVE TREATMENT There is relatively little data available for prognosis for untreated primary liver cancer because this type of cancer seldom goes untreated. Until recently, the effect of medical treatment on survival duration had often been minimal, so the accumulated data on survival rates with treatments given prior to the 1990's have closely reflected the survival rates without treatment. A 1992 report (based on data from the 1980's) indicated a survival curve that is not much different than that for pancreatic cancer: only about 20% survival at one year, and a very low 5-year survival rate of 6% (1). The five-year survival rate derived at that time was 15% when the cancer was localized and surgically removed (stage I), but only 2% when the cancer had already spread to other sites (stage IV). Recently developed treatments, including improved surgical techniques and new chemotherapy drugs and delivery methods (e.g., catheterized chemo-embolization), may improve the outcomes, especially for the earlier stages of the disease. When delayed until the disease is in an advanced stage, available treatments have little effect on survival. Thus, for example, in a Chinese study using modern medical techniques (2), patients with advanced liver cancer were treated with either nolatrexed or with doxorubicin: it was reported that neither treatment had much effect. The median survival time was about 4 months. In a French study (3), it was shown that five prognostic factors (other than those that had been used for staging the disease) could be combined to closely predict outcomes for primary liver cancer. The following were associated with poor prognosis: 1. Karnofsky index being less than 80% (measure of disease impact on ability to carry out daily activities); 2. high bilirubin (serum value >50); 3. high serum alkaline phosphatase (more than twice the upper limit of normal range); 4. higher serum alpha-fetoprotein (>35); and 5. portal obstruction observed by ultrasound. By using these measures, the authors were able to describe three risk groups (low, medium, high) with markedly different average 1-year survival rates of 79%, 31%, and 4%, respectively. Patients with few of the adverse indicators would usually respond well to therapy and were likely to survive for at least one year, while the survival rate for those with several of the negative indicators (which correspond to advanced disease) was very limited, with short survival duration. Therefore, by collecting this detailed information, which involves a patient survey (Karnofsky), a blood test for indicators related to liver disease (alpha-fetoprotein is an indicator of certain cancers, especially liver and pancreatic cancer), and an ultrasound test of the liver, the prognosis for the first year can be given with more confidence than by simply using a diagnosis of liver cancer with or without metastases.

PROGNOSIS WITH PARTIALLY EFFECTIVE THERAPIES In a recent evaluation of surgical treatment of liver cancers secondary to colorectal cancer (which itself would have been previously treated by surgery plus chemotherapy), it was reported (4) that 5-year survival was 37% and 10-year survival was 22%. But, the ability to give a more specific prognosis for a patient could be improved by considering several individual factors. The following factors were associated with poor prognosis: 1. positive margin (cancer cells found at the edge of the removed mass, indicating cancer cells were still present in the liver); 2. cancer found outside the liver; 3. node-positive primary cancer (the original cancer site included cancer cells in local lymph nodes, suggesting wide-spread metastases);

4. interval from finding primary tumor to finding metastasis less than one year; 5. more than one hepatic tumor; 6. hepatic tumor larger than 5 cm; and 7. CEA level >200 (cancer embryonic assay: a blood test revealing cancer cell activity). The last five criteria were said to be especially valuable for prognosis and could be used for determining what type of therapy to attempt; if up to 2 criteria were met, the outcome of standard treatment might be favorable; if more than 2, then new experimental therapies might be tried, as the outcome by current methods is unlikely to be favorable (meaning that the survival data for no treatment or ineffective treatment should apply). A study (5) of surgical resection of primary liver cancer that was accompanied by underlying cirrhosis revealed a 5-year survival rate of 57% for those with small tumors (less than 5 cm), but only 32% for those with large tumors (>10 cm). Aside from tumor size, other factors that indicated poor outcome were high alpha-fetoprotein and vascular invasion of the tumor. In a study of prognosis for primary liver cancer treated by surgery, it was shown that getting a clean margin, even if two surgical attempts were necessary, was very influential in overall survival. In the general case, it was reported that 1-, 2- (not 3-), and 5-year survival rates were 75%, 56%, and 29% for surgical treatment. Certain factors were found to be associated with a poor prognosis: vascular invasion, metastatic disease, and positive margin. For those who had two surgeries in order to get a clean margin, the risk of death was 5 times that of those who got a clean margin the first time; if there was no clean margin the second time, the risk of death was 15 times higher. Thus, taking into account the surgical outcome-by examining the removed mass-could greatly improve the ability to give an accurate prognosis. Comparing outcomes of diverse treatments, an Italian study (6) involving 178 patients indicated the following survival rates: Treatment

1-year Rate

3-year Rate

5-year Rate

Chemotherapy or no specific therapy

13%

3%

0%

Chemo-embolization

55%

26%

13%

Hepatectomy

72%

58%

58%

Liver transplant

81%

74%

74%

These data give very favorable prognosis for certain treatments, but must be viewed cautiously: the number of patients per group that resulted in favorable outcome was low (e.g., liver transplant: 22 patients; hepatectomy: 11 patients) and the treatments were selected on the basis of the nature of the cancer condition. In general, liver transplant is a therapy limited to those who have a well-defined tumor mass but in a location (or within a particular liver condition) that precludes successful hepatectomy (resection). The 13% survival rate at one year for simple chemotherapy described in this study was consistent with the Chinese report that standard systemic chemotherapy had little effect and resulted in median survival of only about 4 months. Systemic chemotherapy is often applied when there is metastatic cancer (stage IV). In a U.S. study (7) involving liver metastasis from colorectal carcinoma, chemo-embolization (doxorubicin, mitomycin C, and cisplatin; followed-up by 5-FU with leucovorin) yielded a 1-year survival rate of 58% (consistent with above 55% rate for chemoembolization) and the median survival time was 14 months. The authors of this study did not find that this outcome was better than that obtained with systemic chemotherapy (the 5-FU plus leucovorin) for this type of disease. In a German study (8) involving liver metastases from colorectal cancer, all patients were first treated by surgery to remove the tumors. Some patients then received hepatic artery infusion of mitomycin C and 5-FU. The strongest factor in determining outcome was the disease status at the initiation of therapy: there was a 5-year survival rate of 64% for those with no mesenteric lymph-node metastases, but only 29% for those with the metastases. There was no advantage found with the arterial chemotherapy. Overall, 5-year survival rates for the patients were on the order 25-31%.

SUMMARY OF WESTERN MEDICAL SITUATION Liver cancer has a poor prognosis with a low chance of survival past one year, whether the cancer is primary or secondary, when untreated or treated by simple systemic chemotherapy, or when treated by any means when the cancer is advanced (large tumor, significant impact on serum indicators of liver involvement, rapid metastasis). The best indicator of survival outcome is the initial condition of the cancer at the time of diagnosis, more so than the type of treatment applied. When the initial conditions are good (small tumor, little or no vascular invasion, liver condition good), certain therapies are effective, notably surgical resection. The best survival outcome reported in the literature involves cancer that is limited to the liver, with transplantation of the affected organ. However, liver transplantation is itself risky and involves long-term immunosuppressive chemotherapy; further, there are not enough livers available for transplant, requiring an extended wait until the surgery can be done. The next best treatment reported is removal of the tumor and affected part of the liver. If the surgery shows no cancer at the margins and no lymph node spread, then the prognosis is very good. Chemotherapy is reported to have varying effects and the search for a reliable chemotherapy regimen is being actively pursued. Chemoembolization, an intensive localized chemotherapy method, is currently being used as a means of improving the prognosis. However, this intensive chemotherapy has severe side effects and the long-term survival rates remain low, with positive outcome mainly for those with the favorable prognostic factors at the time of diagnosis, including ability to remove small tumors by surgery.

CHINESE HERBAL THERAPIES AND THEIR EFFECT ON PROGNOSIS FOR LIVER CANCER Primary liver cancer is much more common in the Orient than in the West. This difference is now understood to be due to the much higher incidence of viral hepatitis infection in the Orient, as this infection leads to liver cirrhosis, a major contributor to primary liver cancer. Some areas within the Orient have especially high rates of liver cancer, with Shanghai, Canton, and Hong Kong being among the

highest. In China, about 100,000 patients die each year of primary liver cancer; the World Health Organization estimates the worldwide total number of annual cases at 430,000 (15). By contrast, primary liver cancer is rare in the U.S., though its incidence is increasing as the result of spread (which occurred mainly during the past 30 years) of hepatitis B and C. As explained in Experience in Treating Carcinomas with Traditional Chinese Medicine (10), traditional doctors have thought that liver cancer is mainly caused by "dietetic injuries, emotional disturbance, and accumulation of toxic materials and blood stasis, which lead to impairment of the liver and the spleen and stagnation of the liver qi." Other factors are "damp-heat, alcohol, emotional disturbance, water toxin, or malaria that adversely affect the liver and spleen." The tumor mass results from "prolonged stagnation of the liver qi, transforming into fire, which accumulates together with damp-heat. Stagnation of the liver qi will become more and more serious, the blood stasis more and more aggravated, and the lump larger and larger." The modern medical view is that repeated damage of the liver-with repair mechanisms brought into play-results in high levels of activation of the liver DNA, with increasing risk of transformation to neoplasm. Viral hepatitis and alcohol abuse are contributors to the liver damage; aflatoxin, a mold metabolite found in improperly stored foods, can also contribute to liver cancer. Based on the traditional Chinese view, treatments are aimed at supporting the stomach/spleen function, regulating liver qi, dispersing stagnant blood, resolving toxin, and dissolving masses. Numerous formulas based on these principles of therapy have been suggested in the Chinese literature on treating cancer. An example is Gan Ai Tang (Liver Cancer Decoction) which is not a single formula but a basic approach to treatment. One version is: bupleurum, blue citrus, curcuma, corydalis, white peony, red peony, fu-shou, saussurea, eupolyphaga, leech, and pangolin scale. This decoction is to be taken with Rhubarb and Eupolyphaga Formula (Dahuang Zhechong Wan; a strong blood-vitalizing prescription containing several insect drugs) in pill form. Another version of Gan Ai Tang is produced from the above prescription by replacing red peony with zedoaria and sparganium, and adding the following herbs: lonicera, dandelion, zizyphus, tang-kuei, and atractylodes (also accompanied by Rhubarb and Eupolyphaga Formula). Reliance on animal drugs, whether or not they are actually effective, is evident upon reviewing the herbal formulas recommended for treatment of liver cancer when traditional medicines are the sole or primary therapy. For example, cancer specialist Jia Kun (who developed the anti-cancer prescription Ping Xiao Dan) recommends a prescription that includes tortoise shell, turtle shell, oyster shell, earthworm, wasp nest, snake skin, and scorpion, along with just four plant-derived materials (18), as one of the formulas to accompany Ping Xiao Dan when treating liver cancer. In the book Illustrated Guide to Antineoplastic Chinese Herbal Medicine (19), five formulas from the Chinese medical literature are cited as treatments for primary liver cancer. These include one prescription that contains pangolin scale, oyster shell, and armadillidium (wood louse); another that contains the toxic insect mylabris; and another called the "Five Insect Pill," comprised of leech, tabanus (gadfly), eupolyphaga (beetle), gecko (lizard), and bufo (toad secretion). The term "chong," often translated as insect, as in the name of this formula, actually refers to small creatures. Two formulas without animal drugs are mainly comprised of high dosages (20-30 grams each) of "anti-cancer" herbs, such as scutellaria, oldenlandia, and lobelia (see Table 1). I n Treating Cancer with Chinese Herbs (20), three prescriptions for liver cancer are described based on clinical work done in China; one contains pangolin scale, tortoise shell, and oyster shell; another contains tortoise shell and centipede; the third contains gallus (chicken gizzard lining). An ancient concept that is still being relied upon in some of these formulations is that the animal drugs, especially insects, can deeply penetrate (because of their natural tendency to scurry about) into areas of swelling and obstruction and dissolve the accumulation. Advanced liver cancer is marked by hard swelling of the liver and ascites, which do not respond to most plant-based treatments; therefore, these animal agents are brought into play. Some of the materials, such as turtle shell, oyster shell, and gallus, are traditionally indicated for a wide range of swellings; others, such as centipede, scorpion, and mylabris (which are toxic), are selected for serious diseases. In the book Anticancer Medicinal Herbs (32), the following is said about pangolin scales, which are frequently mentioned in prescriptions for liver cancer: It is recorded in Records of Integrated Chinese and Western Medicine that: 'Pangolin scale, with a stinking smell which enables it to scurry actively through the whole human body, can activate the viscera, penetrate the channels and collaterals, reach joints and passages, and clear away blood stasis and stagnation. The drug can be used at will to treat furuncle and carbuncle with instant results. The drug is also effective in treating abdominal mass, paralysis, difficult urination and defecation, and abdominal pain.' This section of the anticancer book includes a prescription for hepatocarcinoma that incorporates pangolin scale, oyster shell, and earthworm along with plant materials that vitalize blood circulation (i.e., persica, carthamus, curcuma, and moutan). According to specialists in the use of insect drugs, there are specific methods of applying them and cautions to observe (29): Because the chong drugs are hard to dissolve in water, applying them in decoction form usually gives a poorer result; instead, clinical practice is usually based on baking them to dryness for preparing pills or making a powder to swallow directly. Since the chong drugs possess a strong penetrating and dispersing effect (just as they scurry about when alive), and some have drying, heating, and strong blood activating action, they should be administered carefully: it is better to start with small dosage and then increase by degrees, but never apply them in excessive dosage.

PRACTICAL ASPECTS OF DIAGNOSIS AND TREATMENT IN CHINA Liver cancer remains asymptomatic until it is relatively far advanced. Due to lack of diagnostic tools for detecting liver cancer in China, this disease was only diagnosed in the advanced stage (usually corresponding to the modern stage III and stage IV liver cancers). Symptom alleviation had become the primary outcome measure, and herbal formulas were recommended for and adjusted to the specific symptoms such as poor appetite, abdominal distention, pain, and fever. In 1973, a committee was formed to help coordinate research and treatment efforts for primary liver cancer. They found that the mean survival rate among 3,254 case reports available to them was 5.7 months (11). Mean (average) survival time is usually slightly longer than median survival time, because the figures may be skewed by a small number of long term survivors. Earlier diagnosis of the disease, currently available in China only to a limited extent, has made it possible to attempt more comprehensive treatment, usually with Western medical intervention as the basis. Still, in a review article on integrated traditional

Chinese and Western medicine for primary liver cancer (14), it was pointed out that advanced cases make up more than 90% of the total patients that come for treatment. A recent article on combined Western and Chinese therapies (27) pointed out that "90 percent of primary hepatocellular carcinoma patients were in the middle or advanced stage when they came for medical care. Because most of them missed the chance of surgical resection, and were insensitive [non-responsive] to systemic chemotherapy and radiotherapy, their prognosis usually was very bad and their survival period was, in general, 3 months." This survival duration is consistent with what has been reported when stage IV cancer patients were treated in China by herbal therapies prescribed on the basis of differential diagnosis (34). The median survival time was 2 months, mean survival time was 3.5 months, and the survival rate at 6 months was 11%. Most Chinese clinical reports about treatment of primary liver cancer emphasize the value of surgical intervention for ultimate success in treating liver cancer. For example, one physician specializing in integrated traditional and Western medicine (28) wrote: "Generally, satisfactory results can be expected only for patients at the early stage treated by surgical intervention." Pan Mingji (11) describes some of the attempts to combine traditional Chinese herbs with surgery and other Western medical therapies. Among the suggestions for treatment: One week prior to surgery, take herbs, vitamins, and drugs as needed to improve overall health. As an example of herbal treatment, he recommended a large prescription with herbs that nourish yin, tonify qi, and clear heat. Key ingredients were the tonics pseudostellaria, astragalus, glehnia, ophiopogon, asparagus, and gynostemma, and the heat-clearing herbs rhubarb, coptis, scute, and solanum. After surgery, use herbs to aid recovery. As an example of treatment he suggested a formula similar to that used preoperatively, but some of the heat clearing herbs (rhubarb, coptis) were replaced by digestion promoting herbs (raphanus, gallus, malt, atractylodes). Poor appetite and resulting poor nutritional status are considered an impairment to quick surgical recovery. During chemotherapy, use herbs to reduce adverse reactions; a formula similar to that used in the pre-operative week is recommended. During radiation therapy, use tonic herbs. A specific formulation is not mentioned, but "aggressive traditional medicines should be avoided" and replenishing tonics emphasized. Herbal prescriptions that are used when Western medical therapies are not applied are also suggested by Pan, based on syndrome differentiation according to traditional Chinese medical principles. The suggested formulas contain the following "anti-cancer" herbs: solanum, scutellaria, lobelia, oldenlandia. These herbs (see Table 1) are relatively non-toxic and can be used in substantial dosage (20-30 grams of each per day). Aside from these anti-cancer ingredients, the formulas are comprised of herbs that address the particular Chinese medical syndromes. As examples: for qi and blood stasis: include sparganium, curcuma, bupleurum, red peony; for qi deficiency with dampness: include atractylodes, hoelen, codonopsis, plantago, alisma, coix; for damp-heat: include rhubarb, scute, gardenia, coix, polyporus, plantago seed, ching-hao; and for yin deficiency: include ophiopogon, asparagus, glehnia, dendrobium, anemarrhena, yu-chu, rehmannia, and tortoise shell. These suggestions are presented without accompanying evidence of efficacy. Table 1: Anti-Cancer Herbs of Low Toxicity Used to Treat Primary Liver Cancer in China. The following materials are among those included in several Chinese herbal formulas used in the treatment of primary liver cancer. Their main functions are to "remove toxins, resolve swellings, and disperse accumulations of fluids or stagnant blood." The traditional actions mentioned in the table are quoted from Oriental Materia Medica (25). In contrast to toxic materials such as toad secretion and mylabris, these herbs are relatively non-toxic; some are listed in the Chinese texts as "slightly toxic" and others are considered toxic in the U.S. (based on the herb constituents) but not in China (based on clinical experience). When attempting to treat the tumor or its accompanying abdominal swelling (local liver swelling or ascites), these herbs are usually combined with others that regulate qi circulation (e.g., bupleurum, cyperus, saussurea, and various citrus materials) and that vitalize blood circulation (e.g., sparganium, zedoaria, tang-kuei, cnidium, salvia herb, pangolin scale, and eupolyphaga). Common Name Pinyin Armadillidium

Source Material Armadillidium vulgare

shufu Cremastra

Traditional Actions disperses stagnant blood, promotes diuresis, removes toxin, controls pain

Dosage and Comments 3-6 grams; this is the wood louse, it is a rarely used item that is mentioned in several treatments for liver cancer

shancigu

Cremastra variabilis; also reduces heat, removes toxin, from Pleione bulocodioides disperses accumulation, dissipates swelling

Lobelia

Lobelia chinensis

promotes diuresis, removes swelling, 30-60 grams of fresh herb; 10-15 removes toxin grams dried herb; used for ascites; not considered toxic in China but U.S. FDA lists lobelia as restricted due to toxicity of lobeline

Oldenlandia diffusa

cleanses heat, removes stagnancy, removes toxin

banbianlian

Oldenlandia baihuasheshecao

up to 9-15 grams; listed as "slightly toxic"

30-120 grams; usually along with scutellaria

Paris

Paris sp.

dispels heat, removes toxin, resolves 15-30 grams; listed as "slightly phlegm, disperses accumulated toxic" masses

Scutellaria barbata

cleanses heat, removes toxin, disperses stagnancy, controls bleeding, controls pain

Solanum nigrum; Solanum lyratum (shuyangquan) is also used

dispels heat, removes toxin, 15-30 grams; not listed as toxic in promotes blood circulation, disperses China, but U.S. FDA restricts use of swelling Solanum species (nightshades) due to content of solanine alkaloids

zaoxiu Scutellaria baizhilian Solanum longkui

15-30 grams; frequently combined with oldenlandia

CLINICAL REPORTS OF LIVER CANCER TREATMENT A recent Chinese publication (12) compared treatment of primary liver cancer with radiation plus placebo or radiation plus Chinese herbal medicine. The herbal formula used was a modification of a traditional prescription for qi and blood stasis: Xuefu Zhuyu Tang. The traditional prescription includes the qi-regulating herbs bupleurum and chih-ko and the blood-vitalizing herbs persica, carthamus, tangkuei, cnidium, red peony, and cyathula. According to the medical report, 1-, 3-, and 5-year survival rates improved by about 20% with the use of the Chinese herbs. The development of metastases outside the liver was not influenced by treatment. A 20% increase in survival rates is regarded as marginally significant (in terms of clinical outcomes as well as statistical significance) in the Western medical literature. Thus, for example, if a 1-year survival rate is 50% by radiation alone, the claimed benefit of adding Chinese herbs is a survival rate of 60%; similarly, a 5-year survival rate of 20% without herbs would improve to a survival rate of 24%. In addition to slight improvements in survival rate, this report indicates reduction of symptoms, with an improvement in quality of life. In a review of treatment approaches to liver cancer (14), integrated radiation therapy plus Chinese herbs for middle-stage primary liver cancer was reported to yield 1-, 3-, and 5- year survival rates of 60%, 35%, and 25% respectively. Better rates were obtained when higher doses of radiation could be tolerated, which was the case for 70% of patients who also received Chinese herbs. In that circumstance, 1-, 3-, and 5-year survival rates increased to 100%, 68%, and 68% respectively. This is comparable to the results reported in Western clinics for hepatectomy and liver transplant, but the ability to tolerate high levels of radiation probably signifies a healthier patient at the initiation of treatment. It was suggested, by other liver cancer researchers mentioned in this review, that, as an accompaniment to radiation therapy, formulas comprised mainly of herbs that tonify spleen qi and regulate qi circulation (those that protect the body from damage) may produce a better result than formulas relying on herbs that vitalize blood and clear toxic heat (herbs used to treat the tumor mass). When advanced cases of liver cancer (with jaundice, ascites, and metastases) are treated by the combined method, there is some slight survival benefit reported compared to Western medical treatments alone. In one study, median survival for the group treated by combined therapy (24 patients) was 7.5 months, with 1-year survival at 21% and 3-year survival at 7%. Administration of Chinese herbs was compared to use of standard chemotherapy in a study (17) of patients with primary liver cancer who were mainly in middle-stage liver cancer (classification: stage II and stage III). The patients had already undergone some standard medical therapies, but did not adequately respond. In the herbal treatment group (200 patients), syndrome differentiation pointed to about half the group being of the qi stagnation and blood stasis type, and the other half of the group belonging to the qi and yin deficiency type. The formula administered, called Qinglong Wan (Green Dragon Pill), was comprised of the qi and yin tonic herbs ginseng, astragalus, codonopsis, lycium fruit, adenophora, and atractylodes in a partial Rehmannia Six Formula base of rehmannia, moutan, and cornus, plus the blood-vitalizing herbs tang-kuei, salvia, pangolin scales, frankincense, myrrh, san-chi, and succinum (additionally, haematite and lonicera were included; proportions of the ingredients were not stated). The herbs were made (process not defined) into pills and taken 8 grams at a time with warm water, a half hour after meals, three times daily, for a total of 24 grams per day. The control group (70 patients) received chemotherapy (mitomycin C and adriamycin) through a hepatic artery catheter. The authors of the study reported that the herb therapy helped alleviate several symptoms, including weariness, fever, pain, nausea, vomiting, and abdominal bloating. As a result, patients in the herb treatment group tended to consume more food (and maintain or even gain weight during the treament period) than those in the chemotherapy group. Further, the levels of hemoglobin (representing red blood cell levels), leukocytes, and platelets were better than in the control group. The study lasted two months and monitoring of patients was followed up for only a few months thereafter, so long-term survival data could not be reliably obtained. Early deaths occurred in about 7% of the herb group and 3% of the chemotherapy group, with mean survival time of about 100 days; the rest of the patients had a mean survival time of about 5 months at the end of follow-up (time of death after that was unrecorded). About 10% of patients in both the herb and control groups showed marked alleviation of symptoms. Most of the difference between the two groups, in terms of response to therapy, involved a larger proportion of patients being stabilized by the herbal treatment compared to a small proportion stabilized by the chemotherapy. A similar approach was taken by physicians at the Hunan Tumor Hospital (31). They compared the use of Chinese herbs with chemotherapy or radiation therapy for patients admitted with stage II or stage III primary liver cancer. Their prescription included astragalus, codonopsis, atractylodes, hoelen, bupleurum, pangolin scales, persica, salvia, sappan, paris, oyster shell, armadillidium, prunella, and other unspecified herbs. The formula would be modified according to syndrome presentation, with herbs for either qi and blood stasis, liver/spleen disharmony, or yin deficiency syndrome. In all treatment groups, most patients still had short-term survival (under one year), but in the herb treatment group, 12% of the patients survived more than 2 years, compared to none in the chemotherapy and radiation groups. It is possible that selection criteria for the different treatments might have influenced the outcome, but the authors reported that administration of the herbs produced obvious effects in terms of patient symptoms. In another study (13), patients who had intermediate or advanced liver cancer previously treated by surgery (but where it was found that the tumors could not be excised) were then provided with new therapies. One group (the control) was treated by routine chemotherapy, which, as noted before, has minor impact on survival. The mean survival time for the control group was 5.3 months, consistent with the Chinese report from 1983 of 5.7 months. The other group was treated with Chinese herbs. The formula administered was a modification of the traditional Bupleurum and Turtle Shell Combination (Chaihu Biejia Tang), that was modified to include a number of herbs considered beneficial for inhibiting cancer and reducing abdominal swelling: solanum, eupolyphaga, scutellaria, and

alum. In addition, herbs to promote digestion (shen-chu, malt, gallus, cardamon, atractylodes) were included. According to the medical report, the use of the Chinese herbs resulted in a longer mean survival time of 10 months. In terms of symptom alleviation, the Chinese herbs were reported to be markedly effective in 38% of patients, and of some effect in 45% of cases, while 17% had no evident improvement. An early trial (patients treated from 1966-1984) was based on using differential diagnosis and herbal treatment for patients undergoing chemotherapy or radiation therapy (techniques that were, at the time, not very effective) for intermediate and late-stage primary liver cancer (28). A number of traditional formulas were given including Danggui Liuhuang Tang for a fire syndrome, Xiangsha Liujunzi Tang for stagnation of fluids, Buzhong Yiqi Tang , Pingwei San, Sijunzi Tang , and other spleen-stomach formulas for weak qi and poor digestion, and Chaihu Shugan San for liver qi stagnation. The total number of patients was 50, but the number in each group was quite small, so comparisons were difficult to make. Nonetheless, the authors claimed that patients who had a spleen-deficiency type of syndrome responded best to the combined therapies and had an improved survival time, as compared to those with yin-deficiency syndrome or other patterns. It was suggested that the reason for this benefit was that the herbal treatment had immunoregulatory effects that had clinical significance for this group of patients. A trial involving transcatheteral arterial chemotherapy and embolization (known as TACE) included administration of Chinese herbs (27). Unfortunately, the number of patients involved was small, making a detailed analysis difficult, and the patients generally had advanced cancer, meaning that chances of prolonged survival were already small. The control group also used Chinese herbs, but a less effective Western medical therapy (transcatheteral artery infusion of chemotherapy, but not embolization). The basic formula provided included qi tonics (astragalus, atractylodes, polygonatum), qi- and blood-regulating herbs (cyperus, corydalis, peony, red peony, zedoaria, pangolin scales, san-chi), anti-cancer herbs (scutellaria and hongcaozi, a toxic species of Polygonum), and digestive aids (crataegus and shen-chu). According to the authors, the impact of the Chinese herbs was to "remit the patients" symptoms, increase the body's immunity, decrease toxicity effects of radiotherapy and chemotherapy, improve the liver function, and, to a certain extent, stop the tumor growth and prolong the survival period." Average survival duration with TACE plus Chinese herbs was 13 months compared to about 9 months for the control treatment. In some cases, liver cancer patients treated by chemotherapy or by Chinese herbs are described solely in retrospect (case reviews) rather than in a designed clinical trial in order to gain some understanding of the effects. In one such report (24), 45 patients treated with Chinese herbs and 20 patients treated with chemotherapy were depicted. The overall outcomes in terms or survival time were not very different. These patients that were the subject of study had all died, with median survival time of about 6 months and mean survival time of about 8 months (note: other patients had survived at the time of the analysis and were not included in the evaluation). The herbal formula given included cyperus, curcuma, akebia fruit, sparganium, zedoaria, turtle shell, scutellaria, and salvia herb, and was modified according to syndrome presentation (the two primary syndromes were liver-qi stagnation with spleen deficiency and liver-qi stagnation with blood stasis). One of the apparent benefits of the herbal therapies, which included administration of san-chi in cases of digestive tract hemorrhage, was a lower incidence of such hemorrhage contributing to the cause of death.

TOPICAL THERAPIES Many patients with advanced liver cancer have difficulty consuming both food and herbs. One of the approaches developed by Chinese physicians is to apply herbs topically in an effort to reduce cancer pain, alleviate some of the swelling, and, according to reports, improve the survival time. As an example, a medicinal plaster containing the following herbs was developed for patients with liver cancer (21): cremastra, zedoaria, realgar, eupolyphaga, san-chi, rhubarb, toad venom, borax, euphorbia, borneol, and musk. Additional herbs might be added in response to specific symptoms. The individual herbs are finely powdered then combined and mixed with a sticky material to make a plaster. It is applied over the liver region or area of pain (about 25 x 15 cm area) in a layer about 0.5 cm thick on a non-toxic plastic membrane. The plaster is changed once per week. According to the authors of the report, the herbal plaster had these actions: improve blood circulation, dissipate blood stasis, and soften masses. They explained that: "Most of the medicinal materials for topical use are similar to those used orally. However, since it is necessary for topical drugs to be absorbed by the skin or mucous membrane, the action is necessarily slow and prolonged. The skin exposed to the drug should be as extensive as possible and some penetrating drugs need to be added. Musk, being an example with a pungent odor and bitter taste, has a good analgesic effect." They recommend the plasters for treating pain and swelling, as an adjunct to chemo- or radiotherapy. Another example was described in a report of topical powder used for treating cancer pain (22). The patients treated had various kinds of cancers with primary liver cancer being the most prevalent type. The plaster was made with more than 20 ingredients, including fresh arisaema, raw aconite, liquidambar, pteropus, musk, borneol, paris, huangyaozi (a potentially toxic species of Dioscorea), phragmites, pangolin scale, and gleditsia spine. A paste was made by combining the fine herb powder with tea, which was then applied to the affected area with a thickness of at least 0.2 cm. The paste was covered with gauze which was affixed with adhesive tape and left in place for 6-8 hours; after about 12 hours without the plaster, another batch was applied. It was claimed that there was a high rate of good analgesic effect for patients who had become refractory to standard drug pain relievers. In these two plasters, musk and borneol are included to induce penetration of the herbs and they provide some analgesic effect; toxic materials such as toad venom, realgar, fresh arisaema, and raw aconite are powerful agents that have analgesic and anti-cancer actions (they must be used very cautiously internally and are inappropriate for use in Western clinics). In the second formula, phragmites is added, it was said, in order to help reduce the toxicity of raw aconite and raw arisaema. In a review of various herbal treatments for liver cancer pain (23), the section on external therapies included a dozen prescriptions that had been reported on in Chinese medical literature. Generally, they contained ingredients such as those described above, with emphasis on toad venom, aconite, realgar, raw arisaema, myrrh, frankincense, musk, and borneol. Several formulas contained the anticancer herb paris. As the reviewer of the treatments stated: "The severe pain seriously affects the quality of life, leading to disrupted internal homeostasis and immunologic functions, which, in turn, adversely affect prognosis of the patient. Better analgesic modalities are urgently needed." At the Sandong Provincial Hospital, it was reported that by applying Putuo Plaster (ingredients not specified) for patients with primary liver cancer, there was remarkable pain relief in 83% of the patients (35). The author of the study claimed that the patients experienced improved quality of life and could, as a result of the alleviation of pain, survive longer than those who did not

receive the plaster. In the West, morphine and morphine derivatives are the drugs of choice for severe pain. One of the problems that is then encountered is severe constipation and impairment of mental function. Therefore, if the analgesic drug dosage can be minimized by combination with topical herbal treament, it may be possible to better manage the case. In the Western clinic, a combination of selected ingredients mentioned in the above formulas, such as paris, myrrh, frankincense, and borneol, could be easily made from available materials and would be of very low toxicity. Still, without the toxic analgesics used by Chinese doctors, the effect of herbs on pain will be somewhat limited and the extent of pain relief to be expected should not be overestimated. The constipating effect of high morphine dosage can be counteracted with Chinese herbs (30). A formula based on Major Rhubarb Combination (Da Chengqi Tang), with rhubarb (added to the decoction late in order to preserve the laxative action), magnolia bark, chihshih, raw rehmannia, scrophularia, ophiopogon, pseudostellaria, raphanus, and mirabilitum (taken separately, dissolved in water), was reported effective for morphine-induced constipation if taken twice daily. The formula could be modified to treat various deficiency syndromes (e.g., add astragalus for qi deficiency, tang-kuei for blood deficiency, cistanche and cuscuta for yang deficiency). Among the patients treated were those with primary liver cancers and other types of cancer. It was reported that use of the decoction in high dosage (most of the herbs in amounts of 15-20 grams per day), could yield a lasting effect even though the opioids were continued but the herbs discontinued. If constipation recurred, then the herbs would be taken again.

RECENT ADVANCES Modern Chinese efforts of treating liver cancer with Chinese herbs is largely based on the "interventional" method, which often involves Western style approaches, but relies on Chinese herbs as substitutes for standard chemotherapeutic drugs (15). For example, bletilla powder, zedoaria oil, and brucea oil have been used (individually) for chemo-embolization therapy. These are injected into the hepatic artery. Other examples are: a combination of musk, borneol, and alum injected into liver tumors, which was reported to yield a 1-year survival rate better than a comparable chemotherapy group (but the trial size was small, with 11 patients receiving the herb therapy); injection of cinobufotalin (a toad secretion preparation) injected into the tumor in patients also given chemotherapy; and injection of zedoaria, frankincense, and myrrh extracts into the liver (which was said to produce less side effects than treatment by 5-FU). These treatment methods present many of the same risks as the embolization and perfusion techniques relying on Western drugs, and they are less well studied. Still, for the Chinese cancer specialists who face a very large number of cases of advanced primary liver cancer, the natural products provide a fertile ground for seeking out treatments with fewer side effects and equal or better results than the current chemotherapy methods. One of the interventional treatments relying on a non-toxic herb is infusion of salvia extract into the hepatic artery (15, 16). This herb was chosen because patients with advanced liver cancer usually show several signs of blood stasis. According to authors of one study involving this method (16), salvia is able to prevent damage from hepatic autoimmunity, protect hepatic cells, and invigorate regeneration of damaged cells in patients who had failed to respond favorably to an initial treament by chemo-embolization (using Western drugs). It is possible that oral ingestion of salvia in high doses (20 grams per day is used orally in treatment of some other liver diseases, such as viral hepatitis) may confer some of the benefits claimed for the arterial injection method. Another non-toxic method used as an adjunct therapy is injection of polysaccharide fractions from mushrooms (26). In a study of immune responses to the therapy, it was reported that: "Treatment [of primary liver cancer] by excision or embolization to reduce the tumor burden of patients is the prerequisite for restoring immune functions. The result of this study showed that the effect of MPI [mushroom polysaccharide injection] was more evident when applied to post-operations patients." The study, involving intramuscular injection of polysaccharides at 4 mg once daily for 60 days, resulted in a statistically significant improvement in CD4+ T-cells. Oral administration of polysaccharides usually involves 100 times the dosage (i.e., 400 mg daily) or more, in order to yield significant T-cell improvements. The higher oral dosage is required due to poor absorption of the very large polysaccharide molecules that are the most active fraction obtained from mushrooms. It was not established by the study of T-cell levels that longevity was improved by the treatment, but impaired immune functions can lead to lethal infections in cancer patients. Similarly, a preparation made with earthworm as the main ingredient was reported to be "a non-toxic radiation sensitizer and chemotherapy enhancer," that could improve the outcome of liver cancer treatment (33). In a small study involving intra-arterial chemoembolization therapy, patients that received capsules containing an earthworm preparation showed less bone-marrow suppression (measured by leukocyte and platelet counts), and had a more significant reduction in alpha-fetoprotein and CEA levels.

SUMMARY OF THE CHINESE SITUATION Chinese herbal therapies have been applied to treatment of liver cancer with and without Western medical treatment, but mostly in conjunction with Western medicine or used in a manner similar to that of Western medical drug treatments. Based on literature reports, for which the number of patients is relatively low and the reliability of the study has not been evaluated, the use of Chinese herbs in conjunction with Western therapies improves symptoms for many patients and increases mean survival time and survival rates. In the Chinese health care system, neither herbs nor Western medical therapies (alone or in conjunction) have a substantial effect on survival for advanced liver cancer, but the herbal therapies are reported to reduce pain and other symptoms. Orally administered herbal therapies for liver cancer (as primary therapy or adjunct to Western medicine) include qi tonics, "anticancer" herbs of low toxicity, and a large selection of herbs that regulate qi circulation, vitalize blood, nourish yin, and promote digestive functions. Topically administered herbs generally include toxic analgesics and aromatic resins. Animal drugs are prevalent in both internal and external therapies, with particular emphasis on shells, scales, and skins of various animals, and whole insects, worms, and lizards. Injection of herbs for chemo-embolization therapy is one of the current areas of active research in China. For the Western clinic, Chinese herb therapies as an adjunct to standard medical therapies appears to be a promising route towards making limited improvements in prognosis and for making significant improvements in the overall symptom picture (e.g., reducing nausea, improving appetite, inhibiting gastro-intestinal hemorrhage, alleviating pain). As a result of progress in modern medical treatments, slight enhancements in outcome attained by incorporating Chinese herbs may lead to significantly improved long-term survival rates and cure rates (5-10 years of cancer-free survival). Therefore, the Chinese method of therapy is of potential value beyond the limited effects attained in Chinese studies that involved advanced liver cancer treated with Western medical methods that were less-

effective than those available now.

REFERENCES 1. Miller BA, et al, Cancer Statistics Review 1973-1989, 1992 National Cancer Institute Publication No. 92-2789, Bethesda, MD. 2. Mok TS, et al., A multi-center randomized phase II study of nolatrexed versus doxorubicin in treatment of Chinese patients with advanced hepatocellular carcinoma, Cancer Chemotherapy and Pharmacology 1999; 4(4): 307-311. 3. Chevret S, et al., A new prognostic classification for predicting survival in patients with hepatocellular carcinoma, Journal of Hepatology 1999; 31(1): 133-141. 4. Fong Y, et al., Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer; analysis of 1001 consecutive cases, Annals of Surgery 1999; 230(3): 309-318; discussion: 318-321. 5. Fong Y, et al., An analysis of 412 cases of hepatocellular carcinoma at a Western medical center, Annals of Surgery 1999; 229(6): 790-799; discussion: 799-800. 6. Sangro B, et al., Prognosis of hepatocellular carcinoma in relation to treatment: a multivariate analysis of 178 patients from a single European institution, Surgery 1998; 124(3): 575-583. 7. Leichman CG, et al., Hepatic chemo-embolization combined with systemic infusion of 5-FU and bolus leucovorin for patients with metastatic colorectal carcinoma; Cancer 1999; 86(5); 775-781. 8. Rudroff C, et al., Prospective randomized trial on adjuvant hepatic-artery infusion chemotherapy after R0 resection of colorectal liver metastases, Langenbecks Archives of Surgery 1999; 384 (3): 243-249. 9. Huffman GR, Uzar A, and Choti MA, Effect of an initial positive margin on the prognosis of patients undergoing liver resection for hepatocellular carcinoma, Society for Surgery of the Alimentary Tract Abstracts, 1998 Digestive Disease Week. 10. Shi Lanling and Shi Peiquan, Experience in Treating Carcinomas with Traditional Chinese Medicine, 1992 Shandong Science and Technology Press, Shandong. 11. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle, 1992 Fujian Science and Technology Publishing House, Fujian. 12. Han JQ, Chen SD, and Zhai LM, Clinical study of combined Chinese herbal medicine with move stripe field radiation in treating primary hepatocellular carcinoma, Chinese Journal of Integrated Traditional and Western Medicine [Chinese] 1997; 17(8): 465-466. 13. Lu Nailang, et al., Bupleurum and Turtle Shell Combination in treating primary liver cancer, Sichuan Journal of Traditional Chinese Medicine 1989; 5: 30-31. 14. Yu Erxin, Combined treatment of advanced primary hepatocellular carcinoma with traditional Chinese medicine and Western medicine, Chinese Journal of Integrated Traditional and Western Medicine 1997; 3(2): 86-88. 15. Cheng Jianhua and Liu Xinhong, Development in the interventional herbal treatment of primary liver cancer, Chinese Journal of Integrated Traditional and Western Medicine 1998; 4(1): 61-65. 16. Peng Zhengshun, et al., Therapeutic effects of perfusing compound Salvia miltiorrhiza injection through the hepatic artery in the late stage of hepatocellular carcinoma, Chinese Journal of Integrated Traditional and Western Medicine 1995; 1(3): 179-183. 17. Chen Changhuai, et al., Observation on primary liver carcinoma treated with Qinglong Bolus, Journal of Traditional Chinese Medicine 1996; 37(3): 165-166. 18. Jia Kun Jia Kun, Prevention and Treatment of Carcinoma in Traditional Chinese Medicine, 1985 The Commercial Press, Hong Kong. 19. Ou Ming, et al., An Illustrated Guide to Antineoplastic Chinese Herbal Medicine, 1990 The Commercial Press, Hong Kong. 20. Hong-Yen Hsu, Treating Cancer with Chinese Herbs, 1990 Oriental Healing Arts Institute, Long Beach, CA. 21. Li Huigang, et al., A report on four cases of liver carcinoma treated by topical adhesive method, Journal of Traditional Chinese Medicine 1996; 16(4): 243-246. 22. Yang Genglu, et al., Controlling cancerous pain with analgesic powder for cancers, Journal of Traditional Chinese Medicine 1995; 15(3): 174-177. 23. Wang Guimian, et al., The application of traditional Chinese medicine to the management of hepatic cancerous pain, Journal of Traditional Chinese Medicine 1994; 14(2): 132-138. 24. Yang Zongyan and Sui Xiwen, An analysis for death causes in 45 cases of liver cancer treated with traditional Chinese drugs, Journal of Traditional Chinese Medicine 1999; 19(2): 97-99. 25. Hsu HY, et al., Oriental Materia Medica, 1986 Oriental Healing Arts Institute, Long Beach, CA. 26. Chen Weiqiang and Chen Yangshu, Effect of mushroom polysaccharide injection on T-cell subset and soluble interleukin-2 receptor in peripheral blood in primary hepatoma patients, Chinese Journal of Integrated Traditional and Western Medicine 1998; 4(4): 296-297. 27. He Yong He and Fang Jiliang, Traditional Chinese medicine combined with hepatic arterial chemotherapy and embolization in treating primary hepatocellular carcinoma, Chinese Journal of Integrated Traditional and Western Medicine 1997; 3(2): 117-119.

28. Liu Fang, Application of traditional Chinese drugs in comprehensive treatment of primary liver cancer, Journal of Traditional Chinese Medicine 1990; 10(1): 54-60. 29. Chen Jiarong and Jiang Hong, Current status of application of insect and snake drugs in treating pain of the waist and legs, Chinese Journal of Orthopedics and Traumatology 1993; 6(1): 46-48. 30. Liu Yulong and Liu Weisheng, Clinical research on constipation caused by opioid analgesics treated by "adding water to float boat method," New Journal of Traditional Chinese Medicine 1999; 13(1): 17-18. 31. Pan Minqiu and Li Yacheng, Treatment of primary hepatic cancer of the II and III stages with Chinese medicinal herbs , unpublished manuscript, 1999 Hunan Tumor Hospital. 32. Chang Minyi, Anticancer Medicinal Herbs, 1992 Hunan Science and Technology Publishing House, Hunan. 33. Tian Qiong, Guo Weiping, and Wang Suoci, Treatment of hepatocellular carcinoma with dilong capsule and intra-arterial chemotherapy, Chinese Journal of Clinical Oncology 1994; 21(6): 445. 34. Wu Ysheng, Clinical observations of terminal primary hepatocellular carcinoma treated by traditional Chinese medicine in 35 patients, New Journal of Traditional Chinese Medicine 1991; 23(10): 21-23. 35. Wang Delong, Analysis of 70 cases of primary liver carcinoma treated by Putuo Plaster and herbs, Chinese Journal of Integrated Traditional and Western Medicine 1990; 10(12): 723-725. December 1999

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REDUCING INFLAMMATION WITH DIET AND SUPPLEMENTS: The Story of Eicosanoid Inhibition general review by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Several important diseases are mediated by production of molecules known as eicosanoids, so named because they are derivatives of the 20-carbon arachidonic acid ("eicos" is from the Greek word eikosi, the number 20; see Figure 1). These diseases include heart attack, asthma, arthritis, ulcerative colitis, asthma, dysmenorrhea, and recurrent headaches.

Figure 1: Arachidonic acid: three dimensional representation, top; chemical structure diagram, bottom. The molecule is a long chain of CH and CH2 units, terminated by the acid unit (COOH). There are 20 carbons in a linear chain that is folded as indicated in the 3-D representation. The story of eicosanoids and their involvement in inflammation and chronic diseases is complex and rapidly evolving. Information here is necessarily simplified and is intended to help explain the basis for consuming certain foods, oil-based supplements, and herbs in an effort to prevent or help control certain diseases. The eicosanoids of concern are divided into three groupings (further subdivided by letter and number, as in PGE 1 , based on the structural features of the molecule: see Figures 2 and 3 for chemical structure diagrams and Tables 1 and 2 for individual eicosanoid effects): prostaglandins (PG): primarily have the effects of influencing platelet aggregation (inhibiting or increasing) and constricting or relaxing blood vessels. Some prostaglandins have favorable effects, such as insuring the integrity of the gastric lining, regulating kidney function, and initiating some stages of childbirth, but many produce negative effects, such as intensifying pain, causing cramping, and restricting blood circulation. PGE2 is one of the main prostaglandins involved in inflammation. thromboxanes (TX): are produced by platelets; they enhance platelet aggregation and also cause constriction of blood vessels and bronchioles. Thromboxanes are mostly known for their negative impact, particularly on cardiovascular health (TXB) and also as contributor to asthma (TXA), but they may play a role in the immediate response to injury, to limit blood loss. leukotrienes (LT): are produced by immune system cells and stimulate production of immune system signaling molecules such as interleukins (IL), interferon (IFN), and substances involved in anaphylactic reactions. Leukotrienes are mostly known for their contribution to allergies and autoimmune diseases. There are other, less well-studied eicosanoids (e.g., such as those known as HETEs and EETs and lipoxins, all these being closely related to the leukotrienes). The process yielding inflammation and/or more severe disease symptoms begins with a stimulus (e.g., injury, infection, autoimmune trigger) that produces increased cellular cAMP, promoting production of the eicosanoids. This initiation process is followed by a cascade of events involving responses to these eicosanoids, potentially yielding fluid exudation, circulatory changes, increased pain sensitivity, and other manifestations of the disease. While inflammatory responses to acute infections and injuries mediated by these eicosanoids have certain beneficial effects, persistent inflammation has a degrading effect that can lead to debility and death.

Figure 2: Prostaglandins and thromboxanes. Prostanoic acid is the basic prostanoid molecule, and the ring structure (top) varies to yield the different groups of prostaglandins and thromboxanes (bottom). These are all formed from arachidonic acid by the action of the COX enzymes.

Figure 3: Leukotrienes; these are formed from arachidonic acid by action of the LOX enzymes.

EICOSANOID PRODUCTION Eicosanoids are produced primarily from arachidonic acid that has been released from cell membrane phospholipids by the action of the enzyme phospholipase-A2. This enzyme is routinely present to participate in the maintenance of the cell membranes, but is induced in larger amounts by the triggers that are involved in initiating or maintaining inflammation. Release of arachidonic acid by phospholipaseA2 can be inhibited by the action of corticosteroid drugs. Most drug treatments for diseases that involve painful inflammation block the production of eicosanoids after arachidonic acid has already formed (see Figure 4 for site of action diagram). The most frequently used drugs inhibit the cyclooxygenase enzymes (COX). This is understood to be one of the main roles of the over the counter non-steroidal anti-inflammatory drugs (NSAIDS), such as aspirin, acetaminophen, and ibuprofin. There are several cyclooxygenases, of which COX-1 and COX-2 are most intensively studied (a third, COX-3, is under investigation). Although there are some caveats to this statement, the general view is that inhibiting COX-2 reduces inflammation, while inhibiting COX-1, which can also inhibit inflammation, produces many of the undesired side effects of the drugs (by blocking production of desirable prostaglandins, thus causing gastric damage and, with prolonged use of high doses, renal toxicity). This interpretation arises because COX-1 enzymes are produced in most of the body tissues and are present all the time, helping maintain homeostasis, while COX-2 is present in more limited quantity and in only some tissues, but appears in large amounts in response to inflammation triggers (COX-2 induction is inhibited by corticosteroid drugs). So, a recent area of drug development (since 1990, with drugs appearing in 1999) has been with inhibitors that target COX-2, but leave COX-1 uninhibited. The COX enzymes are involved in producing both PGs and TXs (these two groups of cyclic eicosanoids are called prostanoids). Unfortunately, it turns out that blocking COX-2 strongly and for a prolonged period, can still have adverse effects by inhibiting some desirable byproducts of its action and by diverting arachidonic acid metabolism to production of undesirable leukotrienes (and HETEs). COX-2 inhibitors have fewer gastric side effects than general COX inhibitors, but still have them; they may also produce undesirable cardiovascular side effects. All of the drugs blocking prostanoid synthesis from arachidonic acid are usually preferred over the more powerful steroids because of undesirable systemic effects of the steroids. Most recently, much interest has focused on LOX (lipoxygenase) inhibitors that mainly block leukotriene synthesis. There are three main LOX enzymes that are known to be involved in the leukotriene pathway, 5-LOX, 12-LOX, and 15-LOX. Most attention has focused on 5-LOX, which appears to be the key enzyme when it comes to blocking leukotriene synthesis. For many diseases, especially

those with a basis in autoimmune processes, where immune cells are intimately involved, inhibiting the prostanoids is not sufficient to give relief. For asthma, where constriction of the bronchioles is the trigger to an attack, LOX inhibitors are a critical method of therapy and this application is the first one for drug development (leukotrienes induce bronchiospasm; prostaglandin inhibitors, such as aspirin, can induced asthma attacks, perhaps by leaving more arachidonic acid available for the LOX enzymes). Ideally, one would like to be able to inhibit both COX-2 and 5-LOX simultaneously, to maximize anti-inflammatory effects. Thus, drug researchers are now intensively seeking compounds of low toxicity that block COX-2 and 5-LOX.

Figure 4: Steps in the biosynthesis of eicosanoids where different drugs have their effects (the usual NSAIDs are COX inhibitors; LOX inhibitors are NSIADS of a new type). TABLE 1. Properties of Significant Eicosanoids. Some eicosanoids affect immune messengers called interleukins (ILs; especially IL1α and IL-2) and interferon-gamma (INF-γ). Eicosanoid

Major Site(s) of Synthesis

Major Biological Activities inhibits platelet and leukocyte aggregation, decreases T-cell proliferation and lymphocyte migration and secretion of IL-1Α and IL-2; induces vasodilation and production of cAMP increases vasodilation and cAMP production, enhancement of the effects of bradykinin and histamine, induction of uterine contractions and of platelet aggregation; decreases T-cell proliferation and lymphocyte migration and secretion of IL-1Α and IL-2 increases vasoconstriction, bronchoconstriction and smooth muscle contraction a short-lived precursor to thromboxanes A2 and B2 , induction of platelet aggregation and vasoconstriction

PGD2

mast cells

PGE2

kidney, spleen, heart

PGF2α

kidney, spleen, heart

PGH2

many sites

PGI2

inhibits platelet and leukocyte aggregation, decreases T-cell proliferation and lymphocyte heart, vascular endothelial migration and secretion of IL-1Α and IL-2; induces vasodilation and production of cells cAMP

TXA2

platelets

induces platelet aggregation, vasoconstriction, lymphocyte proliferation and bronchoconstriction

TXB2

platelets

induces vasoconstriction

LTB4

immune cells*

induces leukocyte chemotaxis and aggregation, vascular permeability, T-cell proliferation and secretion of INF-&gamma , IL-1 and IL-2

LTC4

immune cells*

component of SRS-A**, induces vasodilation, vascular permeability and bronchoconstriction and secretion of INF-&gamma

LTD4

immune cells*

predominant component of SRS-A, induces vasodilation, vascular permeability and bronchoconstriction and secretion of INF-&gamma

LTE4

mast cells and basophils component of SRS-A**, induces vasodilation and bronchoconstriction * mainly from immune cells, such as monocytes, basophils, alveolar macrophages, neutrophils, eosinophils, mast cells, epithelial cells; ** SRS-A = slow-reactive substance of anaphylaxis TABLE 2. Physiological Effects of Prostanoids.* Affected Part

Effects of Specific Prostanoids

Vascular smooth muscle

PGEs & PGI2 → smooth muscle dilation → vasodilation PGF2a & TXA2 → vasoconstriction

GI tract smooth muscle

PGI2 , PGF2 & PGI2 → smooth muscle contraction → cramps PGE → decreased gastric acid secretion & ulceration

Lung smooth muscle

PGI2 & PGE2 → vasodilation & constriction, respectively TXA2 is a vasoconstrictor & bronchoconstrictor PGFs contract while PGEs relax respiratory smooth muscle

Platelets

PGE1 & PGI2 → decreased platelet aggregation TXA2 → increased platelet aggregation

Reproductive organs

PGE2 & PGF2a → uterine contractions initiate & stimulate labor; menstrual pain

Kidneys

PGE regulates arteriolar tone, compensatory vasodilatation, maintains normal blood flow, increased glomerular filtration rate

fever: PGEs act on thermoregulatory center in brain → increased body temperature pain: PGs → sensitize pain receptors to stimulation → increased pain PGs promote vasodilation & increased vascular permeability *Note: The other eicosanoids, leukotrienes (LTs), are less fully researched and more consistent in their actions than the prostaglandins and thromboxanes. All LTs are extremely potent smooth muscle contractors. LTB4 promotes white blood cell adherence, chemotaxis & degranulation. LTC4 , LTD4 & LTE 4 promote increased vascular permeability, plasma exudation & mucus secretion. LTs also promote bronchoconstriction and vasoconstriction; they decrease myocardial contractility and coronary blood flow. Inflammatory processes

DIET, EICOSANOIDS, AND INFLAMMATION Even if drug therapy successfully blocks the COX and LOX enzyme systems, arachidonic acid can still be converted into other damaging molecules, such as epoxy derivatives. So, another approach to treating the diseases involving eicosanoids seems desirable: to try to prevent eicosanoid production by dietary modifications. Not all of the phospholipids in cell membranes include arachidonic acid, only those that were derived from certain dietary fatty acids, mainly linoleic acid. The concept of dietary control over these diseases is based, in part, on starving the eicosanoid system by reducing the fatty acids (specifically, the polyunsaturated fatty acids, PUFAs) that can eventually make arachidonic acid, thereby slowing down the production of eicosanoids when a stimulus occurs. Two main fatty acid groups are considered in relation to this dietary approach: one is the omega-6 fatty acids, which become phospholipids readily converted into arachidonic acid, and other is omega-3 fatty acids, which become phospholipids that are not as easily converted to arachidonic acid (they become, instead EPA and DHA; see Figure 5). The difference between omega-3 and omega-6 fatty acids is the location of double bonds in the hydrocarbon chain. The dietary approach requires learning the fatty acid profile of food oils (see Table 3) in order to shift from one high in omega-6 fatty acids (which is the normal condition for most diets) to one high in omega-3 fatty acids. As can be seen in Table 3, if one is seeking to consume a high proportion of omega-3 fatty acids compared to omega-6 fatty acids, there are very few oils that are especially favorable. Oils that are considered beneficial in other contexts (e.g., olive oil, non-animal oils, wheat germ oil, etc.) do not present a favorable fatty acid ratio (they may have less saturated fats and contain other beneficial constituents). Of the food materials listed, only fish provide a significant omega-3 profile and do so with both short chain and long chain fatty acids. Fish oil provides a second benefit, in that it reduces T-cell stimulation in the intestinal tract that may be involved in triggering inflammation and auto-immune responses. Perilla seed oil and flax seed oil are usually obtained as dietary supplements, not used as foods. Canola oil, which has become a mainstay of the food product manufacturing industry, is considered valuable because it has low saturated fat, a relatively favorable omega-3/omega-6 ratio (the best of the readily available vegetable sources), and is easy to get and inexpensive. Olive oil, considered amongst the most healthful, contains a relatively large amount of oleanolic acid, which may help block eicosanoid production; it can have a favorable effect, but not by providing large amounts of omega-3 fatty acids.

Figure 5. Right: enzyme action on dietary oils: production of arachidonic acid from omega-6 fatty acids; omega-3 fatty acids yield, instead, eicosapentaenoic acid (EPA), which is further metabolized to form docosahexaenoic acid (DHA). Left: the basic dietary omega-6 fatty acid (linoleic acid) and its product arachidonic acid; the basic plantbased omega-3 fatty acid and its product of metabolism, DHA, which, like EPA, is obtained directly from fish oil. The molecules are labeled according to the number of carbons and number of double bonds in the chain. TABLE 3. Fatty Acids of Food Oils in Descending Rank by Short Chain Omega-3/Omega-6 Ratio. The oils have been subdivided by categories, but the list order for all oils is by omega-3/omega-6 rank, not just by category. The data shown indicates parts per million (ppm) of the component in the oil. These oils provide about 120 calories (kilocalories) per tablespoon. Long chain (20 and 22 carbon) fatty acids are almost exclusively found in fish oils; the long chain omega-3 fatty acids in fish are EPA (20-carbon) and DHA (22- carbon). Data were provided by the National Institutes of Health. Food Oil Identity and Specification

18-carbon Short 6

Short 3

20- & 22-carbon Long 6

Long 3

Herbal Oils: Selected for High Omega-3 Fatty Acid Content Perilla seed oil

1680

8960

0

0

Flaxseed oil

2240

7980

0

0

Fish Oils: High in Long-Chain Omega-3 Fatty Acids

Fish oil, herring

156

417

39

1509

Fish oil, salmon

210

525

92

4657

Fish oil, sardine

274

592

239

3096

Fish oil, cod liver

127

254

127

2557

Fish oil, menhaden

293

575

159

3624

Miscellaneous Oils with at Least 10% Omega-3 Butter oil (ghee; moisture removed)

288

185

0

0

Oil, canola

2842

1302

0

0

Oil, mustard

2146

826

0

0

Oil, walnut

7194

1414

0

0

Oil, soybean

6936

925

0

0

Oil, soybean lecithin

5465

698

0

0

Oil, wheat germ

7453

938

0

0

Shortening, household, lard + vegetable oil

1242

141

0

0

Miscellaneous Oils with Considerably Less than 10% Omega-3 Oil, olive

1067

81

0

0

Oil, soybean (hydrogenated; margarine)

4746

354

0

0

Mayonnaise, soybean and safflower oil

7176

414

0

0

Shortening, industrial, lard + vegetable oil

2317

128

0

0

Oil, sunflower > 70% oleic

505

27

0

0

Oil, rice bran

4542

218

0

0

Margarine-butter blend

2162

103

0

0

Oil, palm

1238

27

0

0

Oil, corn

7888

95

0

0

Oil, sesame

5617

41

0

0

Oil, sunflower, linoleic < 60%

5413

27

0

0

Oil, cottonseed

7004

27

14

0

Oil, grapeseed

9466

14

0

0

Miscellaneous Oils with no Detectable Omega-3 Oil, peanut

4320

0

0

0

Oil, coconut

245

0

0

0

Oil, sunflower, linoleic > 60%

8935

0

0

0

Oil, palm kernel

218

0

0

0

The idea of adjusting the diet and taking supplements to control eicosanoid-based diseases is a popular one amongst some proponents of natural health care, and there is considerable research supporting the approach, but it must be viewed in proper context. Fats in a healthy diet comprise about 30% of the daily caloric intake, and it is recommended that polyunsaturated fatty acids make up about 10% of the caloric intake. This corresponds, roughly to 150 grams of PUFAs per week. What contribution will be made from eating fish and taking supplements? The fish with the highest levels omega-3 fatty acids are listed in Table 4. If a person consumes 1 pound of fish per week, this provides about 2-10 grams of omega-3 fatty acids. If one additionally takes encapsulated oils, either from plant sources or fish, the usual dosing is about 3 grams of oil per day. Up to 2/3 of the supplement oil may be omega-3 fatty acids (mainly as EPA and DHA in the fish oil), so up to 14 grams per week can be obtained from taking capsules. Together, these measures might contribute about 10-15% of one's total PUFA intake. To further assure a good level of omega-3 versus omega-6 fatty acids, one would minimize consumption of oils that are at the bottom Table 3. When consuming meats, preference should be given to those from grass-fed animals rather than corn-fed animals, as the meat of the former will have some omega-3 fatty acids, while the latter will not (corn provides almost no omega-3 fatty acids). TABLE 4. Examples of Fish with High Levels of Fats and Omega-3 Fatty Acids. Amounts shown are percent of the uncooked fish, as presented typically in shops. Fish

% Total Fat

% Omega-3 Fatty Acids

Pollack

1.0

0.4

Halibut

2.3

0.4

Striped bass

2.3

0.8

Smelt

2.4

0.7

Rainbow trout

3.4

0.6

Swordfish

4.0

0.6

Bluefish

4.2

0.8

Freshwater catfish

4.3

0.4

Bluefin tuna

4.9

1.2

Salmon (Atlantic)

6.3

1.4

Albacore tuna

7.2

2.1

Lake trout

9.4

1.4

Chinook salmon

10.4

1.4

Mackerel (Atlantic)

13.9

2.3

Herring (Atlantic)

18.0

1.6

Over the long term, with years of following such a regimen of eating fish and/or using favorable vegetable oils and taking supplements, while reducing omega-6 rich foods, certain health benefits can be expected (statistically) because of the lower production of eicosanoids. In areas where fish consumption is high, such as Japan, Greenland, and the areas bordering the Mediterranean Sea, the population ingests a considerably higher proportion of omega-3 fatty acids than in other areas where there is little fish consumption, and the measured risk for death by cardiovascular diseases is decreased. This indicates that years of eating such a diet may reduce the vasoconstriction, platelet aggregation, and chronic arterial inflammation that lead to heart attacks and stroke. Similarly, it is believed that such diets can reduce the incidence of certain cancers, such as prostate cancer and colon cancer, by a similar mechanism of reducing adverse eicosanoid effects. By contrast, attempting to strongly control inflammation in acute manifestations such as asthma and arthritis by diet alone becomes much more difficult. Not only is it difficult to get adequate quantities of omega-3 fatty acids to resolve the acute condition (since omega6 fatty acids are still so prevalent), but excessive use of omega-3 fatty acids, via supplementation, may have undesired effects. At high levels, these fatty acids may produce an undesired level of immune suppression and they serve as pro-oxidants (which can be partly countered by consuming antioxidants in the diet, such as those in tea, fruits, and vegetables, or taking additional supplements, such as vitamins C and E). To have a strong favorable impact in a short time, a more dramatic change in eicosanoid production may be needed, attained by limiting production of eicosanoids from arachidonic acid.

BLOCKING OF COX AND LOX ENZYMES BY NATURAL THERAPIES Certain herbs (and individual active ingredients from herbs, see Appendix for the example of PCTs) inhibit the COX and/or LOX enzymes at dosages that can be appropriate for oral consumption. These may serve as alternatives to drugs, especially for milder forms of the eicosanoid-dependent diseases. Some of them are being used clinically, such as curcumin, boswellic acid, oleanolic acid, allicin, berberine, and the tea catechins. As this research is intensively being pursued, any list of potential agents is incomplete. Examples of herb ingredients with eicosanoid inhibitor activities are provided in Tables 5 and 6, modified from lists developed by Dr. James Duke. TABLE 5. Sample Plant Constituents with Cox-2 Inhibitor Activity. The substances listed here have been subjected to in vitro testing with effective concentrations determined. When possible, these concentrations are given in terms of IC50 (the inhibition concentration that yields a 50% inhibition of the enzyme). As a reference, the drug indomethacin has an IC50 of 1 uM. The lower the IC50 value, the more potent the compound. Units of measurement are either micromolar (uM) which takes into account the molecular weight of the substance, and micrograms/milliliter (ug/ml), which only takes into account the weight of the substance. Substance

Sample Plant Source

Inhibitor Activity Measure

Apigenin

tea, numerous sources

22.5 uM

Rutaecarpine

evodia (wuzhuyu)

2.5 ug/ml

Ursolic acid

ligustrum (nuzhenzi)

IC50 = 130 uM

TABLE 6. Sample Plant Constituents with Lox-Inhibitor Activity.

Sample Plant Source

Constituent

Inhibitor Activity Measure

Allicin

garlic (dasuan)

D = 25 ug/ml

Berbamine

hu-chang (huzhang)

IC50 = 40 uM

Berberine

coptis (huanglian), phellodendron (haungbai)

IC50 = 118 uM

Boswellic acid

frankincense (ruxiang)

IC50 = 1.5 uM

Caffeic acid

taraxacum (pugongying)

IC50 = 62-148 uM

Epicatechin

tea

IC50 = 140 uM

Epicatechin-gallate

tea

IC50 = 18 uM

Epigallocatechin

tea

IC50 = 21 uM

Fisetin

chih-shih (zhishi)

IC50 = 11 uM

Flavone

numerous

IC50 = 32 uM

Galangin

galanga (liangjiang)

IC50 = 20 uM

Morin

morus (sangbaipi)

IC50 = 160 uM

Quercetin

numerous

IC50 = 0.1-5 uM

Theaflavin digallate

tea

IC50 = 0.25 uM

Ursolic acid

ligustrum (nuzhenzi)

IC50 = 180 uM

SUMMARY AND SUGGESTIONS There is no doubt that inhibiting eicosanoid synthesis by modern drugs therapies is effective for many people in reducing the inflammation and the accompanying pain of many diseases, particularly arthritis. It has been shown that regular consumption of aspirin, even in small doses of about 80 mg/day, reduces risk of heart attack and colon cancer, and this effect appears to be mediated, at least in part, by inhibiting eicosanoids. For those suffering from serious diseases, many wish to avoid using the standard drugs, or avoid using them frequently, due to experience of side effects or concerns about side effects. Prolonged use of corticosteroid drugs and NSAIDS has been linked to serious reactions in some individuals. In order to take reasonable steps to minimize the symptoms of these diseases through means other than relying on the drugs, it is important to understand the process by which the inflammation and other disease manifestations (e.g., platelet sticking, bronchiospasms) occur. Detailed analysis of the pathways to inflammation indicate that linoleic acid, the basic omega-6 fatty acid, is transformed into arachidonic acid, which is incorporated into phospholipids making up all cell membranes. A stimulus then returns the phospholipid to arachidonic acid, which is metabolized by certain enzymes (mainly COX and LOX) into prostaglandins, thromboxanes, and leukotrienes that are critical to yielding various disease manifestations, including constriction of blood vessels and bronchioles, changes in platelet function, and development of inflammation. Two basic means of interrupting this pattern seem evident: 1. Avoid producing arachidonic acid by ingesting less linoleic acid and, instead, load the membranes with phospholipids derived from omega-3 fatty acids, so that the initial stimulus to inflammation produces less arachidonic acid. 2. Inhibit the enzymes (e.g., COX and LOX) involved in the production of the eicosanoids from arachidonic acid. This is the function of modern drug therapies, including steroids and non-steroid drugs, but can also be a goal of herbal therapies. To load the body with omega-3 fatty acids in place of omega-6 fatty acids, one can consume oily fish (with salmon, albacore tuna, and sardines being palatable and readily available options) in place of other foods (e.g., corn-fed beef), and rely on food oils that have a higher ratio of omega-3 to omega-6 fatty acids than might normally be consumed. The main food oils (readily available and commonly used) with somewhat favorable fatty acid profiles are butter, canola oil, and soy oil. The food sources can be supplemented by speciallyprepared oils, usually made available in capsules. The primary supplements with omega-3 fatty acids are perilla seed oil, flax seed oil, and fish oil. One should be careful, however, not to rely excessively on these oil sources for a prolonged period, particularly the herbal supplements, as they may be missing beneficial components that can be obtained from other dietary oils and the herbal oils might contain some ingredients that are not beneficial with long-term use. Even when dietary changes are made and supplements are taken to increase omega-3 fatty acids, there are still plenty of dietary omega-6 fatty acids to contribute to the process of inflammation, because so much of the naturally-occurring oils in foods are of the omega-6 type (these are usually the majority component). Still, the changes in diet and use of supplementary oils may reduce the severity of the inflammatory response sufficiently to reduce drug therapies. Inhibiting enzymes that produce eicosanoids from arachidonic acid is still of interest for those who can pursue the route of improving the balance of ingested oils. Drinking tea and consuming garlic (with food or in capsules or tablets) is a simple method of providing some inhibition of the COX and LOX enzymes (with other favorable effects expected from these dietary components). Curcumin (from turmeric), quercetin (from numerous sources; dietarily it is mainly obtained from onions, applies, fruit juices, and tea, supplements are often derived from eucalyptus), and boswellic acid (from frankincense), are apparently safe methods of getting these enzyme inhibitors. Researchers are also actively seeking other natural LOX inhibitors. Particularly promising are branched chain fatty acids, mainly 12-MTA and 13-MTA (methyltetradecanoic acid); these are potent inhibitors of the 5-LOX enzyme. Ursolic acid, a component of several herbs used in Chinese medicine, is a moderately strong inhibitor of both COX-2 and 5-LOX (see the Appendix). There is growing evidence that dietary factors can influence diseases, particularly in terms of lowering risk over an extended period of time. People who consume more fish, fruits, vegetables, and tea, have been shown in various studies to have a lower incidence of several serious diseases. Many fruits and vegetables provide flavonoids that may be inhibitors of inflammatory eicosanoids. Many of the

substances listed in Tables 5 and 6 are flavonoids (or modified flavonoids, such as polyphenols). There can be many contributing factors to yield health benefits from these dietary components, not just reduced eicosanoid production. Relatively high doses of effective herb components (comparable to doses of over-the-counter NSAIDS, which are typically taken in the range of several hundred milligrams per dose) may be useful in reducing acute inflammation by significantly blocking eicosanoid production. These dosages are not easily obtained in convenient form without using concentrated extracts of the herbs. Thus, the complete natural regimen for reducing inflammatory eicosanoid production includes dietary changes and use of supplements that include oils (rich in omega-3 fatty acids) and herb extracts that reduce arachidonic acid metabolism.

APPENDIX. Pentacyclic Triterpenes (PCTs) as Inhibitors of Inflammation Pentacyclic triterpenes (PCTs) are a subdivision of an important group of botanical active constituents known as triterpenoids; when complexed with sugar molecules PCTs are called triterpene glycosides, or saponins. Several of the PCTs have inhibitory action for the COX and/or LOX enzymes. Two of the most widely occurring and intensively investigated pentacyclic triterpenes are ursolic acid and its isomer oleanolic acid; their chemical formulas are identical, and their structures differ only by the location of a methyl group (CH3), as displayed at the top of the structure diagrams below (Figure 6). These substances are of considerable interest for potential health benefits, including protective effects against development of cancer, inhibition of existing tumor cells, protection against chemotherapy and radiation therapy adverse effects, anti-inflammatory activity, antioxidant activity, cardiovascular protective effects, and antiviral effects. Several medicinal herbs that contain oleanolic acid, such as ligustrum, forsythia, and swertia, are remedies employed in China and Japan for the treatment of hepatitis. Isolated oleanolic acid has already been used in China as a treatment for hepatitis for many years. Ursolic acid is known for its ability to inhibit skin inflammation; in Japan it is also used as a topical protectant against skin cancer.

Figure 6: Ursolic Acid (left), Oleanolic Acid (right). These compounds are synthesized in plants from squalene, a compound in which there are no closed carbon rings, but which has the basis for developing five ring (pentacyclic) compounds. Ursolic acid was named after the herb Uva Ursi (bearberry; urs is the root term for bear). Oleanolic acid was named for the olive (olea is the root term for olive), which is rich in this compound; there is a plant family called the Oleanaceae, whose members usually contain oleanolic acid. In general, plants that contain ursolic acid also contain oleanolic acid and vice versa.



Ursolic acid and oleanolic acid form a waxy coating that is found on some plant leaves and fruits. For example, Ligustrum trees (in the Oleanaceae family) are commonly called wax trees because of these components. Ursolic acid is one of the main waxy components on apples that contributes to the smooth, shiny appearance (not to be confused with waxes sometimes added to aid storage of fruits). Squalene (left) is found in some foods, mainly concentrated in oils, such as olive oil, wheat germ oil, and bran oil (about 0.5% of the oil). The most abundant source of squalene is the liver of deep sea sharks (up to 85% squalene in liver oil). Squalene from shark livers is sold in capsules as a dietary supplement that is claimed by proponents to enhance immune functions and reduce inflammation.

The pentacyclic triterpenes are subdivided into several groups, such as the following: Oleanane: oleanolic acid, ginsenosides (glycoside form), fusidic acid; Ursane: amyrin, ursolic acid, asiatic acid, boswellic acid; and Lupane: lupeol, betulin, betulinic acid Of these, PCTs other than oleanolic and ursolic acid that have received considerable attention are boswellic acid (from frankincense, the resin of Boswellia serrata); asiatic acid (from gotu kola, the aerial part of Centella asiatica), and betulinic acid (from birch trees, the bark of Betula spp.). Their pharmacology is similar to that of oleanolic and ursolic acid. For example, all are being investigated for anti-inflammatory and potential anticancer effects.

Boswellic acid

SOURCES OF OLEANOLIC AND URSOLIC ACID Chinese natural products manufacturers are now making high concentrations of oleanolic acid and ursolic acid for formulation in various internal and topical remedies. The technical extracts contain from 25% to 99% pure compound. By contrast, standard herb extracts (e.g., hot water extracts) have up to 2.0-2.5% of ursolic or oleanolic acid (commonly obtained from holy basil, Ocimum sanctum, a common ingredient in Ayurvedic formulas). Plants rich in ursolic acid include Greek sage (Salvia triloba), oleander, rosemary, lavender, and thyme (each having at least 1% ursolic acid in the leaf or whole plant)

DOSAGE Clinical use of ursolic acid as an isolate is new, but oleanolic acid, which is nearly identical in structure but apparently milder in action, has been used for some time. Effective daily doses of oleanolic acid, based on its application in treatment of hepatitis, are reported in the range of 75-300 mg/day. For a standard dried hot water extract of an herb, which may contain about 2% of the PCTs, that dosage corresponds to use of about 4-15 grams of the extract, a large amount. Additional information on dosage of compounds of this type (see: Platycodon and other herbs with triterpene glycosides ) indicates that a daily dose of about 300 mg is safe and potentially useful for long term applications and 600 mg is safe at least for short term dosage. Dr. Acharan Narula describes use of 300-500 mg or oleanolic acid as an intestinal anti-inflammatory and recommends Olenoate, a product of oleanolic acid in capsules of 100 mg each. For ursolic acid, in vitro studies have shown that it is about twice as effective as an anti-inflammatory compared to indomethacin, a potent NSAID that is administered in doses of just 50-100 mg/day; however, when converted to actual human use, the dose of ursolic acid needed may prove higher. Boswellic acid, another PCT that inhibits 5-LOX, and is used as an anti-inflammatory for arthritis, Crohn's disease, and asthma, is administered in doses of 400 mg 3 times a day of an extract standardized to contain 37.5% boswellic acids, which corresponds to 450 mg/day of boswellic acid. In general, the PCT dosage for anti-inflammatory effects appears similar to the dosage of NSAIDS.

May 2003

TREATMENT OF SYSTEMIC LUPUS ERYTHEMATOSIS (SLE) WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Lupus is an autoimmune disease involving antibodies that attack connective tissue. The disease is estimated to affect nearly 1 million Americans, primarily affecting women and arising mainly between the ages of 20-40. In China, lupus is even more prevalent than in the West, affecting about 5 million people. The principal disease form is a systemic one (systemic lupus erythematosis; SLE), which is the subject of this article, though a more circumscribed form, discoid lupus, sometimes occurs. The systemic disease includes production of antinuclear antibodies (ANA; mainly targeting the nucleic acid guanosine), generation of circulating immune complexes, and activation of the complement system. Most cases of lupus are mild; however, in some severe cases, untreated lupus can be fatal as it progresses from attack of skin and joints to internal organs, including lung, heart, and kidneys (with renal disease being the primary concern). Lupus mainly appears as a series of flare-ups, with intervening periods of little or no disease manifestation. Triggers for the flare-ups include emotional distress and ultraviolet light exposure; infections may also serve as triggers. Modern medical treatment involves immunosuppressive strategies, mainly the use of corticosteroids such as prednisone, which are given during periods of flare-ups, but may also be given persistently for those who have experienced frequent flare-ups. Even with effective treatment, which reduces symptoms and prolongs life, the combination of drug side effects and continued low-level manifestation of the disease can cause serious impairment and premature death. New disease management strategies include cyclophosphamide, methotrexate, antimalarials, hormonal treatment (e.g., DHEA), and antihormonal therapy (e.g., the antiprolactin agent bromocriptine). Antimalarial therapy has a long and successful track record in the management of patients with mild SLE, especially for patients who manifest cutaneous symptoms (it is usually effective for discoid lupus, which is characterized by cutaneous symptoms). Medium to long-term use of hydroxychloroquine, alone or in combination with mepacrine, ameliorates lupus and may reduce the relapse rate. The dose of corticosteroids given for lupus patients may be reduced when antimalarials are used, and the side effect profile of these antimalarials is quite limited (though overdosing can cause significant reactions). Antimalarials have certain beneficial effects on lipid and glucose metabolism as well as having weak anticoagulant activity. One of the main Chinese herb therapies for lupus is the antimalarial herb ching-hao (qinghao, Artemisia annua) and its active component arteannuan. Traditional Chinese texts from the Qing Dynasty period indicate an awareness of the disease, suggesting that summer heat causes the red patches to appear because of an underlying heat toxin in the blood that is activated by the heat. In fact, it could be that the sunlight (a natural and strong ultraviolet source) is the primary trigger, rather than heat. Herbs that clear heat and toxin, nourish yin (to control heat), or reduce the impact of damp-heat (associated with late-summer weather conditions) were recommended. The herbs and formulas for lupus were based on the treatments for warm diseases. Such formulas had been popularized by Wu Youxing and others as a response to numerous serious epidemic diseases that occurred toward the end of the Ming Dynasty period. Lupus, which often presented with fever as well as reddened skin, was considered one of the warm diseases. Chinese medical journals have relayed information about lupus treatment throughout the 20 th Century and it remains a subject of intense interest. In most cases, lupus is treated in China with corticosteroids; in addition, herbal therapies are frequently employed as an adjunct to steroids. The modern Chinese literature focuses on two primary means of treating lupus with herbs: using antitoxin herbs (usually in conjunction with herbs that vitalize blood circulation) and using ching-hao or its active components. Because the Chinese medical literature on lupus is so extensive, only sample information from recent clinical trials will be presented here to illustrate the practices that have evolved after several decades of experience. Because it is difficult to interpret clinical results with lupus treatments due to the high variability of the disease manifestation in each person over time, only the details of the treatment methods and some laboratory measurements will be relayed here. In all cases, the study authors determined that the patients who were treated with herbs plus prednisone responded better than those who were treated with prednisone alone (e.g., quicker response time, more complete resolution of symptoms, less prednisone required so fewer side effects). The basic treatment time in each case is 3 months, which would often be repeated for a total of six months treatment duration.

SAMPLE TRIALS Trial I. Over the period 1993-1998, doctors at the Zhejiang College of TCM (Hangzhou) treated 149 cases of SLE (1). The patients were randomized into two groups: 1. The predinsone plus herbs group-92 patients, 86 females and 6 males, aged 15-67 years, mean 30 years; course of disease: two months to 5 years, average 2 years; and 2. The prednisone group-57 patients, 51 females and 6 males, aged 16-61 years, mean 29 years; course of disease: 3 months to 6 years, average 2 years. The two groups resembled each other in sex, age, course of disease, and pathological activity. Symptoms frequently identified were oral ulceration, skin lesions, fever, joint pain, irregular menstruation (excessive bleeding), and photosensitivity. The prednisone therapy was administered in the same way for both groups, with dosing in the range of 10-60 mg of prednisone per day depending on the pathological status. When the symptoms improved, the prednisone dose was tapered until it could be stopped entirely. The basic herb formula was composed of the toxin-cleaning, stasis-resolving, and yin-nourishing agents (the latter help control the heat syndrome): 30g buffalo horn slice (decocted before adding the other ingredients), 30g isatis leaf, 30g oldenlandia, 12g red peony, 12g moutan bark, 6g cimicifuga, 18g rehmannia, and 12g ophiopogon. This formula is based on the traditional Xijiao Dihuang Tang (Rhino Horn and Rehmannia Combination) with a high dose of buffalo horn replacing a small dose of rhino horn, as is common in modern Chinese practice. Aside from the formula's named ingredients, the other two components of the traditional formula are moutan and red peony; it is indicated for erythema due to feverish diseases. In this case, isatis leaf, oldenlandia, and cimicifuga are added to the

traditional formula as antitoxin herbs, based on the theory that a hidden toxin remains in the blood and is activated by summer heat. Ophiopogon is added to extend the yin nourishing and heat clearing effects of rehmannia. Modifications to the base formula were made as follows: with obvious erythema, add 9g ching-hao, 30g lithospermum, and 9g campsis flower; for joint pain, add 30g erythrina bark, 30g clematis, 12g chin-chiu (qinjiao), and 15g millettia; for oral ulcer, add 7g raw licorice, 9g scute, and 12g sophora root; for fullness in the abdomen and with poor appetite, add 9g magnolia flower, 10g fu-shou, and 12g gallus; for irregular menstruation, add 12g raw peony, 6g blackened typha, and 30g leonurus; Trial II. In a follow-up study at the same institute (2), the researchers evaluated 45 SLE patients during the period 1995-1999, divided into two groups (2): 1. The prednisone plus herbs group-25 cases, 2 males and 23 females, aged 16-53, average 30 years; and 2. The prednisone group-20 cases, 2 males and 18 females, aged 20-55, average 30 years. The two groups resembled each other in sex, age, and pathological condition, without significant difference. Additionally, a healthyperson control group of 30 healthy blood donors, aged 18-56, mean 29 years, was included for evaluation of blood components. For the prednisone group, according to the pathological state, prednisone was used at a dose of between 10 mg and 60 mg; when the condition improved, the prednisone was decreased gradually. The herb group took a formula called Langchuangding as well as prednisone. Langchuangding was similar to the previously reported formula, with 18g rehmannia, 12 g ophiopogon, 9g ching-hao, 30g isatis leaf, 30g oldenlandia, 12g red peony, 10g moutan, 30g lithospermum, and 9g campsis, decocted in water, taken two divided doses, morning and at night. Lithospermum is an herb commonly employed when there is redness of the skin; it is included in formulas for erythema and acne. One of the objectives of the study was to measure blood levels of neopterin, a substance metabolized from the nucleic acid guanosine. It is produced from macrophages stimulated by ?-interferon and released by activated T-lymphocytes. The neopterin level can sensitively reflect an activated state of the cell mediated immune system, which can be widely employed for monitoring autoimmune diseases, transplantation immune rejection, tumors, and acute or chronic infectious ailments. This study revealed that the serum neopterin level of SLE patients was distinctly higher than that of the healthy control group (655 vs. 265 µg/liter), as had been shown in other evaluations, supporting the view that activation of the cellular immune system was involved in the SLE flare-ups. The addition of Chinese herbs to the treatment helped lower neopterin levels (to 354 µg/liter), as well as reducing erythrocyte sedimentation rate, complement C3 levels, and symptoms of facial erythema and oral ulceration. Similarly, it was shown that the immunostimulant soluble blood component interleukin-2R (sIL-2R) is elevated in patients with lupus, and declines during periods of remission and upon treatment with the Chinese herb formula. Trial III. In a small trial conducted in 1997 at the First Affiliated Hospital of Guangzhou University of TCM, patients were similarly divided into two groups (3): 1. The integrated group-25 patients, 3 males and 22 females, aged 12-49 years, average 29 years; and 2. The control group-20 patients, 2 males and 18 females, aged 13-51 years, average 30 years. The two groups were comparable each other, with an average 3.5 years duration of disease. The group receiving herbs were given Lingdan Pian, which was composed of ching-hao, moutan, chin-chiu (qinjiao), turtle shell, buffalo horn, rehmannia, licorice, scrophularia, and other herbs. Each tablet contained 0.5 g crude herbs made by the pharmacy of the author's hospital, 5 tablets a time, 3 times per day. The patients also received arteannuin (in the form of succinic ester), 50 mg a time, twice a day, and a low dose of prednisone, 0.25-0.80 mg/kg (i.e., for a woman of about 50 kg, 10-40 mg/day), taken once upon rising in the morning. The control group received only prednisone, but at a higher dose of 0.81-1.25 mg/kg (i.e., for a woman of about 50 kg, 40-60 mg/day), taken once upon rising. The patients would also be treated with stomach-protectant (to avoid damage due to steroids), vitamins, and symptomatic treatments. As can be seen, all patients in the three evaluations took rehmannia and moutan, the classic herbs for treating redness due to heat in the blood. Ching-hao was included in most treatments and is reported to improve the T-cell activities by promoting the suppressor cells (T-8 cells) so as to reduce the hyperactivation of the T-4 cells that promote the autoantibody production. The herb chin-chiu was also used frequently; this herb is thought to provide a powerful anti-inflammatory action, thereby lowering the required dosage of prednisone to be used. All patients took prednisone, the standard Western medical treatment for inflammatory autoimmune diseases. Together, the herbs and drugs were said to provide prompt alleviation of symptoms, improve immunological parameters, and reduce the dosage requirement for drugs. The nephrotic syndrome that often accompanies lupus after several years of flare-ups is one of the life-threatening complications, though modern drug therapy and renal transplant technology can prevent loss of life. the syndrome is usually marked by a large quantity of albumin (protein) in the urine, with corresponding decline of serum albumin, and with some edema. From the perspective of traditional Chinese medicine, most of these patients suffer from qi and/or yang deficiency of the spleen and kidney, often with complications of blood stasis. As with the general treatment of lupus, all patients receive Western medicine and some also receive Chinese medicine. The Western medicine therapy used most often is cyclophosphamide, a highly toxic drug that must be used carefully; it is often given in pulsed therapy to avoid continuous exposure. Prednisone could also be used along with cyclophosphamide. As an example of evaluating the mixed drug and herb therapy, a study at the Department of Nephrology at the Second People's Hospital of Fujian (4) compared use of the drug therapy alone (75 patients) or accompanied with Chinese herbs (80 patients). The Chinese herb therapy was based on differential diagnosis of the patients, with most patients receiving either a modification of the traditional Zhen Wu Tang (Vitality Combination) or a

modification of the traditional Shen Ling Baizhu San (Ginseng and Atractylodes Formula). The base formula derived from Zhen Wu Tang contained 9g aconite, 6g atractylodes, 10g hoelen, 10g peony, and 9g fresh ginger. The base formula derived from Shen Ling Baizhu San contained 12g codonopsis, 12g hoelen, 12g atractylodes, 15g rehmannia (cooked), 10g coix, 15g eucommia, and 10g cornus. To these base formulas, additional herbs could be used to address blood stasis (e.g., leonurus, salvia, persica, carthamus, cnidium, red peony), renal obstruction (e.g., rhubarb and oyster shell), or toxic heat syndrome (e.g., oldenlandia, scutellaria, lithospermum). During the 3-month course of therapy, if certain other syndromes arose (such as yin deficiency or yang deficiency), appropriate herbs could be added to address these disorders. According to the authors of the study report, symptoms of fever and edema cleared up more quickly when the herbs were used (10 days vs. 22 days for fever; 15 days vs. 32 days for edema), while there was no difference in the rate of improvement for skin rashes (32 days) and arthritis (16 days). Further, those taking the herbs had a more complete resolution of imbalances in plasma and urinary albumin and blood creatinine. It was further claimed that the side effects of cyclophosphamide and prednisone were less in the group treated with Chinese herbs. In conclusion, Chinese medicine appears to be suitable as an adjunct to modern medical therapies when used for a period of about 3 months, a course of therapy that is to be repeated if necessary. While earlier Chinese reports suggested that Chinese herbs alone could function reasonably well as a treatment for lupus (5), this approach appears to have been largely abandoned, at least for the more serious cases seen in Chinese hospitals. For mild cases of lupus, using Chinese herbs as a sole remedy may be a reasonable choice, so long as modern medications are added in the event of a worsening syndrome. It is important that the treatment be sufficiently effective so as to minimize the chance of damage to the internal organs.

REFERENCES 1. Fan Yongsheng, et al, Observation on clinical effect of hormone combined with toxin-cleaning, stasis-resolving, and yinnourishing method for the treatment of systemic lupus erythematosus, Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine 1999; 19(10): 626-627. 2. Wen Chengping, et al, Effect of Langchuangding on serum soluble interleukin-2 receptor and neopterin level in patients of systemic lupus erythematosus, Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine 2001; 21(5): 339-341. 3. Zhong Jiaxi, et al, 25 cases of systemic lupus erythematosus treated by integrated traditional Chinese medicine and Western medicine, Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine 1999; 19(1): 47-48. 4. Wu Xiang, et al, Clinical observation on nephrotic syndrome of lupus nephritis treated with integrated Chinese and Western medicine, Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine 1998; 18(12): 718720. 5. Wang ZY, Clinical and laboratory studies of the effect of an antilupus pill on systemic lupus erythematosus, Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine 1989; 9(8): 465-468, 452. August 2001

LYME DISEASE: Treatment with Chinese Herbs by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Lyme disease is the result of a spirochetal infection (Boerrelia burgdorferi) transmitted to humans by deer ticks (mainly Ixodes scapularis, though a relative, I. pacificus is the carrier in the Western U.S.). The infection sometimes results in a serious disease pattern, most often characterized by progressively worsening arthralgia, though a central nervous system disorder or even a heart disorder may arise (1, 2, 3, 10). The disease is named for the town (Old Lyme, Connecticut) where, in 1975, a number of children presenting symptoms similar to juvenile rheumatoid arthritis were eventually found to have acquired this Boerrelia infection. The occurrence of Lyme disease is regional, being dependent on: 1. the distribution of the ticks that carry the bacteria (prevalent in forested areas in temperate climates, such as northern U.S. and northern Europe); 2. the presence of this particular bacteria in the ticks. The bacteria is carried by animals, particularly mice and deer, that are bitten by the tick; in the endemic area, only about 15-30% of ticks are infected; and 3. exposure of the human population to the ticks, which generally requires living in or venturing into areas where the ticks can be directly encountered. Contact with a tick does not necessarily mean the disease will be experienced. In fact, it is estimated that only 1-3% of tick bites result in Lyme disease. While the region where infection is a somewhat likely possibility is expanding, the primary distribution still remains limited. As of 1995, it was reported that Boerrelia infections in the U.S. occurred mainly in 8 states of the northeastern U.S. and one Midwest state (Wisconsin). Retrospective studies indicate that there were probably a few cases of this disease many decades earlier, with cases appearing in Massachusetts and Wisconsin in the 1960s, and in northern Europe as early as the 1920s. There is some evidence to suggest cases of this or a very similar disease in Germany-a country that was heavily forested and full of deer-in the 1880s. The reason for the sudden epidemic of the disease during the past 25 years has been the change in land use and lifestyle that occurred, such as new growth of forests in abandoned farm land and movement of city dwellers into the forested countryside, either for recreation or for a new place to live. For those who are at risk for acquiring the infection, a vaccine against Boerrelia burgdorferi has been approved by the FDA and is now readily available. There is no reference to Lyme disease in the Chinese literature and there may be none for some time, as most of China's forests have been eliminated. There are other spirochetal infections that have been addressed by Chinese physicians and by Chinese researchers conducting clinical trials or laboratory tests of infection-inhibiting properties. The relevant organism most often studied in China is Leptospira, which causes the disease called leptospirosis. This organism is carried by a wide range of animals, and is not uncommon in animals raised for food. In China, it has long been common practice for each family to keep animals, such as pigs and chickens, in and around their homes, so exposure has been possible for a large portion of the population. The bacterium can enter the body through the skin, usually from contact with animal urine. A small outbreak occurred at Fort Bragg in the U.S. in 1942, and the disease was nicknamed Fort Bragg Fever. Its cause was traced to swimming in ponds and streams that had been contaminated by livestock urine. Fewer than 200 cases occur in the U.S. each year, mostly in the warm southeastern states.

TRADITIONAL AND MODERN VIEWS OF LEPTOSPIROSIS AND ITS TREATMENT The Leptospira infection causes fever and chills, headache, and muscle ache (especially in the shoulders). These symptoms match the Shang Han disease described in the ancient text Shang Han Lun. In fact, the initial course of leptospirosis follows a pattern, over a period of several days, that is somewhat like that described in the ancient text. In the advanced stage, leptospirosis can cause liver disease (with jaundice) or a severe form of meningitis; the symptoms of some cases of advanced Shang Han disease are similar. According to proponents of the general application of the Shang Han Lun as a guide to treatment of disease, the formulas recommended in that text could be used for modern diseases with similar symptom presentation. Accordingly, early stage of spirochetal infection, such as Lyme disease and Fort Bragg fever, might be treated by the same formulas used in the Shang Han Lun (see: A modern view of the Shang Han Lun). Modern understanding of these infectious diseases may help reflect on the development of Chinese concepts of disease causation and treatment. Shang Han disease occurred most frequently in winter, the time of year when animals were brought into the house, thereby increasing opportunity for exposure to pathogens; thus, exposure of people to cold may not have been the reason that some diseases were observed to occur during the cold season. Similarly, the summer heat syndrome, which often produces digestive system disturbances, may not be the direct result of exposures of humans to the damp, hot climate, but exposure to pathogens that grow in that climate and infect the food and water supplies (see the articles: The six qi and six yin and Pill Curing and Huoxiang Zhengqi Pian). The book Modern Study and Application of Materia Medica (4) provides information about herbs reputed to inhibit Leptospira based on laboratory testing (herb extract applied to cultured bacteria causing them to die) and, in some cases, clinical evaluation (herbs administered to infected patients resulting in clearance of symptoms). The following list of leptospira-inhibiting herbs was culled from the Chinese medical literature: Isatis leaf Isatis root Andrographis Coptis Scute Phellodendron Forsythia

Smilax Gardenia Hu-chang Chien-li-kuang Verbena Sanguisorba Ching-hao

Most of these herbs treat a condition described as damp-heat; many of the herbs have broad-spectrum antibiotic and antiviral properties. The book Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (5), no doubt relying on the same source material, listed the first nine ingredients of the above list as inhibitors of Leptospira; this text also presents five traditional formulas suggested for treating leptospirosis, divided by syndrome: Exogenous pathogen invading the qi phase (this corresponds to the initial disease symptoms, which may include a flu-like pattern): Yin Qiao San (Lonicera and Forsythia Formula). Summer heat and damp heat misting the three burners (for treatment of skin manifestations of the disease, such as rashes): Sanshi San (Three Stone Powder, made with calamine, gypsum, and red kaolin; this is applied topically). Acute jaundice (this is the manifestation of leptospirosis as liver disease): Ermiao San (Red Atractylodes and Phellodendron Powder; this is a general formula for damp-heat). Summer heat injuring the lung: Xin Jia Xiangru Yin (Modification of Elsholtzia Combination; the base formula contains elscholtzia, dolichos, and magnolia bark; a common addition is coptis). Heat invading the pericardium with liver wind moving internally (this is the manifestation of leptospirosis as meningitis): Zhengan Xifeng Tang plus Angong Niuhuang Wan (Decoction to Subdue Internal Wind plus Pill of Ox Gallstone to Pacify the Palace). All of the recommended formulas treat a heat syndrome, and include herbs that alleviate damp-heat, though they include few herbs from the list of those that have thus far been shown to inhibit the subject organism in laboratory and clinical tests. The herbal therapies may alleviate symptoms without curing the spirochetal infection, while it is the cure of the disease, defined by freedom from the bacteria, that is the goal of most Western patients and their physicians.

CLINICAL EVALUATIONS There was considerable clinical research into treatment of leptospirosis in China during the early 1970s (9). It was reported that tablets prepared from equal amounts of the extracts of scute, lonicera, and forsythia, administered three times daily in large amounts were useful for treating mild and moderate cases of the disease. Andrographis extract, in the form of an injection or tablets of the crude extract or of the isolated lactones, was reported to effectively treat leptospirosis. In one evaluation, 31 of 35 cases were said to be cured by the andrographis lactones (mainly diterpene lactones, which are also found in the anticancer herb rabdosia). More recently, Deng Shifa reported on efforts at prevention and treatment of leptospirosis (6, 7). He administered a decoction prepared from fresh, rather than dried, herbs, using ching-hao, houttuynia, eclipta, imperata, mentha, lonicera stem, humulus (lucao), and rhubarb. This formula only includes one herb, ching-hao, from the list of individual herbs above. The drink was consumed 4-6 times per day (that is, at intervals of 2-4 hours), and it was reported that recovery from symptoms occurred, on average, in about 11 days. The results obtained with the Chinese herbs were similar to those obtained with penicillin, based on cure rate, which was 97%. The same herb formula, with rhubarb deleted, was said to help prevent leptospirosis. Another spirochete, Treponema, gives rise to two diseases, syphilis (from T. pallidum) and yaws (from T. pertenue ) . Since these diseases are easily controlled by modern antibiotic therapy, there is little mention of herbal remedies in the literature. Smilax (tufuling), an herb for damp-heat that is included in the list of anti-leptospira herbs, is still prominently mentioned for this application (4, 8). In Western herbal practice, a species of Smilax, known popularly as sarsaparilla, was used for treatment of syphilis. This repeated reference to the herb in clinical use supports the idea that smilax may have a reliable inhibitory effect for spirochetal infections. Treponemes have been isolated from the blood of patients with Lyme disease, suggesting that the ticks may harbor both types of spirochetes.

TCM ANALYSIS OF LYME DISEASE The traditional Chinese medicine (TCM) analysis of a new disease, such as Lyme disease, depends on the disease manifestations and the analysis of other diseases that have some characteristics in common with it. The salient features are these: 1. the tick introduces the pathogen into the blood stream directly; 2. the infection typically yields a blotchy red rash, often in a "bull's eye" pattern of red skin coloration and swelling, about 3-20 days after the tick bite; 3. there may be flu-like symptoms, including fever, headache, sore throat, nausea, fatigue, swollen glands, stiff neck, aching muscles; and 4. if unresolved there may be recurrences of fever and, usually after several months, arthralgia, usually in the knees, with swelling and hot feeling. It is estimated that 25-50% of those infected do not get the rash or flu-like symptoms, and that about half of those who experience the rash go on to experience arthralgia. The disease may be interpreted in TCM terms most simply as a heat pathogen entering the blood, which can reside as a "hidden toxin" in some individuals, manifesting disease symptoms later, after some factor activates it. As an example of traditional prescribing that might be appropriate to Lyme disease, a formula recommended for a heat toxin entering the blood and producing eruption of macules (11) is Lonicera and Gypsum Combination (Liangxue Baidu Tang; Cool Blood and Defeat Toxin Decoction). It contains forsythia, gardenia, scute, and coptis, which are included in the list of anti-leptispirosa herbs, along with gypsum, talc, lonicera, anemarrhena, carthamus, moutan, raw rehmannia, scrophularia, and imperata (the original formula also included horns of antelope and rhino).

TREATMENT OPTIONS IN THE WEST Medical studies suggest that if the Boerrelia infection can be treated soon after it occurs with antibiotics, there is strong likelihood of it being eliminated quickly and completely. The current medical treatment for Lyme disease is a course of therapy using doxycycline, amoxicillin, penicillin, or erythromycin. These are taken orally except in severe cases in which they may be administered intravenously instead. Many of those who become infected spontaneously recover within days or months even without antibiotics (no doubt, the

bacteria eventually succumbs to the immune system). For those who have the infection for months prior to treatment without improvement, antibiotics may need to be administered for several months before the infection finally resolves, and some cases may entirely escape cure with this therapy due to the characteristics of the bacteria (ability to avoid the immune system by antigenic changes on its surface and ability to avoid antibiotic inhibition by infiltrating areas of the body, such as the joints, that have lower levels of exposure to the drug). The absence of direct clinical evaluation of Chinese herbs in relation to Lyme disease means that there is some difficulty recommending that this method be used in lieu of the currently accepted course of antibiotics. Some individuals may wish to attempt to increase the chances of success with antibiotics or even shorten the duration of treatment with antibiotics by combining a Chinese herbal treatment, and a few individuals may wish to try using Chinese herbs alone, saving the antibiotic therapy as a back-up. One would apply herbs that are reputed to inhibit other spirochetes (since these should have an excellent chance of inhibiting this one), as well as any herbs that might treat the specific symptoms or the patient's constitution. The Seven Forests herb formula tablet Isatis 6 provides isatis leaf, hu-chang, and andrographis from the list of herbs given above, and the Seven Forests formula Forsythia 18 provides forsythia, gardenia, scute, phellodendron, and coptis, which are also on that list. Together, these formulas may provide the bacterial inhibition that is sought from Chinese herbs in a convenient form of administration (suggested dosage would be 3-5 tablets of each formula, three times daily). As with treatment of any infection, the intended application is a high dosage for a few days or weeks. Since the formulas fall into the category of clearing heat, persons with symptoms and signs indicating a constitutional cold syndrome would probably do better to have a personalized formula made (e.g., extract granules), combining the desired anti-bacterial ingredients (which have a cold nature) with herbs for addressing the constitutional imbalance. The single herb ching-hao may be of interest in treating this disease. This is an herb for damp-heat that is one of the most effective herbal agents for treating malaria, another parasitic disease (though a very different pathogen) introduced directly into the blood stream by an insect (mosquito). It was included in the formula recommended by Deng Shifa for treatment and prevention of leptospirosis. Aside from being listed as an anti-spirochete based on laboratory evaluation, this herb also helps regulate the immune system in cases of autoimmune disorders. For example, it is found useful in treating the autoimmune attack against connective tissue (mainly skin and joints) in patients with lupus (9). The arthralgia experienced by persons with advanced Lyme disease may involve some autoimmune component (at this time, it is unclear whether persistence of the bacteria is solely responsible for persisting symptoms or if there is an induced autoimmune process that contributes to the symptoms). Further, if the symptoms of arthralgia have already developed, then herbs traditionally used for that purpose would also be administered (selection of ingredients would depend on symptom presentation and constitutional factors). Lonicera stem, included in the treatment for leptospirosis described by Deng Shifen, may be of interest, as it is used like lonicera flower as an anti-toxin agent, but is considered a specific treatment for arthralgia. Based on the analysis that has been presented here, for patients willing to take a decoction or dried decoction, the following is proposed as a base formula that may be modified, if deemed necessary, for individual needs: Anti-Spirochete Mixture (equal parts) Smilax Ching-hao Forsythia Hu-chang Andrographis Lonicera stem When using a decoction, the dosage of individual herbs should be 12-15 grams for a one day dose. Using dried decoctions, a daily dosage of 15-18 grams of the mixture would be appropriate. Three times per day dosing is a usual recommendation for the treatment of infections.

REFERENCES 1. Biddle W, A Field Guide to the Germs, 1995 Henry Holt and Co., Inc., New York. 2. Karlen A, Man and Microbes, 1995 G.P. Putnam's Sons, New York. 3. Lane K (executive editor), Merck Manual of Medical Information, Merck & Co., Inc., West Point, PA. 4. Dong Zhi Lin and Yu Shu Fang, Modern Study and Application of Materia Medica, 1990 China Ocean Press, Beijing. 5. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 1, 1993 Heilongjiang Education Press, Harbin. 6. Deng Shifa, Preliminary study on the prevention and treatment of leptospirosis with traditional Chinese medicine, Lianing Journal of Traditional Chinese Medicine 1985; 9(5): 15-17. 7. Deng Shifa and Sheng Rixin, Treatment of leptospirosis with Qixian Drink, Zhejiang Journal of Traditional Chinese Medicine 1991; 26(7): 293-294. 8. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 9. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore. 10. Robbins SL, Cotran RS, and Kumar V, Pathologic Basis of Disease, Third Edition, 1984 W.B. Saunders Company, Philadelphia, PA. 11. Hsu HY and Wang SY, The Theory of Feverish Diseases and Its Clinical Applications, 1985 Oriental Healing Arts

Institute, Long Beach, CA.

June 1999

CHINESE HERBS FOR LYMPHEDEMA Exploring the Principles of Treating Phlegm-Damp Accumulation by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND The lymphatic system runs throughout the body. Unlike the system of vessels that transports the blood, the lymphatic system lacks independent musculature to pump the lymph through the body. Instead, the lymphatic flow occurs secondarily to the pumping action in nearby blood vessels (primarily the veins) and as a simple result of physical movements of the body. Lymph gains its contents from the blood, and the lymph vessels (which are larger than capillaries but much smaller than the smallest veins) drain the majority of their contents back into the blood stream via the thoracic duct at the base of the neck. There are small, bean-shaped lymph nodes laced along the lymphatic vessels, but the major clusters are in the neck, armpits, abdomen, and groin. During an infection, it is common for the lymph nodes to become enlarged, sometimes noticeably so, as they fill with immune cells and the debris from immune attack. Lymphedema (also spelled lymphoedema), is a swelling of the subcutaneous tissues by accumulation of lymph fluid (1). The disorder has become a common medical concern as the result of modern treatments for breast cancer: mainly surgery, but also radiation therapy. In many cases of breast cancer, it is standard practice to remove tissues beyond the main tumor mass. In addition to taking some surrounding breast tissue (or all, in the case of mastectomy), several or all of the adjacent lymph nodes in the arm pit are excised. Lymph node removal is undertaken mainly as a means of excising more of the cancer cells when the nodes have been invaded or are suspected to be involved. Sometimes, limited lymph node removal is carried out as a means of determining the extent of the spread of the breast cancer (the still-experimental procedure is called sentinel node biopsy). The node removal (or damage, in the case of radiation therapy affecting the nodes) reduces the efficacy of lymph movement; lymphedema can result. Rates of occurrence of lymphedema secondary to breast cancer treatment are reported to be on the order of 9% to 20% (2, 3). The risk is higher for more advanced cancers requiring more extensive surgery and/or radiation. Lymphedema can also occur as the result of injuries as well as from any disease process that damages or obstructs the lymph nodes (e.g., lymphedema has been noted in rare cases with sarcoidosis and Kaposi's sarcoma). In addition, lymphedema of the legs occurs in elderly persons suffering from chronic venous insufficiency, since the pumping of blood through the veins contributes to the movement of lymph (4). Lymphedema is more common in women than in men, and leg edema is more common with aging. The main symptom of lymphedema is the evident swelling, with only slight pitting, which can increase the volume of the affected limb by up to 50% for the arms; up to about 25% for the legs. Other symptoms, especially in the more severely edematous cases, may include pain, tightness, tension, heaviness of the limb, hardness of the tissues, stiffness of the affected limb, and, in persistent cases, there can be ulceration due to the impaired circulation (5). Lymphedema is usually treated by a combination of non-invasive physical methods (6). These include manual lymph drainage (in essence, massaging the fluid out of the arms), compressive bandaging (preventing accumulation of fluid by restricting arm volume), and physical exercises (that promote lymph drainage). These methods not only can greatly reduce lymphedema, but, in many cases, the results are lasting (at least, until local trauma or other inducing event triggers another bout of swelling). In most cases of lymphedema relatively little pharmacological intervention is now used. Outside the U.S., a treatment method based on use of natural compounds known as benzopyrones has been studied. The benzopyrone therapies will be discussed in a later section of this article.

CHINESE MEDICAL THERAPIES Chinese medicine has some history of treating conditions that are similar to, or may be, lymphedema. Lymph nodes were indirectly recognized, even in ancient times, as areas that easily become lumpy, but lymph was not known in the same sense that it is recognized in modern medicine. The condition of lymphedema fits the traditional category of phlegm-damp accumulation. The fluid swelling would, by itself, lead one to classify the disease as a dampness accumulation (corresponding directly to the Western term edema). The phlegm aspect of the condition is related to the thickness of the fluids involved. As we know from modern research, lymph is a somewhat milky fluid that replenishes the blood with chyle (emulsified fat), erythrocytes (red blood cells), and leukocytes (white blood cells); it also carries protein debris. A more watery accumulation based on a less-dense fluid, as occurs in cases of pitting edema, would be considered a moisture accumulation but not a phlegm-damp accumulation. The Chinese term for phlegm-damp is tanyin; tan refers to thickened fluids, while yin refers to thin fluids. Both the thick and thin fluids of the tanyin syndrome are pathological: they represent an abnormal accumulation of fluids. The confluence of the two terms occurs when describing a large volume of somewhat thick fluid and is distinguished from a simple phlegm disorder, which has a lower volume of accumulated material. In seeking a Chinese herbal therapy for lymphedema of the arms, one looks to both the general treatment of phlegm-damp accumulation and to any historical references to disorders of the arms that correspond most closely to lymphedema. In addition, treatments aimed at the more common problems of lymph node swelling (lymphadenitis), numbness and aching in the arms (corresponding to dampness accumulation), and at swellings, lumps, and pains in the breasts (corresponding to the breast involvement in modern cases) would be potentially useful as reference points for treatment of lymphedema secondary to breast cancer. Herbal therapies that are suitable for treating these conditions were developed primarily by a single well-known Chinese physician scholar of the Ming Dynasty: Gong Tingxian. The formulas were presented in his book Wanbing Huichun (Restoration of Health from Myriad Diseases; restoration of health is literally described as return (hui) of Spring (chun)). In this book, published in 1587 (at about the same time as the Bencao Gangmu was completed), there is a special section on aching in the arms, but Gong also dealt generally with the problem of phlegm-damp accumulation in several sections of his book. An examination of his formulas that are still in use will reveal the main herbs he relied upon. A further analysis of his formulation methods is presented in Appendix 1, including treatments for other types of diseases.

NOTES ON GONG TINGXIAN AND HIS FORMULAS Gong Tingxian (1522-1619) was born into a long line of family physicians in what is today called Jiangxi Province. His father, Gong Xin, was a famous doctor, honored with an appointment to the prestigious Imperial Medical Academy. Although Gong Tingxian took his medical studies very seriously as a youth, he apparently did not have the more aggressive, career-oriented attitude that some other family members exhibited. Long before his name became known in medical circles, his younger brother and one of his nephews had already become medical officials. Early on, he withdrew into a life of solitude in the countryside. It was not until 1593, at the age of 71, that Gong Tingxian suddenly became well known, after curing a case of severe abdominal distention suffered by the favorite concubine of the king of Lu. He was appointed, like his father, as a physician of the Imperial Medical Academy. Gong was a prolific author, writing into his 90's, and creating 16 works. In his 60's, still in this phase of obscurity and prolonged retreat, he wrote Zhongxing Xianfang (Divine Prescriptions from the Apricot Grove ) and Wanbing Huichun. He also wrote Gujin Yijian (The Mirror of Ancient and Present Medical Science ), followed up by Shou Shi Bao Yuan (Achieving Longevity by Guarding the Source), a five volume addendum; other works include Yunlin Shengou (Divine Rules of the Cloud Forest; Cloud Forest being one of Gong's Taoist names), and Lufu Jinfang (Secret Prescriptions of King Lu's Mansion). The formulas of Gong Tingxian are widely used in Japan because he stuck closely to the Han Dynasty tradition, which the Japanese consider the ultimate resource for Chinese herbal medicine. He designed formulas that reflected the work of the Shanghan Lun and Jingui Yaolue of the Han Dynasty and the formulas of the Hejiju Fang of the Song Dynasty, which usually had a formulation style similar to the Han prescriptions. He relied mainly on the same somewhat limited selection of herbs that were used in those texts. Gong's most famous work, Wanbing Huichun, had its formulas made from about 240 different ingredients. His book Yaoxing Geguo (Drug Properties in Verse) published around 1615 A.D., described 400 herbs, having added another 160 items that were in frequent use at the time, though he preferred to stick to certain well-established ingredients. By contrast, the contemporary Bencao Gangmu described over 1,800 items. Gong's approach to medicine during the Ming Dynasty was remarkable for his lack of interest in the prevailing theories and new systems of categorization that had come into vogue (7). Instead, he retained the fundamental concept that incorrect living left the person open to adverse influences. He relied mainly on the ideas about pathological influence prevalent during the Han Dynasty period: demons and wind (see Demons as a cause of disease and Drawing a concept: feng (wind)). Therefore, while disease prevention was to be based on proper lifestyle, the treatment of disease was aimed at dispelling the pathogenic factors and resolving the consequences of their harmful actions (8). He designed numerous formulas for treating wind ailments, relying heavily on the botanically-related herbs angelica (baizhi), siler (fangfeng), and chiang-huo (jianghuo), all of which are in the same plant family (Umbelliferae) and have similar active constituents (see: Analysis of prescriptions for arthritis). The main effect of wind and other evil influences on the body, as understood by Gong, was a binding up of the flow of qi and moisture. Therefore, he selected herbs to disperse the qi and fluid stagnation, such as magnolia bark, citrus, red atractylodes, saussurea, cyperus, and cardamon (aromatic herbs that penetrate damp congestion), and herbs used generally to dry and drain out accumulated dampness and phlegm, especially hoelen, atractylodes, pinellia, ginger, bamboo, and arisaema. Unlike the Japanese, Chinese doctors after the Ming Dynasty have not taken interest in Gong's formulas to any great extent, so most discussions about the clinical application of the formulas comes from Japanese sources. Information about traditional and modern applications of the formulas can be found in Commonly Used Herb Formulas with Illustrations (9), which reflects the Kanpo medicine system used in Japan and Taiwan. To help clearly illustrate the selection of herbs used for phlegm-damp syndromes, several of Gong Tingxian's formulas are presented in Table 1 in a format intended to illustrate their common ingredients. These formulas treat stagnation of qi, moisture, and phlegm. One can see that his favored herbs were hoelen, atractylodes, pinellia, arisaema, citrus (of various types, including chih-shih, chih-ko, and blue citrus), licorice, ginger, magnolia bark, saussurea, cardamon, and cyperus. Table 2 describes the formula indications in relation to lymphedema of the arms, including disorders involving the chest area and breasts. Table 1: Sample Formulas for Resolving Phlegm-Damp Accumulations by Gong Tingxian. Common names for the formulas are presented at the top; the pinyin transliteration of the traditional names are given in Table 2. Herbs are laid out in rows of similar ingredients, a blank means the herb is not included in the formula. Herbs that have similar botanical origins and active constituents are included in a single box, such as pinellia and arisaema (both warming, phlegm-resolving herbs from the same family), citrus species (citrus, blue citrus, chih-shih, and chih-ko), and cardamon varieties (cardamon, tsou-tou-kou, and cluster). In many of the formulas, atractylodes refers to a combination of white atractylodes (baizhi) and red atractylodes (cangzhu), but this is not specified here. The last box is reserved for other ingredients, with up to a maximum of four specified items (if additional items are present, they are listed as "others"). Hoelen and Alisma Combination is the representative formula, containing all of the key herbs listed except pinellia and arisaema. Hoelen and Alisma Combination

Pinellia and Arisaema Combination

Tang-kuei and Pinellia Combination

Atractylodes and Cardamon Combination

Magnolia and Hoelen Combination

hoelen

hoelen

hoelen

hoelen

hoelen

atractylodes

atractylodes



atractylodes

atractylodes



pinellia & arisaema

pinellia





citrus & chih-shih

citrus

citrus & blue citrus

citrus

citrus

licorice

licorice

licorice

licorice

licorice

ginger, fresh

ginger, fresh

ginger, fresh



ginger, fresh

magnolia bark



magnolia bark

magnolia bark

magnolia bark

saussurea





saussurea



cardamon





cardamon



cyperus



cyperus





alisma, polyporus, areca peel, juncus

chiang-huo, bamboo sap, sinapis, scute

tang-kuei, peony, bupleurum, gardenia, others

morus bark, perilla seed, aquilaria

polyporus, alisma, cinnamon twig, jujube

Cyperus and Cluster Bamboo and Ginseng Siler and Chiang-huo Combination Combination Combination

Trichosanthes and Chih-shih Combination

Chih-shih and Cardamon Combination

hoelen

hoelen

hoelen

hoelen

hoelen

atractylodes



atractylodes







pinellia

pinellia



pinellia

citrus

citrus & chih-shih

citrus

citrus & chih-shih

citrus & chih-shih

licorice

licorice

licorice

licorice

licorice

ginger, fresh

ginger, dried

ginger, fresh

ginger, fresh



magnolia bark







magnolia bark

saussurea





saussurea

saussurea

cardamon and cluster





cardamon

cardamon and tsaotou-kou

cyperus

cyperus





cyperus

jujube, ginseng

bamboo, coptis, bupleurum

tang-kuei, bupleurum, jujube, chiang-huo, others

scute, tang-kuei, platycodon, bamboo, others

fennel, corydalis

Table 2. Indications for the Formulas Relevant to Lymphedema Secondary to Breast Cancer Formula (Common Name/Pinyin)

Relevant Indications

Hoelen and Alisma Combination Fenxiao Tang

edema

Pinellia and Arisaema Combination Qingshi Huatan Tang

swollen lymph glands

Tang-kuei and Pinellia Combination Pinggan Liuqi Yin

fibrocystic breasts

Atractylodes and Cardamon Combination Chuan Sijunzi Tang

phlegm accumulation in weak individuals

Magnolia and Hoelen Combination Weiling Tang

edema

Cyperus and Cluster Combination Xiangsha Yangwei Tang

dampness accumulation occurring after an illness

Bamboo and Ginseng Combination Zhuru Wendan Tang

phlegm accumulation

Siler and Chiang-huo Combination Jiawei Baxian Tang

numbness and paralysis of limbs

Trichosanthes and Chih-shih Combination Gualou Zhishi Tang

phlegm accumulation

Chih-shih and Cardamon Combination Zhisuo Erchen Tang

stagnant water and phlegm in the chest

The famous 20th-Century Japanese doctor Keisetsu Otsuka developed a new formula based on the prescriptions in the arm-ache category of Wanbing Huichun. He called it Erzhu Tang, referring to the combined use of white and red atractylodes (baizhu and cangzhu; e r = two) that was often used by Gong for dampness accumulations. The formula also included pinellia and arisaema for resolving phlegm. The common name assigned to the formula is Atractylodes and Arisaema Combination. It is derived from the bestknown standard phlegm-damp formula, Erchen Tang (Citrus and Pinellia Combination, with citrus, pinellia, hoelen, ginger, licorice). To this base formula are added: red and white atractylodes and cyperus for aromatically dispersing fluid accumulation; chiang-huo and clematis for dispelling wind-damp from the arms; and scute for drying dampness.

The formula is similar to Gong's original Pinellia and Arisaema Combination (Qingshi Huatan Tang ; Clear Moisture and Resolve Phlegm Decoction), which includes angelica in addition to the related chiang-huo, and has bamboo and sinapis in place of clematis and cyperus. Otsuka's formula has become a key prescription for treating shoulder bursitis, which is understood to be a phlegm-damp accumulation in the shoulder, for which the inducing factor is wind (from the traditional perspective; the modern view is that a traumatic pressure to the bursa causes the inflammatory condition with fluid swelling). The general description of the formula's use is "aching in the arms due to the presence of phlegm and stagnant water."

BENZOPYRONES Benzopyrones are a type of flavonoid; one of the main benzopyrones that has been of interest in relation to lymphedema is coumarin. This compound should not be confused with the powerful blood thinner coumadin, which is a derivative of coumarin; coumarin does not have the anticoagulant properties (see note following Table 3). The story of benzopyrones has been developed primarily by one individual: J.R. Casley-Smith. He has been publishing articles about lymphedema and its treatment for more than 40 years (10). He described the use of benzopyrones, coumarin and troxerutin, for this purpose in 1974 (11). In fact, there are 58 published articles (including published letters, editorials, and conference reports) on lymphedema by Casley-Smith. Most of the articles are either about, or include mention of, the benzopyrone treatments. According to Casley-Smith, benzopyrones function by inducing macrophages, increasing both their number and their activity. These macrophages then lyse the proteins in the lymphatic fluid. The resulting smaller proteins can then be resorbed, with concurrent reduction in water volume of the affected area. Further, the benzopyrenes may aid in the movement of the collected lymphatic material by other mechanisms of cellular stimulation. The claim is that the benzopyrones begin acting within about 24 hours of ingestion but that the process of resolving lymphedema by their use can take several months. In one study using a mixture of flavonoids different than those relied on by Casley-Smith but, presumably, with the same action, improvements were said to be observed starting from the third month of treatment (12). The usual treatment time in clinical trials for lymphedema using benzopyrones is six months. While Casley-Smith indicates that the benzopyrones do not remove the cause of protein-rich edemas for which it is effective, the improvement is said to be very useful. Even topical application of the benzopyrones is said to be of benefit and combined topical and internal treatment is reported to yield the best results (13). Coumarin, the benzopyrone claimed to be highly effective in relatively low dosage (about 400-800 mg/day), is commonly found in sweet clover (Melilotus officinalis) and tonka beans (Dipteryx odorata) which are the main natural sources for the lymphedema-resolving drug products that are available in several countries (but not the U.S.). Other flavonoids have been claimed to be effective, including diosmin, which is derived from citrus and is made into a drug product in Europe for vein problems that include edema. Aesculin, a related compound from horse-chestnut, has been recommended for treatment of venous insufficiency and is considered a potential treatment for lymphedema, especially of the legs. It is not known, at this time, what range of flavonoids are effective. The degree of effectiveness of benzopyrones for lymphedema is not well-established; Casley-Smith describes the action as slow but safe, with the ability to change a gradually worsening condition into a gradually improving one. There is some research activity regarding the benzopyrones outside of the Casley-Smith facility of Australia, especially in Italy. Benzopyrone treatment has not been approved in the U.S. and a study that might have led to its use here yielded a negative result. The study was conducted at the Mayo Clinic and tracked 140 women taking either placebo or 200 mg of coumarin twice daily (total: 400 mg, the usual recommended dosage that is reported effective in other studies). No significant difference was noted, and a potential negative effect was observed: 6% of the women showed some evidence of liver toxicity (14). Casley-Smith has relayed Australian data that suggests a 3% incidence of liver toxicity from use of coumarin, and also mentions some cases of nausea or diarrhea from the treatment. In a study he published in the New England Journal of Medicine (5), benefits of the treatment were described in terms of reduction in volume of the affected limb. The lymphedema in arms was 46% above normal volume before treatment and reduced to 26% above normal volume after six months; in legs, the change was from 25% above normal to 17% above normal. In other words, the lymphedema was only partly reduced and required prolonged therapy. Therefore, while benzopyrones may have an effect on lymphedema, the search for other natural substances that might be of benefit should continue. Coumarin occurs widely in the plant kingdom, but is usually present only in trace quantities. It is not found in significant amounts in herbal medicines, but other closely related compounds are found. It is interesting to note that the formulas of Gong Tingxian depicted in Table 1 always include one or more of the benzopyrone-containing herbs (see Table 3). Other herbs in the formula may contain active constituents different than the benzopyrones that could have an effect on edema. Table 3: Commonly Used Chinese Herbs with Benzopyrones. Not all the varieties of benzopyrones are listed here, as these herbs contain many variants of the ones listed. These benzopyrones are similar to coumarin, which is the main item recommended by CasleySmith. Other non-benzopyrone flavonoids found in formulas by Gong Tingxian include those from scute and morus bark. Herbs

Benzopyrones

citrus varieties, including citrus, blue citrus, chih-shih, chih-ko

7-hydroxycoumarin, 7-geranyloxycoumarin, auroptenol, crenulatin, 7demethylsuberosin, suberosin

licorice

7-hydroxycoumarin, 7-methoxycoumarin, glycyrin (not to be confused with glycerin)

Angelica species; including angelica, chianghuo, tu-huo, tang-kuei

7-hydroxycoumarin, scopoletin, osthenol, ostholumbelliprenin, angelol, angelin

Note on coumadin: Coumadin, also known as warfarin, is a powerful anticoagulant that was discovered in improperly cured leaves and flowering tops of sweet clover (Melilotus officinalis) . The compound, known by the chemical name dicoumarol, is now prepared synthetically. Because the base molecule for coumadin and related drugs is coumarin, they are sometimes known as coumarin drugs. However, no anticoagulant properties have been attributed to coumarin itself.

REFERENCES

1. Beers MH and Berkow R (editors), The Merck Manual of Diagnosis and Therapy, 1999 Merck Research Laboratories, Whitehouse Station, NJ. 2. Kasse AA, et al., Risk factors for lymphedema of the arm after mastectomy for breast cancer, Dakar Medicine 1999; 44(1): 32-35. 3. Pecking A, Medical treatment of lymphedema with benzopyrones; experimental basis and applications, Journal of Vascular Diseases 1990; 15(2): 157-158. 4. Mortimer PS, Implications of the lymphatic system in CVI-associated edema, Angiology 2000; 51(1): 3-7. 5. Casley-Smith JR, Morgan RG, and Piller NB, Treatment of lymphedema of the arms and legs with 5,6-benzo-[alpha]pyrone, New England Journal of Medicine 1993, 329(16): 1158-1163. 6. Boris M, et al., Lymphedema reduction by noninvasive complex lymphedema therapy, Oncology 1994; 8(9): 95-106. 7. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. 8. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 9. Hong-Yen Hsu and Chau-Shin Hsu, Commonly Used Chinese Herb Formulas with Illustrations , 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA. 10. Casley-Smith JR, Foldi M, and Zoltan OT, The treatment of acute lymphoedema with pantothenic acid and pyridoxine: an electron microscopical investigation, Lymphology 1969; 2(2): 63-71. 11. Casley-Smith JR, Foldi-Borcsok E; and Foldi M, Fine structural aspects of lymphoedema in various tissues and the effects of treatment with coumarin and troxerutin, British Journal of Experimental Pathology 1974; 55(1): 88-93. 12. Bettorello G, et al., Contribution of a combination of alpha and beta benzopyrones, flavonoids, and natural terpenes in the treatment of lymphedema of the lower limbs at the 2d stage of the surgical classification, Minerva Cardioangiology 1996; 44(9): 447-455. 13. Casley-Smith JR and Casley-Smith JR, Treatment of lymphedema by complex physical therapy, with and without oral and topical benzopyrones, Lymphology 1996; 29(2): 76-82. 14. Loprinzi CL, et al., Lack of effect of coumarin in women with lymphedema after treatment for breast cancer, New England Journal of Medicine 1999; 340(5): 383-385.

APPENDIX: The Formulation Strategies of Gong Tingxian. The basis of the formulation style pursued by Gong Tingxian can be traced rather directly from the Shanghan Lun and Jingui Yaolue by Zhang Zhongjing (at the end of the Han Dynasty) and from the Song Dynasty Compendium Hejiju Fang (Taiping Huimin Hejiju Fang). During the Song Dynasty, the Han Dynasty books by Zhang (originally a single volume, split into two), were revived, and the Hejiju Fang was ordered by the Emperor; it contained many prescriptions using the same basic herbs and similar formulation styles. Certain formulas formed the basis of Gong's work, such as Citrus and Pinellia Combination (mentioned above), as well as Tang-kuei Four Combination, Four Major Herbs Combination, Pinellia and Citrus Combination, and Bamboo and Hoelen Combination. The relationships of the formulas can be illustrated as follows. Table 4 (a & b): Derivatives of Tang-kuei Four Combination ( Siwu Tang ). Tang-kuei Four Combination was first described in the Hejiju Fang. There are two groups of formulas presented here. The first group of formulas (Table 4a) mainly includes additional herbs for clearing deficiency heat (e.g., anemarrhena, phellodendron) and getting rid of dampness (e.g., citrus, hoelen, atractylodes). The second group of formulas (Table 4b) is derived from Tang-kuei Four Combination plus Coptis and Scute Combination ( Huanglian Jiedu Tang, a formula of Ge Hong of the Qin Dynasty); the eight herb formula was put together by Gong Tingxian. Those base formulas are then modified by adding herbs that dispel wind (e.g., mentha, angelica or chiang-huo, and siler) and resolve inflammation and abscess (e.g., forsythia, platycodon, and licorice). Table 4a: Tang-kuei Four Combination (Siwu Tang)

Phellodendron Combination (Ziyin Jianghuo Tang)

Scute Combination (Zishen Tonger Tang)

Tang-kuei and Rehmannia Combination (Buyin Tang)

Clematis and Stephania Combination (Shujing Huoxue Tang)

tang-kuei

tang-kuei

tang-kuei

tang-kuei

tang-kuei

cnidium



cnidium

cnidium

cnidium

rehmannia

rehmannia, raw

rehmannia, raw

rehmannia, raw

rehmannia, raw

peony

peony

peony

peony

peony



licorice



licorice

licorice



anemarrhena

anemarrhena

anemarrhena





phellodendron

phellodendron

phellodendron





citrus



citrus

citrus







hoelen

hoelen



atractylodes





atractylodes



ophiopogon, asparagus

cyperus, bupleurum, scute, angelica

eucommia, fennel, psoralea, ginseng, achyranthes

ginger, chiang-huo, clematis, siler, stephania, gentiana, persica, angelica, achyranthes

Tang-kuei and Gardenia Combination (Wen Qing Yin)

Gardenia and Vitex Combination (Xigan Mingmu Tang)

Chrysanthemum Combination (Zi Shen Mingmu Tang)

tang-kuei

tang-kuei

tang-kuei

tang-kuei

tang-kuei

cnidium

cnidium

cnidium

cnidium



rehmannia

rehmannia

rehmannia



rehmannia

peony

peony

peony

peony



coptis

coptis

coptis

coptis

coptis

scute

scute

scute

scute

scute

phellodendron

phellodendron



phellodendron



gardenia

gardenia

gardenia

gardenia

gardenia



mentha



mentha

mentha



chiang-huo

angelica

angelica

angelica



siler



siler

siler



forsythia



forsythia

forsythia



platycodon

platycodon



platycodon



licorice

licorice

licorice

licorice



gypsum, schizonepeta, tribulus, cassia

chrysanthemum, ginseng, juncus, tea, vitex

schizonepeta, chih-ko, bupleurum

chih-ko, juncus, tea

Table 4a: Schizonepeta and Gardenia and Forsythia Mentha Combination Combination (Jingjie (Qingliang Yin) Lianqiao Tang)

Table 5: Derivatives of Four Major Herbs Combination ( Si Junzi Tang). Four Major Herbs Combination is a formula of the Hejiju Fang. Like the base formula, the new formulas derived from it tonify the spleen. Ginseng and Zanthoxylum Combination treats intestinal parasites and Lotus and Citrus Combination treats weakened digestion and diarrhea; both Gleditsia Combination and Astragalus and Platycodon Formula treat skin infections and abscesses. Four Major Herbs Combination (Si Junzi Tang)

Ginseng and Zanthoxylum Combination (Lizhong Anhui Tang)

Lotus and Citrus Combination (Qipi Tang)

Gleditsia Combination (Tuoli Xiaodu Yin)

Astragalus and Platycodon Formula (Qianjin Neituo San)

ginseng

ginseng

ginseng

ginseng

ginseng

licorice

licorice

licorice

licorice

licorice

hoelen

hoelen

hoelen

hoelen



atractylodes

atractylodes

atractylodes

atractylodes









astragalus

astragalus







tang-kuei

tang-kuei







cnidium

cnidium







angelica

angelica







platycodon

platycodon



zanthoxylum, mume

crataegus, citrus, lotus seed, dioscorea, alisma

lonicera, gleditsia, peony

siler, magnolia bark, cinnamon twig

Table 6: Derivatives of Bamboo and Hoelen Combination (Wendan Tang). Bamboo and Hoelen Combination was first presented in a Song Dynasty text by Chen Wuci. Most of these formulas were listed also in Table 1. Bamboo and Hoelen Combination is, in turn, a derivative of Erchen Tang (Citrus and Pinellia Combination) of the Hejiju Fang, comprised of pinellia, citrus, hoelen, licorice, and ginger, which are here listed first. Gong's main alterations are adding more herbs for resolving dampness and phlegm (e.g., atractylodes and platycodon) and adding herbs for clearing heat (e.g., bupleurum and scute). He has not included zizyphus, an ingredient of Wendan Tang, in his formulas; it is a moist herb that might contribute to building up fluids.

Bamboo and Hoelen Combination (Wendan Tang)

Pinellia and Arisaema Combination (Qingshi Huatan Tang)

Bamboo and Ginseng Bupleurum and Combination (Zhuru Pinellia Combination Wendan Tang) (Cingfu Tang)

pinellia

pinellia

pinellia

pinellia



citrus

citrus

citrus



citrus

hoelen

hoelen

hoelen

hoelen

hoelen

licorice

licorice

licorice

licorice

licorice

ginger

ginger

ginger

ginger

ginger

chih-shih



chih-shih



chih-shih

bamboo

bamboo

bamboo



bamboo

coptis

coptis

coptis

coptis





atractylodes



atractylodes







platycodon



platycodon



scute



scute

scute





bupleurum

bupleurum



zizyphus

arisaema, angelica, sinapis, chiang-huo

ginseng, cyperus

alisma, scirpus, zedoaria, crataegus, ginseng, polyporus, jujube

gardenia, tang-kuei, saussurea, trichosanthes seed, fritillaria, cardamon

August 2000

Trichosanthes and Chih-shih Combination (Gualou Zhishi Tang)

o

MAXIMIZE YOUR RESULTS Suggestions for MS Patients at the ITM Clinics by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Natural medicine, and Chinese medicine in particular, is a fully participatory activity. That is, there is the work of the practitioner in providing a treatment, but there is also the active involvement of the person receiving treatments. Below are some of the suggestions that can be made to enhance outcomes by more comprehensive participation. 1. Acupuncture. In the practice of acupuncture, it is up to the practitioner to select a treatment strategy (points to be treated and technique of locating points, inserting the needles, and adjusting them after insertion). The person receiving acupuncture can help make sure that the acupuncture treatment is having the desired effect. First, there is a response to needling which is called getting qi (qi is pronounced “chee” and refers, in this case, to the movement of energy through the acupuncture meridians—channels of the energy flow that mainly exist close to the skin). To a certain extent, this is something that the practitioner can detect (there is often a slight movement of the needle, as if being pulled into the point), but, as importantly, it is something that the individual being needled can detect and report. The qi reaction may differ for the different points, and may differ from one day to the next or even from one time of day to another. It is described variously, as warmth, distended feeling, numbness, and, in some cases, propagation of the feeling from the point being needled along the body surface to another point or area. The sensation should not be pain, though it may initially feel uncomfortable because of its unfamiliararity. According to traditional doctors, getting good results is dependent on getting qi. Failure to get qi can be because the needle missed its mark (either in location or depth of insertion), because the manipulation of the needle (pulling, pushing, twirling, agitating) was not adequate to attain the response, or because the flow of qi through the meridian at the particular time of day is insufficient (in which case, another meridian may need to be treated). Let your acupuncturist know if you are getting the qi reaction. The acupuncturist should, especially with scalp acupuncture treatments, restimulate the needles at intervals of 5–15 minutes, in order to restore the qi sensation during the period of needle retention. In the case of scalp acupuncture, if you have muscular disabilities, you should attempt to move the affected part immediately after needle stimulation. If movement is not possible, the acupuncturist may help you make passive movements. If the affected part is not subject to voluntary movement (e.g., retina, bladder, etc.), then one should focus one’s attention on the part being treated and/or make movements of nearby muscles (e.g., back or legs for bladder; eyes for retina). In China, patients with serious illnesses are often treated with an intensive course of acupuncture. As an example, they might receive acupuncture once each day for ten consecutive treatments, followed by once every other day for ten treatments, followed, if necessary, by another ten treatments at the rate of 2–3 per week. Thus, one might receive 30 treatments in a two month period. In the U.S., it is more common for people to come for treatments once per week, but they might miss one treatment per month, on average, so that in a two month period they receive only 6–7 treatments, with an extended interval between treatments. If possible, get more frequent treatments, at least during the first three months of therapy and at any time when the disease is flaring up or seems to be progressing to a more serious condition. 2. Herbs Herbal therapies can have a powerful impact on physiological functions, including the full spectrum of immune responses. In many instances, they can substitute for drugs, providing a more healthful alternative. Unlike drugs, which concentrate a small amount of powerful chemicals into a tiny pill or injection, herbs are crude materials, mainly comprised of mild biochemicals that cannot be concentrated into a small volume. Therefore, the amount of herbal material that may need to be ingested could be quite high. In China, persons with MS or similar diseases often drink a decoction (tea made by boiling herbs for about an hour) made with about 1/4–1/3 of a pound of dried herbs. When using pills, it is common for the Chinese to administer large honey-bound pills (boluses) that have a weight of 6–9 grams: they are not swallowed whole, but chewed. Sometimes, there is a combination of pills and teas used in the treatment. In the U.S., most patients dislike preparing and drinking the teas or chewing up huge pills. Therefore, they are provided with dried teas (in the form of powders or granules that are swallowed with water) or smooth tablets (typically 700 mg/tablet). To get a dosage equivalent to what is used in China, one would consume about three tablespoons of the dried teas or 18–24 tablets of ground herbs (or a combination of the two materials) each day. The amount of herbs that is suitable for you is the amount that produces the reasonably expected results. This may be less or more than the dosage that is most often used in China. Typically, herbs will be consumed in these seemingly large dosages for at least two to three months, and then followed up with a somewhat smaller dosage (usually relying on pills only) for up to two years (longer if needed to keep symptoms under control). It is not uncommon for American patients to complain of digestive system reactions to herbs. This might be alleviated by changing the time of taking herbs in relation to meals, by taking digestive enzymes or other digestive aids, by taking a smaller dose of herbs more frequently, by adjusting the diet, or by changing the herbal formulation. The precise nature and timing of any apparent adverse reaction to herbs should be reported to the prescriber so that appropriate adjustments can be made. If an obvious allergic reaction occurs (most often this will be a skin rash), discontinue use of the herbs at once. When herbs are used to substitute for drug therapies, be careful about stopping use of any drug abruptly. Some drugs should be withdrawn slowly (especially corticosteroids), while others should be stopped rather than reduced in dosage (sometimes the case with antibiotics). Check with your doctor.

3. Nutritional supplements Deficiencies in several nutrients have been suggested to affect MS, including antioxidants (several vitamins, minerals, and amino acids), B-vitamins (associated with nerve functions), and essential fatty acids (which may reduce autoimmune responses). Further, absorption of nutrients may be reduced in persons who have chronic or advanced disease. Therefore, supplements are frequently recommended. Some of the important nutrients take up a substantial volume, including calcium, magnesium, vitamin C, flavonoids, essential fatty acids, and amino acids. Therefore, as is the case with the herb therapies, the amount of tablets or capsules to be consumed may seem rather large. Some items, such as amino acids or lecithin, might be given in bulk form rather than capsules or tablets so as to provide adequate dosage. Nutritional substances often have their best effects if taken along with a nutritious diet: the foods will provide cofactors that could aid in the absorption and utilization of the nutrients. Unlike herbs, nutritional supplements rarely cause adverse reactions. However, if you have received high dosage nutritional supplements by prescription, be careful about adding any other supplements, to avoid the possibility of elevation to potentially harmful levels. Some nutrients are so poorly absorbed or distributed that they are better administered by injection. For example, vitamin B12 may have both nutritional and pharmacological action if present in high enough dosage, but the amount absorbed orally may be very low. Injections of up to 1–2 mg at a time can be given, and these can be repeated weekly (in rare cases, even more often). Magnesium may benefit problems of pain, numbness, and muscle spasm if injected close to the area that is affected. 4. Life Style Staying active, physically and mentally, is important to regaining and maintaining health. Habits that impair physical or mental functions, including smoking, drinking, not getting enough sleep, lack of effective communication with others, and not having pleasant surroundings, make it more difficult to attain good health. It has been shown that certain physical activities, such as Tai Chi exercises, can enhance balance, strength, and emotional stability. Range-of-motion swim exercises and yoga are likely to be helpful in maintaining nervous system function and muscular strength without spasm. Persons who have successfully dealt with MS have often told their story in articles and books; while their particular method might not apply to you, they may offer some guidance in attitude, habits, and opportunities to pursue. November 1996

THE TREATMENT OF MENOPAUSAL SYNDROME WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Menopausal syndrome varies markedly among women. The most common symptoms include hot flushes (often called hot flashes, but the disorder involves red "flushing" of the skin), dryness and thinning of skin and vaginal wall, mood swings and depression, and insomnia. In addition, there is often a gradual weakening of the bones (reduction of bone density) known as osteoporosis that eventually leads to easy fracture. All of these symptoms are the result of declining levels of sex hormones, especially estrogens. In seeking information about potential Chinese herbal therapies for menopause, one is directed to the modern rather than the traditional practices. This is because there is limited reference to this problem in older Chinese medical literature. As an example, in the highly respected 14th century book Danxi Zhifa Xinyao (1), there are chapters on gynecology and childbearing, but just a single mention of menopause, with reference to a problem of abdominal pain said to be the result of menopause. It is unclear to what extent the various menopausal symptoms had been experienced by women in the Orient prior to the modern era. Several factors could have contributed to a low level of concern for menopausal symptoms. There are significant differences between Chinese women in past centuries and modern Western women, in dietary constituents, amount of manual labor, frequency of child bearing, and life span, affecting the incidence and nature of various menopausal symptoms. There could also have been a less frequent seeking of medical attention for menopausal syndrome which, even if the symptoms were significant, might not have been deemed serious enough to require treatment. By contrast, women today are asked to address the long-term implications of menopause, such as osteoporosis and the risk of heart disease, even if their symptoms of menopause are currently negligible. The occurrence of symptoms, even if not severe, simply increases the urgency of this already-expected seeking of assistance. Although little valuable information about early treatments for menopause is available, we do have access to an ancient description of female aging and loss of fertility from the first pages of the Neijing Suwen (ca. 100 B.C.). The changes in the body are depicted in seven year intervals (2): At 28 years, the bones and tendons are well developed and the hair and secondary sex characteristics are complete. This is the height of female development. At 35 years, the stomach and large intestine channels (yangming channels) that govern the major facial muscles begin to deplete: the muscles begin to atrophy, facial wrinkles appear, and the hair begins to thin. At 42, all the yang channels (taiyang, shaoyang, yangming) are exhausted, the entire face is wrinkled, and the hair begins to turn gray. At 49 years, the ren and chong channels are completely empty, and the tiangui has dried up. Hence, the flow of menses ceases and the woman is no longer able to conceive. This description still applies reasonably well, though we know that each individual women ages differently and not precisely according to a set 7-year cycle. The main difference between modern experience and this description is that with skin care products, modern diet (rich in vitamins), and less sun exposure, fewer women have their entire face wrinkled by age 42. In the same text, there is an explanation for the rare cases where older men and women are still able to have children. This capability is said to be due to two factors: These individuals inherited an unusual abundance of jing and also realized how to lead their lives properly and protect their vitality. At age 64 for males and 49 for females, these individuals still have excess kidney energy as well as qi and blood, so they still have the capacity to procreate. For those who have not inherited an abundance of jing or have not protected it via their lifestyle, herbalists hold out some hope, if not for restoration of fertility, at least for fewer signs of the associated aging process, by providing tonics that nourish the kidney energy, the qi, and the blood. Such treatment may slow down the physiological changes that lead to uncomfortable menopausal symptoms. FORMULAS RECOMMENDED FOR MENOPAUSE Rehmannia, because it is said to nourish yin and blood, benefit the kidney and marrow, and reduce fevers (see: Rehmannia), is an herb commonly selected for treatment of menopause by modern Chinese doctors. This herb is often used in the context of a formula that is focused on nourishing kidney yin or kidney yang or both, depending on the needs of the individual. Following are several currentlyrecommended menopause formulas derived from several modern Chinese textbooks that have been translated to English, and from one article that presented a survey of several clinical practices in China. These formulas are described in terms of a one-day dose in decoction form; the amounts are in grams. Most herbs are prescribed in the standard doses of 9–15 grams, with larger amounts of the mineral materials (e.g., 30 grams for dragon bone, dragon tooth, oyster shell), and smaller amounts for strong-acting herbs, such as aconite, cinnamon bark, and coptis, or for herbs that are added to benefit the stomach function, such as ginger, jujube, and licorice (when licorice is not also a main herb of the formula). Rehmannia is sometimes used in heavy doses of 24 grams or more. From Clinic of Traditional Chinese Medicine (3): Deficiency of Kidney Yin Deficiency of Kidney Yang Rehmannia, cooked: 24 Rehmannia, cooked: 24 Dioscorea: 12 Cornus: 9 Cornus: 9 Aconite: 6 Lycium: 12 Cinnamon bark: 6 Peony: 12 Antler gelatin: 9 Uncaria: 12 Eucommia: 9 Tortoise shell: 9 Placenta: 12 Ligustrum: 9 Eclipta: 9

Cuscuta: 9 Epimedium: 9 Codonopsis: 12 Atractylodes: 12 Ginger: 3

Deficiency of Yin and Yang Rehmannia, cooked: 9 Tang-kuei: 9 Anemarrhena: 9 Phellodendron: 9 Curculigo: 9 Epimedium: 9 Morinda: 9 Ligustrum: 9 Eclipta: 9



Baked licorice: 12



From English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (4): Kidney Yin Deficiency Kidney Yang Deficiency Rehmannia, cooked: 15 Rehmannia, cooked: 15 Dioscorea: 15 Dioscorea: 15 Cornus: 12 Cornus: 12 Hoelen: 12 Lycium: 15 Lycium: 18 Cinnamon bark: 6 Peony: 15 Aconite: 6 Licorice: 6 Cuscuta: 24 Dragon bone: 30 Antler gelatin: 12 Oyster shell: 30 Eucommia: 30

From Clinical Manual of Chinese Herbal Medicine and Acupuncture (5): Deficiency of Kidney Yin Deficiency of Kidney Yang Rehmannia, cooked: 10 Rehmannia, raw: 10 Dioscorea: 10 Cornus: 10 Cornus: 10 Hoelen: 10 Lycium: 10 Lycium: 10 Uncaria: 15 Epimedium: 6 Maurita shell (zibeichi): 15 Curculigo: 6 Lotus plumule: 3 Codonopsis: 10 Atractylodes: 10 Uncaria: 10 Maurita shell: 10 Ginger: 6 Citrus: 6 From A Clinical Guide to Chinese Herbs and Formulas (6): Deficiency of Kidney Yin Hyperactive Liver Yang Rehmannia, raw: 15–30 Dioscorea: 15 Cornus: 10 Hoelen: 10 Moutan: 10 Lycium: 10–15 Tortoise shell: 10–15 Anemarrhena: 10 Phellodendron: 10 Dragon bone: 15 Oyster shell: 15–20

Deficiency of Spleen and Kidney Rehmannia, cooked: 15–30 Dioscorea: 15 Cornus: 10 Lycium: 10 Aconite: 2–5 Cinnamon bark: 2–5 Deer antler: 5–10 Cuscuta: 15 Tang-kuei: 10 Codonopsis: 10 Atractylodes: 10

In Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine (11): the author suggests the bolus of Rehmannia Six Formula (Liuwei Dihuang Wan ) with Bupleurum and Tang-kuei Formula (Xiaoyao Wan), each one 6 grams each time, three times daily, for predominance of yin deficiency. Alternatively, for predominance of yang deficiency, use the bolus of Rehmannia Eight Formula (Jingui Shenqi Wan ) with the bolus of Ginseng Spleen Tonic Pills (Renshen Jianpi Wan), each one 6 grams each time, three times daily. Alternatively, he recommends the following general formula, a modification of Rehmannia Six Formula called Zishui Qinggan Yin, which is designed to specifically aid psychological distress as a manifestation of menopause: Rehmannia (half raw, half cooked): 20 Dioscorea: 12–15 Cornus: 10 Moutan: 10–12 Alisma: 12 Hoelen: 15 Epimedium: 12 Bupleurum: 10–12 Zizyphus: 30 Lily: 21–24 Gardenia and peony could be added to this prescription for symptoms of irritability and prolonged feeling of heat. The large dose of zizyphus and lily is directed at treating insomnia and night sweating. Further modifications of the formula are recommended for various syndromes; for example, if there is yin deficiency of liver and kidney, one can add anemarrhena, scrophularia, tortoise shell, dragon’s tooth, and magnetite. From Menopause syndrome treated by traditional Chinese medicine (7): The author reports that "the classic formula" and "the one considered most effective for menopausal syndrome" is Zuogui Yin modified with tortoise shell, ligustrum, and epimedium, as follows: Rehmannia, cooked: 15 Dioscorea: 20 Cornus: 15 Hoelen: 20 Lycium: 15 Tortoise shell: 30 Ligustrum: 15 Epimedium: 6 Baked licorice: 5 He then relayed the recommendations at several hospitals and colleges around China. Some examples of those treatments follow. The Shanghai College of Traditional Chinese Medicine recommends three formulas:

Deficiency of Kidney Yin

Deficiency of Kidney Yang

Deficiency of Yin and Yang

Rehmannia, raw: 15 Dioscorea: 15 Cornus: 10 Hoelen: 12 Alisma: 9 Moutan: 6 Anemarrhena: 9 Phellodendron: 9 Magnetite: 20 Shen-chu: 12 Cinnabar: 3

Ginseng: 9 Tang-kuei: 6 Atractylodes: 9 Hoelen: 12 Zizyphus: 12 Ginger, fresh: 3 Aconite: 3 Astragalus: 12 Longan: 12 Saussurea: 6 Polygala: 9 Licorice, baked: 6 Jujube: 5

Rehmannia, cooked: 20 Dioscorea: 10 Cornus: 15 Lycium: 15 Tortoise shell: 20 Anemarrhena: 9 Phellodendron: 9 Aconite: 6 Cinnamon bark: 3 Licorice, baked: 6

Beijing City Hospital of Traditional Chinese Medicine recommends these formulas: Deficiency of Liver and Kidney Rehmannia, raw: 15 Rehmannia, cooked: 15 Lycium: 15 Tortoise shell: 20 Morus fruit: 15 Oyster shell: 30 Dragon bone: 30

Deficiency of Kidney Yang Curculigo: 15 Epimedium: 15 Morinda: 15 Tang-kuei: 15 Codonopsis: 15 Deer antler: 15 Fenugreek: 15 Cuscuta: 15

Kidney and Heart not Communicating Rehmannia, raw: 15 Rehmannia, cooked: 15 Cornus: 10 Fu-shen: 10 Lycium: 15 Ligustrum: 10 Asparagus: 10 Lily: 10 Lotus heart: 6 Dragon teeth: 30 Scrophularia: 15 Ophiopogon: 10 Polygala: 6 Coptis: 5 Cinnamon bark: 5

From Practical Therapeutics of Traditional Chinese Medicine (16), the main prescription recommended is Zuogui Yin, with tortoise shell and ho-shou-wu added to reinforce the effects of nourishing yin and subduing yang; but for a case dominated by yang deficiency, Yougui Wan is recommended instead, combined with Lizhong Tang: Deficiency of Kidney Yin Rehmannia, cooked: 24 Dioscorea: 12 Cornus: 12 Lycium: 12 Hoelen: 9 Baked licorice: 6 Tortoise shell: 30 Ho-shou-wu: 15

Deficiency of Kidney Yang Rehmannia, cooked: 24 Dioscorea: 12 Cornus: 9 Lycium: 12 Antler gelatin: 12 Cuscuta: 12 Eucommia: 12 Cinnamon bark: 6 Aconite: 6 Tang-kuei or Nutmeg: 9 Ginseng: 12 Atractylodes: 9 Ginger, dry: 9 Baked licorice: 6

In the yang-deficiency therapy, tang-kuei is replaced by nutmeg in cases of loose stool. For a combination of yin and yang deficiency syndromes, the authors mention in passing the use of Erxian Tang, which is a modern prescription that was developed to treat post-menopausal hypertension. This formula was outlined, above, for deficiency of kidney yin and yang in the first set of formulas from Clinic of Traditional Chinese Medicine. SUPPORTING RESEARCH In an overview of integrating Chinese and Western medicine approaches (8), Zhou Jinhuang and Zhang Yongxiang selected Rehmannia Six Formula as an example of an ideal agent to indicate the progress that is being made through this approach. They reported that, with regard to menopausal syndrome: The use of Rehmannia Six Formula not only relieves the symptoms and ailments of the patients, but also brings back the normal balance of their female sex hormones, i.e., an increase of serum estrogen level with a lowering of the high FSH (follicular stimulating hormone) and LH (luteinizing hormone). Analysis of the physiological effects of the traditional prescription in terms of biochemical markers is the aspect of integrative medicine that the authors were illustrating. One mechanism by which Rehmannia Six Formula leads to changes in sex hormones has been suggested to be via the adrenal cortex. A recent study of cortisol production tends to confirm this. Twenty women with periodontitis and low plasma cortisol levels were treated with Bushen Guchi Wan, a derivative of Rehmannia Six Formula with hoelen and dioscorea replaced by lycium and drynaria (9). The herbs were powdered, made into a pill with honey and administered in a dose of about 7 grams of herbs each time, twice daily, for three months. The treatment increased the plasma cortisol levels and this effect was maintained for a year. It is possible that the active constituents interact directly with the adrenal cortex, or via other endocrine glands (e.g., pituitary or hypothalamus as has been suggested for ginseng and deer antler), or both. In a study of Rehmannia Six Formula in women with menopause of recent onset (mean age was 51 years), 9 grams of the formula was administered daily (in two divided doses) for two months (10). It was reported that the treatment resulted in decline of serum FSH and LH by half, and increase of estradiol of 20%. Estrogen receptors in peripheral leukocytes more than doubled. The authors suggested that this formula benefited menopausal women by regulating both hormone levels and hormone receptors. When Rehmannia Six Formula in pill form (9 grams per day in two divided doses) was given for a year to women who suffered early menopause due to surgery (15), it was found that the level of FSH decreased slightly, while the level of estradiol increased markedly. According to the analysis by the authors, the effect of administering the herbs was observed within three months, and then became more notable by six months, and was sustained at that level for the rest of the year. However, the authors also reported that the already

atrophied vaginal epithelium was not affected by the treatment. A study of tonification therapy to treat osteoporosis in post-menopausal women (12) revealed that a modification of Rehmannia Six Formula, with main ingredients rehmannia, cornus, dioscorea, epimedium, and cuscuta, markedly increased estrogen levels, especially during menopause, but also in women treated 5-10 years after menopause. The dosage used was 6-12 grams each time (in pill form), twice daily for three months. Bone mass density was only marginally improved. A similar study (13) of women suffering from osteoporosis yielded better results on bone density. The patients were first diagnosed as to the type of kidney deficiency syndrome suffered. Half the cases were described as general kidney deficiency (sometimes called kidney qi deficiency), while most of the other half of the cases had a dominance of kidney yin deficiency. The women were treated with a formula that included rehmannia, cornus, tortoise shell, schizandra, dipsacus, drynaria, morinda, loranthus, and placenta; for cases of deficiency of kidney yin dominating, the formula was adjusted to include dioscorea, lycium, and polygonatum. The formula was given in the dose of 9 grams each time (in pill form), three times daily for 10-12 weeks. The treatment markedly increased bone density as measured at the radial bone (arm); at the same time, symptoms of kidney deficiency syndrome, which often reflect the decline in hormones in menopausal women, were partially alleviated. The dosage of herbs was higher in this study than in the previous one. Aside from effects on estrogen, Rehmannia Six Formula was shown to increase the level of activated vitamin D in the serum of laboratory animals with osteoporosis that had been induced by corticosteroid administration (14). The herb formula was able to counteract the loss of bone density, restoring the density close to the levels of normal control animals, and the effect was thought to be partially mediated by the vitamin D. SUMMARY As this review of the literature illustrates, there are numerous prescriptions that have been recommended as a basis for treating menopause. In most cases, alternative formulations were mentioned that are intended to address the less common manifestations of menopausal syndrome. The most commonly used ingredients in these formulas are rehmannia, cornus, dioscorea, hoelen, lycium, tortoise shell, epimedium, and licorice. This list of ingredients matches the modification of Zuogui Yin cited by Luo Yuankai, and his colleagues (in the survey article on menopause formulas) as the one considered most effective, except that ligustrum might not be included. The modified Zuogui Yin can be viewed alternatively as a modification of Rehmannia Six Formula (Liuwei Dihuang Wan ), with moutan and alisma deleted, and replaced by two yin and blood tonics (lycium, tortoise shell), one yang tonic (epimedium), and one qi tonic (baked licorice). Lycium fruit plus epimedium has been used by Chinese physicians as an inexpensive substitute for deer antler: deer antler or antler gelatin is an ingredient of several of the formulas listed in this article. The modification of Rehmannia Six Formula with additional tonic herbs that might be recommended on the basis of this survey of menopause formulas is: Menopause Formula #1 Rehmannia, cooked: 15 Dioscorea: 12 Cornus: 12 Hoelen: 12 Lycium: 15 Tortoise shell: 15 Epimedium: 9 Baked licorice: 6 The dosages of the individual ingredients given here are characteristic of those recommended in the numerous sources; for some ingredients, they are somewhat less than the dosage recommended by Luo Yuankai. The total decoction involves 96 grams of herbs, which can also be prepared as dried hot-water extracts, with a daily dosage of about 16-18 grams/day. This formula addresses menopausal syndrome of the type described as deficiency of kidney yin or deficiency of kidney and liver, which is usually the first one mentioned in the literature because it is the most common syndrome. Since several experts also offer a treatment for kidney yang deficiency, practitioners are advised to check for evidence of significant yang deficiency before electing to use this particular formulation. Based on the formulations described above, if yang deficiency is noted, one may add either the combination of cinnamon bark and aconite (especially for chilly symptoms or pain) in a dosage of about 5-6 grams each, or a combination of deer antler (or antler gelatin) and cuscuta (herbs that are less warming and more nourishing than cinnamon plus aconite) in a dosage of about 9-15 grams each; tortoise shell may be deleted, especially when adding antler and cuscuta. In early menopause, while menstrual bleeding is still occurring irregularly, raw rehmannia in place of cooked rehmannia, and a larger dose of tortoise shell, may contribute a hemostatic effect if bleeding is excessive.

REFERENCES 1. Yang Shouzhong (translator), The Heart and Essence of Danxi’s Methods of Treatment, 1993 Blue Poppy Press, Boulder, CO. 2. Maoshing Ni, The Yellow Emperor’s Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA. 3. Zhang Enquin, Clinic of Traditional Chinese Medicine, 1990 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai. 4. Xu Xiangcai (chief ed.), English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 12 (Gynecology), 1989 Higher Education Press, Beijing. 5. Zhou Zhong Ying, and Jin Hui De, Clinical Manual of Chinese Herbal Medicine and Acupuncture, 1997 Churchill Livingstone, London. 6. Chen Songyu and Li Fei, A Clinical Guide to Chinese Herbs and Formulae, 1993 Churchill-Livingstone, London. 7. Luo Yuankai, et al., Menopause syndrome treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1989; 7(1-2): 55-64. 8. Zhou Jinhuang and Zhang Yongxiang, The pharmacological basis of the Chinese integrative medicine, Chinese Journal of Integrated Traditional and Western Medicine, 1997; 3(4): 242-245. 9. Zhao Ruifang and Sun Xigao, Effect of Bushen Guchi Wan on plasma cortisol level in patients with periodontitis, Journal of the Fourth Military Medical College 1989; 10(3): 205-207. 10. Zhang Jiaqing and Zou Dajin, Changes in leukocytic estrogen receptor levels in patients with climacteric syndrome and the therapeutic effects of Liuwei Dihuang Wan, Chinese Journal of Integrated Traditional and Western Medicine, 1995; 1(1): 9-12. 11. Shao Nianfang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine , 1990 Shandong Science and Technology Press, Shandong. 12. Liu Hedi, et al., The influence of kidney tonic herbs on relative parameters and bone mass density in post-menopausal females, International Journal of Oriental Medicine, 1998; 23(4): 205-207. 13. Liang Li, et al., Clinical observation on osteoporosis treated with traditional kidney-tonifying medicaments , Journal of Traditional Chinese Medicine, 1994; 14(1): 41-44. 14. Chen Yanping, et al., Effects of Liuwei Dihuang Wan and some other TCM drugs on bone biomechanics and serum 25(OH)D3 content in rats, Journal of Traditional Chinese Medicine, 1994; 14(1): 41-44. 15. Wu Xiening, et al., Comparative effectiveness of Chinese H3 and Liuwei Dihuang Wan in female climacteric and their mechanism of action, Journal of Traditional Chinese Medicine 1987; 7(4): 266-268. 16. Yan Wu and Fisher W, Practical Therapeutics of Traditional Chinese Medicine, 1997 Paradigm Publications, Brookline, MA.

APPENDIX: Nutritional Supplements for Menopause. Nutritional supplements may become necessary, even with a good quality diet, to compensate for lowered nutritional absorption (and, in some cases, reduced ingestion of high nutrient foods) associated with aging or with chronic illness. In particular, nutrients that aid bone mineralization are critical during and after menopause to help prevent loss of bone density. A collection of research abstracts regarding nutrition and menopause has been published by Dr. Melvyn Werbach, in his book Nutritional Influences on Illness (1996 Third Line Press, Tarzana, CA.). Following are some examples of important nutrients. Boron: 1-2 mg per day (do not exceed this dosage). Boron helps calcium absorption by the bones and may potentiate the action of estrogen. Calcium: Total intake should be 1200-1500 mg per day; typical dietary intake is 500-900 mg/day in menopausal women, so 300-1,000 mg supplementation may be necessary. Hydroxyapatite (derived from bone), calcium citrate, and calcium malate are currently thought to be the best sources for preventing and treating osteoporosis. Milk and milk products are also good sources of calcium. In Chinese herbal preparations, calcium is present in various shells (tortoise shell, oyster shell, maurita shell), fossils (dragon bone and dragon teeth), antler (deer antler), and other animal and mineral source materials. Fluoride: Fluoride helps increase bone density. Black tea has 1-4 mg fluoride per cup. Fluoride as a supplement is currently available only by prescription; excessive ingestion can harm bones and is toxic. Many city water supplies have added fluoride. Folic acid: 800 mcg per day. Folic acid reduces build-up of homocysteine, an amino acid which is associated with increased risk of heart attack and with impairment of bone formation. Magnesium: Total intake should be as high as 600-700 mg per day (about twice the recommended daily intake for younger adults). Current recommendations are to consume at least half as much magnesium as calcium. High levels of magnesium cause loose stool or diarrhea (magnesium retains water in the intestines): this is the limiting factor in magnesium dosage. Magnesium enhances calcium absorption and retention. Like calcium, magnesium is a component of shells and fossils used in Chinese medicine. Manganese: 20-40 mg per day. Manganese is necessary for bone mineralization. Silicon: This mineral is often available in the form of plant extracts, such as from "horsetail." Silicon aids calcium absorption into bone and is a component of bones, ligaments, and tendons that adds strength. The appropriate dosage level has not been determined as yet. Zinc: 15 mg per day. Zinc is necessary for bone formation; it also increases vitamin D activity and promotes immune functions. Avoid increased levels of zinc in cases of autoimmune disorders, as the immune stimulus promoted by zinc may intensify the level of autoimmune responsiveness. Vitamin B6 : 10-40 mg per day. Like folic acid, vitamin B6 reduces homocysteine levels. Vitamin D: 400 IU per day during menopause; for women over 65, use 400-800 IU per day. Vitamin D increases calcium absorption. Vitamin D is produced in the body in response to exposure to sunlight (15 minutes per day without sun blocking agents is sufficient); those who do not get enough sun exposure must supplement with vitamin D3 . Milk has vitamin D3 added; for those who do not consume milk products (lactose intolerance is a frequent problem in post-menopausal women), vitamin D supplements should be used. Vitamin E: 400–800 IU per day. Sudden introduction of high doses of this vitamin is contraindicated in cases of high blood pressure, as it can cause an increase in blood pressure; gradual increase in dosage avoids this problem. Dry forms of vitamin E are preferred over oily forms when using higher dosages. Vitamin E is an antioxidant and potentiates the action of estradiol. Vitamin K: 50-100 mcg per day. This vitamin plays a role in bone calcification. Most of these vitamins and minerals can be obtained by using a single vitamin/mineral supplement, so it is usually not necessary to obtain several different nutritional pills. Seed herbs used in Chinese formulas, such as ligustrum and cuscuta, provide some omega-3 fatty acids; omega-3 fatty acids decrease excessive plasma lipids, soften the skin, and reduce inflammation. Large doses (15 grams per day or more) of these seed herbs in decoction will provide a clinically significant level of the fatty acids. Menopausal symptoms may be reduced in some women by ingestion of sufficient levels of this type of fatty acid. Other sources are fish oils, which mainly provide eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA), and seed oils of evening primrose, black currant, borage, and flax. The suggested dosage of the oils (as isolated, they are usually provided in 500 mg soft gelatin capsules) is 3 grams per day.

March 1999

REDUCTION OF MOUNTAIN SICKNESS WITH CHINESE HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Increasingly, people are traveling into the mountains. In 1997, it was reported that there was a traffic jam at the upper levels of Mount Everest, earth’s highest peak, as so many mountaineers scrambled to reach the top during the short window of time when the weather permitted such a feat. Aside from trekkers, there are many people visiting high altitude destinations for purposes of vacation and exploration, such as Lhasa (Tibet), Katmandu (Nepal), and Machu Pichu (Peru). Mountain sickness, a condition which is brought on by the lower level of oxygen, and, to a lesser extent, the reduction of air pressure, usually affects people at altitudes of 2,500 meters or more (8,000+ feet), though sensitive individuals may show some symptoms above 2,100 meters (7,000+ feet). There is an increasing percentage of individuals affected—and more dramatic effects occur—as the altitude increases. In fact, experienced mountain climbers, as well as those who have little prior high-altitude exposure, have been known to suffer severe consequences, sometimes death, at altitudes of 9,000 feet and higher, as a result of mountain sickness. Dr. Peter Hackett, himself a climber, observed numerous trekkers passing through the town of Pherich, at 4,200 meters (14,000 feet) on the trail to Mt. Everest’s peak, and described, in his book Mountain Sickness (1), his growing knowledge of the health problems that occurred. The incidence of mountain sickness for mountain climbers during typical ascent was reported to be 65% at 4,200 meters and, in other observations, for those climbing Mt. Rainier in Washington, it was 66% at altitudes up to about 4,500 meters. Mountain sickness generally produces symptoms about six hours or more after arriving at high altitude or after increasing altitude by more than 300 meters (above the level of 2,100–2,400 meters) in a day. Most skiers avoid mountain sickness because they spend less than six hours at an altitude where the problem might arise and then spend the night at an altitude for which mountain sickness does not occur. Adaptation to high altitude, with alleviation of symptoms, usually requires 1–3 days, though it takes about two weeks to attain complete acclimatization. Symptoms associated with acute mountain sickness may include: Headache Fullness or tightness in the chest Insomnia Irregular breathing (especially at night) Lassitude Loss of appetite Loss of coordination Nausea Edema of eyes and face Vomiting (usually not of the lower body, however) Reduced urine output Cough Weakness Shortness of breath Legs feeling heavy Some of these symptoms may be experienced while climbing mountains or working at high altitudes and may not be due to mountain sickness, but are the result of other factors, such as exertion and failure to drink enough fluids. However, exertion and inadequate hydration can also worsen actual cases of mountain sickness. Therefore, it is important to become familiar with its symptoms and signs, so that one can respond appropriately if mountain sickness occurs. Since the disorder can have fatal consequences (most often from pulmonary edema), it is important that the response to mountain sickness include no further climb in altitude; in severe cases, there should be a prompt decline in altitude by at least 300 meters, preferably more (600–1,200 meters in response to pulmonary or cerebral edema). The most common symptom of altitude sickness is headache, which may partly result from the body’s attempt to maintain high oxygen levels for the brain, thus increasing blood flow to the head. The main physiological response of medical concern is the development of edema. In particular, one can suffer from cerebral edema (which may result in persistent headache, incoordination, and lassitude; it usually does not occur below about 6,000 meters), and/or from pulmonary edema (resulting in fullness of the chest, irregular breathing, difficult breathing; it may occur at 3,000 meters). Either of these are potentially fatal. While fluid is escaping from the blood vessels and accumulating in the brain, lungs, or face (the latter condition not being dangerous except when eyelid swelling is so severe that it impairs vision), the individual becomes quite dehydrated, and it becomes increasingly important to drink fluids (which are often difficult to get as the altitude increases, since the very heavy bottles of water are not easily transported to the higher altitudes where natural flowing water is not available; melting snow requires fuel and considerable preparation time). Reduction of urinary frequency and development of dark colored urine (representing its concentration of biochemical substances in small volume) reflects both the lack of adequate water ingestion and the loss of fluids from the blood to the tissues. In addition, digestion becomes impaired. Some of the nausea and vomiting that occurs is secondary to the experience of severe headache (as experienced, for example, by migraine sufferers at normal altitudes), but Dr. Hackett suggests also that appetite is also generally weakened and malabsorption occurs. These conditions may further lead to limited fluid intake and also nutrient deficiency. AVOIDING MOUNTAIN SICKNESS Aside from the herbal therapies to be described below, there are certain important steps to take to avoid mountain sickness. Dr. Hackett lists these: 1. Whenever possible, do not fly or drive to high altitude. Start below 3,000 meters (10,000 feet) and walk up. However, if taken passively to altitude, do not exert yourself or move to a higher altitude for the first 24 hours. 2. Once above 3,000 meters, limit your net gain in altitude (your sleep altitude) to 300 meters per day (1,000 feet). You can climb higher than that in one day—in fact, it may be beneficial to aid adaptation—but you must descend far enough that the overnight is spent at this altitude. 3. For every 1,000 meters gain in elevation, take an acclimatization day. This means that after three days of climbing about 300 meters per day, take one day without further climbing. 4. Prevent dehydration by consuming a minimum of 1.5 liters water per day (or enough water to assure clear urine), avoid overexertion,

consume a high carbohydrate diet, and carry potent diuretics in case edema occurs. HERBAL MOUNTAIN SICKNESS PREVENTION STRATEGIES FROM CHINA Since the 1950’s, but mainly since around 1970, millions of Chinese people have been transported from typical Chinese altitudes of 0– 650 meters (0–2,000 feet) to Tibet, primarily in the area of Lhasa, where the city altitude is 3,500 meters (12,000 feet), and much higher altitudes are inhabited in the immediately surrounding areas. This high altitude is usually attained during a three day truck drive up the mountainous border region (often from Chengdu in Sichuan Province), though air transport has been available to a limited extent since 1980. Adjacent to Tibet is China’s Qinghai Province, which has many towns at high altitude: Chinese people from the lower altitude provinces have also been relocated here, to live at altitudes of 3,000–4,500 meters (10,000–15,000 feet). Mountain sickness is a common reaction as people first reach their destinations in Tibet and Qinghai Province. The symptoms, sometimes quite severe, and the need for rest in order to prevent developing symptoms, would often cause a delay of about 10 days in getting to work. The problem was so common and so disruptive that many Chinese researchers investigated possible preventive treatments for the condition. One of the most widely used remedies has been Codonopsis Combination, also known as Compound Codonopsis Tablet, which has been used since the 1970’s. No reports were found detailing the precise ingredients of this formulation. The effectiveness of Codonopsis Combination (Compound Codonopsis Tablet) was reported by Sun Jianchang and colleagues at a hospital of Chengdu military command (2). Soldiers going to Tibet were treated with the formula, taking 5 tablets twice daily for 20 days starting 3 days prior to arriving at altitude. They were reported to be free of some common signs of mountain sickness, such as vomiting, anorexia, and weakness, and they had a lower incidence of dizziness, headache, palpitation, shortness of breath and nausea than a control group which did not take the herbs. In 1982, Peng Hongfu, at the Institute of Army Hygiene, Academy of Army Medicine (Beijing), published his report (3) on use of Chinese herbs to counteract mountain sickness. This work was an attempt to improve on Codonopsis Combination, which had performed reasonably well, but with about half the individuals using it still getting some degree of mountain sickness. In selecting remedies to test, Fang considered that the main problems were qi deficiency affecting the lungs and dampness accumulation. According to the principles of traditional Chinese medicine, qi deficiency and dampness accumulation can be addressed by tonifying the spleen and lungs and by including herbs to drain dampness. He experimented with five formulas, including Codonopsis Combination as the control. His main focus of adjustment was adding hoelen to help remove water accumulation. The new formulas were Codonopsis and Hoelen Combination and Astragalus and Hoelen Combination; the latter available in three slightly different formulations (formulation details were not revealed by the author). Codonopsis is described (4) as having the ability “to invigorate the function of spleen and stomach, to replenish the vital energy [qi] of the spleen and lung, to promote the secretion of body fluids.” Astragalus is described as having the following functions, among others: “to replenish the vital energy [qi]; to regulate water metabolism and reduce edema.” Hoelen is described as having the ability “to regulate water metabolism and resolve dampness, to reinforce the spleen and stomach, to pacify the heart [sedative action; alleviates insomnia].” Peng reports on a study in which troops were sent to Lhasa and the surrounding areas, with altitudes of 4,300–5,400 meters. The troops were all male, and most were aged 18–22. Three days before arriving at the Tibetan plateau, they began taking the herbs and continued to do so for two weeks after arriving. Evaluations of the reaction to the altitude were done by symptom survey, rating the overall responses to altitude as none, light, moderate, or heavy. The study was carried out during the period 1974–1977, with over 400 participants. According to the report, the group who took Codonopsis Combination had 45% reporting no mountain sickness and 38% reporting light reaction, and the rest (16%) having a moderate to heavy reaction. With the new Astragalus and Hoelen Formulas, a higher proportion, 57%, reported no mountain sickness, while a lower proportion, 31%, showed a light reaction, and only 12% had a moderate to severe reaction. Thus, the newer formula appears to have slightly increased the rate of avoiding mountain sickness. Unfortunately, since there was no true control group (receiving nothing or a placebo), it is difficult to know if the improvements were highly significant. For perspective, we can consider the reports of other individuals going to similar altitudes. In another article on the subject (5), it was mentioned that 77–80% of persons going to Tibet or Qinghai experience some degree of mountain sickness at altitudes of 4,400 to 4,900 meters. As mentioned above, incidence of mountain sickness among climbers at other sites is reported to be about 65–66% (34–35% with no mountain sickness) at 4,200 to 4,500 meters. One would expect that among a more general population who are not experienced climbers, such as those sent to Tibet and Qinghai, the incidence of mountain sickness might be somewhat higher, as would also be expected for the slightly higher altitude range (about 300 meters). Thus, the figure of 77–80% having some degree of mountain sickness (20–23% having no mountain sickness) appears comparable to other figures given in the literature. If the ingestion of herbs can prevent mountain sickness in 45–57% of individuals, as reported above, that would be a substantial improvement. In Peng’s article, the same herb formulas given to the soldiers were tested in treatment of hypoxya (low oxygen) in laboratory animals. These experiments are relatively easy; animals are placed in a chamber (with or without administration of herbs, depending on the group) and the air is slowly withdrawn, mimicking the problem of going to higher altitude. The survival of the animals over time is then monitored. There are two kinds of hypoxia that can be introduced in the laboratory. One is that which mimics high altitude, in which case the oxygen level becomes low as the total air pressure is reduced (hypobaric condition), and the other is accomplished by using a reduced oxygen air at normal pressure (normobaric condition; same as at sea level). These different laboratory conditions can yield different kinds of results. Peng’s work was with hypobaric conditions. In one test, control animals had a mean survival time, at the very low pressure condition used, of 6.7–6.8 minutes; by contrast, with use of the herbal formulas, the survival time increased to 16.5–26.1 minutes, with the lowest results from Codonopsis Combination and the best results from Astragalus and Hoelen Combination. In another experiment, using intermittent hypoxia, survival of test animals was greatest with Codonopsis and Hoelen Combination, with 100% surviving pressures corresponding to 11,000 meters elevation (Mt. Everest’s peak is about 9,400 meters), compared to 50% for controls. Clinical studies were also done with ganoderma preparations (5). Tableted extracts of ganoderma were given to troops starting the first day of their journey by truck into the mountains (on the way to being stationed in Tibet or Qinghai), and continued for six days (herbs taken twice per day, 3 tablets each time). Reactions to high altitude were rated as non-reacting (work unaffected, but there could

be a light response that would persist for no more than two days), mild, medium, or serious. Accordingly, it was reported that 86% of the participants were non-reacting and 13% had a mild reaction, avoiding headaches and vomiting. Both extract of cultured mycelium and extract of mushroom produced the same results. Laboratory studies confirmed the benefits of the ganoderma preparations in animals exposed to reduced oxygen. In other reports, ginseng, tienchi ginseng (sanqi), gynostemma (jiaogulan; it has active ingredients in common with ginseng), and eleuthero ginseng (ciwujia) were found to be of potential benefit in protecting against mountain sickness, as demonstrated by the laboratory hypoxia testing. The general theory is that herbs having qi tonification properties, such as codonopsis, ginseng (and varieties thereof), astragalus, and ganoderma, aid the utilization of oxygen, thus preventing the adverse reactions to low oxygen. Hoelen is added to eliminate the edema that accompanies more severe altitude sickness. A recent study by Chen Jianzhong, et al., (12) involved administration of ginseng and hoelen, prepared as a concentrated decoction liquid. The liquid was administered in three doses, to total 100 ml per day (derived from 10 grams ginseng and 20 grams hoelen), during the day before departing from Chengdu to Tibet. A control group was not treated. The participants in the study had already spent time living in Tibet and were spending time both in Tibet and Chengdu (or other lowland areas). Both the treated and untreated groups experienced higher heart rates and blood pressure after arriving in Tibet. However, the treated group had a normal ECG axis, but there was significant deviation from normal in the control group. Also, the treated group had a much shorter time required for resting before going back to work in Tibet (about 7 days) compared to the control group (usually about 10 days, but this time it happened to be 15 days). Since these individuals had previous experience going to Tibet, they could act as their own controls to some extent. For example, in the treatment group, when they last went to Tibet, 12.9% were hospitalized due to mountain sickness, while on this trip, having taken the herbs, only one person (1.4%) was hospitalized. The control group on this trip had 10% hospitalized. In all, it was reported that 2/3 of the treatment group had a reduced level of mountain sickness compared to the previous trip. Ginseng was the focus of another study, conducted by Fang Zhong and his colleagues (13). Individuals going to Tibet from Chengdu were given 20 grams of ginseng powder (Jilin red ginseng) starting two days prior to the trip by airplane. These individuals had prior experience going between these two sites: in fact, on average, six trips before this one, and they experienced mountain sickness. This time, 30% of the group experienced no mountain sickness, or only a light reaction that lasted a brief time; 56% of the group had less mountain sickness than on previous trips. A matched control group was also monitored: those taking ginseng had a lesser increase in heart rate and lesser change in electrocardiogram than those not using ginseng. As with the previously mentioned study, rest time before getting back to work was also shorter with use of ginseng, with results almost the same as in that study. A ginseng-based formula, Sheng Mai Yin, was tried by Zhang Zaohua and Song Lanzhi (14). Residents of Lijiashan Village (at 2,500 meters) were given a liquid preparation of this formula at 10 ml. each time, three times daily for five days, providing the extract of 3 grams of ginseng, 6 grams of ophiopogon, and 3 grams of schizandra each day. These individuals then drove to Kunlun Mountain (4,475 meters). After arriving, they stopped taking the herbs and took some measurements on the next day. The researchers measured the level of atrial sodium-peptide, a blood component that has been shown to have a close relationship to blood oxygen transport. Usually, this compound is found in abnormal levels when the heart and lungs are in a pathological condition that reduces oxygen transport. Comparing individuals taking Sheng Mai Yin with a control group not taking the herbs, and also comparing laboratory animals (rats) transported to and from the same altitudes (with Sheng Mai Yin group and control group), it was shown that Sheng Mai Yin inhibited the decline in atrial sodium-peptide. The animal studies also revealed a likely basis for pulmonary edema and consequent death from this disorder: high altitude conditions reduced the phospholipid content of blood cells, which caused a loss of stability in the alveoli, which could cave in due to the lack of blood cell fullness. The effect of gynostemma was compared to Compound Codonopsis Tablet by Chen Yaozhang and colleagues (15). One group of participants took a train from Chengdu to Geermu City (in Qinghai Province) and then, on arrival, began to drive to Lhasa. Gynostemma extract, in granule form, was given starting in Chengdu (12 grams each time, three times daily), and Codonopsis Tablet was taken starting the same time, 4 tablets each time, three times daily, for a total of 12 days. Another group took the plane from Chengdu to Lhasa and then took a bus, the same day, to an Army station at 4,370 meters. They began taking the herbs five days prior to the flight. A control group took none of the herbs. According to the report, for those going by train and truck, 75% of those taking the gynostemma granule and 65% of those taking the Codonopsis Tablet had essentially no mountain sickness reaction (the difference being insignificant), but only 28% of the control group reported no reaction. For those going by plane, then gynostemma treatment appeared to perform better than the Codonopsis Tablet, with no major reactions in 80% of the gynostemma group, 57% of the Codonopsis Tablet group, and only 30% of the control group. PROLONGED EXPOSURE TO LOW PRESSURE AND LOW OXYGEN Persons who live at high altitude experience changes in their blood that help compensate for the low oxygen levels. There are more red blood cells retained in circulation and more hemoglobin to carry oxygen. Such changes take about a week or two at high altitude to develop (with 80% adaptation accomplished in about 10 days). Most mountain climbers do not spend this much time at high altitude and thus have to deal only with acute reactions to altitude. Rats exposed to low pressure (corresponding to 5,000–6,000 meters altitude) for two weeks respond with increased RBC and hemoglobin counts (10). This response was virtually eliminated if the rats were given Jianghong Pian (literal: reduce the red tablet). The formula is comprised of astragalus, carthamus, eupolyphaga, cinnamon bark, and rhubarb. Presumably, the herbs reduced the body’s need for higher RBC and hemoglobin by reducing the oxygen utilization requirements of the body and enhancing the oxygen carrying capacity of the blood cells. Such treatment for humans would only seem suitable for moderate-duration visits to high altitude; for example, when remaining at an altitude for two to three weeks. During this interval, altitude-related problems may still arise during exertion due to incomplete adaptation. For longer duration visits, one would benefit from simply having the blood system undergo the usual adaptation to the higher altitude via blood system changes, which is likely to eventually occur even if herbal therapies are continued. However, with increased time at high altitude, one can develop a persistent qi deficiency syndrome, as revealed by Chinese studies. Guo Yonghui, at the Institute of Traditional Medicine of Qinghai Province, evaluated persons who were living at high altitude for a

long time (11). He observed that qi deficiency was a common syndrome. This condition was diagnosed for 41% of those living between 2,000 and 3,000 meters, in 57% of those living between 3,000 and 4,000 meters, and 69% of those living between 4,000 and 5,000 meters. Persons who had moved to high altitude from a lower altitude were more likely to develop a qi deficiency syndrome (even after years at the high altitude) than those who were born there (52% versus 39%), implying some difficulty in fully adapting to the high altitude. For both the native born and immigrant populations, qi deficiency syndrome occurred more frequently with aging at the high altitude. However, qi deficiency also occurs more frequently with age at low altitude. The qi deficiency syndrome might be associated with different traditionally-defined organ systems in different individuals: it is mainly associated with either the spleen, lung, heart, or kidney systems, or some combination of two or more of these organ systems. Guo reported the unsurprising result that as altitude increased, lung qi deficiency was the more likely condition to be experienced. He pointed out that at low altitude, qi deficiency often is associated with aging and affects primarily the spleen and kidney, while high altitude causes an earlier, environmentally induced qi deficiency that more often affects the lungs. Although he did not suggest any herbal therapies for these conditions, clearly, regular ingestion of qi tonic herbs, and those that benefit the lungs in particular, would be a logical choice based on his observations. Blood stasis is also a problem at high altitude. According to a study by Jiang Zhengqian in Lhasa (16), there is a condition known as “plateau sickness” that occurs with persons living on the Tibetan plateau. Individuals with this condition have polycythemia, cardiac disease, hypotension, and other conditions that are related to living at high altitude for a prolonged period. In a survey of 370 outpatients at the TCM clinic in Lhasa, 89 suffered from this condition. Further, a total of 252 of the patients surveyed had signs and symptoms of blood stasis, observed in terms of sublingual vein enlargement and discoloration, blood-stasis type coloration of the tongue body, and blood-stasis type nail bed coloration and response to pressure (slow return of color after pressing). Of the 89 with plateau disease, 84 had blood stasis symptoms, but even among those with ordinary diseases (that are common at all altitudes), blood stasis was found in 60% of the individuals. Incidence of blood stasis increased with greater duration of living at the high altitude. It was found in 81% of those living in Tibet more than 20 years, but only in 36% of those living in Tibet under 10 years (age may have been a partial contributor to this phenomenon). Relaying an earlier study, Jiang points out that the specific viscosity of whole blood in long-term residents of Lhasa was 7.2 for males and 5.6 for females, which is slightly higher than that for newer immigrants, but much higher than that for people living close to sea level (4.9 for men, 4.6 for women). At his clinical facility, virtually all patients receive treatments that include blood vitalizing herbs, and a treatment for plateau sickness involves “removing blood stasis...clearing up the ying system and removing heat from the blood, warming yang and dispelling heat, invigorating qi and strengthening the spleen....” This method, he reports, produces relatively satisfactory short-term results. ADAPTOGENS IN LABORATORY TESTS The term “adaptogens” was coined in the 1940’s to attempt to describe the concept that certain herbs (or isolated chemical compounds) could help laboratory animals in experiments resist severe stresses, that is, help them to adapt to a difficult condition. The hope was that such substances could also help humans adapt to stressful conditions. Testing of adaptogens often includes exposure of animals to low oxygen, low temperature, and continual high-level physical activity (induced by threat of pain or death). These experiments reflected some of the situations sometimes facing humans. The underlying concept, using a modern medical viewpoint, was that the adaptogen aided the homeostasis mechanisms. From the traditional medical viewpoint, the adaptogen supported the rectifying qi, that is, the normal qi of the individual that not only maintains homeostasis under non-stress conditions, but also helps resist pathological qi that causes disruption. As an example of the continuing work in this field, Bao Lihua and his colleagues at the Harbin University of Medicine (6) tested a ginseng and royal jelly liquid mixture, using American ginseng (which is now cultivated in Heilongjiang Province in China, of which Harbin is the capital city). Mice were exposed to low pressure or to low temperature (–11 C). Protective effects of the tonic liquid were noted to be dose-dependent and it was claimed that this mixture was protective whereas the similar product made with Chinese ginseng was not. It is known that American ginseng contains a considerably higher concentration of ginsenosides than Chinese ginseng, so if the studies were done with relatively low dosages, the Chinese ginseng may have failed to perform well in this study. In an earlier study, (7), ginsenosides from Chinese ginseng were shown to protect mice from low pressure hypoxia in a dose dependent manner at 100–200 mg/kg (but were not effective at lower dosage). In another study, ginsenosides at 540 mg/kg protected mice subjected to hypoxia, reducing lactic acid levels and preventing changes in cyclic nucleotide levels in the cerebrum and myocardium (8). It would appear that royal jelly in the combination product did not make a significant contribution to protective effects. In the book Applications and Pharmacology of Chinese Medicinal Materials (9), a listing is provided of the herbs that had been investigated and shown to enhance tolerance to hypoxia. These are items that were evaluated in laboratory animals and reported in the Chinese medical literature prior to 1986. The listing includes the blood-vitalizing herbs salvia, sanqi, bulrush, and carthamus; the tonics ganoderma, rehmannia, epimedium, ophiopogon, and yu-chu (a type of polygonatum); the heat-clearing herbs ardisia, chyrsanthemum, sophora, antelope horn, and hemsleya; and miscellaneous herbs chuan-shan-lung (a species of dioscorea used for arthralgia), fo-shou (called finger citron, used for dispersing qi and dampness), and trichosanthes fruit (used for clearing phlegm). The blood-vitalizing herbs may be of special value since at high altitude there is increased likelihood of blood clots (thrombosis), especially deep vein thrombosis of the calves. This may be the combined result of lower amounts of water and higher amounts of red blood cells flowing through the vessels. BROADER APPLICATIONS In response to this work with mountain sickness and hypoxia, it has been proposed that such herbs would aid in athletic performance for those who undertake extreme levels of exercise (at normal altitude) that tax both the oxygen carrying capacity of the blood and the air intake level of the lungs (e.g., for distance racers). Sports performance studies have been done which purportedly show better performance when ingesting these tonic herbs prior to racing. As further response, the Olympic Committee has banned the use of such substances (especially ginseng) prior to competitive events to remove the possibility of enhancement of natural performance. Further, since lack of oxygen destroys cardiac or brain tissues when a blood clot blocks the arteries, it might be presumed that ingestion of these tonic herbs would limit the damaging effects of heart attack or stroke. Finally, in cases of emphysema and other degenerative lung diseases, these herbs may prevent further collapse of the alveoli and improve the blood oxygen levels. By selecting tonic herbs with

blood-vitalizing properties (e.g., ganoderma and tienchi ginseng) or mixing tonics (e.g., codonopsis, ginseng, astragalus, gynostemma) with blood-vitalizers (e.g., salvia, carthamus, or peony), one should be able to enhance blood circulation and oxygen utilization for preventing catastrophic events associated with aging, as well as avoiding temporary problems, such as mountain sickness. Similar treatment strategies have been developed independent of the mountain sickness work (and are reported effective in laboratory animal and clinical research), relying on traditional Chinese medical principles. SUGGESTED HERBAL PROTOCOL According to the studies conducted thus far, it appears reasonable to begin ingestion of herbal prophylaxis for mountain sickness at least 3 days prior to arriving at high altitude (about 2,100 meters) and to continue the use of the herbs for the entire duration of a high altitude visit. Although the clinical trials described above reported that pretreatment with herbs would protect against mountain sickness even when herb ingestion ceased upon arriving at high altitude, it seems prudent to reinforce the protective effects by continuing use of the herbs. The cessation of herb ingestion at arrival gave researchers the chance to make observations, including ECG, heart rate, and blood tests, with the herbs cleared from the system in order to illustrate true prophylactic action. In other situations, the herbs would be recommended to be used for several more days, as they were in some of the studies. In general, qi tonic herbs, such as codonopsis, ginseng (and varieties thereof), astragalus, and ganoderma are reasonable choices for mountain sickness prophylaxis, and one might add a blood-vitalizing herb, such as salvia. For altitudes in excess of about 2,900 meters, diuretic herbs, such as hoelen, should be included in the treatment until the risk of edema is no longer significant. The Chinese sources sometimes failed to provide details about dosage. However, in the cases where tablets were used, the dosage was 3–5 tablets each time, twice daily. These tablets were made of dried extracts of the herbs. In cases of using herbal powders and liquid extracts, dosages of individual herbs (e.g., ginseng) or herbal formulas (e.g., Sheng Mai Yin) were in the range of 10–30 grams per day. Unlike treatment of chronic diseases, these preventive strategies generally involved single herbs or small formulas of just a few herbs. For persons who plan to stay at high altitude for prolonged periods, the problems of qi deficiency and blood stasis should be addressed. For the most part, the same herbs can be relied upon for this purpose as for preventing mountain sickness. REFERENCES 1. Hackett PH, Mountain Sickness: Prevention, Recognition, Treatment, 1980 American Alpine Club, New York. 2. Sun Jianchang, et al., Prophylactic effects of Compound Dangshen Tablet on high altitude reaction: effects on symptoms and hemodynamics, Sichuan Journal of Traditional Chinese Medicine 1989; 7(1): 13–15. 3. Peng Hongfu, Study of Astragalus and Hoelen Combination for preventing acute mountain sickness, Medical Journal of Chinese People’s Liberation Army 1982; 7(3): 135–138. 4. Him-che Yeung, Handbook of Chinese Herbs and Formulas, vol. 1, 1985 Institute of Chinese Medicine, Los Angeles, CA. 5. Anonymous, Spot survey on the prevention of acute mountain sickness with ganoderma, Chinese Traditional Herbs, 1979; 6: 29–31. 6. Bao Lihua, et al., Effects of American Ginseng/Royal Jelly Syrup in mice against anoxia and low temperature, Journal of Harbin Medical University 1992; 26(1): 14–15. 7. Lu Ge, et al., Comprehensive evaluation of the antihypoxia action of ginseng root saponins , Journal of Shenyang College of Pharmacy 1987; 4(2):131–135. 8. Fang Yunxiang et al., Effects of ginsenosides on ultrastructure and levels of lactic acid and cyclic nucleotides in ischemic myocardium of mice, Chinese Journal of Integrated Traditional and Western Medicine 1987; 7(6): 354–356. 9. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, vol. 2, 1986 World Scientific, Singapore. 10. Zhang Jingming, et al., Pharmacology and toxicity of Jianghong Tablet, Chinese Traditional and Herbal Drugs 1988;19 (10): 458– 461. 11. Guo Yonghui, et al., Investigation of the relationship between altitude hypoxic circumstance and deficiency of vital energy, in Sinomed ‘87 International Conference on Traditional Chinese Medicine and Pharmacology Proceedings , 1987 China Academic Publishers, Shanghai. 12. Chen Jianzhong, et al., Observation of 120 cases of preventing mountain sickness by using Ginseng and Hoelen Combination, Qinghai Medical Journal 1986 (3): 41–43. 13. Fang Zhong, Jiang Weiyu, and Yang Zhenghua , Observation on prophylactic effect of ginseng against acute high altitude reactions in 90 cases, Zhejiang Journal of Traditional Chinese Medicine, 1996 (5): 231–232. 14. Zhang Zaohua and Song Lanzhi, High altitude conditions and qi deficiency (III)—A trial of Sheng Mai Yin applied to prevent high altitude reactions, 1990 (6): 42–44. 15. Chen Yaozhang, et al., Observation of preventive effect of Gynostemma Granule on acute high altitude symptoms, Medical Journal National Defense of Southwest China, 1993; 3(5): 257–259. 16. Jiang Zhengqian, Survey and analysis of 370 highlanders for signs and symptoms of blood stasis, Journal of Traditional Chinese Medicine 1996; 16(3): 190–193. NOTE: The transport of Chinese people, mainly Chinese troops, to Tibet is part of a repressive action of the Chinese government against the Tibetan people that has included political, social, cultural, and religious interference, torture, and killings. Most of the reported clinical trials involving mountain sickness prevention and treatment were conducted in hopes of making it easier for Chinese troops to enter and stay in Tibet. This is an unfortunate source of research information. It is hoped that the results of this research can have some benefit to the world’s population and that eventually the Chinese will have no need for further testing along these lines because the frequent mountain sickness problem will be solved by staying at low altitude.

September 1997

TRADITIONAL CHINESE MEDICINE AND MULTIPLE SCLEROSIS A patient guide by Edythe Vickers, N.D., L.Ac., and Subhuti Dharmananda, Ph.D.

BACKGROUND: EASTERN AND WESTERN PERSPECTIVES Traditional Chinese medicine (TCM) has evolved over the past two and a half millennia to become the second largest health-care system in the world, after modern Western medicine. Because of its reliance on ancient doctrine and experience, TCM holds that the causes of most diseases as stemming from spiritual, emotional, behavioral, dietary, and climatic factors, in contrast to the biological and biochemical basis seen by practitioners of modern Western medicine. Chinese medical treatment is aimed at adjusting the environmental and human influences through lifestyle adjustments, the use of medicinal herbs, and physical therapies. Since modern Western medicine —with its reliance on the latest research findings and technologies—depicts the causes of most diseases as stemming from genetic, structural, pathogenic (infective or toxic), nutritional, and behavioral factors, treatments are bioengineering, surgery, chemotherapy, dietary restriction, nutritional supplements, and behavior modification. Given that TCM and modern Western medicine have some overlap—in that they both recognize the roles that diet and behavior play in disease etiology—a detailed exploration is warranted. With regard to diet, Chinese medical doctrine holds that all ingested substances, whether classified as food, herb, or drug, have an influence on physiological function. The influence of an ordinary apple, for example, is said to be cooling and astringent, benefiting the digestive system and lungs. On the other hand, mutton is warming and moisturizing, benefiting the digestive and endocrine systems. By cooking foods through different methods, or adding seasonings during cooking, the nature of the food can be altered. Depending upon the selection of foods and their specific method of preparation, a person may maintain the balance that exists, restore balance, or, with the incorrect choices, become unbalanced. The role of the traditional-style medical doctor is to direct the individual to eat foods and consume herbs that will restore and maintain the balance that has been lost. A well-known saying in the Orient is: “Medicine and herbs have a common source; herbs and food have common uses.” This means that foods, herbs, and medicines must be considered as one subject when it comes to health. Western medical theory holds that foods are comprised of chemicals, that the body reduces the complex foods to a mixture of these basic chemical components through the digestive process, and that the body takes only those components it needs and eliminates the rest. The dietary chemical components that are currently deemed essential to health have been determined to be important mainly by the process of individually eliminating them from the diet of test animals and observing whether or not an abnormality arises, then restoring the substance to see if the abnormality is corrected. Based on these observations and analysis of human dietary intakes, a list of recommended daily amounts of nutrients has been developed, and individuals are asked to be sure that all these recommendations are met, regardless of their source. However, because recent experience has shown that high-fat diets can increase risks of cancer and heart disease, an upper limit is placed on the ingestion of total fats, and of the subgroup saturated fats. In a similar manner, an upper limit is recommended for total intake of cholesterol, salt, simple sugar, and total calories to help minimize the occurrence, and severity of certain diseases, such as atherosclerosis, hypertension, and diabetes. TCM practitioners recommend the use of foods on the basis of the inherent qualities of the whole, prepared, food, while modern Western-medicine practitioners recommend the use of foods based on the quantities of certain constituents, source and method of preparation notwithstanding. Since in the Orient, herbs are regarded as having a similar use as foods and similar origin as drugs, they are likewise used according to their inherent qualities to help achieve bodily balance. In the West, herbs are not deemed essential (they are generally low in nutrients and their need in human health has not been firmly established), so they are simply not recommended. Further, because of lack of experience using herbs instead of poisonous plants serving as the source of powerful drugs (e.g., foxglove as the source of digitalis), fear of adverse reactions or of unforeseen future risks from using herbs frequently outweighs the attraction of any possible health benefits. Regarding the influence of behavior on health, Chinese medical doctrine suggests that certain behavioral patterns associated with emotional experiences may lead to disease. Probably the most important causative factor identified in this medical system is the failure to resolve emotional distress by appropriate familial and societal interactions. It is understood that unrelieved emotional stresses cause alterations in the functions of the internal organs, ultimately leading to their malfunction and the initiation of disease processes. For example, a large portion of the cases of cancer, autoimmune diseases, and gynecological disorders are thought, by the Chinese physicians, to be induced by or promoted by anger, depression, and anxiety. Appropriate resolution in the Orient may include discussing the situation and the emotional problem with respected elder family members to obtain wise advice towards resolution; attaining agreement with one’s spouse over areas of controversy; and simply obeying the rules laid down by Confucius or other great thinkers regarding one’s place in the family and within the greater society. This concern is basically for spiritual health, in the sense that one can, and should, strive to resolve spiritual emptiness—a potential basis for disease and failure to handle emotional situations—by communication with spiritual leaders in the community and by following the teachings of revered historical figures. It should be noted that, during the past few decades in the People’s Republic of China, this aspect of health care has been demoted in emphasis due to the government’s negative position on religion and spirituality; a failed policy that is now slowly turning around. Western medical theory expresses the idea that various human behaviors entail certain risks associated with disease or debility. Cigarette smoking, excessive drinking of alcohol, over-eating, illicit drug use, and participation in activities that have a high accident rate (e.g., automobile racing, skiing) are examples of high-risk behaviors. Continuation of these behaviors may lead to diseases, injury, or death. To alter the behaviors, education is offered to clarify the nature of the risk, and interested individuals may participate in programs to assist behavior changes (e.g., AA meetings). While it has been recognized recently that emotional stress and depression can have an adverse impact on immune function, there is rarely any further elucidation of the link between emotion, high-risk behavior, and the onset of disease. In fact, recent research findings suggesting that there are genetic factors behind the undertaking of high-risk behaviors has focused attention on the biological side of the problem, rather than the emotional. Nonetheless, there is increasing discussion of the value of “support groups” in reducing disease symptoms and enhancing survival in cases of serious illnesses. Participation in such support groups has been shown to alleviate depression and double the life span of patients with terminal breast cancer. In China, the extended family and members of the local community are supposed to be in place at all times as a support group, but this is often not the case in America where high divorce rates and relocation of family members have been dominant features of the social landscape for generations. It can be seen that, even in these two areas (diet and behavior) of overlapping ideas about disease etiology, there are considerable

differences between the TCM and modern Western viewpoints. As a result, the diseases are described in different terms and treated by different means. In those areas where there is even less overlap in ideas about cause of disease, there are greater differences in the therapeutic approaches taken, and it becomes quite a complex task to describe the Chinese theory in terms that would be comprehensible to someone trained in the modern Western medical way of thinking. MULTIPLE SCLEROSIS As relates to MS, the Chinese believe that the disease process most likely originates with a combination of spiritual and emotional factors, and that the “trigger” for the disease may be an experience of a feverish illness, usually an infectious disease. The weakening of and loss of control over the musculature may come about because the critical energizing and regulating functions of the internal organs have become disturbed due to the loss of spiritual focus, perhaps because of a frightful experience which has “scattered one’s soul from its resting place.” The triggering disease consumes vital fluid essences that are essential to nourishing the body and providing a relaxing medium for the spirit. Without spiritual relaxation, there is ongoing agitation, and destruction of bodily harmony. Western medicine is still pursuing the precise description of MS, but currently it is believed that a combination of genetic predisposing factors and an episode of a common viral disease initiates an autoimmune process which leads to the symptoms of the disorder (inhibition of nerve transmission to the muscles), exacerbated by subsequent infections or other stimulants to the autoreactive immune system. In other words, the disease has nothing to do with either personal experiences (other than having an infection) or general bodily balance, but rather is attributed to an inherited coil of DNA and another slice of DNA provided by the virus. Therefore, TCM diverges from Western medicine by placing human experience above inheritance and biology as a cause. TCM practitioners would not deny that the specific disease manifestation—multiple sclerosis, rather than another chronic disease causing similar symptoms— might be based on heredity, but they would focus on other experiences to explain why the disease arises and persists. Therefore, the Oriental and Western views can be partially reconciled by saying that a genetic propensity for the disease needs to be present in order for one to experience MS, but that life experiences other than the viral infection might also be necessary cofactors to initiate and maintain the full disease process. MS is a relatively rare disease in China, and this is believed by modern researchers to reflect a genetic difference between the Oriental population and the others—mainly Caucasian—that have a higher incidence of the disease. Further, MS is more common in individuals who grew up in northern areas rather than southern areas, suggesting either exposure to a pathogen or food product that is more common in the cold climates. Among those with the necessary genetic and environmental factors, the reason why some are afflicted with MS and others are not, or why the disease follows such different courses in different individuals, remains an open question for which TCM theory may provide some insights. Although the Chinese see anxiety, depression, fright, and fear as contributors to the disease process (helping to initiate and aggravate the condition), Western doctors observe these emotional patterns in patients diagnosed with the disease and attribute the emotional conditions largely to a reaction to the diagnosis. That is, once a person is informed that they have a disease which may be progressive and debilitating, they become anxious, depressed, and fearful. Western doctors observe demyelination of the nerve fibers and its eventual scarring (sclerosis) as the characteristic pattern of MS. Demyelination—a loss of fatty substance surrounding the nerve fibers—roughly corresponds to a description, by Chinese doctors, of the loss of a vital fluid essence (jing). The autoimmune process, with stimulated production of antibodies that attack the body instead of attacking a pathological organism, corresponds roughly to the Oriental description of dysfunction and disharmony of the internal organs. Where the Western physician imagines the microscopic changes revealed from isolated tissues, the Chinese physician imagines broad processes that correspond to things experienced in daily life. TREATMENT STRATEGIES To resolve MS, a current Western medical approach is to find a protein that will block the autoimmune attack, thereby stopping any further demyelination, and thus preventing further development of MS. Another is to apply a peptide (cytokine, a small protein, such as interferon) that regulates immune responses and controls initiating viruses, thus reducing the number of MS attacks. There are numerous other methods being investigated, in which something is introduced into the body to interfere with the autoimmune process. The Chinese medical approach is also to introduce something into the body, with the aim of replenishing body essence and to rehabilitate internal organ functions, through diet and herbs, rather than products of advanced technology. Acupuncture is applied in an effort to rectify the circulatory disturbances that arise from the disharmony of organ functions; the improved circulation helps the organs and tissues return to a normal, healthy condition. Further, steps to resolve underlying spiritual and emotional distresses are undertaken on the basis of discussions and recommendations. The herb combinations prescribed by doctors of Chinese medicine are selected on the basis of past experience with treating “flaccidity syndromes” (mostly diseases other than MS that cause muscular weakening) and on the basis of the current health status of the individual. The latter is to be established by asking questions and conducting some traditional diagnostic procedures, such as analyzing the appearance of the tongue and feeling of the pulse at the wrist. Not only do the symptoms of MS vary from individual to individual, but also the health histories (such as coexisting diseases or syndromes) are different, and these factors must be accounted for in determining suitable prescriptions. Acupuncture treatments are likewise selected on the basis of previous experience with other patients, such as those who experience paralysis due to stroke, and on the basis of unique characteristics of the individual currently under treatment. Thus, there is not a single remedy for MS that can be offered through the traditional Chinese medical approach, but rather a composite treatment based on individual needs. According to a published clinical trial and a small number of individual case reports from China, MS symptoms can be effectively controlled in many patients by consistent use of Chinese herb formulas. To attain a successful outcome, the correct herb prescription for the individual’s unique needs must be selected, the dosage must be adequate, and the duration of treatment must be long enough so that beneficial results persist once the therapy has been completed. The duration of therapy for MS patients reported in Chinese studies ranges from two months to over two years; herbs used to prevent exacerbations might be taken for several more years. If the herbs are discontinued after the initial treatment period, some patients may remain free of symptoms for many years. In some cases, there can be a relapse, but prompt resumption of herb use will help the

individual regain freedom from disease symptoms for a period of time. Despite the long duration of therapy necessary in some cases, it is not uncommon in China for improvements to be noted within the first two months. Improvements to be expected include an enhancement in one’s overall sense of well-being, a reduction in the severity of persisting symptoms, a reduction in the use of drugs that control symptoms, including antidepressant drugs, and a reduction in the incidence of bouts of weakness. In some cases (perhaps 20%), the individual will apparently be cured. In a Chinese study [1] with 35 patients, four different herb formulas were developed. People were treated according to the diagnosis that would place each into one of the four broad diagnostic categories that matched the herb therapeutics. The complex herb formulas were prepared as decoctions (tea made by boiling the herbs for about 45 minutes) using 8 to 15 grams of each ingredient (a total of about 150 grams per day), consumed as a cooling drink (rather than hot, as many MS patients have an aversion to heat). Anti-inflammatory Western drugs were given during acute active periods of the disease. Except for three patients that discontinued treatment within the first ten days, some improvement was found in all who tried this method. Two cases were deemed basically cured after taking just 45 and 68 doses; 15 were markedly improved, and another 15 somewhat improved—most of them taking 20 to 40 doses. Eleven of the patients had tried corticosteroids unsuccessfully before switching to the traditional herb combinations; of these, 7 were markedly improved, 3 improved, and only 1 failed to respond. The same researchers then conducted a study [2] of prevention of exacerbations. 30 MS patients (15 male and 15 female) were given an herbal formula, called Ping Fu Tang , comprised of 17 herbs. Each herb was used in a dosage of 8–15 grams (except two auxiliary herbs used in low dosage), with a total daily dosage of about 150–180 grams of herbs in decoction. The herbs were taken in two to three divided doses each day. The patients took these herbs for a period of 3 to 13 years (average of 6 years) and during this period, only two mild exacerbations occurred in the group. By contrast, a control group of 15 MS patients had an exacerbation rate of 1–4 times per year. Two case studies of MS treatments were reported [3] from the work of Dr. Domei Yakazu in Japan. Good therapeutic results were described from the regular ingestion of an herb formula over a period of two and a half years in a man aged 48, and marked improvement was noted in a woman, aged 34, who consumed two traditional formulas for a period of approximately two months. According to a translated report from China [4], a female patient, aged 38, was treated with herb decoctions for about 15 weeks and was then given herb pills to take regularly for one year. The clinicians reported that she was cured as a result of the treatment. A general survey of Chinese journals shows that there are a small number of other similar reports, each article describing one or two patients treated with obvious benefit. The dosages of herbs used in Chinese clinical studies that have demonstrated successful resolution of MS, and other chronic diseases, tend to be quite high. Longer-term therapy with lower dosage, as used in Japan, has been reported to produce good results, but no claims of cures, as yet. Because Americans are not used to relying on herb remedies, the dosage applied in China may seem exceptionally high when compared with ingestion of drugs, vitamins, or even herb remedies that are administered for less serious disorders. Chinese herbs may be provided in bulk form to make a strong decoction, or by spoonfuls of powdered herb or extracts. If the herbs are taken in pill or tablet form, the number of them to be ingested might be quite high (e.g., 24 large tablets per day). While the herb compounds used in treating MS are nontoxic, it is possible to experience some reactions. The most likely adverse response is a gastro-intestinal reaction that might include indigestion, loss of appetite, nausea, vomiting, diarrhea, flatulence and bloating. Such reactions can usually, but not always, be eliminated by changing the time of taking the herbs in relation to meals, by providing a digestion-promoting formula (or a simple ginger tea) to be taken at the same time, or by using a different prescription. In a very small number of cases, an allergy-like reaction may arise, and this usually manifests early in the treatment with a rash which will be alleviated when the use of those particular herbs ceases, but will quickly reappear if the same herbs are taken again. If herb therapy is the primary method of treatment and if there are no special difficulties encountered (e.g., no need for frequent changes in prescription), an office visit every two to three months may be adequate once a treatment program has been established. If acupuncture is pursued as an additional therapy, treatments might be undertaken at the rate of three to four times per month (more frequently following an exacerbation of MS). An acupuncture procedure known as scalp acupuncture appears to provide the best results. A specialist in this type of acupuncture, Mingqing Zhu, works at the Chinese Scalp Acupuncture Center in San Francisco. He has written a book about his techniques [5], which is available from the Center, and has personally trained many American acupuncturists in its use (practitioners can also learn many of the techniques from his book). In addition to the traditional Chinese techniques, nutritional interventions may be suggested; these are based on Western research, but have been adopted as part of natural medicine in modern China. For example, studies have shown that some individuals with MS have low blood levels of vitamin B 12, a nutrient which is essential to myelin sheath repair (it may be necessary to give this nutrient by injection, since poor intestinal absorption may be the reason for low blood levels). Calcium supplements can be especially important to women suffering from MS, since any reduced mobility from the disorder can lead to increased risk of osteoporosis. Magnesium supplements could be helpful in reducing spasms, which are a problem for some persons with MS. Dietary modifications, to remove allergens and to adjust the fat content (to very low levels), have been reported as helpful in some patients. At ITM’s An Hao Natural Health Care Clinic in Portland, Oregon, about 45 MS patients have undertaken treatment with Chinese herbs, nutritional supplements, and acupuncture during the past eight years, most of them carefully monitored during 1994–1996 as part of a study partially funded by gifts from the MS Foundation of Fort Lauderdale, Florida. Using the protocols at the An Hao Clinic, including scalp acupuncture, as long as the treatments are pursued regularly, there is relief of many symptoms (including urinary disorders and constipation), less use of certain drugs (notably antidepressants), and reduction or elimination of attacks of muscular weakening and incoordination. Adverse reactions to the standard herb formulas have not been a problem with this relatively small group, but a number of patients were unwilling to take the large amounts of herbs recommended. We do not know, at this time, to what extent it is possible to reverse neurological damage that leads to a person being wheelchair bound. At our clinic, several persons with MS who use walking aids (such as canes or walkers) have been able to eliminate the need for these devices as the result of acupuncture treatments, especially the scalp acupuncture that has previously been used by Dr. Zhu to successfully treat paralysis due to stroke. One person with MS who was wheelchair bound was able to begin standing and walking with the assistance of a walker, but still uses the wheelchair much of the time. The outcome depends on the nature and extent of the nerve damage that has occurred, and on the willingness and ability of the person to attempt the physical therapies to restore mobility. If there remains some limited ability to walk when acupuncture and herb therapy are initiated, then it is very likely that the individual can be

coaxed into a greater mobility. Irregularity in using Chinese medical therapies (infrequent acupuncture, missing daily doses of herbs) appears to be the main reason for poor results among those with the relapsing/recovering type of MS. With MS, as with many other chronic diseases, some individuals who try the Chinese medical approach stop using it before it can have a marked effect. This drop-out from treatment may be due to inconvenient access to the clinical site, unwillingness to take the herbs and supplements regularly, or disappointment if there is not prompt, dramatic, and sustained benefit. Few participants, regardless of their enthusiasm for the method, were able to come to the clinic for twice-per-week acupuncture, during the first 2–3 months of treatment, as would be preferred from the practitioner’s point of view. Since sclerosing is a cumulative process, effective control of the disease over an extended period of time can also prevent the worsening of symptoms that occurs when large areas of nerve fibers are damaged. For many chronic diseases, Western medicine offers a control of symptoms through life-long administration of a synthetic drug. Substituting a life-long application of Chinese herb formulas may produce comparable results, while avoiding some of the side-effects typically associated with the chemical isolates that comprise pharmaceutical products. More importantly, the Chinese medical therapies aimed at relieving the MS can help treat other health problems at the same time. ACCESS For persons in the Portland area, it is possible to be enrolled in the ongoing MS study program at ITM’s clinic (write to ITM for a packet of information; 2017 S.E. Hawthorne, Portland, OR 97214). For persons elsewhere in the U.S., ITM has a Practitioner Reference Guide listing about 400 practitioners who have direct access to ITM’s information about treatment protocols. Additional resources for treatment, both orthodox and alternative, are available from the Multiple Sclerosis Foundation (MSF, 6350 N. Andrews Ave., Fort Lauderdale, FL 33309). ADDENDUM In the book Insights of a Senior Acupuncturist, Miriam Lee describes her concept of MS and its treatment [6]. Lee practiced acupuncture in China and Singapore for more than twenty years before coming to the United States, where she continued her practice for twenty more years before writing her book. The following are excerpts from her analysis of one patient, a forty year old woman, who had received a medical diagnosis of presumptive MS of recent origin. Whether or not the case was actually MS or some other nerve disorder that produced similar symptoms is not relevant to the significant factors of the Chinese medical analysis. For the previous two years, the patient had experienced a period of intense depression, anger, and sadness, following the ending of a relationship...excessive emotions, especially those associated with a broken heart, sadness, anger, depression, worry, constant replay of mental dialogues—”he said...I said...”—were the deeper root of her problem. These mental dialogues were destructive, never-ending loops that can bind up a person’s qi [or “chi”, circulating vital energy] with a chain as strong as iron and consume it with nothing to show but suffering. When this internal dialogue takes over, the patient cannot concentrate, cannot sleep, may eat a lot and gain no weight or may eat little and add pounds, all indications of internal secretion imbalance. Eventually, muscle control is lost and coordination is impaired. Acupuncture can restore some amount of control once it has been lost, but requires many sessions over a long period of time. If the syndrome is recognized and dealt with early, the worst effects can be averted and the body’s fuller utilization of its qi can be restored in a course of treatment two times a week for several weeks. Though treatment can help to break the blockages of the energy, the patient herself must decide to step out of the circle of thoughts and memories, hurt, anger, guilt, and resentment. Acupuncture treatment can increase the qi available to make these changes in dealing with life’s problems and thus change the vicious downward circle into a beneficial upward one. I advised this woman to sing. Not sad songs but hymns of praise. To sing them out loud, not just hum, paying attention to the words. The issue in this woman’s case was, in part, a spiritual one. Besides the fact that singing does wonders for the lungs and circulation, the words serve as a reminder of the wonders of creation that are all too easily forgotten in the face of hurt and disappointment...Nothing is really worth the slow dying that results from hanging on to old hopes and negative feelings, but human beings unfortunately seem to do so.” This description was accompanied by mention of some appropriate acupuncture points used in the treatment sessions and certain dietary modifications, but the main focus was the mental—and spiritual—aspects of the process, which influence the circulation of qi, and eventually cause the disease to manifest in the form of MS. The genetic background, viral influence, immune disorder, or myelin sheath destruction are not part of the description: those are merely the scientifically isolated features of what happens to the body as the mind goes through its crisis. As to the chances of success with this method for treating persons with MS, Dr. Lee states: “It takes many treatments and a strong commitment to changing lifestyle, diet, and emotional habits.” REFERENCES 1. Lu Xi and Wang Yaohua, Thirty-five cases of multiple sclerosis treated by traditional Chinese medicine principles according to differential diagnosis, Chinese Journal of Integrated Traditional and Western Medicine 1990, 10(3). 2. Lu Xi, Wang Huayen, Wang Yaohua, Research on the prevention of MS reoccurrence with traditional Chinese medicine , Journal of Traditional Chinese Medicine 1995; 36(7). 3. Hsu Hong-yen, Neuromuscular disorders and diseases, Bulletin of the Oriental Healing Arts Institute 1978, 4 (4). 4. Xie Hai Zhou and Li Xiao Lu, The clinical application of tonifying and benefiting the kidney essence for multiple sclerosis , Journal of the American College of Traditional Chinese Medicine, 1985, 4. 5. Zhu Mingqing, Zhu’s Scalp Acupuncture, 1992 Eight Dragons Publishing, Hong Kong. 6. Lee, Miriam, Insights of a Senior Acupuncturist, 1992 Blue Poppy Press, Boulder, CO. For additional information, consult the book Chinese Herbal Therapies for Immune Disorders by S. Dharmananda, 1988, revised

1993, ITM, 2017 SE Hawthorne, Portland, Oregon 97214.

APPENDIX: Typical Treatment Protocol Used at ITM’s Clinic Acupuncture: provided at least three to four times per month initially, and twice per month later, with a focus on scalp points. Treatment time is about 20 to 30 minutes. There may be certain needles left in place for a longer period, to be removed after returning home. Herb tablets: a general formula for autoimmune disorders plus a general formula for “kidney/spleen deficiency syndrome” is taken daily. An anti-viral formula is kept on hand to be used in place of the other herbs in the event of initiation (apparent or evident) of a viral infection; this is to avert an exacerbation induced by the viral infection. Nutritional supplements: a multivitamin/mineral tablet is used daily to provide calcium, magnesium, and B-vitamins (two tablets each time, twice daily, provides 500 mg calcium and 400 mg magnesium plus numerous other nutrients), and B 12 injections are given weekly (some persons learn to self-administer the injection). Actual treatments are adjusted according to diagnosis and specific symptoms. A health professional trained in TCM can determine what adjustments might be necessary. If no obvious benefit is noted within three months of regular therapy, a different approach should be tried.

July 1996

CHINESE HERBAL TREATMENT FOR MULTIPLE SCLEROSIS AND OTHER FLACCIDITY SYNDROMES, INCLUDING MYASTHENIA GRAVIS AND AMYOTROPHIC LATERAL SCLEROSIS. by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

A NEW DISEASE Multiple sclerosis (MS) is a modern disease. It may have occurred in earlier centuries, but theoretical and diagnostic limitations made it impossible to clearly define this disease. The earliest recorded medical discussions of MS are at the end of the last century, and it is difficult to trace potential cases of the disorder more than a few decades before that. The use of “sclerosis” in the disease name is in reference to the scarring of the nerves (formation of plaques, where myelin no longer forms) of the central nervous system (CNS) that results from inflammation and subsequent destruction of their myelin sheaths. The detection of demyelination in living persons requires the most modern of medical techniques. Until the development of magnetic resonance imaging (MRI) in the early 1980’s, confirmation that a person suffered from MS had to await autopsy, though the disease could be guessed with some reliability by a comprehensive description of its course and manifestations. One test, the hot bath diagnostic procedure, was used for about fifty years (until MRI became prevalent): persons with MS would usually display more severe symptoms after exposure to a hot bath. The onset of the disease is insidious and its course is highly variable over time. In some cases, minor neurological disturbances precede the more characteristic flare-ups (called exacerbations) by several years. Symptoms may be quite different among individuals. Weakening of the legs, bladder, and colon—muscles in the lower body—are common, but so are mental fogginess and optic neuritis— indicating brain damage. The term ‘multiple’ is used because many nerves are affected, but the disease might show evident impact on only a single muscle group during the first years of development. Even with modern technology, a firm diagnosis of MS is not easily established by physicians until it has reached a somewhat advanced stage—sometimes a decade or more after the onset of troublesome symptoms. The average age at diagnosis of MS in the U.S. is about 31. IMMUNOLOGICAL NATURE OF THE DISEASE An extensive review of the immunological disturbance in MS was presented by Byron Waksman of the New York chapter of the Multiple Sclerosis Society in 1986 (1). The chronic nature of the disease appears to be linked to the presence of a specific gene belonging to the major histocompatibility complex (MHC) that results in susceptibility to the disease. Individuals without this genetic background may suffer from acute demyelinating diseases (such as Guillain-Barre syndrome) without experiencing relapse and progressive deterioration, as occurs with MS. Other autoimmune diseases, such as insulin-dependent diabetes, myasthenia gravis, thyroiditis, and chronic ulcerative colitis, often occur in the same individuals who experience MS, or in their parents, siblings, or children, as a result of the genetic background that predisposes the individual to autoimmune disease. The child of a parent that has MS has about a 40 times higher risk of developing MS than others (2). MS is a rare disease in China, Japan, and other parts of Asia. Similarly, the disease is not found among African blacks (but is found among a small proportion of American blacks who have Caucasian ancestors), Eskimos, and several other population groups. It occurs with fairly high frequency in the Caucasian population, with about 75% of cases being female (in China, it appears that only about 50% of cases are female). In the U.S., the incidence rate for MS is estimated to be about 0.08–0.12% of the population (about 250,000– 350,000 cases at present), but it is about 0.3–0.4% of Caucasian women over the age of 30. There are clear genetic influences not only on the incidence of the disease among races and within families, but also on the tendency to suffer certain symptoms of the disease. Differences between Japanese and American patients in the main site of attack against the central nervous system have been noted: 50% of Japanese cases of MS involve the optic nerve and spinal cord only, and another 33% of the cases additionally involve the cerebrum; among Americans, the comparable figures are 13% and 66%, respectively. It is apparent that viruses play a role in both the development of the disease and its flare-ups. It has been proposed that during an immune attack against one or more of the common viral infections, a T-cell line is established that, when activated, attacks myelin, with myelin basic protein (BP) as one of the key sites of attack. This may occur even if the virus does not enter the nervous system (the primed T-cells from the peripheral blood can attack myelin so long as the T-cell surface receptor has a close enough match to myelin BP). A possible risk factor for developing the disease is late experience—close to time of puberty—of common childhood infections, such as rubella, measles, and mumps. Measles, in particular, appears to be an initiating virus. It is possible, but not demonstrated, that immunization against these childhood viral diseases may prevent them from acting as initiators of MS; it is too soon after the introduction of mass immunizations to tell the effects (though we should know soon). Even so, other viruses may replace those mentioned above in the role of MS initiation. For example, HHV-6, a herpes virus that causes the childhood disorder called roseola, and which may exist undetected in a large portion of the population, appears to be involved in several other diseases and has been suggested to be one of the potential culprits in MS, since the virus is found in the oligodendrocytes of MS patients (30). The virus is found in the region of the MS plaques but not the unaffected parts. While HHV-6 is found in persons without MS, it is not found in the oligodendrocytes in otherwise healthy people. HHV-6 infects both the T-cells, altering their activity, and the central nervous system. CNS infections with the virus are associated with multifocal demyelination and can produce a disease that appears identical to MS (31). Interest in HHV-6 has been stimulated by findings that it can co-infect cells that are infected by human immunodeficiency virus (HIV) and can activate replication of that virus (it is thus called a transactivator). It is possible that HHV-6 plays a role in MS in conjunction with other viruses. Interestingly, the incidence of MS is higher (within the Caucasian population) in the far northern and far southern latitudes towards the earth’s poles. From this observation, it has been suggested that where one lives around the time of puberty may be the key factor in disease initiation, as opposed to where one lives when the disease manifests obvious symptoms. The risk at puberty might be related to growth of the central nervous system and changes in immune responses under the influence of hormones during that stage of development. The uneven distribution of MS cases around the world has been suggested to be related to exposure to viruses or bacteria from animals, such as dairy cows or dogs (3). In one instance, islands in the North Atlantic that were free of MS showed a high incidence

of MS cases a few years after army garrisons had been on the island for a while, implicating an infectious agent carried by the army members or their accompanying dogs or other livestock. It has also been suggested that deficiencies in certain nutrients (such as calcium, vitamin D, vitamin B12, selenium, and essential fatty acids) during the development of the nervous tissues may enhance risk for suffering from MS (4). The metabolism of vitamin D and calcium are influenced by sun exposure, and there can be dietary factors influencing availability of all these nutrients that may vary by location and culture. During the 1980’s, some observers revived the earlier proposal that MS was the result of a spirochetal (bacterial) infection of the CNS. In part, this was because of the newly identified Lyme Disease, caused by a tick-borne spirochete, and it has a regional occurrence (favoring northern deciduous forests) and autoimmune-like character (5). The earlier hypothesis, proposed in 1909 and considered a possibility through the 1950’s, was that MS might have been due to another spirochete, the one that causes neurosyphilis, or one like it. Thus far, a bacterial infection has not been shown to be the immediate cause of MS, but the several decades long history of proposals that MS is initiated by an infection shows a consistent understanding that the disease is not solely based on genetics, climate, emotions, or other non-infection etiologies. By contrast, the neuromuscular Charot-Marie-Tooth disease, which also causes weakening and wasting of the leg muscles and, later in its development, other peripheral muscles, appears to be based primarily on genetic background. Once T-cells aimed at myelin sheath surface proteins have developed, later infections, not necessarily the same as the initiating virus, can trigger a subsequent flare-up of the autoimmune disease. Many patients observe a close connection between experience of influenza or common cold and symptoms of the disease, and this connection is documented (32). It has been proposed that flare-ups that do not appear to follow an infection actually follow either an infection that did not manifest overt symptoms or activation of a latent virus (such as one of those in the herpes family) without evident symptoms. A successful immune response to the infectious agent may have prevented the symptoms from developing, but then continued on to attack the myelin. Not only viruses, but other types of infections, such as bacteria or parasites, might induce MS exacerbations (6). Several viral and bacterial peptides have been shown to activate T-cells that were primed to attack myelin BP. Chronic sinusitis has been strongly associated with MS, with the possibility that the sinus infection (which can be viral or bacterial) induces an immune response that eventually promotes the attack against myelin. It has recently been suggested that the cytokine called tumor necrosis factor (TNF) is associated with production of multiple sclerosis symptoms (7). This cytokine is found in the myelin lesions and cerebral spinal fluid of MS patients. TNF, and other cytokines (e.g., interleukins 1,4, and 10, and interferon gamma) that might act concurrently, are induced in several infectious and parasitic diseases. HHV-6 is a powerful inducer of TNF in peripheral blood mononuclear cells (43). Interferon gamma and TNF slow the suppression of immune attack. As a result, an immune attack against a minor infection may be prolonged until myelin is also attacked, and the action of the cytokines may then prolong the MS exacerbation. The antidepressant drug rolipram is a TNF inhibitor that has been suggested as a useful therapy for MS (8); several other drugs have been revealed to have anti-TNF activity in recent years, including: ketotifen (used for treating asthma), thalidomide (a sedative), and pentoxiphyllene (used for treating blood clotting in peripheral vessels); some of these could also be of benefit for persons with MS (the selection of drugs allows choice among the primary indications for their use). Interferon beta (provided as the drug betaseron), inhibits interferon gamma and TNF and aids the function of suppressor T-cells. In the cerebral spinal fluid of MS patients, it has been found that there is a significantly higher level of aldehydes, including formaldehyde (33). These aldehydes can cause protein cross-linking (thereby making the proteins physiologically inactive) and block nerve impulses. Their action is more evident at higher temperatures, which may partly explain the hot-bath phenomenon in persons with MS. The high levels of aldehydes may be associated with the observed phenomena of reduced antioxidant activity in persons with MS, suggesting a role for oxidative stress in the susceptibility to or expression of exacerbations (34). It has been proposed that weakening of the blood-brain barrier may permit easier access of low density lipoproteins (LDL) and other substances to the cerebral-spinal fluid that make the myelin more susceptible to oxidative damage and immune system attack (35). LDL tends to be high in persons who are physically in active and in those who consume large amounts of saturated fats. According to this line of thought, agents that promote greater integrity of this barrier could slow the progression of MS by limiting inappropriate access to the nerves. Administration of antioxidants, including vitamin C, vitamin E, and glutathione have been shown to improve the antioxidant activity (36), but have not yet been tested long enough to demonstrate an impact on the frequency, severity, or duration of exacerbations. In most cases, an infection (or other inducing agent) initiates an autoimmune attack or enhances an ongoing attack that produces notable symptoms. These symptoms may last for a few days to a few weeks in the remitting type of MS. Within a few days of the immune activation, the natural regulation of the immune system—which may be inhibited due to host factors or the influence of chronic viral infection—produces a withdrawal of the attack, and there can then be recovery of the damaged nerves (which is quicker, as with other injuries, with youth and good nutritional status). With each exacerbation (autoimmune attack), there is local vascular inflammation (in the area of the CNS), usually with severe local edema, followed by demyelination of the affected nerves, resulting in scarring if the attack is sufficiently severe (remyelination of the nerves can occur if there is limited damage). Steroids administered at the onset of an exacerbation may reduce demyelination, but long-term administration offers little benefit. In persons who respond poorly to steroids, it is possible that processes other than immune attack and inflammation, such as aldehyde formation and oxidative stress, continue to enforce the nerve damage. The process of demyelination is one of the causes of muscular weakening or numbness: nerve transmission via the affected nerves is disrupted. Even so, areas of plaques as seen by MRI, which represent essentially irreversible damage, do not necessarily cause persistent interference with nerve transmission. Some individuals show little or no symptoms even with extensive plaque formation, while others show significant impairment with little evidence of plaques. This is probably because there are other mechanisms of nerve inhibition and because the nervous system is sometimes able to develop alternative routes of transmitting the essential information. However, once the damage from repeated attacks has reached a certain level of severity, the disease manifestation (e.g., muscular weakening) in most individuals becomes continuous rather than intermittent. Further, when a person is debilitated for an extended period of time, they may cease the attempt at movement and thus deprive the nervous system of the stimulus needed to reroute signals. There are at least two types of MS disease described by the course of development. The intermittent type (or relapsing-remitting) is one in which there are flare-ups of the attack against myelin followed by a period of recovery, often with several weeks, months, and

sometimes years, before the next attack. The average rate of exacerbations during the first years after diagnosis is about 1.25/year. In a few cases, the cycle of attacks appears to end spontaneously and there may be few, if any, residual symptoms; the MS does not progress to a more serious or paralytic condition. The progressive type usually follows a course of steadily worsening debility, where there may be only a few days of relative relief, followed by continued progression of the disease. This type leads to severely impaired immobility and eventually to death; fortunately, it is the less common form. With current therapies that can benefit persons with MS (when applied in a timely manner), the main long-term problem may be deterioration of health due to lack of exercise, with accumulation of secondary diseases. In sum, persons who experience MS usually have a genetic background that makes this particular disease more likely. They then experience an infection (or combination of infections) that establishes the possibility of autoimmune attacks against myelin. A combination of other factors then converge to enable the disease process: these may include nutritional deficiencies, damage to the blood-brain barrier, low antioxidant potential, and chronic CNS infection. Finally, the disease manifests in a series of exacerbations, usually induced by acute infections, turning into a progressive, non-remitting disease when and if the immune system loses its ability to withdraw the antimyelin attack or when other processes (such as accumulation of oxidized fats) continue to damage myelin. While this scenario may need to be updated somewhat as additional information is acquired, it is sufficient to suggest several methods of therapy, some of which have already provided help to persons with MS. Before turning to the Chinese medical analysis of the disease, it is worth mentioning some other diseases that have related characteristics. Since MS is not a frequent disease in China, experience treating several other disorders that have muscular weakening and autoimmune processes in common, may help to add to our knowledge of successful approaches. Myasthenia gravis (MG) produces symptoms of muscular weakness; like MS, it is insidious, variable, and potentially fatal (in the progressive form of the disease). MG appears to be initiated by a virus, but the site of attack by the activated T-cells is different than with MS—the acetylcholine receptors of the nerves are affected. The motor neuron degenerative diseases also share some similarities with MS. In one, amyotrophic lateral sclerosis (ALS), the muscular weakness usually begins in the hands and spreads to the forearms and legs. This is accompanied by (and often preceded by) spasms and increased tendon reflexes. The site of autoimmune attack appears to be mainly the anterior horns of the motor neurons; the brain functions are not affected. Unlike MS and MG, it does not often display extended periods of remission, rather, it tends to progress rapidly, often leading to death within 5–6 years. A more benign form of this disease is progressive spinal muscular atrophy, which causes muscle wasting and weakness, but does not cause significant shortening of lifespan. CHINESE MEDICAL THEORIES In the most ancient Chinese medical texts, and in many subsequent works, there are some references to diseases with symptoms of muscular weakening. These are called weizheng: flaccidity syndromes. There are four basic causes of, or contributors to, the development of these syndromes: 1. A feverish disease (now understood to be caused by an infection in most cases) damages the nutritive essences that supply the muscles and tendons [note: in Chinese traditional anatomy, the terms often refer to functions more than to isolated tissues. The tendons “aid in controlling movements.”] 2. Organ dysfunctions result in poor nutrition or in inhibited circulation, thus denying nutrition to the destination tissues. 3. Spiritual exhaustion reduces the communication between the mind and body, affecting sensation, movement, and mental clarity. 4. Adverse dietary factors can lead to weakness of muscles and laxness of tendons, and they can exacerbate deficiency of essence. In the Huangdi Neijing Suwen, (9) the problem of muscular flaccidity receives an entire chapter. The basic ideas, largely retained since ancient times, have been elaborated recently in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (10). The general problem is described as being due to a disorder affecting one of the five internal organ systems (zang). Thus, there are five types of wei (flaccidity) syndromes. Three of these might be of interest in regard to diseases such as MG, MS, and ALS. Maiwei (vessel flaccidity, associated with the heart system) is described as muscular atrophy and debility of the lower limbs caused by pathologic heat of the heart, “empty” blood vessels, and malnutrition of the muscles of the lower limbs. Rouwei (muscle flaccidity, associated with the spleen) has symptoms including sensory disturbance of the skin, and atrophy, flaccidity, and debility of the muscles. The syndrome is due to pathogenic heat and dampness invading the spleen with impairment of stomach yin. Guwei (bone flaccidity, associated with the kidney) is caused by severe exhaustion of kidney yin and essence with accompanying deficiency fire that causes atrophy and flaccidity of the muscles of the lower limbs and weakness of the spine that makes it impossible for people to support themselves in an upright position. The modern texts make some slight rearrangements of the categories, for example: liver/kidney weakness is presented as a single category, rather than two categories. A combination of the liver/kidney and spleen types is probably closest to depicting MS and other neuromuscular disorders that affect the lower limbs first. The wei syndromes were described as being initiated by pathogenic heat (or damp-heat, the combination of two adverse influences) and display their symptoms of muscular weakening as a result of fluid and nutrient deficiency (e.g., lung fluid dryness, empty blood, stomach or kidney yin deficiency). The two other wei syndromes, affecting the tendons (liver; causing contracted ligaments) or the skin/hair (lung; causing cracked and brittle skin, paralysis of extremities), are also thought to be initiated by heat followed by impairment of fluids. The Neijing emphasizes that lack of nourishment in the channels (meridians) and in the muscles is the principal cause of the flaccidity. The Chinese concept of nourishment is broader than that identified in modern terminology as essential food components, because it includes several of the metabolic products of the food components (for example, hormones generated from precursors) and their entry into destination tissues (promoted by local microcirculation). To remedy the problem using acupuncture (the main therapy mentioned in the Neijing), one tonifies the deficiency by using the spring points (rong) on the meridians and promotes the flow of nutrients and energy through the meridians by treating the stream points (shu): “This fortifies the deficient, and restores order to what is rebellious.” The traditional means of treating fluid impairment is to nourish blood and essence. There are several herbs classified as blood and essence tonics. In addition, qi tonics will help generate the essential fluids from foods. Connecting to the Western conception of the disease, the initiating infections for MS and for its exacerbations may involve a febrile syndrome; the imbalance that results might be

destruction of fluids (the myelin sheath being a fluid fatty membrane; its quality is similar to that of essence; the brain and spinal cord are understood, by the concepts of traditional Chinese medicine, to be an extension of the kidney system, the storehouse of the essence). An alternative traditional description of flaccidity syndrome—with similar conclusions—in presented in an article about treating one patient with MS (11). The doctors, Zhou and Lu, pointed out that ancient scholars believed the loss of sensations, one of the common MS symptoms, is related to the po (primitive instinct; one of the “souls” described in Chinese medicine). The po is governed by the spirit (shen) which subsists on the essence (jing). Quoting from the Huangdi Neijing Lingshu: “The p o enters and exists with the essence...spiritual exhaustion scatters the soul and the po.” Pursuing this line, the authors state: The kidney houses the essence; the brain is the mansion of the original spirit. Disorders of the spirit are usually related to a deficiency and damage of kidney essence which results in malnourishing of the brain. An insufficiency of original spirit in turn affects the function of the po. The manifestations of pain and soreness of the back, atrophic weakness of the legs, looseness of the lower passes (colon and bladder), and a sinking, thready, weak pulse confirm the diagnosis of kidney deficiency with damage to the essence. Poor memory and insomnia show an insufficiency of the sea of marrow (brain). The kidney essence is the most refined of the body fluids recognized by traditional doctors. It is a substance that is, in part, present at birth (perhaps corresponding to the genetic material) and is, in part, replenished by refinement of nutritious food. Exposure to cold, excessive experience of fear, overindulgence in sexual activity, frustration from not being able to fulfill one’s wishes, over-tiredness from traveling in conditions of severe heat, consumption of too much salt, and physical injury to the internal organs are causes of kidney weakness cited in traditional literature. Other causes may include traumatic injury to the internal organs, effects of invasive surgery, chemical damage to the endocrine system, and chronic infections. Dietary causes of flaccidity are usually described in terms of excessive intake. Aside from excessive consumption of salt damaging the kidney system, too much sour food is said to cause muscular laxity, and too much sweet food weakens the functions of the spleen, the organ system that is most essential to the nourishment of the muscles. Too much spicy food will cause further damage to depleted yin and essence. Therefore, diet is important to avoiding development of flaccidity syndromes or to counteract a disease which produces flaccidity.

BASIC HERBAL THERAPY FOR FLACCIDITY SYNDROME The recommended traditional herb formula for treatment of the liver/kidney deficiency type wei syndrome is Hu Qian Wan . The Chinese name may be roughly translated as Pill of Tiger’s Walk; it refers to the well-controlled movements a tiger makes from a place of hiding while stalking a prey. The tiger also represents the yin: a tiger in hiding has great potential for expressing its power, and that hidden potential is yin. The herb formula has the therapeutic action of nourishing yin (Hu Qian Wan is sometimes described as the Pill of Hidden Tiger). As with other traditional treatments, the formula may be modified somewhat according to clinical presentation, especially at the initiation of therapy. For long-term applications, it is considered a well-balanced prescription. Hu Qian Wan (25) is a formula devised by Zhu Danxi (1280–1358 A.D.) that was recorded in his book Dan Xi Xin Fa (Dan Xi’s Theories). Zhu Danxi was originally known as Zhu Zhenheng, and he lived in Danxi (Zhejiang Province). He became known as the renowned physician of Danxi, and was thus given the name Zhu Danxi thereafter. Zhu is known as leader of one of the four schools of Chinese medical disease etiology and treatment that evolved during the period of 1150–1350 A.D.; Zhu’s was the last of these schools (26) and one of the most influential in subsequent centuries. The four schools of thought were labeled according to the type of therapy that was predominantly advocated: cooling, purgation, spleen/stomach tonification, and yin nourishing. In modern practice, the latter two tonification-based schools remain dominant forces, joined by the late 19th century “school” of vitalizing blood circulation. Zhu believed that the yin was always at risk for becoming deficient. Thus, in most chronic diseases, the aim of therapy should be to protect and nourish the yin. He devised several new formulations, many of them containing herbs that nourish the yin and cleanse deficiency fire (which is a type of yang agitation that can arise from yin deficiency and can cause worsening of yin deficiency). Zhu lived in southern China, where it was more likely that persons would suffer from the effects of heat and depletion of yin. He felt, however, that the main cause of yin deficiency was over-indulgence, including sexual excess, which could drain the kidney essence. He also pointed out that certain herbs could be damaging, especially for stroke, paralysis, nervous, and mental diseases: those containing what we now call heavy metals, and those which have properties of being spicy, fragrant, dry, hot, and stimulating (which could further weaken the cooling, moistening yin). Hu Qian Wan is an expanded version of another of Danxi’s formulas, Da Bu Yin Wan (Great Yin Nourishing Pill), made with rehmannia and tortoise shell to nourish the yin, and phellodendron and anemarrhena to clear deficiency fire. To make Hu Qian Wan, one adds certain to this basic formula several ingredients to treat the specific manifestation for which the formula was intended: weakness of the lower back and knees, flaccidity of muscles and bones, and difficulty walking. The key additions are tiger’s bone (now replaced by other bones) and cynomorium. Tiger’s bone is said to treat weak and soft sinews and bones, and weakness of the knees and legs caused by deficiency of liver and kidney. Cynomorium has the same uses, and is also indicated for exhaustion of body fluids. These two herbs transform the basic treatment for yin deficiency into a treatment for flaccidity affecting the lower back and legs. One of the aims of the formula is to alleviate weakness of the tendons, which is deemed the main reason that there is difficulty in walking. Peony is added to the prescription to enhance the action of rehmannia in nourishing the liver, so as to benefit the liver’s associated tissues—the tendons. Citrus and dry ginger are added to aid the stomach in digesting the combination of rehmannia and cynomorium, which are quite rich and heavy in nature. Hu Qian Wan is sometimes extended with tang-kuei, achyranthes, and mutton (a recommendation from a 17th century text), usually for cases of severe blood deficiency; other variations are prepared by adding yang tonics (in which case anemarrhena and phellodendron may be removed) or qi tonics. The usual preparation method is to combine the herbs ground up to powder and honey to make 9 gram pills (about 6 grams of the herbs per pill). It is taken one pill each time, 2–3 times daily (12–18 grams of the herbs per day). The prescription that was initially given to the patient described by Zhou and Lu was a modification of another traditional formula used for flaccidity: Dihuang Yin Zi (Rehmannia Formula for Paralysis), a decoction containing rehmannia, cornus, schizandra, polygala, acorus, morinda, cistanche, aconite, cinnamon bark, hoelen, ophiopogon, and dendrobium. It nourishes the yin, but also revitalizes the yang. The modified formula was taken daily by the MS patient for more than three months. As a follow-up, Hu Qian Wan was administered in conjunction with the Dihuang Yin Zi decoction for one year. According to the doctors, The patient was eventually cured, thus confirming the benefit of kidney-nourishing decoctions and pills for MS. Zhang Jianguo presented a case study (12) of treatment for chronic progressive spinal lateral sclerosis. As with the above analysis, the patient was diagnosed as suffering from deficiency of kidney and liver, insufficiency of blood and essence, and malnourishment of ligaments and bones. The treatment was a modification of the “Decoction of Flying Feet” (derived from Hu Qian Wan and Deer Antler Gelatin Pills) which includes the tonics: tortoise shell, rehmannia, tiger bone, eucommia, dipsacus, cuscuta, atractylodes, and licorice; later the prescription was modified by adding astragalus. The formula tonifies qi, yin, and yang. Treatment time was two months and gradual normalization of limb movements ensued. A formula for treating wei syndrome was developed by Hukui Futei in Japan, based on Hu Qian Wan (27). It is called Wei Zheng Fang (Flaccidity Syndrome Formula) and is made with rehmannia, anemarrhena, phellodendron, peony, tang-kuei, achyranthes, atractylodes, astragalus, and eucommia. It has been used in Japan for treating disorders such as multiple myelitis, polio, and paralysis due to beriberi. Dr. Domei Yakazu reported good results in treating an MS patient using this formula for two and a half years. In a review of traditional concepts of paralysis, Dr. Hong-yen Hsu (13) describes the syndrome of atrophy of the muscles. There are two sub-categories: weak and strong confirmation (constitution). The weak confirmation is caused by yin weakness which impairs the flow of bodily fluids thereby preventing nutrients from reaching the muscles and bones...the strong confirmation may occur when the flow of the sunlight yang meridian becomes imbalanced by an attack of wet fever [damp-heat]. This will then impair the circulation to the limbs and cause the muscles to atrophy. A strong confirmation may also be induced by lung fever, wet sputum, or stagnant blood. This explanation is based on the Neijing description. To rectify the problem in individuals suffering from deficiency of liver and kidney, recommended formulas are Ginseng and Tangkuei Ten Combination (Shichuan Dabu Tang) and Tiger’s Shinbone and Cynomorium Combination (Hu Qian Wan ) for kidney and liver deficiency. For the strong confirmation, recommended formulas are San Miao Wan Modified (phellodendron, atractylodes, achyranthes, tang-kuei, stephania, tokoro, tortoise shell) for damp heat; Dao Tan Tang (with chih-shih, arisaema, pinellia, hoelen, citrus, ginger, and

licorice) for sputum obstruction; and Tang-kuei Four Combination Modified (tang-kuei, cnidium, peony, rehmannia, persica, carthamus, zedoaria) for blood stagnation. According to traditional theory, a chronic disease that is caused primarily by deficiency syndrome tends to be insidious, while those caused by excess syndrome tend to show rapid progression. TREATING AUTOIMMUNITY Zheng Wentao and Mengrou undertook a general analysis of autoimmune disorders (14), with a detailed description of three autoimmune diseases: systemic lupus erythematosus, myasthenia gravis, and scleroderma. The basic approach might reflect on ways to evaluate the immunological aspect of MS. Citing traditional literature, the authors state: With the stationing of genuine qi in the interior watching over the spirit, sickness is unable to intrude...the righteous qi is generated, transformed, and supplied by the essence of fluid and grain. When the spleen is flourishing, the external evil is unable to enter the body. The spleen is the material source of the body’s defense mechanism. Thus the flourishing or degeneration of the spleen function will reflect the strength or weakness of the body’s immune system. The zhengqi (translated as genuine or righteous qi) is the guardian of the body’s health and the regulator of the immune system. Since qi tonic herbs are the basis of prescriptions for promoting zhengqi, these comments speak in support of the use of qi tonic therapies for autoimmune disorders. However, the authors continue: “Kidney yin and yang are the key factors in the regulation and balancing of yin, yang, qi, blood, and all the body’s immune mechanism. The visceral organs through their mutual dependence and restriction follow the rule: extreme damages; balance stabilizes; stabilization allows generation. Proper regulation of the normal immune response is thus achieved [through balance].” Such statements argue for the use of kidney (essence) nourishing herbs and following a balanced life style, in treating autoimmunity. “Qi in excess may inhibit or override, as stated in the Five Element Theory. The end result is the creation of an imbalance of the immune regulation, thus generating autoimmune diseases. According to the author’s observation, there may appear in the course of an autoimmune disease symptoms of deficiency, excess, or a combination of deficiency and excess.” Thus, while deficiency of qi and essence may form the basis of autoimmunity, at certain times in the development of autoimmune diseases, treatment of excess (accumulation) may be of importance. MYASTHENIA GRAVIS Zhang and Meng state that: “According to TCM, the spleen governs the muscles, the four extremities, and the upper and lower eyelids. Therefore, the causative mechanism for MG is injury to the spleen and stomach and deficiency and degeneration of the central qi.” They recommended the use of large doses of Ginseng and Astragalus Combination, with doses of astragalus in the range of 30–90 grams. Further, “systemic MG is due to deficiency and injury of the spleen and stomach involving both the liver and kidney. This causes stasis of qi and blood, lack of transformation of fluid, obstruction of the meridians and luo vessels [meridians, jing, are generally distributed vertically and run through the deep tissues; connecting branches, luo, are distributed horizontally and superficially], and a decreased ability to move the ligaments and bones.” The authors state that favorable results have been obtained using large dosages of herbs. In addition to Ginseng and Astragalus Combination, they recommend Cinnamon and Aconite Combination, Pill of Right Restoration, and Fortified Pill of Buddha’s Warrior Attendant; these latter formulas all contain kidney tonic herbs and have a warming action that helps to overcome stagnation. For another case, characterized by “maximum depletion of the spleen and kidney, and indissoluble phlegm and turbidity, the recommended treatments were large dosages of Saussurea and Cardamon Combination to invigorate the spleen and clear away the dampness, and the kidney tonifying Rehmannia Eight Formula, in addition to the previously mentioned prescriptions. A specially-modified formula made with astragalus, codonopsis, atractylodes, aconite, cinnamon bark, rehmannia (raw), dioscorea, cornus, hoelen, lycium fruit, deer antler gelatin, and morinda was said to have produced dramatic effects after fifteen days of treatment (this is following treatment with the other prescriptions). In the book The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine (15) Shao Nianfang divides MG treatments into two basic categories: deficiency of spleen/kidney (weak category) and damp-heat (strong category). The deficiency type, especially with qi and yang deficiency, is said to be the most commonly-observed, clinically. Recommendations for treating deficient patients include use of a large dosage of astragalus and inclusion of chih-shih (which will clear phlegm-damp obstruction). For yang deficiency patients, the use of aconite is helpful and the amount should be large (30–60 grams, boiled for two hours). In general, according to Shao, for MG of the deficiency syndrome type, one can use patent medicines such as Buzhong Yiqi Wan (Ginseng and Astragalus Combination), Fuzi Lizhong Wan (Aconite, Ginseng, and Ginger Combination), Hu Qian Wan, Jin Suo Gu Jing Wan (Lotus Stamen Formula), and Renshen Jianpi Wan (Ginseng Stomachic Pills), or a decoction made with ginseng, atractylodes, astragalus, platycodon, lycium fruit, aconite, cimicifuga, bupleurum, pueraria, tang-kuei, ma-huang, and licorice (Ginseng and Astragalus Combination modified). The dosage of the herbs is from 6 grams (licorice) to 60 grams (astragalus) each, with a total of about 200 grams for a one day dose. For yang deficiency patients, one can add cinnamon bark and deer antler; for yin deficiency patients, one can add Hu Qian Wan to the treatment. For the damp-heat type, it is suggested to use the patent medicines, such as Longdan Xiegan Wan (Gentiana Combination) or Yangyin Qingfei Wan, or the decoction of atractylodes, phellodendron, scute, dioscorea, stephania, coix, peony, chaenomeles, glehnia, silkworm excrement (San Miao San modified). The dosage of herbs is from 10 grams (phellodendron, scute) to 30 grams (coix) with a total daily dose of about 150 grams. Citing a case study of early onset of MG, Shao describes a young man with four limbs so flaccid and weak that he could not hold something in his hands, nor could he walk. He was diagnosed as suffering from deficiency of central qi following an acute illness with fever. He was given a decoction of atractylodes, pueraria, licorice, chih-shih, and tang-kuei. After fourteen days there was some improvement, and the formula was modified by adding lycium fruit, ho-shou-wu, aconite, and achyranthes. Treatment with this modified formula was followed for thirty days, after which there was significant reduction of symptoms. Finally, the patient was given Ginseng Stomachic Pills and Rehmannia Eight Formula daily. A follow-up two years later showed that recovery was complete. Li Genghe (16) recommended that the treatment of MG follow the principle of tonifying the spleen and kidney. For spleen deficiency, the Ginseng and Astragalus Combination was used with optional additions of polygonatum, dioscorea, dolichos, and placenta. For spleen deficiency complicated by kidney yin deficiency, the Decoction of Left Restoration plus astragalus, atractylodes,

and codonopsis was used (optional additions were ho-shou-wu, ophiopogon, peony, gelatin, and placenta). For spleen deficiency complicated by kidney yang deficiency, the Decoction of Right Restoration with eucommia replaced by deer antler, and with the addition of astragalus, codonopsis, and tang-kuei was used (optional additions were cynomorium, morinda, psoralea, eucommia, loranthus, and placenta). Li noted that common cold and bronchial infection (e.g., pneumonia) were predisposing factors for exacerbations. While steroids could be effective at that time, use of Chinese herbs was helpful in supporting the energy of the body and strengthening resistance; he recommended using ginseng, gecko, rehmannia, aquilaria, placenta, oyster shell, and licorice. CLINICAL TRIALS IN CHINA 1. Multiple Sclerosis The largest study (17) of Chinese medical treatment for MS was carried out by Lu Xi and Wang Yaohuo at the Departments of Neurology and Traditional Chinese Medicine in Fujian. Patients were first divided into four groups for differential treatment, two groups with deficiency-type syndrome and two groups with excess-type syndrome. The categories and treatments were: 1. Liver/kidney yin deficiency: raw and cooked rehmannia, lycium fruit, anemarrhena, salvia, peony, cornus, ligustrum, deer horn glue, tortoise plastron glue, achyranthes (chuanniuxi), tang-kuei, and licorice. This is a modification of the traditional Left Restoring Pill (Zuo Gui Wan) with the addition of anemarrhena, ligustrum, salvia, tang-kuei, and peony; it is somewhat similar to Hu Qian Wan . Each herb is used in a dosage of 10–12 grams per day, except licorice (5 grams). 2. Spleen-stomach weakness: astragalus, salvia, codonopsis, atractylodes, hoelen, pinellia, citrus, jujube, and licorice. This is a modification of the traditional Major Six Herbs Combination (Liu Junzi Tang) with astragalus and salvia added. Each herb is used in a dosage of 8–15 grams per day, except jujube (12 pieces) and licorice (4 grams). 3. Qi and blood stasis syndrome: astragalus, codonopsis, salvia, rehmannia (raw), peony (red and white), bupleurum, tang-kuei, scute, cnidium, pinellia, and licorice. This formula combines Minor Bupleurum Combination (Xiao Chaihu Tang) with three herbs for promoting blood circulation—salvia, peony (red and white), and cnidium—plus astragalus. Each herb is present in the amount of 9– 15 grams per day, except licorice (4 grams). 4. Damp-heat syndrome: ching-hao, talc, peony, scute, bupleurum, bamboo, akebia, hoelen, chih-shih, pinellia, rhubarb, jujube. This formula is similar to treatments for febrile diseases described in previous centuries, such as the Ching-hao and Scute Combination (Hao Jin Qingtan Tang). Each herb is present in the amount of 8–12 grams, except jujube (12 pieces). The formulas would be modified for certain presenting symptoms. For example, for urinary incontinence, add cuscuta, alpinia, and rose fruit; for constipation, add ho-shou-wu, persica, cistanche, and rhubarb; for mental fogginess, add schizandra; for abdominal distention, add magnolia bark and chih-shih; for muscular atrophy, add tang-kuei, gelatin, and dipsacus. The decoctions were consumed as a cooling drink (rather than hot; because many MS patients have an aversion to heat), once per day. Anti-inflammatory Western drugs (dexamethasone or prednisone) were given during acute active periods. Thirty-five patients were treated and except for three that discontinued treatment within the first ten days, some improvement was found. Two cases were deemed basically cured after taking 45 and 68 doses; 15 were markedly improved and another 15 somewhat improved, most of them taking 20–40 doses. Eleven of the patients had tried corticosteroids unsuccessfully before switching to the traditional herb combinations; of these, seven were markedly improved, three improved, and only one failed to respond. These researchers followed up their work with an attempt to prevent exacerbations (18). They prescribed Ping Fu Tang (Pacify Relapse Decoction) to 30 patients over a period of 3–13 years (average of 6 years). The formula contained astragalus, codonopsis, hoelen, atractylodes, pinellia, licorice, jujube, bupleurum, scute, tortoise shell, ligustrum, tang-kuei, peony, ophiopogon, rehmannia, lycium, and anemarrhena. The prescription basically has the effect of tonifying qi, yin, and blood, and clearing deficiency heat. It can be seen that this prescription is derived from the first two formulas listed in the previous article for treatment of multiple sclerosis, based on deficiencies of liver, kidney, and spleen (it also has some herbs of Minor Bupleurum Combination, as mentioned below). The preventive therapy was basically a tonic formula. It was prescribed in the form of a decoction, taken in 2–3 daily doses, using 8–15 grams of each herb (except smaller amounts of licorice and jujube). According to the researchers, relapses were prevented except for two patients who each experienced only one minor exacerbation, each event following a viral infection (common cold). A control group of MS patients not treated by this remedy was monitored for three years: they suffered from exacerbations at the rate of 1–4 times per year. Ping Fu Tang included rehmannia, tortoise shell, peony, and anemarrhena, ingredients of Hu Qian Wan, which have the functions of nourishing yin and blood and cleansing deficiency fire. In addition, they added ligustrum, lycium fruit, and ophiopogon to nourish yin. A strategy for nourishing blood and essence is to tonify the qi so that more nutrients are obtained from the food. The formula included astragalus, codonopsis, hoelen, atractylodes, licorice, and jujube towards this end (these herbs also enhance immune functions to aid resistance to infections that induce exacerbations). Since the point of the treatment was not to rectify flaccidity, but rather to prevent flaccidity by preventing exacerbations, the herbs for treating flaccidity in the legs, such as tiger bone and cynomorium found in Hu Qian Wan were not included. Also, as the patients are being treated continuously with the yin-nourishing tonics, it is not necessary to strongly inhibit deficiency fire, so phellodendron is not essential to the prescription (anemarrhena, unlike phellodendron, has the secondary property of being a yin tonic). Thus, the treatment largely reflects the principles of Zhu Danxi in relation to understanding the cause of a flaccidity syndrome. The doctors explained that part of their thinking in developing the formula was based on the current understanding of autoimmunity, which explains the presence of so many qi tonics and the herbs of Minor Bupleurum Combination (Xiao Chaihu Tang), such as pinellia, bupleurum, and scute, which is believed to be helpful in chronic inflammatory diseases. If a T-cell attack against myelin sheaths is initiated by influenza, common cold, sinusitis, or other infections, ability to prevent such infections or halt their progress would be one obvious key step in preventing damage due to the usual sequence of events in an exacerbation. Protection from transmissible viral infections, such as staying away from those who are currently suffering from the infection, is one method of prevention. Enhancing the immune system functions with tonic herbs is another method. Many Westerners are led to believe, by poorly written articles on immune disorders, that enhancing immune system vigilance would worsen any autoimmune disease; however, this would only be a potential problem during an exacerbation; even then, other components of the immune system that help to shut-down the autoimmune attack may be coaxed into activity with proper immune-regulating herbal treatment strategies.

2. Amyotrophic Lateral Sclerosis and Progressive Spinal Muscular Atrophy Case studies of ALS were reported by Lin Tongguo (19). In one case, the primary formula combined tonic herbs: astragalus, tang-kuei, peony, rehmannia, aconite, cinnamon bark, and lycium fruit, with several herbs used to promote circulation of blood and relieve spasms (the spasms being a significant problem in many cases of ALS): centipede, scorpion, persica, carthamus, morus twig, and clematis. These herbs were made as a decoction taken in divided doses three times daily for several days. In addition, a small amount of powder made from strychnos and musk (0.25 grams of each, three times daily) was given. As follow-up, the decoction formula was modified (cnidium, platycodon, chih-ko, tiger bone, deer antler, and zaocys were added; morus twig and clematis were deleted) and made into pills instead of decoction, to be taken 18 grams per day—the musk and strychnos powders were included in the pills. The pills were taken for two years until the disease was resolved. A follow-up after three years with no further medication showed that the disease had remitted. A similar approach was used with a second patient who consumed a decoction made with astragalus, atractylodes, cinnamon twig, tangkuei, persica, carthamus, centipede, eupolyphaga, fenugreek, aconite (chuanwu), licorice, and zaocys. After using this decoction for several days, the pill described above was used for long-term medication and a clinical cure was obtained, with a follow-up after five years confirming the satisfactory result. The third case emphasized treatment of yin deficiency fire, using a decoction with phellodendron, raw rehmannia, moutan, alisma, anemarrhena, hoelen, stephania, coix, chin-chiu, dipsacus, achyranthes, centipede, and scorpion. This decoction was given for more than two months and then modified, taking out stephania, coix, and chin-chiu, and adding dipsacus, deer antler, epimedium, tang-kuei, cnidium, and carthamus. This formula was then used for more than three months. Finally, the above-mentioned pill was again used for long-term therapy, and a cure was obtained, with no relapse by the end of two years without the medication. In a report by Kang Yanghuo of two cases of progressive spinal myoatrophy (20) the main prescriptions given were variations of Shengji Yisui Tang (Decoction for Generating Muscles and Benefiting Marrow). One such prescription contained tang-kuei, lycium fruit, atractylodes, ophiopogon, tortoise shell, achyranthes, phellodendron, alisma, chaenomeles, and licorice for a yin deficiency case and deer antler, eucommia, atractylodes, astragalus, psoralea, malt, crataegus, pinellia, codonopsis, sinapis, hoelen, alisma, chaenomeles, achyranthes, and cinnamon twig for a yang deficiency case with weak digestion and phlegm accumulation. Treatment time was six months and included acupuncture and massage therapy. Long-term follow-up showed persisting benefits of the treatment, with normal nerve conduction and physical activities. In a study (21) of 15 patients with progressive ALS, a significantly expanded version of Hu Qian Wan was employed. This contained astragalus, epimedium, deer antler, syngnathus, sea horse, ginseng, tortoise shell glue, tang-kuei, peony, rehmannia, lycium fruit, eucommia, dipsacus, cuscuta, cynamorium, atractylodes, coix, citrus, achyranthes, chaenomeles, chin-chiu, agkistrodon, tiger bone, psoralea, anemarrhena, phellodendron, cinnamon twig, chiang-huo, tu-huo, and siler. The formula was based on the traditional prescription Jian Bu Hu Qian Wan (Step Reinforcing Tiger’s Walk Pill). The pills were taken in a dosage of 3–9 grams at a time, 2–3 times per day depending on the person’s constitution and severity of the disease, but were not to be used by patients showing yin deficiency fire syndrome. Two of the patients were said to be cured and five improved. The pills were to be used on a regular basis over a period of several years. Strychnos is sometimes mentioned as part of ALS treatments. A muscle-invigorating combination known as Mobilizing Powder may produce temporary alleviation of flaccidity. The combination includes strychnos, musk, and centipede. Strychnos in small doses tones the muscles and in large doses paralyzes them. It is used in the treatment of other autoimmune disorders, including MG and rheumatoid arthritis. Unfortunately, this herb cannot enter into Western treatments for autoimmune diseases because of concerns over the toxicity of strychnine, one of the main active components. A large scale study of progressive spinal muscular atrophy (80 cases) and ALS (30 cases) was described by Huo Yintang (22). The primary formula used for treatment was Yisui Tang , made with codonopsis, atractylodes, astragalus, rehmannia, psoralea, dipsacus, cuscuta, achyranthes, cibotium, tang-kuei, peony, millettia, tortoise shell, deer antler gelatin (each herb 9–15 grams in decoction), with 5 grams each phellodendron, and anemarrhena. This formula is a substantial modification of Hu Qian Wan , utilizing several yang tonic herbs to replace the tiger’s bone of the ancient prescription. According to the report, 59 cases were considered cured (symptoms alleviated, muscles regenerated, and muscular function restored), 18 markedly improved, 25 improved, and 8 showed no improvement. 3. Myasthenia Gravis Yakazu reported (23) that formulas containing ma-huang, such as Pueraria Combination ( Gegen Tang ) and Minor Blue Dragon Combination (Xiao Qinglong Tang), were repeatedly found to improve symptoms, at least for short-term treatment, in patients with MG. He attributes this effect to the active component ephedrine, which was previously reported to be effective for myasthenia by Dr. Nabi Ryoken in his book The Revised Practical Medical Service. Ma-huang is traditionally used in the treatment of muscular aching and ephedrine is known to promote circulation through the striated muscles. Yakazu also recommended the use of peony and licorice, stating that this combination “adjusts the tenseness” of the muscles. Licorice also has cortisone-like action. These two herbs are frequently used to relieve muscle spasms, perhaps with better effect in patients suffering from deficiency syndromes. In like manner, he thought that pueraria, traditionally used to relax tense muscles in the neck and shoulders, might help to treat flaccidity of these same muscles when given to patients with MG. In the case study of early MG presented by Shao Nianfang, pueraria was included. In a study (24) of treatments for MG reported by Qiu Chengling, eight patients received capsules containing strychnos (0.2 grams per capsule), gradually increasing the daily dosage to reach seven capsules each time, three times daily. In addition, the patients were treated with decoctions according to the classification of underlying syndrome. For those with spleen deficiency, Ginseng and Astragalus Combination (Buzhong Yiqi Tang) plus epimedium was given. For spleen and kidney deficiency, a decoction of astragalus, epimedium, tang-kuei, atractylodes, codonopsis, rehmannia, dioscorea, curculigo, anemarrhena, and morinda was given; in cases of more severe yang deficiency and cold, cinnamon twig, aconite, and deer antler glue were added. As a result of these therapies, 5 of the 8 patients noted significant improvements. Li Genghe (16) reported on the cumulative results of treating 250 patients over a period of five years. He claimed that long-term ingestion of herbs that tonify the spleen and kidney could lead to a clinical cure in nearly half the patients. The duration of therapy necessary was 3–5 months for the eye-muscle type (which was easier to cure) and 6–8 months for the general type. Domei Yakazu believed that those not cured by tonification therapies might benefit from the ma-huang formulas.

SUMMARY OF CLINICAL TRIALS Formal clinical trials involving several patients rather than individual case studies began in 1975 and have included only few hundred patients. Since the Western medical knowledge of the diseases was limited and advanced equipment often not available, the early research was based almost entirely on traditional analysis of treating flaccidity syndrome and guesses as to the treatment of autoimmunity. The claimed positive results, ranging from a high proportion of persons with marked improvements to a substantial number of cases declared cured, were often a consequence of treating patients with different formulas according to diagnostic categories and with changes in prescription during the first few weeks or months of therapy. Tonification of spleen, kidney, and liver are the prominent methods of therapy. It was common to combine decoctions and pills, and to use pills as long-term therapy, which sometimes lasted for two years. In some cases, acupuncture, Western medicine, and other therapies were said to be used: undoubtedly, in most trials the patients received the therapeutic interventions that the physicians felt were necessary within the limitations of what could be offered. AMERICAN PATIENTS WITH MS According to clinicians working at the ITM clinic, diagnosis of American patients suffering from multiple sclerosis reveals the presence of yin deficiency, but relatively little experience of the yin deficiency fire. Rather, these individuals have a greater tendency to display signs of weakness of the stomach functions and some deficiency of kidney yang. This apparent difference between these findings compared to the explanation of leg flaccidity by Zhu Danxi may be related to several factors. For example, MS is more common in the colder northern regions, where yang deficiency is more prevalent, while Zhu observed patients in southern regions where yang deficiency is less common. The cause of the disease, though complex, appears to be infectious agents and autoimmune process, rather than debilitating life style (though life style factors could contribute to disease initiation and progression), which was the dominant concern in Zhu’s time. The Western diet may help to limit deficiency fire syndrome, but might worsen stomach problems. Malabsorption in MS patients has been noted for fats, vitamin B12, and d-xylose, and low HCl levels may be responsible for limited digestion of meats (28). In China, low HCl levels were noted in patients with MG (29), and the lowest levels were closely associated with refractoriness to treatment. DIETARY AND NUTRITIONAL CONSIDERATIONS: EAST AND WEST Providing adequate nutrition is considered critical in the traditional description of flaccidity syndrome. To treat essence deficiency, Chinese doctors recommend that certain foods be eaten, including duck, abalone, pig kidney, liver, lotus seeds, rose hips, and walnuts (29). As mentioned earlier, avoiding certain foods is also a consideration of traditional Chinese thinking. Black pepper is to be avoided in cases of muscular weakness. Recently it was shown that a component of pepper inhibits convulsions and it may have a mild inhibitory action on muscular contraction. Cinnamon, with its key component cinnamaldehyde, should be avoided in persons with MS, as the aldehydes may already inhibit nerve transmission. These two herbs are warm and spicy in nature, and would be limited by the prevailing Chinese theory that spicy herbs can worsen yin deficiency. Cinnamon is used in some treatments of flaccidity, but might be more suitably replaced by other herbs that accomplish the same therapeutic goal, such as cynomorium, morinda, or dry ginger. Ingestion of essential fatty acids and EPA from fish oil appears to be of some aid in treating autoimmunity in general (4). Fatty acids and fish oil supplementation may correspond to tonifying the yin, based on Chinese dietary recommendations. Avoidance of zinc or use of zinc-chelating agents also reduces some autoimmune responses (1), though zinc deficiency can lead to easier experience of viral infections that activate MS attacks. Tortoise shell (rich in gelatin) and deer antler gelatin are included in several prescriptions for treatment of flaccidity of the legs. Glycine is a major component of gelatin, which is classified by Chinese doctors as a blood and yin tonic. The amino acid glycine has been recommended for persons with MS since it counteracts aldehyde accumulation and has antispasmodic properties (daily dosage is about 3 grams per day). Since 1950, it has been proposed that a diet low in saturated fats may benefit some MS patients, and a clinic at Oregon Health Sciences University, formerly run by Dr. Roy Swank, professor of neurology, has specialized in this area of treatment for several years. He recommends no more than 10 grams of saturated fat per day, which basically yields a vegetarian diet supplemented by fish (three or more times per week; the fish oils are considered beneficial as are polyunsaturated oils). Many persons find this diet to strict to be practical. High levels of polyunsaturated oils may increase oxidative stress, and so should be countered by taking antioxidants. Vitamin B 12 is found primarily in animal foods and is also present in walnuts. This vitamin may contribute some of the essencetonifying properties of foods recommended by Chinese doctors. A number of reports of vitamin B 12 deficiency in some MS patients has led to the use of this vitamin in treatment of those who are found to have low B12 either in the serum or the cerebrospinal fluid. Low vitamin B 12 levels were found to be associated with earlier onset of disease symptoms and were reduced by corticosteroid administration (38). However, it may be the unsaturated B 12 binding capacity that is more often low, even if total B 12 levels are normal (39). When patients with chronic progressive MS were given 6 mg of oral B12 every day for six months, there were improvements in visual and brainstem auditory evoked potentials. Since MS patients are likely to have poor B12 uptake, B 12 is often given by injection, with doses up to 1 mg each time. STEPS TO TAKE IN TREATMENT To follow Chinese medical theories and experience in treating MS, MG, ALS, and other flaccidity syndromes, one would undertake the following: 1. Eat a diet that is nourishing to the spleen, kidney, and liver, especially with essence-tonifying foods (this would include various beans and seeds, meats, seafoods, and mildly astringent fruits). Avoid excessive amounts of sour, spicy, and salty foods. Consider use of nutritional supplements with selenium, calcium, vitamin B12, antioxidants, and essential fatty acids. Also consume gelatin or a glycine supplement (3 grams per day), especially in cases where muscle spasms occur.

2. Consume herb formulas that match the particular manifestation of symptoms and signs recognized by traditional medical theory. Deficiency is to be nourished; obstruction, overcome; and excess, drained. In cases of deficiency syndrome (which appear to be the most common), consider the use of substantial doses of tonic herbs, and give special attention to the need for yin or yang tonic agents. Anti-inflammatory drugs may help limit the damage to myelin if their use is initiated early in an attack, but they may have little benefit the rest of the time. Immune-regulating drugs, such as betaseron, can be tried if the herb therapies fail to produce adequate regulation. 3. Avoid viral infections (and other infections) by minimizing exposure to infected persons and to potentially harmful environmental conditions (e.g., chill). Take an antiviral herb combination when an acute viral attack is suspected. Treat all infections promptly, whether using herbs or drugs. 4. Utilize practices that evoke spiritual rejuvenation. Traditional Chinese exercises, such as Qi Gong and Tai Ji Quan may be helpful in strengthening the normal qi, benefiting the kidney, and calming the spirit. They also improve muscle control and balance. 5. Use acupuncture to invigorate circulation of qi and blood in the limbs and to restore nervous system connections. Scalp acupuncture has proven helpful in treating disorders of the central nervous system, including MS (40). Dr. Chen Zelin and Chen Meifang in the book A Comprehensive Guide To Chinese Herb Medicine (41), recommend the following body points for flaccidity syndrome (3– 4 points should be selected for each daily or every other day treatment for 10 days): Flaccidity of the arms: GV 4, 12; LI 11, 15; SI 4, 9; TB 5, BL 11. Flaccidity of the legs: GV 2, 3; BL 57, 60; GB 30, 31, 34, 39; SP 6, 9; ST 36 6. New Western medical approaches should also be considered. Recent research suggests that it may be possible to selectively inhibit the autoimmune attack against myelin using a T-cell receptor (TCR) peptide drug that does not defeat the entire immune system but rather blocks the attack by matching the basic protein on myelin that binds the T-cells. Initial tests in animals with experimental allergic encephalymyelitis, a model for MS, showed good results, and clinical tests in a small number of patients have yielded promising outcomes (42). If successful, the same basic method, using a different peptide, might be useful for other autoimmune disorders, such as MG. The drastic inhibition of immune functions, which is possible with currently-available drugs, such as high dose corticosteroids or cyclosporin, should only be considered as an emergency measure. Chinese herb drugs that inhibit acetylcholinesterase, such as huperzine A and fordine, have been used with some success in treating myasthenia gravis in China. 7. Parents who have MS should take special care to make sure that their children get adequate nutrition, have vaccinations against common preventable diseases, and take steps to avoid excessive exposure to infectious and parasitic agents. Their children have an increased risk of disease due to genetic factors, so that extra care may be needed to avoid development of the disease. ACKNOWLEDGMENTS Several Chinese language articles were translated by Fu Kezhi in Harbin; Deng Zhongjia, through literature research, provided an article o n Ping Fu Tang , a portion of that article was translated by Heiner Fruehauf, Ph.D., L.Ac. in Portland; Dr. Fruehauf also provided translations of articles on ALS and progressive spinal muscular atrophy. Barry Levine, L.Ac. in Norwood, Massachusetts, provided several abstracts and articles on the Western medical analysis of MS and its treatment. The MS Foundation in Fort Lauderdale, Florida provided funding for treatments of MS patients at the ITM clinic. 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Sommer N, et al., The antidepressant rolipram suppresses cytokine production and prevents autoimmune encephalomyelitis , Nature Medicine 1995; 1(3): 244–248. 9. Ni Maoshing, The Yellow Emperor’s Classic of Medicine, Shambala 1995, Boston, MA. 10. Wang Shousheng, Advanced Textbook on Traditional Chinese Medicine and Pharmacology , Volume III, New World Press 1996, Beijing. 11. Zhou Xiehai and Lu Lixiao, The clinical application of tonifying and benefiting the kidney essence in multiple sclerosis, Journal of the American College of Traditional Chinese Medicine 1985; 4: 65–66. 12. Zhang Jianguo, Chronic progressive spinal lateral sclerosis, Journal of the American College of Traditional Chinese Medicine 1985; 4: 66–67. 13. Hsu HY, Paralysis, neuralgia, rheumatism, gout, and their Chinese herb treatment, Bulletin of the Oriental Healing Arts Institute 1979; 4: 4–5. 14. Zhang Wentao and Meng Rou, Autoimmune diseases as treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1982; 1: 39–50. 15. Shao Nianfang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine , Shandong Science and Technology Press 1990, Jinan. 16. Li Gengho, Discussion about myasthenia gravis and the spleen-kidney theory, Journal of Traditional Chinese Medicine, 1986; 6(1): 48–51.

17. Lu Xi and Wang Yaohua, Thirty-five cases of multiple sclerosis treated by traditional Chinese medical principles using differential diagnosis, Chinese Journal of Integrated Traditional and Western Medicine 1990; 10(3): 174–175. 18. Lu Xi, Li Zhiwen, and Wang Hu, Research on the prevention of multiple sclerosis relapse with traditional Chinese medicine , Journal of Traditional Chinese Medicine 1995; 36(7). 19. Lin Tongguo, Treatment of amyotrophic lateral sclerosis with a series of proved formulas , Guangxi Journal of Traditional Chinese Medicine 1983; 6(2): 22–23. 20. Kang Yanghuo, Case reports of flaccid complexes: successful treatment of two cases of progressive spinal myoatrophy , American College of Traditional Chinese Medicine 1985; 4: 59–63. 21. Xie Wengzheng, Treatment of progressive amyotrophic lateral sclerosis with modified Jian Bu Fu Zian Wan , Shanghai Journal of Traditional Chinese Medicine 1985; 11: 32. 22. Huo Yintang, Treatment of myodystrophy with Chinese herbs, Tianjin Journal of Traditional Chinese Medicine 1985; 6. 23. Yakazu Domei, Myasthenia gravis, Bulletin of the Oriental Healing Arts Institute 1985;10 (6): 252–257. 24. Qiu Chenling, Strychnos used in treating myasthenia gravis, Zhejiang Journal of Traditional Chinese Medicine 1986; 21 (1). 25. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, Volume 2 , Heilongjiang Education Press 1993, Harbin, China. 26. Yakazu Domei, The descendent schools: the medical philosophy of Li and Zhu in the Qin and Yuan Dynasties, Bulletin of the Oriental Healing Arts Institute 1985, 10(4): 141–146. 27. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations , Oriental Healing Arts Institute 1980, Long Beach, CA. 28. Murray M and Pizzorno J, Encyclopedia of Natural Medicine, Prima Publishing 1990, Rocklin, CA. 29. Tu Laihei, et al., Pathogenesis of spleen deficiency in myasthenia gravis, in International Conference on Traditional Chinese Medicine and Pharmacology 1987, China Academic Publishers, Shanghai. 30. Challoner, PB, et al., Plaque-associated expression of HHV-6 in multiple sclerosis, Proceedings of the National Academy of Sciences USA 1995; 92: 7440. 31. Carrigan DR, Harrington D, and Knox KK, Subacute leukoencephalitis caused by CNS infection with HHV-6 manifesting as acute multiple sclerosis, Neurology 1996; 47(10): 145–148. 32. Arnason BGW, Interferon beta in multiple sclerosis, Neurology 1993; 43: 641–643. 33. Khokhlov AP, et al., Disorders of formaldehyde metabolism and its metabolic precursors in patients with multiple sclerosis, Zhurnal Nevropatologii I Psikhiatrii 1989; 89 (2): 45–48. 34. Calabreses V, et al., Changes in cerebrospinal fluid levels of malondialdehyde and glutathione reductase activity in multiple sclerosis, International Journal of Clinical Pharmacology Research 1994; 14(4): 119–123. 35. Newcombe J, Li H, and Cuzner ML, Low density lipoprotein uptake by macrophages in multiple sclerosis plaques: implications for pathogenesis, Neuropathology and Applied Neurobiology 1994; 20(2): 152–162. 36. Mai J, Sorensen PS, Hansen JC, High dose antioxidant supplementation to MS patients. Effects on glutathione peroxidase, clinical safety, and absorption of selenium, Biological Trace Element Research 1990; 24(2): 109–117. 37. Zhang Enqin (editor in Chief), Chinese Medicated Diet, Publishing House of Shanghai College of Traditional Chinese Medicine 1988, Shanghai. 38. Frequin ST, et al., Decreased vitamin B12 and folate levels in cerebrospinal fluid and serum of multiple sclerosis patients after highdose intravenous methylprednisolone, Journal of Neurology 1993; 240(5): 305–308. 39. Kira J, Tobimatsu S, and Goto I, Vitamin B12 metabolism and massive-dose methyl vitamin B12 therapy in Japanese patients with multiple sclerosis, Internal Medicine 1994; 33(2): 82–82. 40. Dharmananda S and Vickers E, Synopsis of scalp acupuncture, START Group Manuscripts, 1996. 41. Chen ZL and Chen MF, A Comprehensive Guide to Chinese Herbal Medicine , Oriental Healing Arts Institute 1992, Long Beach, CA. 42. Vandenbark AA, et al., Treatment of multiple sclerosis with T-cell receptor peptides: results of a double-blind pilot trial , Nature Medicine 1996, 2(10): 1109–1115. 43. Flammand L, et al., HHV-6 induces IL-1B and TNF-alpha, but not IL-6 in peripheral blood mononuclear cell cultures, Journal of Virology 1991; 65:5105–5110. November 1996

MODERN CHINESE MEDICAL METHODS FOR MS: Clinical Setting and Patient Reports by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

OVERVIEW ITM operates two clinical facilities in Portland, Oregon for multiple sclerosis (MS) patients. One (“Lovejoy Clinic”) initiated an MS program in November 1993 and the other (“Hawthorne Clinic”) provided an additional site in September 1996. The programs were established, and their activities maintained, with the generous support of the National Multiple Sclerosis Foundation in Fort Lauderdale, Florida. The principal clinician for this program is Edythe Vickers, N.D., L.Ac., but there are currently more than a dozen health professionals employed at ITM to provide services to the MS patients, including a team of acupuncturists and massage therapists, two chiropractors, and a medical doctor. Nearly all participants in the program enrolled on the basis of recommendations from other patients. In total, the two clinics have enrolled 77 patients from November 1993 (including one former patient who was then enrolled in the new program) through end of August 1997. Of these, 50 patients (65%) are currently active participants in the programs; 42 of these patients have participated for three months or longer (8 joined more recently), including 3 long-term participants who visit the clinic infrequently (not currently living in Portland) but continue using the supplements daily. There were 3 patients (4%) who continued participation for more than three months but moved to distant cities, thus ending their participation (they may have found similar services elsewhere). Drop-outs from the program include 24 patients (31%) who visited the clinic at least once, but discontinued participation (usually within a few weeks) for a variety of reasons. The primary reasons cited for dropping out were the inconvenience of coming to the clinic regularly and personal problems (financial, marital, etc.) preventing regular participation; these participants usually mentioned a desire to pursue this therapy but inability to do so. A few persons (about 8; the exact number is uncertain due to lack of complete follow-up) declined further treatment because they did not feel that the treatment method was suitable for them: for example, not liking acupuncture, not wanting to take supplements, not getting sufficient benefits within a reasonable trial period. Patients generally come to the clinic once per week for acupuncture, except for missed appointments due to vacations and other personal matters, health problems, or difficulty arranging a convenient appointment time. On a daily basis, patients take one or more nutritional supplements and most patients take one or more herbal supplements (see appendix for details). Most patients receive a vitamin B 12 injection each week, either administered at the clinic or self-administered at home, and about one-quarter of the current participants take the adrenal hormone dehydroepiandrosterone (DHEA; prescribed at our clinic). Many patients also receive massage and/or chiropractic therapy at our facilities, usually once or twice per month. This combination of therapeutic approaches is similar to what is offered in some hospitals in China, integrating physical therapies with traditional and modern internal medicine. Although the total patient costs for such treatments would usually be in the range of $300 to $400 per month, most of our patients do not have insurance coverage or adequate personal financial resources for this relatively modest health care expense. Patients in this situation are asked to contribute $75/month, but for those who have incomes below 2.5 times the poverty level (which is a common status among our group), the fee is reduced accordingly, with some receiving free treatment. Both ITM and the National Multiple Sclerosis Foundation make up the deficit in payments; we also received a small grant from the McKenzie River Gathering Foundation (in Oregon) which supplemented the program for six months in 1997 (and provided additional funds for a substudy on DHEA in MS patients: see separate report). BASIC DATA: METHODS AND PRESENTATION ITM offered a comprehensive clinical services program with tracking of basic patient data. A randomized, controlled trial was not possible for a number of reasons, including lack of sufficient funds, difficulty in recruiting a large enough number of patients with reasonably similar disease conditions, and the difficulties of providing a comparable control treatment. Further, randomization is quite difficult because the requirements of the Chinese medical program include intensive participation, such as weekly clinic visits and consumption of large numbers of supplement tablets (patients must be able and willing to cooperate). Therefore, we have relied on the following approaches: maintaining records of health history (duration of MS, type of MS, accompanying diseases and syndromes, history of methods attempted to treat MS) and therapies applied at our facilities (details of treatments at each office visit); simple health status reports at each office visit (patient responses to questions); and obtaining summary statements from both participants and practitioners. Below is a brief outline report (intended for quick review of outcomes) for the 42 patients who are currently active participants and who have attended the clinic for at least three months, divided between the two clinical sites. For each patient, the following is indicated: 1. The type of MS: RR = relapsing/remitting; P = progressive (as reported by participant). 2. The duration of participation and number of acupuncture treatments received. 3. Any reports of drug therapies that have been deleted or reduced in dosage. 4. Any reports on changes in mobility. 5. Any reports of other symptom changes. 6. Practitioner comments (section labeled “comments”), usually given when patient reports are unavailable or need further clarification. The reports of drug use changes, mobility changes, and symptom changes are patient responses obtained via a survey from those who were able to fill one out at the end of August 1997. The statements in the section below are close to direct quotation (with editing to fit the presentation format). For those who did not get a chance to fill in the survey report in time, practitioner comments are relied upon instead. Exacerbation reporting is not included here, except as patients commented on the matter. This is because there was a low incidence of exacerbations in those with relapsing type MS, and exacerbations were difficult to identify. Patients are instructed to act immediately upon an apparent exacerbation, with changes in herb formulations and increased frequency of acupuncture therapy. In general, the apparent exacerbations were resolved quickly and there was no evident permanent damage in any of the instances. Therefore, it was

difficult to record the non-distinctive events as a definitive exacerbation. Here is an example of a patient comment on this subject: “If and when a new exacerbation begins, if I come into the clinic right away, the exacerbation can be stopped right away. I’ve had one instance with numbness and foot-dropping of the right leg that was stopped before it really began. I’ve also had eye flare-ups that have been alleviated.” As a result of this experience, the patient also reports that no exacerbations have occurred during this time. There were a few cases in our group of obvious exacerbation: according to patient descriptions, these arose from severe emotional distress (usually, family problems, including divorce, family member illness or death). However, in all cases where participants came in for treatment following the exacerbation, there was no obvious disease progression. According to the reports of participants, exacerbations are reduced, compared to previous experience, in both severity and duration by the Chinese medical treatments. The only participants who displayed some overall health deterioration in the program were a small number of individuals with progressive type MS who were confined to wheelchairs for some time prior to program entry, and who had multiple health problems at the time of joining the program. Even these individuals report relief of some specific symptoms as a result of their participation.

RESULTS The information given here is limited to descriptions of participation, disease status, and reported changes in health attributed to participation in the program. Not reported here (but made available in more detailed annual reports) is information about health history, compliance with herbal protocols, and concurrent use of additional therapies (e.g., Avonex, Solu-Medrol, Baclofen; these are mentioned here only if their use has been reduced or discontinued). The most frequently reported benefits are: decreased use of analgesics, antidepressants, and antispasmodics; increased energy, strength, and mobility; improved sleep, better bladder control, reduced numbness and pain, and lower frequency of infections. GROUP 1: Patients at the Hawthorne Clinic with at Least Three Months Participation Maximum attendance time at this clinical site is 12 months (having been made available at the beginning of September 1996). 14 patients with at least 3 months participation are continuing treatments (7 others have joined the program within the past three months). The mean participation time of the 14 participants is 7 months; they received a total of 388 acupuncture treatments, with an average rate of 4 treatments/month. ________________________________________________________________________________________ Patient KA [RR]: 4 months in program, 19 acupuncture treatments. Drugs Eliminated: Neuro-Trasentin, Aleve. Mobility Changes: tightness in legs decreased occasionally, making it easier to walk. Symptom Changes: slight improvement in bladder control (urination frequency); energy level has greatly improved. ________________________________________________________________________________________ Patient BC [P]: 12 months in program: 41 acupuncture treatments. Mobility Changes: more strength in legs [uses a walker]. Symptom Changes: less mental stress, better coordination. ________________________________________________________________________________________ Patient JC [RR]: 12 months in program: 42 acupuncture treatments. Comments: She is fully mobile, but suffers from numbness and tingling in the hands; general body pain; blurring vision; weakness of arms and legs, and tightness of muscles. She notes prompt relief of numbness and pain with each acupuncture treatment. ________________________________________________________________________________________ Patient LC1 [RR]: 3 months in program: 13 acupuncture treatments. Mobility Changes: better balance, able to stand the whole day and work (full time job). Symptom Changes: numbness (from abdomen down through legs) improved. ________________________________________________________________________________________ Patient LC2 [P]: 4 months in program: 18 acupuncture treatments. Decrease in Drug Use: less pain pills, less antidepressants. Mobility Changes: is now able to go for walks again. Symptom Changes: less pain in arms, hands, feet, and legs; less bladder leakage; less depression. ________________________________________________________________________________________ Patient LF: 10 months in program: 32 acupuncture treatments. Comments: She suffers from urinary incontinence, numbness and tingling in the fingers, fatigue, right leg weakness and pain, with night time leg cramps, double vision (mainly in left eye). Treatment is reported to help with fatigue; her pain, numbness, and tingling are greatly reduced, and leg cramps alleviated. Vision is improved and her appetite is better. When she took a three week vacation, her symptoms returned. ________________________________________________________________________________________ Patient JG [RR]: 5 months in program: 35 acupuncture treatments. Decrease in Drug Use: less Motrin. Symptom Changes: reduction in back pain; burning pain in feet reduced dramatically. ________________________________________________________________________________________ Patient EM [RR]: 3 months in program: 9 acupuncture treatments. Decrease in Drug Use: less Trazodone. Symptom Changes: reduction of tingling in hands and feet; better sleep. ________________________________________________________________________________________ Patient RP: 6 months in program: 26 acupuncture treatments. Mobility Changes: stopped using cane, increased walking distance, increased exercise. Symptom Changes: acupuncture treatment improves energy level and ameliorates “Avonex hangover feeling.” ________________________________________________________________________________________ Patient CR [RR]: 12 months in program: 31 acupuncture treatments. Mobility Changes: can move left leg better [confined to wheelchair]. Symptom Changes: body heat problems better; sleeps better. ________________________________________________________________________________________ Patient AS [RR]: 4 months in program: 21 acupuncture treatments. Symptom Changes: numbness in left arm and hand decreased (frequency of occurrence); asthma symptoms decreased in frequency; increased energy. ________________________________________________________________________________________ Patient CS [P]: 6 months in program: 47 acupuncture treatments.

Decrease in Drug Use: virtually eliminated Valium for sleep; Fiorinal greatly reduced. Symptom Changes: slight improvement in right side numbness; improvement in speech after acupuncture; improved vision. ________________________________________________________________________________________ Patient KS [RR]: 12 months in program; 28 acupuncture treatments. Symptom Changes: increased mental concentration, less fatigue; almost no mood swings; numbness in extremities decreased; less tingling down spine, motor-coordination and sensory difficulties resolved. ________________________________________________________________________________________ Patient MV [P]: 5 months in program: 26 acupuncture treatments. Drugs Eliminated: Baclofen. Drugs Reduced: quinine sulfate. Mobility Changes: able to stand for longer periods of time (is usually in wheelchair). Symptom Changes: reduced drop-foot effect; regained bladder control; reduced pain in collarbone. GROUP 2: Patients at Lovejoy Clinic with at Least Three Months Participation The clinic has been open for the MS program 46 months. With a few exceptions (for example, wheel-chair participants were recommended to the Lovejoy site because of better handicapped access), new patients were not enrolled at this site after the Hawthorne site was opened; thus, the participation time is usually in excess of 12 months. There are 28 patients with at least three months program experience: mean participation time for this group is 23 months. They received 2,098 acupuncture treatments; the average rate of acupuncture was 3.3 treatments per month. The lower rate of treatments per month (compared to the Hawthorne site) is mainly due the fact that some patients enrolled here receive infrequent acupuncture treatments (due to their location) but receive herbs and supplements that they use regularly. Patients at this clinic tended to be more severely debilitated than patients at the Hawthorne clinic. This is mainly because the persons initially enrolling in the MS program tended to have complicated and advanced disease conditions. Later, as the potential benefits of Chinese medical treatments became known, persons with less severe conditions began to enroll (more often at the Hawthorne clinic). There are currently 7 wheelchair MS clients (persons who always or mainly use a wheelchair to get around) at Lovejoy; 2 at Hawthorne. ________________________________________________________________________________________ Patient MA [RR]: 19 months in program: 73 acupuncture treatments. Mobility Changes: arm and leg movement noticeably improved. Symptom Changes: better digestion; eye problems alleviated. ______________________________________________________________________________________ Patient CB [RR]: 28 months in program: 75 acupuncture treatments. Comments: has had numerous surgeries for non-MS spinal injuries; she has morphine pump. Treatments alleviate pain, reduce bladder infections, and improve energy. _______________________________________________________________________________________ Patient DC [RR]: 15 months in program: 44 acupuncture treatments. Mobility Changes: less problem with tripping and stumbling due to reduced stiffness and pain in left leg. Symptom Changes: reductions in pain, stiffness, tingling feeling, twitching, less fatigue; significant reduction in depression and anxiety; less problem with insomnia, avoided infections all winter. ________________________________________________________________________________________ Patient JC [P]: 26 months in program: 106 acupuncture treatments. Drugs Reduced: pain medications. Mobility Changes: better movement, without as much pain. Symptom Changes: have had no major exacerbations, been steadily improving; acupuncture treatment effects last for several days. Comments: she suffers from shoulder and knee pain, left sided weakness, and depression. Treatments improved her sleep, energy, and she gets sick less frequently. ________________________________________________________________________________________ Patient SC [P]: 23 months in program: 91 acupuncture treatments. Drugs Eliminated: Zoloft. Symptom Changes: better digestion and bowel conditions; lost some excess weight. Reduced pain in legs, resolution of bladder infections. Comments: she suffers from right leg weakness, and very low energy (needed to take naps). Reports better energy, relief of constipation; leg weakness not worsening (as it was before). ________________________________________________________________________________________ Patient LD [P]: 18 months in program: 65 acupuncture treatments. Mobility Changes: able to stand with help for about 10 seconds; right arm somewhat stronger, legs stronger. Symptoms Changes: less depression. Comments: she is confined to a wheelchair. Has developed ability to move left foot that had been paralyzed before. Weakness of hands has not deteriorated further.

________________________________________________________________________________________ Patient RF [P]: 27 months in program: 139 acupuncture treatments. Comments: he is confined to a wheelchair. His energy and sleep are better, his urinary and bowel control have improved. ________________________________________________________________________________________ Patient DG [RR]: 31 months in program: 82 acupuncture treatments. Symptom changes: more energy, less pain in back. Comments: she uses a wheelchair, but sometimes can use a walker; has insulin-dependent diabetes and is legally blind; she has also reported better sleep and constipation relieved. ________________________________________________________________________________________ Patient EG [RR]: 21 months in program: 80 acupuncture treatments. Symptom Changes: double vision and right leg numbness present initially has been alleviated; not had any significant exacerbations since staring the program. ________________________________________________________________________________________ Patient MG [RR]: 46 months in program: 145 acupuncture treatments. Note: this patient was treated at our clinic for one year prior to the start of the MS program (and at another clinic offering similar types of therapies for a year prior to that). The number of months and number of treatments indicated above reflects only the portion since the MS program started. Symptom Changes: generally feels better. ________________________________________________________________________________________ Patient DH [RR]: 42 months in program: 51 acupuncture treatments. Comments: this patient does not currently live in Portland area; but she comes to Portland sometimes and gets regular treatments during her visits; she takes prescribed herbs and nutritional supplements regularly. Acupuncture improves her gait and vision (which deteriorates after a while of not getting treatments); acupuncture improves her energy. ________________________________________________________________________________________ Patient BI [RR]: 21 months in program: 82 acupuncture treatments. Drugs Eliminated: Amantadine, Zanaflex, Solu-Medrol. Drugs Decreased: Baclofen (half dosage). Mobility Changes: stopped using the scooter, reduced use of cane. Symptom Changes: improved energy, less severe spasms, stopped having frequent colds, fewer incidents of urinary incontinence, memory problems gone, numbness in legs and feet resolved, vision problems alleviated. Comments: this patient suffered from spasms in her legs; treatment has decreased the spasms considerably. Solu-Medrol made her feel sick (her doctor was opposed to her stopping this therapy). An exacerbation that occurred during her time in the program was treated solely by our methods and she recovered completely. ________________________________________________________________________________________ Patient JJ [RR]: 24 months in program: 91 acupuncture treatments. Drugs Eliminated: Paxil, Amantadine, Depacote, Baclofen, Trazodone. Drugs Reduced: Advil. Mobility Changes: limp is gone. Symptom Changes: less fatigue. Comments: walked with limp; sometimes relied on cane; suffers from depression. With treatment, she doesn’t use a cane now and went back to full-time work. ________________________________________________________________________________________ Patient LK [RR]: 17 months in program: 41 acupuncture treatments. Comments: gets leg weakness, urinary frequency, suffers from depression. With treatment, is currently healthy, asymptomatic. She entered the program right after MS diagnosis. She is currently in Japan, taking the supplements we prescribed. ________________________________________________________________________________________ Patient DL [RR]: 28 months in program: 93 acupuncture treatments. Comments: suffers from urinary incontinence (uses catheter), bladder spasms, etc.; weakness in knee. With treatment, less bladder spasms, knee weakness gone. Very sensitive to heat. ________________________________________________________________________________________ Patient ML [RR]: 30 months in program: 148 acupuncture treatments. Mobility Changes: no longer uses a cane. Symptom Changes: reduction in balance problems; maintenance of weight; sleep problems resolved; episodic depression quickly relieved by treatment; muscle cramps relieved; hives eliminated; sleep improved. ________________________________________________________________________________________ Patient GM [P] 22 months in program: 70 acupuncture treatments. Drugs Reduced: Baclofen [half dosage]. Symptom Changes: much better attitude, better bladder control. ________________________________________________________________________________________ Patient DN [RR]: 24 months in program: 79 acupuncture treatments. Drugs Eliminated: Klonopin, Oxazapam. Mobility Changes: can walk further without being tired, can drive a car.

Symptom Changes: vertigo lessened, eyes better, less constipation, stronger, more energy, fewer exacerbations (had none in the last two years), better coordination. Comments: initially, she walked with a cane, had loss of bladder control, depression. With treatment she is basically healthy; MS symptoms mainly resolved (sometimes gets blurred vision and poor balance, which is resolved again by treatment). ________________________________________________________________________________________ Patient JN [RR]: 19 months in program: 51 acupuncture treatments. Mobility Changes: can stand longer; left knee, leg stronger; can walk longer and foot doesn’t drag as much. Symptom Changes: less pain (in left knee), better mental attitude, better balance. Comments: had balance problems, weakness in left knee, leg, hand; fatigue and insomnia. With treatment is now walking fine, has gone from part time to full time work, better energy and sleep. ________________________________________________________________________________________ Patient KN [RR]: 16 months in program: 9 acupuncture treatments. Comments: he does not live in Portland area, but can drive about three hours to our clinic for some treatments (also gets some acupuncture treatments in Seattle), takes supplements regularly. Had been put on medical leave from Army; was having trouble walking and hand and feet numbness (hand problems interfered with work as mechanic); fatigue. He was able to go back to work.

________________________________________________________________________________________ Patient IR [RR]: 41 months in program: 94 acupuncture treatments. Drugs Reduced: lowered dosage frequency of pain pills from three times per day to two times per day. Mobility Changes: increased use of hands. Symptom Changes: less pain after acupuncture treatments, an effect that persists for several days; less experience of sadness, more positive attitude. Comments: she is confined to a wheelchair; is on many drugs, including pain drugs; has chronic bladder problems. Treatment helps alleviate symptoms; bladder control better. ________________________________________________________________________________________ Patient LR [P]: 28 months in program: 86 acupuncture treatments. Drugs Eliminated: Avonex, steroids (taken once per month). Mobility Changes: range of motion increased; able to move head side to side better; arms move up higher, legs move several degrees further. Symptom Changes: less fatigue, reduced cognitive problems. Comments: she has suffered from memory and concentration problems; fatigue (naps every day). With treatment, better mental focus, better energy (not taking naps). Less sensitive to heat this year. ________________________________________________________________________________________ Patient MR [RR]: 12 months in program: 42 acupuncture treatments. Symptom Changes: increased clarity of thinking; substantial reduction in spontaneous bruising; reduced incidence or duration of common cold; better energy, better sleep; fewer feelings of exacerbation (tingling sensation in fingers and face). ________________________________________________________________________________________ Patient KS [RR]: 22 months in program: 78 acupuncture treatments. Symptom Changes: improvement in concentration; exacerbations (numbness, leg pain, double vision) quickly resolved by treatment; better energy, less problems with sleep; better ability to handle stressful situations. ________________________________________________________________________________________ Patient VS [RR]:16 months in program: 65 acupuncture treatments. Symptom Changes: better memory, digestion, strength; clearer thinking; urinary incontinence relieved; less pain. Comments: suffers from incontinence, arm/leg weakness, memory loss. With treatment, less problems of incontinence; improved digestion. ________________________________________________________________________________________ Patient KS2 [P]: 5 months in program: 15 acupuncture treatments. Comments: confined to wheelchair, severe muscle spasms; legs paralyzed and numb, hands curling. With treatment, alleviated restless leg syndrome; has more energy, bladder control improved. ________________________________________________________________________________________ Patient CU [RR]: 23 months in program: 84 acupuncture treatments. Symptom Changes: more energy, better concentration and memory; relapses following stress or illness were reduced in severity. Comments: digestive system problems. With treatment her energy is better, digestion is somewhat improved. She self-administers B 12 injections every other day.

________________________________________________________________________________________ Patient CW [P]: 6 months in program: 20 acupuncture treatments. Drugs Reduced: Ibuprofen. Symptom Changes: less spasticity in right leg; feels stronger and has more even energy. ________________________________________________________________________________________ In general, patients notice a beneficial effect of the treatment program within the first six weeks of regular participation; if not, they usually discontinue the therapy, as it is inconvenient to pursue without evident results. After that initial period, many patients report that they notice a difference in how they feel and in the severity of their symptoms if they miss one or two weeks of treatment, indicating that the acupuncture office visits are an important aspect of their health maintenance. Long-term participants in our program (those having over 9 months experience, of which there have been 50 in total), continue to pursue weekly office visits when possible. APPLICABILITY TO OTHER PERSONS WITH MS The reduction of drug use attained by many patients is a potential benefit: there will be fewer concerns about drug interactions when prescribing new medications and fewer concerns about immediate or cumulative drug side-effects. Further, reduction of drug dosage can help offset the costs of treatment. The patients report various mobility and symptom changes that may be classified under the general heading of improvements in quality of life. Chinese medical services are provided by about 8,000 licensed acupuncturists in the U.S., and practitioners with similar training are working in a number of other countries. The specific methods used at the ITM clinic are made known to other acupuncturists via mailings to a membership group (currently, about 500 members), posting on the internet (ITM’s world wide web site), and through published articles (mainly in the International Journal of Oriental Medicine). ________________________________________________________________________________________ To contact ITM: Web site: http://www. itmonline.org Fax: 1-503-233-1017 E-mail: [email protected] Phone: 1-503-233-4907 Mail: ITM, 2017 S.E. Hawthorne, Portland, Oregon 97214 USA September 1997

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Towards a Spirit at Peace Understanding the Treatment of Shen Disorders with Chinese Medicine by Subhuti Dharmananda, Ph.D. About the Title Illustration Postscript Chapter One What Is Shen (Spirit)? Chapter Two A Mind that Is Free Chapter Three Emotional Equilibrium Chapter Four Acupuncture Points Chapter Five Acupuncture Treatment Protocols Chapter Six Xuedao Zheng, Bahie Bing, Meihi Ming Chapter Seven Herbs Chapter Eight Traditional Herb Formulas Chapter Nine Sample Herbal Treatment Strategies Chapter Ten Summary, Speculation, Suggestions Appendix Quick Reference to Herb Names

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Neuroprotective Herbs and Active Constituents Approaches to Preventing Degenerative Diseases by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Considerable efforts have been made in recent decades to discover which substances can help prevent serious diseases and even limit the effects of the aging process. Foremost in this area has been research into the role of antioxidants, which come in numerous forms, such as vitamins, minerals, phenolic constituents, and sulfur compounds, from both foods and herbs. These substances may inhibit, among other things, development of cardiovascular diseases and cancer; the evidence for this effect is fairly strong. To get the benefits, the antioxidants must be ingested over a period of years in quantities sufficient to yield the desired effects. The quantities needed to attain measurable effects are often easily within reach through dietary habits. A number of common foods and beverages, such as broccoli, apples, blueberries, wine, and tea (to name but a few), have been identified as beneficial. Antioxidant properties of medicinal and beverage herbs and their active ingredients have been evaluated to determine how these might best fit into a healthful regimen. Several herbal teas appear of potential benefit, including the popular Rooibos tea of South Africa. Ordinary kitchen spices, including rosemary, basil, turmeric, and cumin, have been shown to have potent antioxidant action. The effect of antioxidants is to control damage that is caused by oxidative compounds, mainly free radicals (also called reactive oxidative species, ROS). A free radical is a charged molecule that readily interacts with molecules it encounters to cause oxidation, which damages complex biological molecules: it alters the properties and functions of the affected molecules. Free radicals are produced naturally by metabolism, particularly from our utilization of oxygen (the primary "oxidizing" agent). To avoid damage by these processes, the body has a well adapted system of antioxidant molecules that neutralize the free radicals. A couple of well-known antioxidant systems are superoxide dysmutase (SOD) and glutathione. These antioxidant systems work well in the healthy, young body, but with aging they may become inadequate, and there can be genetic factors that lead to deficiencies of these systems. It is thought that there is then a degenerative effect: with less antioxidant protection, there is more damage; with more damage there is even less antioxidant protection. Not all the protection comes from antioxidants produced in the body as its free radical "surveillance" system. A significant amount comes from dietary components that also serve as antioxidants. Diets vary considerably among individuals and population groups, and the antioxidant ingestion can have a very wide range. Fruits, vegetables, and certain beverages are particularly rich sources. It was recently reported that coffee is the primary source of antioxidants in the American diet, showing both its value and also the lack of antioxidant rich vegetables and fruits in eating habits common to this country (red wine and beer are also among the top ten sources of flavonoids in the U.S.). A major aspect of government sponsored and dietician inspired promotions for improving the American diet is to cajole people into consuming the recommended "five servings a day" of fruits and vegetables. The initial discovery of the importance of dietary antioxidants is traced to population studies correlating dietary habits and incidence of serious diseases, such as cardiovascular diseases (the primary cause of premature death in the U.S. and most developed countries). Certain dietary components have been shown to reduce the incidence of these and other diseases, and one of the common features is the presence of antioxidants. However, that is not always the entire story. As an example, wine consumption has been shown to be associated with not only lowering cardiovascular disease but also with lengthening the life span (on average). This effect is observed for those who drink moderate amounts compared to those who avoid or minimize the beverage and those who drink to excess. One aspect of this effect comes from the antioxidant and circulation promoting action of anthocyanidins and other phenolic compounds that are found in grapes (more so in red or purple grapes); the same effect could be attained from drinking unfermented grape juice (and also from some other fruit juices), though there is little data for this effect since juice is consumed far less frequently than wine. One of the main active components of the grapes is resveratrol, which is included in dietary supplements, and is present in the Chinese herb huzhang (Polygonum cuspidatum), the main raw material for making the supplements. However, a possibly stronger health benefit comes from the alcohol itself, which is absent from plain grape juice and dietary supplements, but is present (and still effective) in beer and liquor. Thus, although the antioxidants are undoubtedly of benefit, they are not the whole story. Alcohol does not act as an antioxidant but has other effects, possibly related to the relaxing action that alcohol consumers notice. This situation is instructive in that avoidance of alcohol was often recommended by proponents of good health and this was largely on the basis of seeing the harm done by excessive alcohol consumption. However, viewing the negative effects of overdosing doesn't shed light on the possibility of beneficial effects from reasonable quantities. There is a somewhat similar situation in the case of coffee consumption; its antioxidants have a certain benefit, but there are also neuroprotective effects from caffeine (as will be mentioned below), which is not one of the antioxidants. Following up on the study methods used to determine dietary components helpful in preventing cardiovascular diseases, a newer area of concern is the prevention of neurodegenerative diseases: conditions such as Parkinson's disease and Alzheimer's disease, as well as stroke (which is also in the category of cardiovascular disease). Antioxidants evidently play a role in protecting neurons; a few specific herbs and their active ingredients have been identified as particularly of value and will be discussed here. Antioxidants are not the only active compounds; substances that may stimulate or sedate the nervous system and those that reduce inflammation also help. The methods suggested to protect against brain damage may seem surprising; for example, laboratory results indicate the possibility of protection from stroke from consumption of caffeine plus alcohol (dubbed "caffeinol"). Although no one is recommending cigarette smoking, nicotine evidently protects against Parkinson's disease, based on studies of people's tobacco using habits. Because clear evidence of protective effects in humans requires long-term administration of the substance and monitoring over a period of years to detect differences in incidence of neurodegenerative diseases, prospective clinical trials are lacking. The best evidence thus far is based on collecting data from large populations of people with or without a degenerative disease and comparing their history of using various substances. For many people, there are certain habits that are more-or-less consistent, such as drinking coffee or tea or alcoholic beverages, and eating certain types of foods (e.g., eating an apple a day); people that avoid certain foods and beverages are also well aware of their avoidance of them. Thus, some items can be relatively easily tracked. This data can then be used to seek correlations

between ingestion of substances and incidence of degenerative diseases, suggesting either protective or harmful effects. The rest of the work is done in laboratory animals. By using appropriate models, one can detect certain protective effects or, at least, a potential for protective effects with short-term studies. Alternatively, one can look for regenerative effects; the regrowth of dendrites, for example, is both a useful repair mechanism for severe damage and a means of repairing minor damage that occurs at the beginning of a degenerative disease process, delaying onset of symptoms. Part of the problem with these laboratory studies, however, is that the monitoring involves only models of human conditions, which may or may not successfully match actual human conditions. The studies may be done with animals or with isolated brain tissues. An example is a screening of herbs for ability to regenerate the neuronal network (1). Three active components of herbs were identified as potentially useful: panaxadiol (a group of ginsenosides) from ginseng, withanolides from ashwaganda (an Ayurvedic herb), and trigonelline from coffee beans. Ginseng and ashwaganda are logical choices for testing because these have been used for treatment and prevention of numerous diseases; coffee is an obvious choice because there is strong evidence from several population studies that it has potent neuroprotective effects. In the study, brain tissue taken from laboratory animals was atrophied by ß-amyloid, the substance that accumulates in the brains of Alzheimer's patients; then the herb extracts were added to see if dendrite formation could be detected. The compounds of interest were also tested in live mice that had an induced Alzheimer's-like disorder, using a memory test, suggesting that these natural substances were also useful in live animals. The three test substances may be of value for humans. One of the difficulties in translating such studies to clinical use has to do with the duration of treatment. The laboratory study involves creating a disease condition immediately and testing the effects of applying the herb components for a very short time. By contrast, the patient with a diagnosis of Alzheimer's disease had a gradual process of brain damage developing for years and will be treated for months or years. The question arises: does the therapeutic effect indicated by the laboratory experiments produce results in the human where there are some similarities but a different process of disease development? If these substances have a benefit for humans that is reflected in the laboratory studies, then moderate doses consumed regularly over years might be able to prevent or at least slow development of the disease; they might even benefit those who already have a neurological disease. The following are herbs that have multiple reports of potential benefits in neuroprotection and neurorepair. To help accurately present the type of research involved, for each one, at least two examples of recent medical journal abstracts (from 2001-2005) are included. The abstracts are found on the PubMed website (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi); statements of particular interest are in bold print, added for this report. The subjects to be covered are: coffee and tea; curry and curcumin; scute; salvia; ginseng; and others (with mention of licorice, forsythia, lonicera, fish oil, and the contribution of fitness).

COFFEE AND TEA Though many think of herbs as alternatives to coffee, this common beverage is also from an herb. There is clear evidence that Parkinson's disease occurs with much less frequency among regular coffee and tea drinkers than among those who avoid or minimize the beverage. An active constituent providing neuroprotection is the caffeine, though, as indicated above, trigonelline from coffee may also be effective. From the Department of Neurology, Singapore General Hospital, Singapore (2): INTRODUCTION: Few studies have examined the relationship of coffee and tea in Parkinson's disease (PD). The potential protective effect of coffee intake and risk of PD has not been studied in a Chinese population. There is a high prevalence of caffeine takers among Chinese in our population. OBJECTIVE: We undertook a case control study to examine the relationship between coffee and tea drinking, cigarette smoking, and other environmental factors and risk of PD among ethnic Chinese in our population. METHODS AND RESULTS: 300 PD and 500 population controls were initially screened. Two hundred case control pairs matched for age, gender, and race were finally included in the analysis. Univariate analysis revealed significant association of PD with coffee drinking (p Exiled Tibetan physician, Lobsang Dolma, 1976, California.

Potala Palace, 1986, Lhasa.

Tibetan medical staff at Mentseekang (hospital section, below), 1986 Lhasa.

Herbal Medicine Page from Traditional Tibetan Medical Text, 1986 Lhasa. May 2000

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MEDICINE IN THE TIBETAN REFUGEE COMMUNITY Statistics from the Drepung Gomang Monastery by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

In Karnataka State, southwestern India (see Figure 1), about 20,000 Tibetan refugees struggle to maintain their traditional culture in exile (see: Drepung Gomang; and From Tibet to India ) . They are confronted with extreme weather conditions (heat during the dry season and monsoons at other times), limited diet, crowded living conditions, and years of minimal access to medical care. One of the monastic settlements in Karnataka, the Drepung Gomang Buddhist Monastic University, built a medical center (Drepung Community Dispensary; see Figures 2 and 3) during 1998-1999. The project was inspired by an unfortunate event: one of the highly realized teachers at the University died suddenly, without there being any chance to save him by local medical interventions. Soon after it was built and consecrated, the dispensary was being fully utilized, with a staff of four (one medical doctor trained in Tibet, plus three assistants; see Figure 4) and a patient load of 150 per day. The dispensary mainly provides Western medicines (including IV drip when needed) and standard first aid procedures (e.g., wound dressings), but also provides Ayurvedic herbal remedies and Chinese style acupuncture therapy. Traditional Tibetan remedies may be recommended at the facility, but these are available at a separate clinic (a branch of the Tibetan Medicine and Astrology Institute of Dharamsala, with a patient load of about 30 per day) that is about a 15 minute walk from the Drepung Dispensary. The Drepung Community Dispensary primarily serves the 4,000 refugees of the Drepung Monastery (1,500 at Drepung Gomang and 2,500 at Drepung Loseling), which provides about 65% of the dispensary patients; a number of lay refugees and even some Indian workers who are doing construction projects in the Tibetan refugee area make up most of the remaining 35% of the patient load. There is one hospital in the refugee area run by the Tibetan Health Department (Doeguling Resettlement Hospital) which suffers from poor management and constant transfer of doctors from one settlement to another, and some of the other monastic organizations have very small dispensaries. Drepung has collected and reported data on the health problems commonly seen at the clinic (see Table 1) and the drugs that are most often prescribed to treat them (see Table 2). In the event that a disease condition is beyond what can be treated at the Drepung Dispensary, the patient is referred to a hospital in the nearby Indian city of Hubli (about 45 km from Drepung). Other efforts to promote the health of the monks at Drepung include: cultivating fruits and vegetables to enrich the diet (an irrigation system has been installed), presenting preventive health care recommendations to the community (an LCD projector was purchased to allow large groups to view information during the presentations), and expanding the range of remedies available for the Dispensary (including modern drugs and herbs). These projects are partially funded by an ITM research and education grant, by direct donations from interested persons (see the Appendix for information about other projects), and through the efforts of tour groups visiting the U.S. (where they provide demonstrations of sand mandala, spiritual theater, pujas, etc.; for a schedule, visit: www.gomangtour.org). Drepung Gomang Monastic University and its clinic may be reached at P.O. Tibetan Colony-581 411; District North Karnara, Karnataka State, India.

Table 1. Frequently Seen Disorders at the Drepung Dispensary

In this table, disorders have been categorized roughly into three groups: acute infections, chronic infections, and pain disorders. Under the heading typical causes, three major problems are to be noted: there are many hundreds of monks living in close quarters and using limited facilities (making it easier to transmit communicable diseases); there is limited hygiene (in that hot water, readily available clean water, and other sanitary facilities are limited); and there can easily be food and water contamination (due to the climate and the general lack of sanitation controls in the area). Disorder

Typical Causes

Therapies Commonly Used

Acute Infectious Diseases Bacterial infection of the eyes

poor immunity, limited hygiene, high density living quarters

gentamycin eye drops, norfloxacin eye drops

Common cold

high density living quarters

phenylpropanolamine (decongestant); ColdOff (proprietary combination)

Cough (bronchitis, sinus drainage due to sinusitis)

weather conditions, close living quarters

cough syrups (Ayurvedic or Western)

Fever (due to various infections)

bacterial infection

paracetamol (antipyretic), ampicillin, penicillin

Diarrhea, gastroenteritis, salmonellosis, dysentery

contamination of food and water supplies, limited food storage

loperamide (for symptoms), metronidazale, nalidixic acid

Hepatitis A (jaundice)

contamination of food and water supplies, limited hygiene

paracetamol, aspirin, vamex (for vomiting); Ayurvedic herbs for liver disorders

Fungal infections (e.g., ringworm)

climate, high density living quarters

qualiderm cream

Others: wound infections, bone/joint infections, mouth infections

limited hygiene

amoxicillin

Chronic Infections

Hepatitis (mainly hepatitis B)

endemic to the area; transmitted by limited hygiene

Ayurvedic herbal formulas

Gastric ulcer (mainly Helicobacter pylori)

weak immune functions, unknown exposure unseparazol, omeprazol, famotidine, factors antacids

Pain Knee pain, leg pain

strenuous work; sitting meditation, arthritis

ibuprofen, paracetamol, aspirin, omnigel cream, diclofenac

Table 2. Review of the Main Western Drugs and Their Uses Drug

General Use

Comments

Amoxicillin

Bacterial infection This is a modification of penicillin, commonly referred to as "broad-spectrum penicillin."

Ampicillin

Infection

This is a modification of penicillin.

Diclofenac

inflammation

This drug is used for treatment of arthritis; it is a non-steroidal antiinflammatory. The drug has a high profile of side effects and drug interactions, so its use is limited (can be used topically).

Famotidine

gastric acid reflux This drug inhibits esophageal irritation due to acid reflux, a condition commonly known as heart burn. The drug is sometimes better known by one of its brand names: Pepcid.

Gentamicin

bacterial infection This drug is not commonly used internally; usually saved for serious infections when other antibiotics fail. Useful topically for eye infections.

Ibuprofen

pain due to inflammation

This is a widely used antiinflammatory drug and pain reliever; it is sometimes known by one of its brand names: Motrin.

Loperamide

diarrhea

This drug reduces the symptom of diarrhea by reducing intestinal peristalsis. It is sometimes known by one of its brand names: Imodium.

Metronidazale

amoebic dysentery This drug inhibits amoebas and some anaerobic bacteria; it is often known by one of its brand names: Flagyl.

Nalidixic acid

bacterial infection Mainly used for urinary tract infections; may be adopted for use in intestinal infections (bacterial).

Norfloxacin

bacterial infection This drug is provided as an ophthalmic solution for eye infections.

Omeprazol

gastric acid excess This drug is used to inhibit excess production of gastric acid that can irritate gastric ulcers and contribute to acid reflux disease. It is sometimes known by one of its brand names: Prilosec.

Omnigel

analgesic ointment This is a topical preparation for inflammation, such as arthritis, with diclofenac, salicylate, and menthol.

Paracetamol (Acetaminophen)

pain, fever

Penicillin

bacterial infection This is a widely used antibacterial drug.

This drug is most widely known in America by the brand name Tylenol. It is elected over aspirin for those who have gastric ulcers or otherwise have sensitive stomachs.

Phenylpropanolamine decongestant

This is a widely used drug, referred to as PPA, that reduces nasal congestion. Recently, the U.S. FDA called for an end to its use as a result of reports of rare but serious cardiovascular complications from its use.

Qualiderm

A mixture of antibiotics: gentamicin (for bacteria), tolnaftate (the active ingredient in Tinactin for fungal infections); iodochlorohydroxyquin (antifungal and antibacterial), and the steroidal antiinflammatory betamethasone.

anti-infection cream

Table 3. Review of the Ayurvedic Formulas and Their Uses

Ayurvedic formulas were provided by Universal Medicaments (Nagpur, India) for the Drepung Community Dispensary. Formula

General Use

Comments

Chyawanprash

aids digestion and This is an herbal honey that contains 36 herbs, mainly Emblica officinalis, Pueraria tuberosa, respiratory system; Piper longum, Santalum album, and Elletaria cardamom. rejuvinative for the elderly

Herbokam

antistress agent; used for fatigue due to overwork and insomnia due to nervousness

Unicough

cough, asthmatic This is a syrup with 16 herbal ingredients, mainly Acacia catechu, Adhatoda zeylenica, Ruta breathing, difficult graveolens, licorice, and basil, with thymol and menthol. expectoration

This is provided in tablets and capsules and is comprised of 8 herbal ingredients, mainly Withania somnifera, Nardostachys jatamansi, Bacopa monierii, Evolvulus aisinoides, and Solanum nigrum.

Valiliv Forte

liver protectant in viral hepatitis

This is a syrup comprised of 10 herbs, mainly Eclipta alba, Terminalia arjuna, Emblica ribes, Crataeva nurvala, Solanum nigrum, and Fumaria parviflora.

APPENDIX: An American Seeing Through Tibetan Eyes by Chela Kunasz

Chela Kunasz, of Boulder, Colorado, has developed several projects to help Tibetan refugees in Karnataka, including Drepung Gomang (through Colorado Friends of Tibet-the Tibetan Settlements in India Project). This is her story; information on the other projects can be viewed on Chela's own web site (www.kunasz.com). Here, she describes the problem of bleeding ulcers, one of the main health problems for the refugees. Having been through a lot of pain with a spinal fusion surgery in 1982 and worried that I might lose the ability to walk or climb, even stairs. I jumped at the opportunity to travel to Tibet in the fall of 1983. I thought of it as a treat for myself, seeing the fabled Shangri-La-like Tibet, seeing the mountains, the colorful people, the legendary city of Lhasa, and perhaps learning a little about their religion that would help me deal with physical pain and uncertainties about my medical future. What I actually experienced that autumn of 1983 was more than the exquisite mountains, including Everest at rosy dawn and the fabled city. I encountered a people who had had their lives and land destroyed by the People's Liberation Army and had experienced oppression and torture originating from the Chinese Government in Beijing. With their forests plundered and overwhelmed by an influx of immigrants from the Chinese mainland who were given Tibetan land and opportunities, many of the native Tibetans still had a very special quality. I wrote in my dairy on the plane on my way home: "I have to begin to learn how to give, to give as the mountain people here gave to me, wholeheatedly, with joy, clarity, and without a calculator running in the back of my head." I somehow felt that a previously undetected burden had been lifted from my back, which had experienced so much pain, but that I did not understand the nature of the burden or the lifting. A lot happened in the next years, including my slowly starting an involvement with Tibetan refugees in southern India. I became particularly involved with a settlement named Doeguling near the Indian town of Mundgod, in Karnataka State, India. It is a so-called "protected area" which is home to 14,000 Tibetan refugees. A special permit from the India Government is required for a stay there by non-Indian citizens. When I first visited Doeguling in 1987, I was a guest and was given a great time; slowly, as I made more visits, I became a family member progressively shown their pain and suffering as well as their cheerful courage and humor. Over time, my friends and I have started 6 different projects with and for the Tibetans now living there. Together, we have projects with and for Tibetan women, including nuns at the Jangchup Choling Nunnery in Village #3 and for laywomen in the 9 villages of the settlement; projects with and for monks at the Drepung Gomang Monastery, and with and for laymen in the villages and the old people's home, the GenzoKhang. There is also aid specifically for children and young people, both through the Office of the Representative of His Holiness the Dalai Lama in Village #3 and the Drepung Gomang School Project. There are also several projects directly concerned with health issues. The Gungru Khangtsen Health Fund is a cooperative and democratically run health project which provides some funds for medical expenses for monks from Tibet who have no where else to turn. The project also is involved in health education, sanitation projects (such as providing more clean water, bathing areas, and dealing with dumps and sewage.) The local Doeguling Hospital is run by an amazing dynamo of a Tibetan who had polio as a child. This talented man has completely turned the hospital around. When I visited the Hospital in 1994, it had mold covering many walls and people were getting sick from the mold at the hospital. Waterfalls cascaded out of the walls during the monsoon! Almost nothing worked in terms of diagnostic equipment. Now there is a Tibetan dentist, a Tibetan lab technician, and other trained personnel, appropriate equipment, and a new TB wing. With so many major accomplishments it should not be held against the Hospital that I had the experience below. The above background sets the scene for the information below from my diary and memory of what happened and what I thought that day in Doeguling. October 27, 1997 "I can't believe that the local Hospital has not been telling people about the known origin and treatment for serious recurring, bleeding ulcers! They know and understand it themselves. I've learned today that perhaps half of the 14,000 people in this camp have this problem to some degree. For some of the worst cases it is also looking like they are more likely to develop stomach cancer after many recurrences of the ulcers. The Hospital employees told me that they don't tell people about the antibiotic cure because many of the people don't have the $30.00 needed for the 3-week course of 2 antibiotics involved in the treatment of the ulcers! Another reason is that the well meaning small clinics in the area keep giving out palliative Pepto-Bismol type treatments and giving the impression that if the hospital charges more for their treatment, the patients are being ripped off. So today, having worked with the Gungru Khangtsen monks as a start, I started a program to identify candidates with these terrible, long-term recurrent bleeding ulcers caused by the Helicobacter pylori bacteria in bad food and water, and to prepay the $30 out of my and perhaps others' pockets. The Tibetans and I began to work on how to make sure the complex instructions for taking the antibiotics are well explained, written down, and shared, as well as understood by others living with the patients so that the regimen would really be followed. When the Hospital saw that we might be able to turn things around, everyone there put a lot of effort into the project. It was an all-morning epic, sitting there in the heat in the local Doeguling Hospital, but those of us hoping for success were excited. By the end of the morning, the patients I was with just looked sick. It turned out that several had more than just ulcers, another thing my inexperienced mind had not considered. And they hadn't had the funds to get their other problems dealt with either. Earlier, some of the monks had shared with me the terrible scars and sores from skin diseases which Tibetan refugees seem to get after arriving in India. They do not have any resistance to a variety of unpleasant diseases which they did not have in high, colder Tibet. The local Indians do not seem to get these and the doctors don't know how to cure them. Often, after about six years of suffering from these problems, resistance comes and the problems diminish. But I was really shocked at

how much I did not know they were suffering when they raised their vests or robes and showed me the awful sores on their chests and legs. It seemed a metaphor for how we so often just see the surface and don't know the suffering which does not show. Others had more ordinary skin problems, some from lack of a change of clothes or access to clean water in which to do laundry and bathe. So later I met with them and we made plans for more shower areas, among other plans. I'd also like to find a doctor who could identify the strange skin problem the Tibetans get, but local doctors can't understand. When another refugee monk had talked to me about his heart problems and high blood pressure, I had asked about diet. It seems so easy in our more comfortable communities here in Boulder, to say "Be careful about your diet." If you are given a bowl of food, with salt and a lot of oily bread, you have the option of not eating it or eating it. And then there is the water. Today, seeing the ravages of bad water, I think I've never been so grateful for just plain drinkable water! And today, I again reflected on my own difficulties with diet and digestion after the morphine and codeine I was given during and after my surgeries. I feel so lucky about my options. I also still feel the suffering of those I met and the quiet grace with which they are carrying on their lives as best they can. Since knowing and working with these brave and courageous people who have lost their Land of the Snows, many of their relatives, and their health, my own story has lost its primacy and when I'm having a hard day, I remember the glowing quality some of these people have, the help they are giving each other, and the smiles and gratitude of all who have had their health restored. I myself was so lucky to be healed by these dear friends today." October 29, 1997 "Today, I visited the Jangchup Choling Nunnery again. I spent some time with a number of the women there and I talked to them about the same issues I discussed with the group of monks. I gave one of the nuns I met, who has a long-term recurring ulcer problem, a letter which she will be able to take to the Hospital for a treatment. One of my friends also staying and working here in the settlement this month has donated some more funds, so we can start treatments at both the monastery and nunnery in a somewhat controlled environment. Later, if we see how this works and we develop some experience and work out any kinks, I definitely want to broaden this to the rest of the Village people. Since I've tried and failed to get the long-expiration date Amoxicillin and Metronidazole which I need for this (the Omneprazole is not so expensive), I'm still concerned about the best way to proceed after we get this program going in a small way. Some day, I hope we can find a way to get these antibiotics with at least a year to go before expiration. Then I think we might be able to get this shipped to Doeguling through an organization such as Direct Relief International. For now, I'm just hopeful that this project could begin to help reduce this unnecessary suffering for so many people."

December 2000



Figure 1: Map of India showing Karnataka State.

Figure 2: Exterior of Drepung Dispensary.

Figure 3: Interior office of Drepung Dispensary.

Figure 4: Drepung Dispensary staff.



Figure 5: Drepung Director reading acknowledgments to the donors.

Figure 6: One of the Tibetan doctors at Drepung.

Figure 7: A monk receiving an inoculation.

Figure 8: A doctor performing traditional pulse diagnosis.

Figure 9:The cutting of the ribbon, officially opening Drepung Gomang.

DREPUNG GOMANG by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Introduction ITM has developed a close working relationship with one of several Tibetan refugee camps in southern India called Drepung Gomang. In 1999, Drepung completed construction of a medical clinic on their land, made possible by support from ITM. The clinic, headed by a doctor trained in Tibet, will provide Tibetan, Chinese, Ayurvedic, and Western medicine. Their ability to provide different methods of health care depends, in part, on the availability of medicines and equipment, which is still limited. One of the important determinants to residents’ health at these refugee camps is basic living conditions. The refugees, most of whom are Buddhist monks escaping life-threatening repression in Tibet, suffer from exposure to severe weather conditions (especially monsoon rains and intense sun), lack of adequate food, deficiencies in basic medical care (with little of the medicines we take for granted), crowding, and lack of fresh water (no plumbing, limited water supply). These problems are being partially remedied by donations from Western nations, mainly the U.S. From July 1999 through February 2000, ten monks from Drepung toured the U.S. to raise funds, ending with a performance at Carnegie Hall in New York City on the Tibetan New Year. During seven months time, with the help of a large donation from the Dalai Lama (who was also touring the country for this purpose), the monks were able to raise about $100/resident at Drepung Gomang. Most of these funds are intended to help construct a new assembly hall so that the group can meet indoors on a regular basis. Their current assembly hall can hold only about half of the current camp population, having been built 25 years ago when there were far fewer residents and when no one could have predicted their numbers would swell to the current level. Following are more details about this group and the efforts being made to assist them. History of Drepung in Tibet and India Drepung Monastery was founded in 1416 A.D., as a Buddhist educational institution. Its founder was Jamyang Choje, a close disciple of the revered Je Tson Khapa. This was the largest monastery in Tibet, initially with two colleges (dratsang), of which Gomang was one. It is of the Gelugpa sect of Buddhism, which is the lineage of the Dalai Lama. At its zenith, before the invasion of Tibet by Chinese communist forces, Drepung had nearly 8,000 monks, and the Gomang, the largest of its four colleges, had 3,300 monks who had come from all over Tibet, as well as from Mongolia and Russia. Gomang produced many eminent scholars, philosophers, and mystics—known throughout Tibet and its neighboring countries—who have maintained the spirit of Buddha’s wisdom and message of inner peace, compassion, and non-violence. When Chinese communist forces took full control of Tibet in 1959, a small band of 160 monks from Gomang were able to flee to India. Many of those who remained in Tibet were killed during the decade of terror that China imposed on Tibet, while others were forced into hiding or to reject, at least outwardly, their true faith. All the dozens of buildings (except the large central prayer hall) of the great and ancient monastery were destroyed. The prayer hall itself was used by the Chinese for storage of grain, damaging the fine artworks that lined the walls. The refugees endeavored to create a Tibetan environment in India in which to preserve and maintain their rich cultural identity and precious religious practices, while in Tibet, the communist soldiers attempted to erase both the Tibetan culture and religion. The refugees, poor and without assistance, were forced to labor at road construction in Chamba and other sites in northern India in order to feed themselves and the children in their care. Both the Tibetan Government in Exile and the Indian Government planned to establish a center for preservation of Tibetan culture and religion in Buxa in North India. Unfortunately, due to the limited rations of food, the adverse climate, and the poverty of the refugees, many failed to survive. Of the original group from Gomang, only about 60 remained and they were joined by about 30 new refugees to form a small community. The Indian Government and Tibetan Government in Exile decided to move the refugees to an area where they could practice farming and where they would be away from the border, where the tension between China and India (over the Tibetan issue) was worsening. They moved to southern India, where Drepung Gomang Dratsang was established at its current site near the town of Mundgod in Karnataka State. Other Tibetan colonies were also relocated to southern India; there are now about 15,000 Tibetan refugees in Karnataka at 2 monastic camps, including Drepung Gomang, and 9 other camps. They are located about 45 km (30 miles) from the closest major town, Hubli. When the college was established in southern India in 1969, its members were allotted three years of rations, after which they were to become self-sufficient. In 1970 they were given 40 acres on which to construct living and working quarters, with the rest being used to cultivate essential crops in order to support about 100 monks and children. At first, the colony suffered from lack of sufficient members. There were the elder monks, but no disciples to whom the teachings and cultural practices could be passed on. However, about 200 young Tibetan refugees soon joined the monastery. After that, a steadily increasing stream of refugees swelled the college population to its current level of 1,400—far too many for the facilities. About 150 more monks escape from Tibet to Gomang each year. In the Tibetan tradition, the place of one’s birth determines which of the several monasteries one will join. Accordingly, the monks at Gomang have come from Domay (eastern Tibet), U-tsang (central Tibet), and Dhotoe (southeastern Tibet). There are also 55 monks from Mongolia and Russian-occupied Mongolia, and a few from Russia. Both Mongolia and areas of Russia adjacent to Tibet and Mongolia have long participated in the Tibetan Buddhist traditions. Each day, 6 days per week (for all but 6 weeks of the year), students at Drepung spend 1 hour in memorization of the classics and 2 hours of debate in the morning, then 3 hours of classroom studies followed by 2 hours of debate in the afternoon. Debating, the main method of acquiring proficiency in the Buddha’s teachings and becoming aware of their full implications, is continued in the evening. Here is a description provided by Gomang: Debate is carried out with the monk sitting on the ground, with his knowledge and wisdom held like shields against the onslaught of his opponent who stands above him, stamping, shouting, firing volley after volley of questions and wit in an effort to find chinks in his spiritual armor and crack his defense. He slams his palms together directing bolts of energy at his

quarry. When the defense fails, the attacker lets out a great victory cry: “T’sa.” The debate is a testing ground for wellstudied monks who have understood the increasingly profound points of Buddhist philosophy learned in the classroom and practiced hour by hour. The debating practice is stimulating and enjoyed: sometimes the monks are still shouting at each other when the breakfast bells are rung at 6:00 in the morning. The children at Gomang study basic education—including mathematics, English, and social sciences—in a small 4-room school. About 200 of Gomang’s monks are under the age of 18, many of them orphans. The college also helps to maintain the traditional Tibetan arts at its Arts and Crafts Center, created in 1992 at the suggestion of the Dalai Lama and headed by Alak Rigda, born in Amdo, Tibet in 1925 (he left Tibet for India in 1955 to continue his Buddhist studies, but was unable to return to Tibet due to the Chinese invasion). The center teaches tangka painting, wood carving, tailoring, and embroidering. The monastery still has only 40 acres of land, part of it used for cultivation (mainly rice, cotton, and sometimes corn). The harvest is only enough to supply about half the monks and there is no more assistance from the Indian government. About half of the land occupied by the Tibetan camps is without any irrigation and subject to drought; Drepung Gomang, being at the end of the water transfer system, has no irrigation. A few years ago, a major drought devastated the crops and brought the center to the limits of subsistence. Recurrent droughts require the Tibetans to spend their limited funds on purchasing food that would otherwise be grown. ITM has contacted an organization called Sahayoga that specializes in irrigation work and has its main offices in Bangalore, about three hours drive from the Tibetan camps. Sahayoga is now working to provide an effective irrigation system for Drepung Gomang as well as for a group of neighboring camps (see following report by Bhavanishankar Bankipur). The Tibetan Government in Exile provides small amounts of subsidies for the Tibetan refugees who are between the age of 16 and 24. The original subsidies of 50 rupees (about U.S. $1.50) per month proved inadequate, so these were raised to 80 rupees per month. However, with the growth in the number of refugees, the amount is likely to be reduced back to 50 rupees, and there is some concern that it will be canceled altogether due to lack of funds. The Drepung facilities, constructed to serve a few dozen monks in 1970, are now in disrepair and far too small for the numerous members. There is little money available for repairs or for new construction except by donations. The last building projects were a small hostel and some small room additions to older hostels for arriving monks, and construction of an expanded debate grounds (still, the open courtyard must be abandoned at times because of monsoon or intense summer sun, as covering has not been built as yet). The monastery has developed plans for building the necessary new facilities, including a small school, living quarters, and assembly hall. The leaders are hoping, one day, to add at least 10 acres of land for farming, so as to become more self-sufficient. Single donations, or monthly support, would be most welcomed by the college. Funds can be given for general support or earmarked for specific applications, such as school, living quarters, medicine, food, etc. Donations can be given by check or money order to: Drepung Gomang, Lama Camp No. 2 P.O. Tibetan Colony District North Kanara - 581411 Karnataka State, India

IRRIGATION PROJECT FOR DREPUNG GOMANG report by Bhavanishankar Benkipur, Director, Sahayoga, Bangalore, India

On 29th November, 1999, our Secretary (R. Doraiswamy), Treasurer (Dr. Somashekar Reddy), and myself visited Drepung Gomang, traveling to Hubli by overnight train. Migmar Tsering (Gomang’s Secretary) and his associates received us at the station and took us to Drepung Gomang. We were well received and had excellent hospitality and were treated very well. We were highly impressed by the traditional Tibetan hospitality. Migmar and his associate took us around the fields that need irrigation facilities. We had a close look at the entire stretch. It appears there is a great potential to boost agricultural production. The field areas lie along the roadside for about one kilometer, close to the Monastery. It is gently sloping to one side in the upland near the monastery, and gradually sloping along the road, with a well defined valley commencing from about the last one-third of its length. At the end of the land near a flowing nala [small stream], and within the Gomang’s land, we can have a small farm pond to collect the drainage waters of the entire field after irrigation. This collected water could be recycled and also used as a recreation and aquaculture lake. Just below the pond at the toe of the earthen barrier we can have a deep tube well at a depth of 300 ft or so. As there is a flowing natural nala close by and being at a depression, it is felt we can have a capacity of 2–3 cusecs discharge for irrigation. The surface aquifer appears to be salty and we can tap a deeper aquifer which will give sweet water for crops and also for drinking purposes. From the tube well, a main line can be taken along the road up to the higher ground close to the administrative complex of the monastery and within the fenced area of the fields. This can have valves at intervals to irrigate the paddy fields at the lower half of the total land. The rising main can lead to a surface storage tank of masonry, located at the highest point. From here we can have a piped supply with filters to develop a microsprinkler irrigation system above the ground level to irrigate horticulture and vegetable crops in about one-third the area (about 10 acres out of about 35 acres under crops; the other 5 acres are occupied by monastery buildings and for other purposes). In all, about 25 acres can be developed for paddy, maize, jowar, and pulses, with 10 acres for cash crops, like orchards, vegetables, and fodder for the cattle, etc. There is a very promising future to develop this land into a model self-sustaining farm and also make surplus to earn revenue. On a rough estimate about 25,000 US dollars may be needed to install a tube well of 2–3 cusecs discharge with submersible pump, main line, laterals, alfalfa valves, microsprinkler systems with filters above the ground for orchard crops, a masonry or concrete storage tank at the highest point to provide adequate storage for balancing and to overcome disruptions in power supply. In the farm land we can have a biomass plant to provide an alternate source of energy in the event of short supplies from the existing lines. We have expertise in agriculture and will provide a package of practices to optimize the production: matching the crops with both the the soil and agroclimatic conditions prevailing there. I have explained details to Migmar Tsering and the Administrator of Drepung. On working out details, the cost could vary, plus or minus. I will try to meet with representatives of some well-known sources who can supply the equipment at least costs with concessions to the refugee camps and try to minimize costs to the extent possible. Apart from this monastery, there are lands of other Tibetan settlements close by and, put together, it will make a sizable project needing minor gravity-irrigation facilities. Though the land of Drepung is in the command of an existing small tank of the irrigation department, being at the tail end, it does not get any water, as all of it is consumed at the upper stretches by the local cultivators. If we consider the total land of all the settlements, we can think of another minor tank, as there are hills close by, and put pressure on the State and Central Government to build an irrigation tank. This will, of course, be a long range plan. Immediately in the short range, the tube well irrigation (as explained earlier) is the best solution to boost up production. The settlements have no sewage disposal arrangements, though there is potable water supply. They need to have one, as untreated sewage left on the ground is polluting the ground waters and also hazardous to the health of the people there. Sahayoga can supervise and act as consultants in the implementation of the projects. We will also arrange with experienced agencies to implement and train the inhabitants locally to maintain and run the facilities. In December, I talked with other agencies about the bigger gravitation-flow irrigation for the entire colony area. This would be accomplished through the construction of two more tanks suitably located in the hillocks nearby, so as to augment supplies to the existing tank to extend irrigation water to all the Tibetan villages, including the other local villages and improving the existing canal system which is in a defunct state. This bigger project will also supply drinking water to Mundgod Town and other villages enroute. Thus, Municipal Council of Mundgod and village Panchayats also can participate in the project by providing partial funds. The Principal Secretary is very much excited about this new concept of participatory water resource development and management and will take up with the Minister concerned in the government for governmental support and assistance. Funds to support Sahayog may be sent to: Sahayog, c/o R. Doraiswamy No. 72, 7th Cross Chikkathayappa Street, Vasanthanagar Bangalore 42, India.

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Update on Drepung Gomang Community Dispensary by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Drepung Gomang Monastery is a Tibetan exile community in southern India, near the city of Hubli. It is one of several such refugee camps in this area that was set aside by the Indian government. There are more than 1,700 monks at the Drepung Gomang site studying Buddhist philosophy in a rigorous program. Most of the monks are from Tibet. They left their homeland, risking their lives in crossing the dangerous border, for better opportunities to study and practice their religion, and to be able to have contact with and get blessing from His Holiness the Dalai Lama. In Tibet, religion is suppressed, the monasteries have been destroyed or are in disrepair, and there is no access to the Dalai Lama or the rest of the Tibetan Buddhist leadership. With generous funds and assistance from its friends around the world, the monastery has been able to survive during the past 35 years. In 1999, with a special fund from ITM, Drepung completed construction of a medical clinic (dispensary) on their land to provide medical assistance to the monks, as well as for Tibetan lay people who are living in the community and Indians in nearby villages. The clinic is a 3,000-square-foot structure that is open daily to the public from 7 A.M. to 6 P.M. (except Mondays). There are 11 rooms, including a large room with beds for patients, a doctor's office, medicine counter and store room, dressing room, small lab, small staff office, a room for a visiting doctor with bathroom attached, and a toilet for patients' use.

The chief physician, Dr. Sherab Gyatso, from Tibet, has formal training in Tibetan medicine; he resides at the Dispensary and is always there if he is needed. Dr. Sherab performs Tibetan acupuncture and prescribes Tibetan herbal medicines as well as Western pharmaceutical medicines. The Western medicines are on hand at the dispensary, but to obtain the Tibetan medicines, the patients have to go to the local Mentsekhang (the settlement's Tibetan Hospital) to purchase them. It is only 10 minute walk to reach there. There are six staff members working with him. All the staff members are monk volunteers of the monastery who have dedicated their lives to serving the poor and needy. Most of the monks don't have any formal medical education. However, one of the staff members, Venerable Tashi Dorjee, has taken part in many health workshops and is able to provide professional help. Also, a monk who works in the laboratory is trained to check sputum for the diagnosis of tuberculosis, to test blood type, and to perform other basic laboratory analyses. He received formal training at the Settlement Hospital. The clinic offers basic diagnostic services, acupuncture, and dispensing of medicines, mainly Western medicines, though also a few Ayurvedic formulations (from Universal Medicaments of Nagpur) are provided. Certain ailments are especially common: stomach ulcer, diarrhea, fever, severe chills, pain, jaundice, high blood pressure, and diabetes. The five most-commonly prescribed medicines at the dispensary are: acetaminophen (for fever and pain); omeprazole (for gastric ulcer); ciprofloxin and Amoxillin (for infection); and Cetirizine (for allergies). Additionally, various common cold tablets and cough syrups are frequently utilized. No surgical procedures are carried out at the dispensary; all surgical cases are referred to hospitals. Similarly, patients with serious medical problems may avail themselves of services from either the Tibetan Hospital in the Tibetan Settlement or from the Indian hospital located in nearby city of Hubli or the one in the larger city of Bangalore. Using funds set aside specifically for this purpose, 70% of the hospital bills incurred by the Drepung Gomang monks are refunded upon submission of a verifiable copy of the medical invoice. Medical consultations at the dispensary are free and the charges for medicines are minimal. There are about 125 visits to the dispensary each day (750 visits per week; sometimes more when seasonal workers are present or when visiting doctors are available). The continuance of this medical care is dependent entirely upon the generosity of donors. Other than above services, Drepung Gomang Dispensary has been inviting Indian doctors (e.g., child specialists, dermatologists, optometrists, internal medicine physicians, etc.) to the dispensary to provide special check-ups twice a month. The response to this offer has been encouraging. Since the consultation is free, many people from all walks of life come to the dispensary for these check ups. On the occasion of big religious gatherings such as Kalachakra (special teachings of His Holiness), the dispensary staff have been able to set up a small clinic, giving free consultation and medical assistance. This was done, for example, during Kalachakra 2002 and also during His Holiness' teachings at Mundgod, a nearby town. The annual budget for the dispensary is about $35,000 (U.S.), a cost of about $1/patient visit (including part of the cost of the medicines and contributions to care at other facilities), of which only about 2/3 of the necessary funds are currently available, the rest is a deficit that needs to be made up from additional donations.

Funds from foreign donors are also used for many other projects at Drepung Gomang, such as a tree plantation project (to provide food, such as mango), running a community kitchen, maintenance of a hostel for newly arrived and visiting monks, purchase of a new tractor, and general welfare of monks. With the continuing increase in the population of monks, the limited funds are adjusted to try and meet the basic needs of every aspect of the monastery. This monastery is the only one in the area that has constructed community latrines (toilets) and bathing facilities for monks and for lay people who visit the monastery. Monks throng to the bath place where water for the bath is supplied from a tap from 2:30-4:30 P.M. Such basic services as the dispensary and bathing facilities are critical to the welfare of the residents.

Dispensary entrance

Monks waiting for services

Note: special thanks to Migmar Tsering, Secretary at Drepung Gomang for the report on which this was based. For more information and photos, see: www.gomang.org.

January 2004





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Pien Ch'iao (Bian Que; ca. 500 B.C.)

Tsang Kung (Cang Gong; ca. 200 B.C.)

Wang Shu-Ho (Wang Shuhe; 180-270 A.D.)

Huang Fu (Huangfu Mi; 214-282 A.D.)

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Sun Ssu-mo (Sun Simiao; 581-682 A.D.)

Chang Chung Ching (Zhang Zhongjing; 150-219 A.D.)

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T'ao Hung-Ching (Tao Hongjing; 452-536 A.D.)

281-341 A.D.)

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Wang K'en T'ang (Wang Kentang; 1549-1613 A.D.)

Wu Yu-Hsing (Wang Youxing; 1582-1652 A.D.)

Wang Chin Ren (Wang Qingren; 1768-1831 A.D.)

Wu Shang Sian (Wu Shangxian; 1806-1886 A.D.)

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This site is devoted to Christian theology of the body for subjects other than those that were the focus of John Paul II's series of talks titled Theology of the Body that dealt with sexuality and marriage (see valuable links to that topic, lower left). There are other important subjects related to the body, including those listed to the left, which are presented in articles posted here and through links to other articles. At the heart of this site is the matter of health, sickness, and healing. Among the primary tenets to be described in relation to healing are: Prayer is a central focus of healing. Prayer, an expression of faith, is a means of healing presented in the Gospels. Prayer does not replace medical help, and there is no conflict between prayer and medical therapy. Turning to prayer as a last resort, when medical therapies have failed, misses the value of prayer in healing; it serves as an integral part of healing. We are commanded to help heal others. This does not mean that everyone needs to become a medical practitioner, though being a physician is a noble profession which may be likened to a religious vocation. There are many ways to help others in healing aside from technical medical interventions. Self-help, although of a distinct value, should not be the primary center of attention in the concept of healing. We are to maintain the health of our bodies in order to serve others. Living in a healthy way can be a model for all. Health is a goal, but is not the only satisfactory condition in life; suffering and debility can be seen as having their own value. Effective health maintenance is important for reducing waste of medical resources better reserved for treating unavoidable sickness and injury.

Vatican texts, especially the writings of John Paul II and Benedict XVI, will form a central reference point for several of the presentations. "Do you not know that your body is a temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore honor God with your body." -1 Corinthians 6:19-20 translation | exegesis | styles | author | contact *The icons at the top of this home page are available from Monastery Icons: http://www.monasteryicons.com/

May the content of this site help the process of unification of the Christian Church, particularly towards the goal expressed by Pope Benedict XVI when he said: "I ask you all to set out with determination on the path of that spiritual ecumenism which, through prayer, opens the doors to the Holy Spirit, who alone can create unity." at Bari, Italy; May 29, 2005

JAPANESE ACUPUNCTURE: Blind Acupuncturists, Insertion Tubes, Abdominal Diagnosis, and the Benten Goddess by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The development of acupuncture in Japan, with its unique style we recognize today, has been attributed to Waichi Sugiyama, who is known as the "blind acupuncturist." Born into a samurai family in 1610, he went blind at an early age. For the blind in Japan, the primary jobs available were acupuncturist, moxibustionist, or massage therapist. He chose to be an acupuncturist. At eighteen, he left the country home of his well-to-do parents and traveled to Edo (now called Tokyo), where he met his first teacher, a sighted acupuncturist named Takuichi Yamase. But, his skill did not progress as he had hoped. After five years under his tutelage, Takuichi threw Waichi out, saying his pitiful techniques would forever keep him from being an accomplished acupuncturist. Heartbroken, Waichi began the long journey home, but halfway there, he collapsed from exhaustion in the town of a famous doctor. As fate would have it, this doctor had been Takuichi's mentor and, after regaining his health, Waichi got another stab at being a disciple of an acupuncturist. With practice, Waichi's needling skills progressed, but, even after a few years of dedication, he still wasn't good enough to practice on others. Desperate for help, he traveled to Enoshima, a small islet about 30 miles from Edo, to pray to Benten for better skill. Benten is the only female deity among the seven Japanese gods of good fortune. She is goddess of language and literature, love and wisdom, music, and the sea. Benten was originally a Hindu goddess (Sarasvati in Sanskrit) later adopted by Buddhists in India. She was enshrined in Japan by the Shogun Yoitmo Minamoto (1147-1199) in support of Buddhism. The Benten figures are usually placed near water's edge to serve as a guardian deity of sea voyages. The Benten enshrined at Enoshima was reputed for her ability to fulfill the wishes of worshippers, but access to the cave with her statue was restricted to special visitors. In 1600, the Shogun Ieyasu Tokugawa (1542-1616) visited the Enoshima Benten and made the site an official prayer hall for the Tokugawa family, which spurred the faith in Benten. In 1603, the temple/shrine complex was opened to the public. It is now a Shinto shrine. Waichi stayed at the shrine, fasting and praying in the cave for three weeks. At the story goes, when he came out of the cave after the fast, he stumbled over a stone (see Figure 1). As he fell to the ground, a pine-tree needle stuck deep into his leg. Cursing, he picked it up, and, as he did, he realized that it was sticking out from a reed of bamboo. Inspiration struck: for the acupuncturists, it is a critically important to stick the needle straight down and attain the proper depth: this pine needle in its bamboo cradle had done just that. Upon his return, he began using a small pipe to help guide the acupuncture needle vertically to pierce the patient's skin. That bamboo reed became the basis for a device known as a kudabari¾ a needle insertion guide tube that is now standard equipment for both blind and sighted acupuncturists worldwide. Waichi's innovation made him a successful acupuncturist; he is credited with having developed 100 acupuncture techniques. Waichi's skill was proven when his acupuncture skill cured Shogun Tsunayoshi Tokugawa (1646-1709) of a serious illness. As an expression of gratitude, the Shogun retained him as his personal physician, conferred the title of Kengyo, the highest official title given to the blind, and he gave Waichi a chunk of land, which became the home to Shinji Koushujo, Edo's first organized school for the blind. In appreciation of his success, Waichi donated a three-story-pagoda in the name of Benten (which was, unfortunately, removed after the Meiji Restoration) and he had 47 mileposts built between Enoshima and Fujisawa, of which 11 are still in existence. He visited Enoshima so often to worship Benten that he was not always available when Shogun Tsunayoshi needed him. To keep Waichi nearby, the Shogun erected a mini-temple sacred to Benten in Waichi's residence. By the time of his death in 1694, at the age of 84, Waichi had established 45 acupuncture schools for the blind throughout Japan. By having books read to him, he studied and then simplified volumes of ancient medical texts, making a substantial body of knowledge available to the blind on a practical level. The stone Waichi had tripped over at the Benten shrine became known as the "Stone of Good Luck." The Benten statue, to which Waichi prayed, was damaged after being set aside during an anti-Buddhist phase of the Meiji Restoration, and has been reconstructed and is available for viewing at Enoshima, though it serves as a museum piece rather than a sacred artwork due to failure of the reconstruction to match the original.

WAICHI SUGIYAMA AND ABDOMINAL DIAGNOSIS

Waichi Sugiyama, in his teachings, made a significant contribution to the theoretical basis of abdominal diagnosis and influenced the practical method of carrying out the diagnosis. In particular, he relied on study of the Nan Jing to develop a five-element abdominal pattern for detecting imbalances. This pattern involved having the fire element (heart/small intestine) evaluated at the upper part of the abdomen; the water element (kidney/bladder) at the lower part of the abdomen; the wood element (liver/gallbladder) at the left part of the abdomen; the metal element (lung/large intestine) at the right part of the abdomen, and the earth element (spleen/stomach) at the center (see Appendix 1). To perform the diagnosis, he recommended using the palm and finger tips of the left hand to gently touch and palpate the skin surface. There is no deep pressure exerted. The diagnosis proceeds from the center to the left and right, and then from the top to the bottom of the abdomen. Abdominal diagnosis would replace, for the blind, the observational diagnosis of traditional Chinese medicine, such as appearance of the tongue and complexion. Among the features to be felt on the abdomen were temperature variations, tightness or looseness of the skin, tension of the muscles, pain or tensing on light pressure, fluid movements (as occur in the intestines) during palpation, sensation of movement across an abdominal region, and any lumps or swellings. Soon after Waichi's death, an herb doctor, Todo Yoshimasu (1702-1773; see Figure 2), also gave a substantial boost to the use of abdominal diagnosis. He developed the concept of conformations-symptom/sign complexes-that were to be associated with each of the essential traditional formulas. He assigned the herb formulas to certain diagnostic indicators found by gently palpating the abdomen. Thus, both acupuncture and herb therapy became tied intimately to the abdominal diagnostic method that thereafter dominated the Japanese system for both the blind and sighted acupuncturists.

THE LEGACY OF WAICHI SUGIYAMA

The guide tube approach to needling allowed for thinner needles to be used. This suited the blind acupuncturists who had to be especially careful about using large needles and deep insertion without being able to see the body. In the modern era, Japan is especially known for its use of very thin needles. However, the shift to the finer needles and the tendency to use these with ever more shallow insertion and little or no stimulus, has led some to remove themselves from any connection to physical reality and to corrupt the acupuncture field with therapies that offer no more than the equivalent of a placebo effect (see Appendix 2). Unfortunately, when Waichi passed away, funding of the acupuncture schools for the blind dried up, and within a couple of decades, all of Sugiyama's schools were forced to close. Blind acupuncture managed to survive as relatively minor profession during the next 180 years, a time when Western medicine was beginning to supplant traditional Japanese medicine. Then, in 1876, the first new private school for the blind (Rakuzen-Kai) was founded, and spawned the modern era of blind education. Within 20 years, three more private schools were providing training for blind acupuncturists and the field opened up again. Blind acupuncture is a nationally recognized practice in Japan today. Currently, 30 percent of the roughly 90,000 licensed acupuncturists in Japan are blind. These practitioners work among the sighted practitioners at clinics and hospitals, or carry out private practices, and pass on their skills to others like themselves in special schools for the blind. They hold the same licenses, earn the same wages, and charge the same fees as the sighted acupuncturists. There is a national association for blind acupuncturists (Zenshinshikai) to deal with their unique situation. Blake More of Point Arena, California, interviewed blind Japanese acupuncturists and published his report in the 1995 article Acupuncture’s Blind Side, which appeared in the magazine Time Out, published in Tokyo (for the complete are article, visit http://www.snakelyone.com/BLIND.htm). Information from that article is relayed here, with supplemental information from the schools mentioned. Tomoyuki Hoshiyama is a blind acupuncturist who teaches at the Hiratsuka School for the Blind (founded in 1910; it offers kindergarten through high school classes to about 100 students) in Hiratsuka City, south of Tokyo. Hoshiyama began studying acupuncture when he was 19, needling his parents for homework in order to perfect his technique; a sacrifice he describes as "painful for them, difficult for me." He says he went into teaching five years ago because he wanted to help other blind people make positive contributions to society. Hoshiyama's wife of two months, Yoko, also teaches acupuncture to blind students. For the last 11 years, she has been working at her famous alma mater, the School for the Blind at Tsukuba University in Tokyo. One of 14 acupuncture teachers instructing 50 students, Yoko says she got into acupuncture for the same reason most blind people do: necessity. "But then, while I was in the clinical aspect of my studies, I began to understand the benefits of acupuncture. As I watched people experiencing good results, I decided that I wanted to study harder and improve my technique so I could offer even more." Although satisfied with their jobs, both Yoko and Hoshiyama express frustration over the fact that, like others who went to blind schools all their lives, they chose acupuncture more because it was the thing to do rather than because it was their life-long dream. Explains Yoko, "As blind people, we have few occupations available to us, so almost all blind students think about acupuncture at one time or another, particularly if they hope to be productive members of society. Even today, the only proven avenues we have are acupuncture, massage, and music." At the Osaka Prefectural School for the Blind, the course offering notes that: "According to the traditional culture in Japan, almost all of visually impaired persons have gotten a job doing massage, acupuncture, and moxibustion. But, we have three departments to get newer occupations, which are physical therapy, music, and computer science." The courses are offered after graduation from high school. The majority of Japan's 69 schools for the blind are almost entirely funded by government sources, that is, they are public schools rather than private. About 600 people like Hoshiyama and Yoko-300 of whom are fully blind-teach acupuncture to visually impaired students in Japan. After graduating from high school and before going on to acupuncture school, students must pass an entrance test just as any sighted student would. Explains Hoshiyama, "Since we all take the same national licensing examination, our acupuncture department offers what sighted universities and colleges do. The main difference is that we use Braille and learn on a special practice model with raised acu-points." But there are some professional limitations: blind acupuncturists can't practice in major hospitals. Among the leading blind acupuncturists is 85-year-old Kodo Fukushima, known as the "godfather" of contemporary meridian therapy and the force behind the enormous Toyo Hari I Teaching Center in Tokyo. His personality is almost as famous as his acupuncture, and he is described as charismatic, dogmatic, charming, and difficult. The 76-year-old Katsuke Serizaw, a near-blind medical doctor and acupuncturist, is another famous personality. He has written numerous acupuncture books for the blind-some of which are available in English-and has upgraded the overall quality of Japan's blind education system. Some blind acupuncturists from Japan have visited the U.S. to share their knowledge. For example, Five Branches Institute in Santa Cruz, California offered a seminar by Anryu Iwashina, from Morioka City. He graduated from the Tokyo National School for the Blind with a degree in acupuncture more than 20 years ago, and trained with Kodo Kukushima at the Tokyo Hari Medical Association. He has traveled to the United States several times since 1988 to offer free acupuncture treatments to the Hopi and Dine people, and to assist at several Sundance ceremonies.

APPENDIX 1: Abdominal Diagnosis in the Nan Jing

The Nan Jing (Classic of Difficult Issues) was compiled around the end of the Han Dynasty (ca. 200 A.D.). It is comprised of 81 issues or questions that are concerns arising from the study of the Nei Jing (Inner Classic) that had been compiled during the early Han Dynasty (ca. 100 B.C.). A large portion of the book is devoted to the five elements depiction of disease causation (especially seasonal influences), the associated internal organs (zangfu; see Figure 3), the disease indicators (such as pulse forms), and the use of acupuncture. As is the case with the Nei Jing, herbal medicine is not a concern. An English translation of the Nan Jing, along with commentaries from well-known Chinese doctors who worked during subsequent centuries, was produced by Paul Unschuld. Waichi studied the Nan Jing extensively, and based his abdominal diagnosis work largely on the contents of the 16th and 56th difficult issues raised in that text. Those sections described movements of qi in the abdomen that corresponded to and preceded (because they were part of the cause) diseases of the five viscera (zang). The implication that he derived from the text was that light touching of the abdomen at the locations indicated in the Nan Jing could detect the moving qi or blocked qi that indicated a disease was developing or already present.

The 16th difficult issue focuses on evidence that localizes a disease to one of the five viscera, to confirm what is felt in the pulse (at the wrist). The information presented can be summarized in a table as follows: Organ

Abdominal Indication

Symptoms Reported by Patient

External Evidence

Liver

Moving qi detected to the left of the navel; if pressed, this region responds with firmness and pain.

Swollen and stiff limbs; dripping urine; difficult stools; twisted muscles.

Tendency toward tidy appearance; virid complexion; inclination to become angry.

Heart

Moving qi above the navel; if pressed, responds with firmness and pain.

Uneasiness of the heart; heart pain; Red complexion; dry mouth, and the center of the palms are hot; dry tendency to laugh. vomiting may occur.

Spleen

Moving qi at the navel; if pressed responds with firmness and pain.

Swollen and full abdomen; food not digested well; body feels heavy; and the joints ache.

Yellow complexion; tendency to belch; tendency to ponder; fondness for tasty food.

Lung

Moving qi to the right of the navel, Panting and coughing; shivering if pressed, responds with firmness from fits of cold and heat. and pain.

White complexion, tendency to sneeze; grief without joy; and an inclination to cry.

Kidney

Moving qi below the navel; if press responds with firmness and pain.

Feeling of qi moving contrary to its Dark complexion; tendency to be normal course; tension and pain in fearful; frequent yawning. the lower abdomen; diarrhea feeling as if something heavy was moving down; feeling cold; feeling of reversed qi in the feet and shinbones.

In the discussion of the 56th difficult issue, involved with detection of accumulations affecting the internal organs, the Nan Jing states that: Accumulations in the liver are called "fat qi." They are located below the ribs on the left side and resemble a cup turned upside down. They have a head and foot, and they last a long time without healing. They let the afflicted person develop a cough with qi moving contrary to the proper direction and they cause alternating fevers. Accumulations in the heart are called "hidden beams." They extend upward [from the navel] to below the heart and last a long time without healing. They let the afflicted person suffer from a feeling of uneasiness in his heart. Accumulations in the spleen are called "blocked qi." They are located in the stomach and resemble a large bowl turned upside down. They last a long time without healing. They cause the person to be unable to pull in his four limbs and they cause jaundice. Accumulations in the lung are called "rest and run." They are located below the ribs on the right side and are several times the size of a cup. They last a long time without healing. They let the person shiver due to alternating perceptions of cold and heat and they let him cough and develop blockages in the lung. Accumulations in the kidneys are called "running piglets." They develop in the lower abdomen and extend upward to below the heart. Like a piglet, they move up or down unexpectedly. They last a long time without ending. They let the afflicted person pant due to qi moving contrary to its proper direction. They cause the bones to weaken and to have little qi. To produce a full system of abdominal diagnosis, the limited indications in the Nan Jing had to be expanded. Therefore, Waichi, and those who followed his example, carefully elaborated sensations felt by the diagnostician of the skin and muscles of the different parts of the abdomen.

APPENDIX 2: Excursions into Unreality

Proponents of Japanese acupuncture often point to an advantage that they perceive over the original Chinese system of acupuncture. The latter is portrayed as intolerable to most Americans because of its use of relatively large needles, deeply inserted and strongly stimulated. The Chinese aim is to attain the qi reaction, called deqi, which has a sensation of heaviness, distention, and numbness, often accompanied by an attempt to get transmitted qi: the experience by the patient of the qi sensation propagating from the acupuncture point towards the part of the body where the disease or injury exists. Japanese acupuncture, as promoted in the U.S., is contrasted as involving extremely fine needles, shallowly inserted and not stimulated to get a strong qi sensation for the patient (the acupuncturist, however, likes to feel a slight bobbing of the needle as it is inserted at the point, which is interpreted, instead, as the qi reaction). Indeed, because many Americans have had bad experiences with medical needles-hypodermic needles flushing liquids into the body, stabs of blood sampling needles, IV needles for drawing blood or dripping fluids-they are not drawn to the strong needle sensations, even if not painful, associated with standard acupuncture. While Chinese acupuncture has been subjected to intensive scientific investigation, Japanese acupuncture is only loosely studied, and its effectiveness, especially when practiced in the very light stimulation forms, is open to question. While practitioners proclaim the benefits they see in their own patients, modern researchers recognize that such observations are often unreliable indicators. Nonetheless, the basic Japanese acupuncture technique is used in Japan by about 90,000 acupuncturists, about 8 times as many acupuncturists as there are in the U.S. So, it is a large field and a good resource for experience. As some practitioners working in the West attempt to rely on ever more subtle treatments, they begin to develop explanations of how such minor interaction with the patient could possibly have a strong effect on healing. This leads to imaginations about energetics of the body and of the acupuncture needles-concepts that have no known basis in reality and little or no connection to the ancient tradition: they are just projections and guesses. Still, the language of the ancient tradition is used and even the language of modern science is

brought in support of the untestable theories and newly devised techniques. Examples of the corrupting influences are: Omura's bi-digital O-ring diagnostic test developed by Yoshiaki Omura. This is no more than the muscle test developed by a chiropractor a few years back (and thoroughly dismissed by anyone who turns to critical analysis of claims made), shifted from the outstretched arm to the thumb and first finger held together. Omura, now living in New York, has written articles that describe his bizarre and obscure explanations in seemingly scientific terms of how photons interact "bidirectionally" with molecules. Manaka's Ion Pumping Cords, developed by Yoshio Manaka, which not only do not pump ions, but are usually utilized by persons who have may have little or no concept of what an ion is or have little concern about making such a claim. Certainly, the study of ions, electrical transmission, and its potential effects on the body are not subjects in acupuncture colleges. The cords are nothing more than a length of wire with a diode (patented), purportedly to allow the flow of ions to go only one way. As practitioners are encouraged to leave behind the long-standing tradition in order to take up these bogus diagnostics and therapeutics, they are further led to bizarre theories about how the body works. This move away from respect for a long lineage of scholars and dedicated doctors frequently leads to bragging about therapeutic triumphs, ones that are not properly recorded in any serious medical journal. Such behavior serves as an insult to the hard working practitioner scholars of the past who tried to encourage students to seek after the truth, rather than follow every fad.

March 2002

Figure 1:The Stone of Good Luck at the entrance of the Benten shrine.

Figure 3:Japanese map of the abdomen, 1685.

Figure 2:Todo Yoshimasu (1702-1773).

KAMPO MEDICINE The Practice of Chinese Herbal Medicine in Japan by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Kampo medicine is widely practiced in Japan, and is fully integrated into the modern health care system. Kampo is based on traditional Chinese medicine but adapted to Japanese culture. With only slight modifications, it has been adopted also in Taiwan and exported from Taiwan to the West. This article presents a concise history of Kampo that helps to elucidate the areas of primary concern to Japanese practitioners and reveals how a collection of certain traditional formulas came to dominate the system. The basic texts of Chinese medicine, such as the Neijing Suwen and Lingshu, and the Materia Medica came to Japan during the 7 th through 9th Centuries. This led to publication of the primary historical text about Chinese medical theory and practice in Japan: the Ishimpo. In the Chinese tradition, there are certain scholar-physicians who have become revered for their work, including Zhang Zhongjing and Sun Simiao, whose formulas and theories were incorporated into the Ishimpo. Japan also has its famous contributors from the classical period (15th to 18th Centuries), such as Sanki Tashiro, Gonzan Goto, and Todo Yashimosu, and renowned 20th-Century physicians, such as Keisetsu Otsuka and Domei Yakazu, who helped restore Kampo after several decades of suppression during the rise of Western medicine in Japan. Kampo (also written Kanpo, Kampo is the older transliteration) literally means the Han Method, referring to the herbal system of China that developed during the Han Dynasty. Although Kampo encompasses acupuncture, moxibustion, and other components of the Chinese medical system, it relies primarily on prescription of herb formulas. Kampo today differs from the practice of Chinese herbal medicine in mainland China primarily by reliance on a different basic collection of important herb formulas and somewhat different group of primary herbs. Thus, for example, one of the most frequently mentioned traditional herb formulas in China is Xuefu Zhuyu Tang (Persica and Achyranthes Combination), a formulation used for treating blood stasis, devised by the reform physician Wang Qingren in the early 19th Century. By contrast, the most frequently mentioned herb formula in Japan for treating blood stasis is Guizhi Fuling San (Cinnamon and Hoelen Formula), a formulation of the Han Dynasty described by Zhang Zhongjing in the 3rd Century. While both formulations originated in China, Xuefu Zhuyu Tang is a relatively new one on the large scale of Chinese medical history, and was devised after Japan had ceased being directly influenced by developments in China. There are certain traditional Chinese medicine books that are relied upon heavily in Japan, providing formulas with a limited number of herbs, while there is a much broader range of sourcestexts, herbs, and well-known formulas-relied upon in China. A factor that has strongly influenced the practice of Kampo during the past 25 years was the formal recognition, by the Japanese Ministry of Health, of certain traditional Chinese herb formulas (and a few formulas of similar nature developed in Japan) as suitable for coverage by national health insurance. These formulas are prepared in factories under strict conditions. As a result, Japanese physicians focus their attention on a small group of formulas: about 80 that are frequently prescribed out of an approved collection of 148 formulas. By contrast, Chinese physicians are not only more likely to work with a larger group of traditional formulas, but also to make entirely new formulations using a diverse array of herbs. Many Chinese herb formulas prescribed by doctors in China are in the form of decoction, and there is no special pricing system in place to direct practitioners towards certain formulations. In addition, China has thousands of patent medicines, many of them introduced before the Chinese government instituted any restrictions on them. In the West, the practice of Chinese herbal medicine has been strongly influenced by Kampo, because the Japanese approach was introduced early (before licensing of acupuncture was established) and effectively.

INTRODUCING CHINESE MEDICINE TO JAPAN

Cultural contact between China and Japan has occurred since ancient times. There is a story that is frequently told in the Chinese tradition about the first Emperor (reign: 221-210 B.C.) who is said to have sent emissaries by ship on the Eastern Sea to find the herb of immortality; it is suggested that they returned from Japan with ganoderma (lingzhi; Japanese: reishi) in completion of their mission. Some Chinese medical works were introduced to Japan as early as the 4th or 5th Century A.D., coming first by way of Korea, which had adopted Chinese medicine by that time. Historical records indicate that a Korean physician named Te Lai came to Japan in 459 A.D., and that a Chinese Buddhist named Zhi Cong brought medical texts with him to Japan via Korea in 562 A.D. It was also during this period that the Chinese written language was adopted in Japan so that the people could learn from China about Buddhism, Confucianism, governmental organization, and the divination arts, opening the way for study of Chinese medicine. The first official classes in Chinese medicine in Japan are said to have been given by a Korean physician in 602 A.D. by order of the Empress Suiko (reign: 592-628 A.D.). During her reign, the Japanese court started sending envoys to China. Some of the Japanese visitors to China, being there primarily on diplomatic missions, brought back medical classics of China. In 701, the Taiho Ritsuryo Code (a series of edicts establishing a particular political and academic structure) was compiled and provided for, among many other things, establishment of a ministry of health (Ten'yakuryo; also translated as the Institute of Medicine). This Taiho Code, influenced by two visits to the Tang Imperial Court by the envoy Enichi, included a division devoted to the Chinese concept of yin-yang, one of the foundations of Chinese medical theories and other aspects of Chinese culture. The services of the health ministry were restricted to the royal court and aristocracy, while Buddhist temples took care of the poor, eventually including Chinese medicine. The Empress Komyo (701-760 A.D.) established a dispensary to supply free medicine to the needy in 730 A.D. The dispensary provided local Japanese herbs, but the method of using the herbs was already influenced by Chinese medical principles. These early contacts and exchanges with Korea and China had only limited implications for medical activities in Japan which, up to that time, had been dominated by shamanism, exorcism, and purifications, with only a slight reliance on herbs, mainly for symbolic use. Widespread interest in Chinese medicine apparently arose as the result of a visit from the Chinese Buddhist priest Jian Zhen (Japanese: Ganjin) who arrived in Japan in 753 A.D. (at the height of the Tang Dynasty in China). Jian Zhen had developed a great knowledge of medicine and herbs. It took five attempts over a period of 12 years before he was able to cross the rough seas to reach Japan. He was blind at the time he arrived, but he was able to accomplish much due to his great generosity. Jian Zhen had come to Japan with medical texts, a collection of herb materials, and a desire to teach. It was said that he had refined his sense of smell so that he could distinguish

between true herbs and any false substitutes despite his lack of eyesight. Most importantly, he provided free medical services, which boosted the respect for both Buddhism and Chinese medicine and, along with the charitable act of Empress Komyo a few years earlier, introduced the concept of social medicine to Japan. A collection of herbs that Jian Zhen and subsequent visitors brought to Japan has been preserved to this day. In the building complex known as the Shosoin (also spelled Seisoyin), resides a collection of herbs that was presented in front of the Buddha statue in the Todaiji Temple at the Imperial Palace (see Figure 1). This collection was dedicated 49 days following the death of the former Emperor Shomu (Seimu Tienno) in 756 A.D. (in the Buddhist system, the determination of rebirth, entry of the spirit into the womb, occurs 49 days after death). The Shosoin has served as a repository and museum for these herbal medicines and miraculously escaped both natural and man-made disasters, making it one of the oldest surviving structures in Japan. The Shosoin had been designed in such a way that it helped prevent the deterioration of the herbs, and it has been ceremoniously aired out for one week each year. According to an inventory record that accompanied the collection, there were 60 different medicinal materials in the original group, though the dispensing of herbs to patients depleted the supplies of 20 of them, leaving 40 of the original samples; there were also 16 herbs that may have been added to the collection after the inventory list was compiled. Scholars have performed analyses of the herb materials to confirm their identity; they have found many of the active ingredients intact after more than 13 centuries. Following the introduction of Chinese medicine by Jian Zhen, a number of Japanese people took an interest in learning and spreading the tradition in Japan, and they got hold of numerous medical works from China. The Xinxiu Bencao (Newly Revised Materia Medica) also known as the Tang Bencao, Tang Dynasty Materia Medica , 659 A.D.), which had been sponsored by the Tang Imperial Court, became an obligatory text in the study of medicine at the Japanese Health Ministry in 787 A.D. Unfortunately, many of the 844 medicinal substances described in the Materia Medica were not available in Japan at the time. At the end of the 8 th Century, the Japanese physician Ilura Yamanoue traveled to China to study Chinese medicine and wrote a poem, published in a 9th Century anthology, mentioning famous Chinese physicians, such as Bian Que, Hua Tuo, and Zhang Zhongjing. A few medical works by Japanese authors were also written during the 9th Century, such as Datong Leiqi Fang (A Generalization of the Ancient Native Herb Formulas) in 808 A.D. and Jin Lan Fang (Precious Formulas) in 868 A.D. A list of Chinese medical books compiled around 895 A.D. included 166 texts. Around 918 A.D., a Japanese medical dictionary (Honzo-wamyo) was written, quoting from 60 different Chinese medical works. The growing collection of Chinese works were used as a source of Japan's primary text on Chinese medicine, the Ishimpo (The Essence of Medicine and Therapeutic Methods; Chinese name: Yi Xin Fang). This text of 30 individually titled scrolls was written by Yasuyori Tamba in 984 A.D. and is the oldest Japanese book on the subject to survive to the present. The Ishimpo is a compilation of medical knowledge and medical theories that were prevalent during the Sui Dynasty (589-618 A.D.) and Tang Dynasty (618-907 A.D.), quoting from more than 100 Chinese texts. This period of Chinese medical history was greatly influenced by the work of two earlier medical authorities: Zhang Zhongjing (ca. 150-220 A.D.) and Sun Simiao (581-682 A.D.). Zhang wrote the medical text that was divided into the Shanghan Lun and Jingui Yaolue . Sun Simiao became known in China as the "King of Medicine" or the "Medicine God;" his herb medicine books were the Qianjin Yaofang and Qianjin Yifang (collectively referred to as Qianjin Fang). In turn, Sun Simiao had been influenced, especially with regard to Taoist practices, by the famous alchemist Ge Hong (281-341 A.D.), who published formulas in his book Zhouhou Beiji Fang (ca. 340 A.D.). The Materia Medica guides that were relied upon at the time were the Shennong Bencao Jing (ca. 100 A.D.) in its revised form, Mingyi Bielu by Tao Hongjing (452-536 A.D.), and the Xinxiu Bencao mentioned previously. Tao Hongjing had classified the herbs of the original Materia Medica of China into three groups: upper, middle, and lower herbs. This grouping had a profound impact on the concepts of medical practice during this era. The upper-class herbs were said to be suited for long-term administration to preserve health and attain long life. While there were numerous plant medicines in this category, the dominant ingredient at the time, the one used most often by Taoist seekers of immortality, was cinnabar (mercuric sulfide). Medicines comprised of large amounts of cinnabar, often with realgar, were popularized by Ge Hong and Sun Simiao, who studied the Taoist arts. Of course, these medicines, considered so valuable for regular intake, were actually poisonous, and both Chinese and Japanese seekers of long life suffered the consequences. The middle- and lower-class herbs were to be used for treating specific diseases, used for a relatively short time, and were deemed to be mildly toxic. In fact, they were often less toxic than cinnabar, but a number of very potent drugs were included, such as genkwa and datura, that supported this classification. The Shanghan Lun and Jingui Yaolue formulas were mostly comprised of plant materials, and the majority had low toxicity. These plant materials were supplemented by minerals or mineralized compounds, most of which were quite safe: oyster shell, dragon bone, gypsum, and talc, for example, are all calcium materials used in some of the formulas. These ancient formulas soon became one of the principal focal points of Kampo medicine. To this day, many Kampo practitioners study and praise the Shanghan Lun and Jingue Yaolue and prescribe their formulas, such as Minor Bupleurum Combination (Xiao Chaihu Tang), Cinnamon and Hoelen Formula (Guizhi Fuling San), Hoelen Five Formula (Wuling San), Pueraria Combination (Gegen Tang ), and Tang-kuei and Peony Formula (Danggui Shaoyao San). These are relatively small formulas (typically 5-9 ingredients) that rely heavily on a small collection of herbs, mainly those categorized in modern texts as surface relieving herbs, heat clearing herbs, moisture draining herbs, and tonics. Japan entered a period of isolation soon after the Ishimpo was published; the last envoy to China returned in 894 A.D. Although there were some individual visits by Japanese scholars to China, the level of exchange was limited. The formulas of Zhang Zhongjing and Sun Simiao, and the accompanying medical theories and practices of their time, dominated Kampo until the end of the 15th Century.

TWO SCHOOLS OF KAMPO: GOSEIHA AND KOHOHA

The Goseiha School (School of Later Developments in Medicine) evolved from a 12-year visit to China (1486-1498) by Sanki Tashiro (1465-1537). While in China, he encountered the powerful influences of what is known as Jin-Yuan medicine (making reference to two Dynasties of northern tribes, the Jin, which coexisted with the Southern Song Dynasty, and the Yuan, or Mongols, who took control of nearly all China). Jin-Yuan medicine was comprised of four major schools of thought about causes and treatment of disease. Among the leading physicians of the Jin-Yuan period that influenced Sanki Tashiro were Li Gao (aka Li Dongyuan; 1180-1251) and Zhu Danxi (1281-1358), founders of the Spleen/Stomach school and the Nourishing Yin school, respectively, emphasizing the tonification therapies

that are denoted in their names (the other two schools focused on clearing heat and on purging evils). In addition to their recommendations for herbal therapeutics, the physicians of the Jin-Yuan period promoted the further development of the five elements system and the associated concepts of the five zang and six fu (yin and yang organs, respectively), and the influence of the environment factors on health. These theoretical components involved considerable speculation about interrelationships within the body and between the body and the environment (as well as between the body and herbs) that came to characterize the thinking of the Goseiha School. This school was also influenced by the neo-Confucianism that was dominating developments in China at this time, largely attributed to the efforts of Zhu Xi (1120-1200). The Goseiha School began on a small scale, but was spread considerably by several of Tashiro's students and followers during the 16th century; this expansion continued into the 17th century. Perhaps the most important figure in the Goseiha School was Manase Dosan (1507-1594), a student of Tashiro's who wrote the eight-volume work Keitekishu (Textbook of Internal Medicine) and founded the Keiteki-In, a private medical school in Kyoto. He expressed the view that for acute diseases one should rely mainly on the formulas of the Shanghan Lun, but that for chronic diseases, the prescriptions of the Jin-Yuan schools (referring, especially, to the two tonification schools of Li and Zhu) are suitable. He also cautioned that herbal drugs possess some natural toxicity and should be used carefully. Dosan's son, Gensaku, also became an influential Kampo practitioner who wrote Igakutienseiki, a book of clinical cases involving famous personages. The framework of the Goseiha School is sometimes called "Dosan Medicine." The Goseiha School ushered in the use of a new group of herb formulas. These included those of Li Gao and Zhu Danxi, but even more importantly, those of the Song Dynasty book Taiping Huimin Hejiju Fang (published in 1110). This book, that had been ordered by the Song Emperor, with the project headed up by the Court physician Chen Shiwen, includes a large compilation of formulas. The work was carried out at a time when there was a revived interest in the Shanghan Lun and Jingui Yaolue in China, and, not surprisingly, many of the Hejiju Fang formulas were similar in ingredients and design to those of the earlier works. Among the many traditional Chinese herb formulas heavily relied upon today that come from this text are Four Major Herbs Combination (Si Junzi Tang), Tang-kuei Four Combination (Siwu Tang), and Bupleurum and Tang-kuei Formula (Xiaoyao San). The Hejiju Fang formulas became as widely used as the Shanghan Lun formulas, infusing a new stimulus into the practice of Kampo. There eventually developed some opposition to the speculative logic associated with the Jin-Yuan teachings. For example, the founder of the Jin-Yuan medical developments, Zhang Yuansu (1151-1234), had proposed that each herb entered one or more specific channels (meridians) to affect the associated organ systems, an idea accepted also by his student Li Gao. This concept, which still appears in modern Materia Medica books (following the listing of the nature and taste of herbs there is usually a listing of affected meridians), has been the subject of objections in both China and Japan. It proposes something that is not considered practical, and that relies too heavily on imposing rigid adherence to the theories of five elements and zangfu without observation of clinical effects. Today, despite the listing of "meridian entrance" of the herbs in the texts, this feature is rarely relied upon in making clinically relevant choices in herbal prescribing. A new school evolved in Japan, which opposed the Jin-Yuan medical reforms and favored practical knowledge and a return to the earlier teachings (i.e., up to the Tang Dynasty): the Kohoha School (School of Classical Formulas). Proponents of the Kohoha School similarly rejected neo-Confucianism in favor of the original Confucian tenets. This school soon replaced the Goseiha School rather than competing side-by-side with it. Though many in the Kohoha School emphasized the teachings and formulations of the Shanghan Lun (i.e., going back to the most ancient and reliable classic text), others did not stick tenaciously to this source text and remained open to later formularies, such as the Hejiju Fang. One of the key features of this school was its reliance on what is now known as confirmation theory (also spelled conformation theory): matching a symptom and sign complex (Chinese: zheng) of the patient to a particular ancient formula, with no intervening speculation, such as had been practiced by the Goseiha School using yin-yang and five element analysis. This method is retained by many Kampo practitioners today. Two specific concepts about disease causation and treatment developed during this period: one based on the problem of qi stagnation; and the other based on the influence of a particular toxin of external origin. An early activist in this School, Gonzan Goto (see Figure 2), placed particular emphasis on the concept that the development of disease is related to stagnation of qi circulation. He noted that some people could remain healthy and unaffected by adverse weather conditions (external disease causes in the Chinese system) and could resist disease due to emotional extremes (internal disease causes in the Chinese system). However, others were readily susceptible to such adverse influences, and this susceptibility, he postulated, was due to qi stagnation. Therefore, he relied on a variety of techniques (not just use of herbs) aimed at overcoming qi stagnation as a means of treating and preventing diseases. The other specific concept of disease is attributed to the most influential figure of the Kohoha School, Todo Yoshimasu (17021773). His understanding was that there was one basic toxin that could enter the body and cause all diseases. He proposed that the differences among diseases and their symptoms were primarily the result of different sites of the body being affected by that same poison. He attached great importance to the Chinese system of abdominal diagnosis that had been all but abandoned in China, stating that the site of the affecting poison could be most easily detected by the condition of the abdomen. Yoshimasu wrote the book Ruijuho (Indications of Kampo Prescriptions) in which he reclassified the formulas of the Shanghan Lun and Jingui Yaolue , believing that the formulas were very valuable, but that the accompanying theory of yin and yang disease types had to be discarded. Many Kampo practitioners still rely heavily on the connections between certain abdominal conformations and the associated formula derived from the Shanghan Lun or Jingui Yaolue . Yoshimasu also wrote Yakucho (Characteristics of Herbs), which remains an important historical work on Kampo. While both these theories of disease causation were as speculative as those of the Goseiha School, the therapeutic approaches recommended were based on empirical observations and practical methods, so these proposals were not considered an impairment to the fundamental principles of Kohoha. A movement in China similar to that of the Kohoha School (but a century later) was led by Zou Shu (1790-1844), author of Ben Jing Shu Zheng (Materia Medica Classic Commentaries & Testimonials; completed 1837, published 1849). His book was in reaction to the Bencao Shu (published 1700), which he felt contained too much of the Jin-Yuan medical theories, while the practical prescriptions of the Shanghan Lun and Jingui Yaolue and the work of Sun Simiao were neglected. He aimed to blend theoretical and practical information and escape the trend towards increasingly obscure approaches to understanding herbs and

formulas. Another important influence in the Kohoha School, at least for those who did not stick tenaciously to the works of Zhang Zhongjing, was the book by the Chinese physician Gong Tingxian (1522-1619), Wanbing Huichun (1587), written by his student Dai Mangong, who later immigrated to Japan. Another immigrant from China was Ma Rongyu, a scholar of the Neijing; his son studied under Gong Tingxian and helped expound his works. Gong's prescriptions relied heavily on the framework developed by the Shanghan Lun, Hejiju Fang, and other ancient texts. He made larger formulas that combined the earlier smaller formulas, and then added a number of herbs that were in vogue at the time (mainly herbs for dispelling heat, cleaning toxins, and resolving swellings; he worked during the time when the concept of epidemic warm diseases was evolving). A good example of Gong's formulations is Tang-kuei and Gardenia Combination ( Wen Qing Tang), which is an eight-herb formulation comprised of a four-herb formula (Coptis and Scute Combination) from Ge Hong's Prescriptions for Emergencies (340 A.D.) and a four-herb formula from the Hejiju Fang (Tang-kuei Four Combination). Tang-kuei and Gardenia Combination would then serve as a base for a large prescription, such as Gardenia and Vitex Combination (Xigan Mingmu Tang), in which Gong incorporated mentha, schizonepeta, platycodon, gypsum, cassia, and other herbs that were commonly used in heat-cleansing prescriptions. Gong's formulas were one of the last major imports from China to this system of medicine. Kampo then became a well-established Japanese medical tradition that was independent of China. During this time, Japan did continue to import medical books, including the Bencao Gangmu (Herbal Compendium) by Li Shizhen, first arriving in 1607, but Kampo progressed on its own track. Some new formulas were devised by Japanese practitioners, such as Sohako Asada and his descendents, but the majority of formulas relied upon for Kampo were those introduced from China up through Gong Tingxian's work. Just as Kampo attained its strength and independent status at the end of the 16th Century, Western medicine came to Japan, and eventually caused the decline in practice of Kampo.

DECLINE OF KAMPO MEDICINE AND RISE OF WESTERN MEDICINE

Western medicine was introduced to Japan by the Portuguese around 1590, a few decades after their first landing in Japan in 1543. Additional entry of Western medicine came via Spain during the early 1600s, but this influence of Portugal and Spain was limited to the coastal regions, such as Kyushu (one of the Japanese islands). The Japanese leadership adopted a policy of national isolation soon after the Portuguese and Spanish incursions, allowing trade and interchanges only with the Dutch (among Western powers) starting in 1639, which brought entry of Dutch physicians and medical works. This foreign medicine took on significance only after Japanese scholars studied it and wrote about it from their perspective. For example, in 1774, Genpaku Sugita published Kaitai-shinsho (The New Book of Anatomy), which greatly enhanced the reputation of Western medicine. Another scholar of Western medicine was Gentaku Otsuki, who pointed out that the two systems of medicine could be complementary, each overcoming the inadequacies of the other. During this time, traditional practitioners began to develop specialization like that found in Western medicine; for example, Genetsu Kagawa (1700-1777; see Figure 3) focused on obstetrics and influenced the field for generations afterward. Seishu Hanaoka (1760-1835; see Figure 4) actively pursued integration of Kampo and Western medicine. The biggest boost to Western medicine in Japan came with the introduction of smallpox vaccination in 1849, fifty years after it had been developed in Europe. Kampo had no comparable disease prevention techniques and its reputation suffered under the light of the successful vaccination campaign. Kampo then went into a period of severe decline from 1868 to 1902 as the result of efforts by the Meiji government. The government based its actions on the concept that Japan was too weak relative to the Western nations, and took drastic steps to build up the military and to strengthen the internal affairs. As part of this, Western medicine was accepted as the most desirable method of therapy and was fully endorsed by the government, with efforts made to suppress the traditional system as being outmoded and contributing to the weakness of Japan. New medical examinations (starting in 1875) focused on chemistry, anatomy, physiology, pathology, pharmaceutics, internal medicine, and surgery, and ignored traditional medicine dogma, herbs, acupuncture, and other aspects of the ancient medicine. In 1883, the government required passing of the new examination even for those who wished to practice Kampo. The medical studies required for this exam were so intensive as to virtually preclude the opportunity to also study Kampo, even if one wished to do so in this climate.

REVIVAL OF KAMPO

Kampo physicians were appalled by the sudden cut-off of the traditional medical system in 1875. Several of them organized the Onchisha Association to defend and preserve Kampo. The principal figures involved were Gyoko Yamada, Shohaku Asada, and Risshi Mori. Beginning in the 1880s they recruited several other Kampo physicians and set up some small hospitals emphasizing Kampo practices. However, by 1887, the organization was disbanded after key members either left the organization due to internal policy dissent or died of old age. In 1895, an attempt to get legislative reform of the medical licensing regulations to allow separate licensing in Kampo failed. Kokkan Azai, one of the main activists in this reform effort died in 1902, with Kampo virtually stamped out. Despite the highly successful efforts of the Meiji government to eliminate Kampo, a few Kampo physicians remained who continued to promote their tradition as the Meiji gave way to the subsequent Taisho government. Although the Taisho still retained its devotion to Western medicine, some revival became possible after 1902, since Kampo was no longer seen as a potential threat to modernization and there was no need to make it a specific target of suppression. The Kampo physicians wrote about the value of Kampo; for example, Keijuro Wada wrote Ikai-no-tettsui (The Iron Hammer of the Medical World) in 1910 and Tadanao Nakayama wrote Kampo-igaku-no-shin-kenkyu (New Study of Kampo Medicine) in 1927. In addition, a course on Kampo medicine was set up at Takushoku University in 1937 (such a course is currently taught at Toyama Medical and Pharmaceutical University). After the 1920s, Kampo was promoted not by old doctors from the pre-Meiji era, but by enthusiastic converts from the modern medical profession. Keisetsu Otsuka, who became one of the most famous Kampo practitioners of the 20th Century, told his story of conversion from Western medicine to Kampo: In 1920, I was a second-year student at Kumamoto Medical School [a Western medicine school]. One day while walking through a park in the suburb of Kumamoto, I saw a sign that said: Chinese Medicine Hospital. I have seen many hospital

signs before and since, but have forgotten them all. Only this one can I still picture in my mind's eye. When I looked at the words "Chinese Medicine," I remember feeling only contempt. I didn't know at the time that the hospital dated from the Tokugawa era and was most famous for its Chinese herbal medicine. I thought the sign was merely advertising for an unlicensed practitioner. It was only many years later, as I myself pursued the study of Chinese medicine, that my memory of that time reawakened. Many people have asked me why I gave up modern medicine to study Chinese medicine, a field at the time ostracized and despised by society. I usually answer: First, I was weak and sickly during my childhood, and treatment with modern medicine proved useless; second, since my entire family consists of doctors, I grew up always surrounded by many books, including those about Chinese herbs as well as other herbs. I truly think that I finally devoted myself to such study because it was destined and not because of the answers that I gave my questioners. Except for chance, I would probably not have devoted myself to the study of Chinese herbal medicine. Thinking over my career, I can recall numerous times when I have cured fellow doctors with Chinese herbs. All of them took Chinese herbs when sick, yet never took up the study of Chinese medicine. In fact, of the many doctors born into medical families and surrounded by Chinese herbs, only a few, such as myself, have ever given up modern medicine to devote themselves to the study of Chinese herbal medicine. One morning in March of 1927, as usual before seeing patients, I was reading the literature section of the Tokubai newspaper. There I saw a review of a book entitled A New Study of Kampo Medicine by Tadano Nakayama. After reading the review, I immediately ordered the book. The review mentioned that the autumn edition of the magazine Japan and the Japanese had carried an article by Nakayama "On the Revival of Chinese Herbal Medicine." Because of the sensation it caused, he had expanded that article into this book. For years I had looked down upon Chinese herbal medicine, but after reading this book I realized that its approach was as clinical and valid as modern medicine. I was ashamed of my ignorance-I had thought it to be only folk medicine. Through reading this book I learned of the classic Shanghan Lun, the oldest book of treatment in the world. One day, I saw an announcement of the publication of the first volume of a magazine called Kokan Igaku (June 1927). I immediately ordered it. Although not a wealthy man, the herbalist, Yumoto, who later became my teacher, published the magazine himself. After reading it, I decided to devote my life to Chinese herbal medicine. Yumoto had graduated from Kinzawa Medical School (a Western medical school) in 1901. His attitude towards the value of the medical practices changed, however, and he gave up modern medicine to study Chinese herbal medicine. At the time (around 1920), there were no Chinese herbal specialists left in practice, but some medical doctors had decided to study the subject, even while maintaining their Western medical practice. A licensed medical doctor would be able to prescribe Chinese herbal medicine, but a Kampo specialist lacking Western medical training could not, because he would have no license to practice. Along with the gradual revival of Kampo medicine via practitioners of modern medicine, another development helped the field to grow: modernization of the dosage form of herbal medicine. In the 1920s, Nagakura, a pharmaceutical company headed by Nagakura Onzo, began developing ways to mass produce Chinese medicine using precision apparatus and scientific methods. This led to the production of dried decoctions in a convenient granular form, commonly called wakan-yaku (Japanese-style classic remedies) that have become a standard method of Kampo medicine administration. In place of a set of small drawers containing a limited number of crude herbs to be selected, weighed, and then sent home with the patient for preparation as a decoction, the manufactured herb formulas were dispensed in a convenient form and simply given to the patient in quantities that would last until the next visit. At about the same time, Tsumora Juntendo, a company founded by Jusha Tsumura in 1893, established a research institute and herbal garden to promote the development of Kampo. Thus, with some doctors learning Kampo, the publication of some Kampo books and journals, the offering of a Kampo course at a medical college, and production of modern herbal preparations, this field of medicine was ready to expand substantially. Shinichiro Takeyama wrote Kampo-ijutsu-fukko-no-riron (Theories on the Restoration of Kampo Medicine) in 1941, ushering in the new age of Kampo practice. Then, World War II put the development of Kampo into the background. Modern medicine, especially surgery and antibiotic therapy, was critical during the war years. When Japan was defeated in 1945, it took several years for the country and its industrial and social activities to recover. The medical doctors who had taken up the practice of Kampo formed the Japan Society for Oriental Medicine in 1950 with 98 members. This organization helped lead the way to the current restored form of Kampo; it currently has about 10,000 members. The work initiated in the 1920s to develop prepared forms of Kampo medicine progressed further to allow for large scale production in the 1950s. In 1967, four Kampo remedies were approved for reimbursement under Japan's national health insurance. In 1976, the Japanese government gave official approval to 82 prescriptions of the Kampo system; these could be purchased under the National Health Insurance System and were available as over-the-counter remedies. In addition, the Department of Pharmaceutical Affairs of the Ministry of Health and Welfare approved 210 herbal formulas (including the 82 already mentioned) for use in medical facilities, where they were also available over-the-counter (but not all of them were approved for coverage by national health insurance). These formulas were adopted as medicines without having to go through the lengthy registration process that was required for modern drugs (and also required for any other herb formulas). Specifically, the long history of use of these formulas was cited as sufficient evidence for their safety, if not for their efficacy, so the accumulation of safety documentation normally required was waived. Today, 148 prescriptions are covered by the national health insurance and more than half of them are the focus of modern Kampo practice. Aside from the formulas that had been adopted several centuries earlier by the Goseiha and Kohoha schools, a few prescriptions of the Warm Disease school that had developed in China during the 18 th Century were also included among the approved formulas. The main influence from this school was the Wenbing Tiaobian (Systematic Differentiation of Warm Diseases; published 1798) written by Wu Jutong (also known as Wu Tang); he presented the popular Lonicera and Forsythia Formula ( Yin Qiao San) and Morus and Chrysanthemum Combination (Sang Ju Yin), both used for the wind-heat type of ailment. In addition to the approved formulas, all of the

individual herbs that go into making the formulas are also approved for use, so that modified formulations, produced by combining single herbs with base formulas or combining only single herbs to make new formulas, are also available for prescription. Kampo spread rapidly during the period 1985-1995; after that, the number of practitioners stabilized at a nearly constant level. By 1985, it was reported that about 20-25% of the medical doctors in Japan were including some herb prescribing in their practice. However, as pointed out by Terasawa Katsutoshi, only about 100 or so doctors were routinely prescribing Kampo medicines to their patients. The proportion of doctors that provide some Kampo medicines has risen to about 50% or more by some estimates, with a proportional increase in Kampo specialists (more than 200). In addition, there are about 10,000 pharmacies in Japan that dispense herb formulas. About 2% of total drug expenditures in Japan are herbal medicines, the largest part of them provided by Tsumora Juntendo, with contributions from about 20 smaller manufacturers. Kampo medicine research is conducted at the Toyama Medical and Pharmaceutical University in Toyama, the Kitazato Institute in Tokyo, and the Kinki University Medical Teaching Hospital near Osaka, as well as at other sites. Surveys conducted in Japan have revealed that the main uses of Kampo medicines are treatment of hepatitis, menopausal syndrome, common cold and other upper respiratory tract infections, autonomic nervous dysfunctions, constipation, cough and asthma, skin diseases (mainly eczema and other categories of dermatitis), lumbago and neuralgia, and gastro-intestinal disturbances.

INTRODUCTION OF KAMPO TO AMERICA VIA TAIWAN

Kampo was brought to Taiwan by Dr. Hong-yen Hsu (1917-1991), a native of Taiwan who had studied pharmaceutical science in Japan and became impressed by the Japanese approach to herbal medicine. He also took an interest in the technology that had been developed by Nagakura. On return from Japan, he established the Sun Ten Pharmaceutical Works in Taiwan and began producing Kampo medicines in 1963. Hsu also became director at the Food and Drug Control Division of the National Health Administration. He promoted the scientific study of Kampo by establishing the Brion Research Institute, where several researchers under his direction evaluated the safety and pharmacological actions of the formulas, their individual herb ingredients, and their active components. These researchers also studied the botanical origins of the medicinal materials sold in the Hong Kong, Taiwan, and Japanese markets. Hsu brought the writings of Kampo practitioners to Taiwan, where their methodology was widely adopted at a time when there was virtually no direct communication with the practitioners in mainland China. The introduction of Kampo to America was also through the work of Dr. Hong-yen Hsu, who emigrated to the U.S. from Taiwan. He set up two organizations in 1975: Oriental Healing Arts Institute (OHAI), to publish translations of Chinese medicine books, and Brion Herbs Corporation, to distribute Kampo medicines and similarly prepared Chinese herb formulas produced by Sun Ten. OHAI published a bimonthly journal (Bulletin of the Oriental Healing Arts Institute; later transformed into a quarterly journal, the International Journal of Oriental Medicine). Many of the journal articles were authored by Japanese doctors, including famous Kampo physicians, such as Keisetsu Otsuka and Domei Yakazu (Oriental Healing Arts provided translation and editorial services). OHAI also published numerous books about Chinese medicine that were primarily based on the practice of Kampo, such as How to Treat Yourself with Chinese Herbs , Chinese Herbal Medicine and Therapy, and Commonly Used Chinese Herb Formulas with Illustrations. The books presented the formulas used by Kampo practitioners and listed the Kampo indications for their use, which often differed, at least in the specific details, from the indications found in books from mainland China (over time, more information from China was incorporated into the OHAI publications). OHAI published several books that were specifically about clinical experience in Japan by Japanese authors, such as: the clinical guide Natural Healing with Chinese Herbs by Otsuka, Yakazu, and Totoro Shimizu; the collection of case reports in Thirty Years of Kampo by Otsuka; and the book Combined Use of Oriental and Western Medicine by Toyohiko Kikutani. Additionally, OHAI published a translation of the Shanghan Lun that was annotated by Otsuka. The Sun Ten herb formulas distributed by Brion Herbs Corporation were the same ones used in Taiwan and Japan. In fact, the Sun Ten factory was the only Taiwanese company, out of more than a dozen making similar products, that supplied Japan, having met the very strict import requirements that had been designed to protect Japanese industries. Later, Sun Ten established a factory in the U.S. to produce the formulas. It is the only major manufacturer of Kampo medicines in the U.S. The manufacturing is directed by one of Hongyen Hsu's sons, Chau-shin Hsu, who also contributed articles and coauthored books published by OHAI. Several other Taiwanese manufacturers of Kampo style remedies now offer their products in the U.S., notably Kaiser Pharmaceuticals and Min Tong, following up on the lead taken by Sun Ten. In addition, Japanese and Korean firms have entered the market (South Korea also utilizes Kampo-style preparations). Translated books about Kampo and herb formulas are distributed to Europe, Canada, Australia, and other areas of the world. The manufactured herb formulas have become popular in the West because of the convenience and quality of the dried extracts, along with further developments such as encapsulation and tableting, as well as the availability of single herb extracts that can be used to make new formulas. The Kampo-style preparations are a source of formulas commonly used both in China and Japan (e.g., Rehmannia Six Formula; Liuwei Dihuang Wan), while the single herbs are a means of providing individualized prescriptions without having patients go through the process of preparing decoctions. The unique Kampo approach to diagnosis embodied in abdominal diagnosis is not used much in America, but the indications for use and understanding of herb formulas that have developed in Japan have enriched the understanding of Chinese medicine for practitioners here. As a means of broadening interest in the Kampo formulas, some efforts have been made at integrating them into the academic format preferred in China. For example, OHAI published A Comprehensive Guide to Chinese Herbal Medicine, by Zelin Chan and Meifang Chen (physicians from Shanghai), in which most of the formulas listed in the book are from the Kampo system, but formula modifications according to signs and symptoms, typical of what is done in China, are also described. Ultimately, Kampo in the West is becoming integrated into a broader system capturing the features of Japanese, Taiwanese, and mainland Chinese approaches to traditional Chinese medicine with the intention of combining effectively with modern (Western) medicine. The experience of medical doctors in Japan working with traditional herb formulas offers one model of how the tradition can be utilized as a valuable part of modern medicine.

RESOURCES

This article was derived primarily from secondary sources in English. Among the main resources were: Dawning of Japanese Medicine: Ishimpo; proceedings of the 1984 conference celebrating the 1,000 year anniversary of

publication of the Ishimpo, part of the 17th International Congress of Internal Medicine, published with the help of Tsumora Juntendo Co., Ltd. This book was provided by the Oriental Healing Arts Institute. Progress of Oriental Medicine-Proceedings of the Sixth International Congress of Oriental Medicine, 1990, sponsored by the Japan Society for Oriental Medicine. Articles published in the Bulletin of the Oriental Healing Arts Institute, including: Yasuo Otsuka, The origins of Chinese herbal medicine, 1985; 10(3): 93-99. Yasuo Otsuka, Introduction to Oriental medicine: The theory of Kampo therapy, 1988; 13(4): 217-221. Books published by the Oriental Healing Arts Institute, especially Thirty Years of Kanpo, by Keisetsu Otsuka, 1984. The book Oriental Medicine: An Illustrated Guide to the Asian Arts of Healing, edited by Jan Van Alphen and Anthony Aris, Serindia Publications (London), 1995. The internet web site of Tsumura Juntendo ( http://www.tsumura.co.jp/English), which includes access to the articles of the journal Kampo Today. Table 1: Important Persons and Events Related to Kampo Medicine. Person

Birth/Death; Chinese Dynasty

Events and Importance to Kampo

Zhang Zhongjing

~150-221 A.D. Han Dynasty

Revered as the most astute physician in the history of Chinese medicine. He completed his works, later divided into Shanghan Lun and Jingui Yaolue, around 200 A.D. His formulas are considered flawless by many Kampo practitioners.

Tao Hongjing

452-536 A.D. Six Dynasties

He revised the Shennong Bencao Jing, creating three categories of herbs (upper, middle, and lower), their implications were to strongly influence the early years of Kampo.

Sun Simiao

581-682 A.D. Sui and Tang Dynasties

Considered to be the God of Medicine, Sun Simiao was the most influential physician to have lived just prior to the introduction of Chinese medicine to Japan. He produced two key works on herbal medicine: Qianjin Yaofang and Qianjin Yifang.

Jian Zhen

~690-760 A.D. Tang Dynasty

Jian Zhen, a Buddhist priest knowledgeable in medicine, introduced the Chinese tradition to Japan in 753. He may be regarded as the founder of Kampo, as his work led to great appreciation for the value of traditional Chinese medicine in Japan.

Yasuyori Tamba

912-995 A.D. Northern Song Dynasty

He produced the Ishimpo in 984, a medical text in 30 scrolls, which became the fundamental text of Kampo; it presents traditional Chinese medical theory and knowledge from the Han through to the Tang Dynasty period.

Chen Shiwen

ca. 1060-1130 Northern Song Dynasty

He and his colleagues compiled the Taiping Huimin Hejiju Fang (1110) under orders of the Chinese Emperor. It is the source of numerous valuable formulas that are still in use today in both China and Japan. It is second only to the works of Zhang Zhongjing as a source for Kampo formulas.

Sanki Tashiro

1465-1537 Ming Dynasty

This Buddhist priest physician went to China (1486-1498) and learned the methods developed during the Jin-Yuan period, especially influenced by Li Gao and Zhu Danxi, which he then taught upon returning to Japan. His efforts led to the founding of the Goseiha School of Kampo.

Dosan Manase

1507-1594 Ming Dynasty

Studied medicine under Sanki Tashiro, then returned to his home in Kyoto to establish the Keiteki-In Medical Center; helped found the Goseiha School; sometimes called the Dosan School.

Gensaku Manase

1549-1631 Ming Dynasty

Helped spread the teachings of the Goseiha School of Medicine along with Genya Okamoto, Doju Nagasawa, Gyuzan Katsuki, Futei Fukui, and Gensen Tsuda.

Gong Tingxian

1522-1619 Ming Dynasty

Gong Tingxian published Wanbing Huichun in 1587; known as the last major source of Kampo formulas from China.

Saramata Takera

1573-1614 Ming Dynasty

Wrote the first text on abdominal diagnosis in Japan, Essentials of Abdominal Diagnosis (sometimes this book is attributed to his descendent Sarayoshi Takera, with publication in 1706).

Geni Nagoya

1628-1696 Qing Dynasty

Considered the founder of the Kohoha School; he was influenced by Ming Dynasty physicians such as Zhang Jingyue.

1659-1733 A.D. Qing Dynasty

Influenced formation of the Kohoha School; two of its most active members, Shutoku Kagawa and Toyo Yamawaki were trained by him.

1683-1755 Qing Dynasty

A student of Gonzan Goto; he wrote two books Ippondo-Gyoigen (Handbook of Medicine) and Ippondo-Yakusen (Handbook of Herbal Drugs). He strongly argued against speculative theories and arbitrary classifications, throwing out the Six Disease Stages concept from the Shanghan Lun.

Toyo Yamawaki

1705-1762 Qing Dynasty

Student of Gonzan Goto and active member of the Kohoha School; he was the first doctor in Japan to carry out a human corpse dissection, with results published in the book Zoshi (Explanation of Internal Organs). This work disproved the traditional theory of five organs and six viscera which was relied upon by the Goseiha School.

Todo Yoshimasu

1702-1773 Qing Dynasty

Criticized the speculative approach of the Goseiha School; stressed abdominal palpation therapy, and the use of strong purging methods. He believed that all diseases came from one poison that could affect different sites to produce various symptoms.

Genetsu Kagawa

1700-1777 Qing Dynasty

Produced a book on obstetrics, Sanron, strongly influencing obstetrics from that time onwards.

Genken Taki

1795-1857 Qing Dynasty

Participated in revival program for reconstituting old texts; leading to printing of Ishimpo in 1859, known as the Ansei version.

Sugita Genpaku

1733-1817 Qing Dynasty

His book, Kaitai-shinsho (New Book of Anatomy, 1774), derived from a Dutch text, helped to introduce Western medicine into Japan; it become the dominant medical system within 100 years.

Seishu Hanaoka

1760-1835 Qing Dynasty

Studied the Kohoha School under Nangai Yoshmasu; also studied surgery and used Kampo for anesthetic in surgical treatments; he created a school of combined Kampo and Western medicine.

Sengen Wuda

dates not available Qing Dynasty

Translated Western texts on internal medicine, producing Selected Essentials of Western Theory of Internal Medicine in 1792.

Sohaku Asada

1815-1894 Qing Dynasty

While he was a practitioner, smallpox vaccination was introduced, leading to decline in Kampo; the Meiji Government restricted entry of Kampo practitioners into medical profession in 1875. Asada helped form the Onchi-sha Association to oppose the restrictions.

Kyushin Yumoto

1876-1941

Researched Kampo remedies and worked to revive Kampo through publications and teachings, focusing on the Kohoha School. His book, Kokan Igaku, influenced many 20th Century doctors.

Wada Keijuro

not available

His book Ikai-no-tettsui (Iron Hammer of the Medical World; 1910), stressed the clinical value of Kampo and inspired many doctors to look at this medical system.

1884-1961

He taught Kampo to several medical students from China University. Those students formed a study group; one of the students, Ken Fujihira (1914-1998) taught Katsutoshi Terasawa, who now teaches Kampo at Toyama Medical University.

Jusha Tsumura

not available

Founded Tsumura Juntendo in 1893 and established the Tsumura Research Institute for Pharmaceutical Science and the Tsumura Herbal Garden in 1924. Tsumura Juntendo would become the largest supplier of Kampo in Japan.

Tadanao Nakayama

not available

His book Kampo-igaku-no-shin-kenkyu (New Study of Kampo Medicine; 1927) inspired Keisetsu Otsuka and others to take up Kampo.

Onzu Nagakura

not available

Established the Nagakura Pharmaceutical Company, which developed the process for scientifically prepared dried herb extracts.

1889-1978

Established the Naito Museum of Pharmaceutical Science and Industry in 1971, providing historical information about medicine in Japan. The museum has over 6,000 books, including many ancient scrolls.

1900-1980

Studied herbal medicine under Kyushin Yumoto; started Kampo practice in 1931, founded the Oriental Medicine Research Center at the Kitasato Institute and founded the Japanese Society for Oriental Medicine.

Gonzan Goto

Shuan Kagawa

Kenzo Okumura

Toyoji Naito

Keisetsu Otsuka

1899-

Medical doctor who began study of Kampo in 1934 under Soguru Nietsuma; clinical director and organizing member of the Japanese Society for Oriental Medicine. Established the Hosono Clinic in Kyoto.

Domei Yakazu

1905-

He practiced Kampo for over 50 years, became Director of the East Asia Medical Association of Japan, and wrote numerous articles and books on Kampo. He has been the main proponent of the Goseiha School in modern Japan, which is continued now by his son Keido Yakazu (1933-).

Takahide Kuwaki

1916-

Well-known clinician and lecturer in Japan, he had been Vice President of the Oriental Medicine International Institute for many years.

Hong-yen Hsu

1917-1991

First Director of the Bureau of Drug Control (Taiwan), founder of Sun Ten Laboratories, Brion Research Institute, Oriental Healing Arts Institute, and Brion Herbs Corporation. Learned Kampo from Keisetsu Otsuka. His son, Chau-shin Hsu, helped translate and edit books and articles on Kampo and manufacture Chinese herb extracts (he is currently in charge of manufacturing in the U.S.).

Arichi Shieru

1922-

Studied Kampo under Hosono Shiro; became Professor at the Institute of Oriental Medicine, Kinki University.

Toyohiko Kikutani

1933-

He was Director of the Japan Society for Oriental Medicine, lecturer at Showa University, and superintendent at Kikutani Hospital.

Katsutoshi Terasawa

1944-

Current Director of the Japan Society for Oriental Medicine, Professor at Toyama Medical and Pharmaceutical University.

Shiro Hosono

Table 2: Examples of Chinese Formulas Frequently Used in Kampo. Most of the two dozen formulas are listed in the Shanghan Lun and/or the Jingui Yaolue , a few are from the Hejiju Fang, and only 3 are from other ancient texts. Pinyin transliteration of the Chinese name, rather than transliteration of the Japanese name is provided because these are the names usually used in the West. Common Name and Pinyin

Ingredients

Typical Applications

Bupleurum and Cinnamon Combination Chaihu Guizhi Tang

bupleurum, scute, pinellia, ginseng, cinnamon, peony, ginger, licorice, jujube

Combined internal and surface disorders; mainly respiratory system diseases; also for epilepsy.

Bupleurum and Dragon Bone Combination Chaihu Jia Longgu Muli Tang

bupleurum, scute, pinellia, ginger, hoelen, cinnamon, ginseng, jujube, dragon bone, oyster shell, rhubarb

Disorders involving mental distress or tremors.

Bupleurum and Peony Formula Jiawei Xiaoyao San

tang-kuei, peony, atractylodes, hoelen, Liver diseases and menopausal bupleurum, moutan, gardenia, licorice, syndrome; also general damp-heat ginger, mentha disorders.

Capillaris and Hoelen Formula Yinchen Wuling San

capillaris, hoelen, atractylodes, alisma, polyporus, cinnamon

Hepatitis, especially with jaundice; edema.

Cinnamon and Hoelen Formula Guizhi Fuling San

cinnamon, hoelen, peony, persica, moutan

Gynecological diseases and numerous symptoms associated with blood stasis.

Coix Combination Yiyiren Tang

ma-huang, tang-kuei, atractylodes, coix, cinnamon, peony, licorice

Arthritis and muscular rheumatism, especially early stage.

Coptis and Scute Combination Huanglian Jiedu Tang

coptis, scute, phellodendron, gardenia

Febrile diseases, inflammation, flushed face, bleeding due to heat.

Four Major Herbs Combination Si Junzi Tang

ginseng, licorice, hoelen, atractylodes

Weakness of spleen/stomach system, indigestion, diarrhea.

Ginseng and Ginger Combination Renshen Tang

ginseng, ginger, atractylodes, licorice

Weakness of the spleen/stomach system, chronic gastritis, chilliness.

Ginseng and Tang-kuei Ten Comb. Shiquan Dabu Tang

ginseng, astragalus, atractylodes, peony, hoelen, rehmannia, cnidium, cinnamon, licorice, tang-kuei

General debility, weak immune system, prolapse of internal organs, poor digestion.

Ginseng Nutritive Combination Renshen Yangrong Tang

ginseng, atractylodes, astragalus, licorice, tang-kuei, peony, rehmannia, hoelen, cinnamon, citrus, polygala, schizandra

Anemia, fatigue, general weakness, poor nutritional status, insomnia, dry skin.

Hoelen Five Formula Wuling San

hoelen, atractylodes, alisma, polyporus, cinnamon

Edema with thirst.

Ma-huang and Apricot Seed Combination Ma Xing Gan Shi Tang

ma-huang, apricot seed, gypsum, licorice, morus

Cough accompanied by sore throat and thirst.

Major Bupleurum Combination Da Chaihu Tang

bupleurum, scute, pinellia, ginger, chih-shih, peony, rhubarb, jujube

Liver and/or gallbladder inflammation, constipation and fullness.

Minor Blue Dragon Combination Xiao Qinglong Tang

pinellia, ma-huang, cinnamon, peony, schizandra, asarum, licorice

Acute ailment with watery sneezing, such as common cold.

Minor Bupleurum Combination Xiao Chaihu Tang

bupleurum, scute, pinellia, ginseng, ginger, licorice, jujube

Alternating fever and chill, digestive disturbance, hepatitis, bronchitis.

Peony and Licorice Combination Shaoyao Gancao Tang

peony, licorice

Muscular tension, especially of the abdomen.

Persica and Rhubarb Combination Tao He Chengqi Tang

persica, rhubarb, cinnamon, mirabilitum, licorice

Abdominal masses, constipation.

Pinellia Combination Banxia Xiexin Tang

pinellia, ginseng, coptis, scute, ginger, Diarrhea with frequent bowel licorice, jujube movements.

Pueraria Combination Gegen Tang

Acute ailments marked by aching in pueraria, ma-huang, cinnamon, peony, the arms and shoulders, lack of ginger, licorice, jujube perspiration, sinus congestion.

Rehmannia Eight Formula Bawei Dihuang Tang

rehmannia, hoelen, alisma, dioscorea, cinnamon, aconite, moutan, cornus

Urinary system disorders, impotence, hypertension, back ache.

Siler and Platycodon Formula Fangfeng Tongshen San

tang-kuei, peony, gardenia, cnidium, forsythia, schizonepeta, siler, talc, mirabilitum, ma-huang, ginger, rhubarb, atractylodes, mentha, platycodon, scute, licorice, gypsum

Obesity, skin rashes and eruptions, constipation, edema, hypertension.

Tang-kuei and Peony Formula Danggui Shaoyao San

tang-kuei, peony, cnidium, atractylodes, alisma, hoelen

Pregnancy disorders, anemia, infertility, chilly limbs.

Vitality Combination Zhenwu Tang

aconite, ginger, atractylodes, hoelen, peony

Abdominal aching, usually with diarrhea; cold limbs, poor digestion, lack of vitality.

Table 3. Some Examples of Abdominal Signs and Corresponding Herb Formulas. Abdominal diagnosis (fuku-shin) has a primary function of determining whether there is deficiency or weakness (kyo), or excess, strength, firmness, or fullness (jitsu), to select the type of therapy needed (e.g., tonification or purging). Specific locations of swelling, hardness, fullness, or palpation will help determine which of several potential formulas to consider; the disease and symptoms further direct the selection of prescriptions. The interpretations of abdominal signs vary somewhat among the Japanese specialists. Abdominal Characteristic

Interpretation

Formulas

Thick abdominal wall, flexible to touch

Firmness confirmation; patient is usually well-set or obese.

Major Bupleurum Combination or Siler and Platycodon Formula, to reduce excess.

Thin abdominal wall, lack of flexibility

Weakness confirmation; patient lacks qi and blood.

Vitality Combination or Ginseng and Ginger Combination, to warm the interior, promote metabolism, and restore qi and blood.

Abdominal distention; resistant to Firmness confirmation; patient pressure due to distention may have constipation and gas.

Major Bupleurum Combination, to reduce the excess.

Chest distress; feeling of pressure in area of lower ribs

Firmness confirmation if firmness and pain with pressure applied below the sternum; weakness confirmation if soft and not painful with pressure.

Use bupleurum-containing formulas; use Major Bupleurum Combination or Bupleurum and Dragon Bone Combination for firm confirmation, Minor Bupleurum for weak confirmation.

Use pinellia formulas (e.g., Pinellia Combination) or formulas for dampness, such as Hoelen Five Formula or Four Major Herbs Combination.

Feeling of distress near the heart (sternum and just below sternum)

With deep palpation below the sternum, there is resistance, as if there is a swelling.

Tension and stress below the navel or feeling of emptiness and weakness at this site

Weakness confirmation associated Use Rehmannia Eight Formula. with kidney deficiency.

Hard swelling in the lower abdomen

Indicates blood stasis syndrome.

Use rhubarb formulas (e.g., Persica and Rhubarb Combination).

Hardness of central line

Feels like a hard substance when palpating the central line of the abdomen.

Above the navel, hardness indicates spleen weakness, use Vitality Combination; below the navel indicates kidney deficiency, use Rehmannia Eight Formula.

Umbilical pain

Patient reports pain with gentle pressure just above the navel.

Indicates muscle tension of an excess confirmation; use Pueraria Combination.

Umbilical weakness

Pressing in and around navel, the tissues are loose and there is easy movement, indicating weakness confirmation.

Use formulas with ginseng, such as Vitality Combination, Ginseng and Ginger Combination, or Four Major Herbs Combination.

Abdominal muscle tension

Rod-like tension on either side of the central line or twitching of abdominal muscles indicates weakness confirmation.

Peony and Licorice Combination.

Figure 1: Shosoin, the ancient repository for an 8 th Century collection of herbs from China.

Figure 2: Gonzan Goto (1659-1733); illustration from the book Portraits of Distinguished Physicians in Earlier Japan.

Figure 3:Genetsu Kagawa (1700-1777), from the Kagawa family collection.

Figure 4: Seishu Hanaoka (1760-1835), on display at the Naito Museum of Pharmaceutical Science and Industry in Kawashima Japan.

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Towards a Spirit at Peace Understanding the Treatment of Shen Disorders with Chinese Medicine by Subhuti Dharmananda, Ph.D. About the Title Illustration Postscript Chapter One What Is Shen (Spirit)? Chapter Two A Mind that Is Free Chapter Three Emotional Equilibrium Chapter Four Acupuncture Points Chapter Five Acupuncture Treatment Protocols Chapter Six Xuedao Zheng, Bahie Bing, Meihi Ming Chapter Seven Herbs Chapter Eight Traditional Herb Formulas Chapter Nine Sample Herbal Treatment Strategies Chapter Ten Summary, Speculation, Suggestions Appendix Quick Reference to Herb Names

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Zen Shiatsu The Legacy of Shizuto Masunaga by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Shiatsu refers generally to a Japanese pressure therapy used to relieve a variety of problems including back pain, neck and shoulder problems, stress, insomnia, digestive problems, and fatigue. It is based on traditional Chinese medicine techniques, particularly massage therapy that has been recommended since ancient tmes, with certain Japanese innovations. Shiatsu acquired its name with the publication of Tenpaku Tamai's book Shiatsu Ho (Shiatsu Method) in 1919. As a technique separate from other manual therapies, such as Anma (which had been developed in Japan during the 17 th century), shiatsu was officially recognized by the Japanese government with a series of laws passed during the period 1955-1964. Its recognition and spread resulted mainly from the efforts of Tokujiro Namikoshi, the founder of modern shiatsu (sometimes called Namikoshi Shiatsu). Namikoshi was author of the book Do It Yourself-3 Minute Shiatsu , which became a best seller; he appeared on television to promote his technique, and used the catch phrase: "All you have to do is press." At that time, finger-pressure was the primary technique of shiatsu. Zen is one of the sects of Buddhism; it involves training the mind through meditation. The fundamental purpose of Zen is to achieve total enlightenment through the discovery of one's basic nature. Its principles and approaches can be applied to numerous human endeavors. Many aspects of Japanese culture have been influenced by Zen, including archery, aikido, judo and other martial arts, gardening and architecture, tea ceremony, calligraphy, and haiku (Japanese poetry). In this case, it is applied to massage therapy. Zen Shiatsu was established by a Shizuto Masunaga (1925-1981; see Figure 1), who was born into a family of Shiatsu practitioners. After studying psychology, he decided to pursue shiatsu as well. While reading the classic medical texts, he investigated the practical clinical aspects of shiatsu. Masunaga became a professor of psychology at Tokyo University and, at the same time, he taught psychology at the Japan Shiatsu School. During the late 1970s, one of his new students, Wataru Ohashi, brought Masunaga to the United States, where he provided some teachings in New York and San Francisco. Masunaga then wrote two books about his theoretical framework for Zen Shiatsu and its practical applications, including Zen Shiatsu: How to Harmonize Yin and Yang for Better Health (written with the help of Ohashi; see Figure 2), and Meridian Exercises, which described yoga-like exercises for self-help in maintaining internal balance and good circulation. Zen Shiatsu is a form of bodywork administered by thumbs, fingers, palms and elbows, feet and knees. It depends for its success on a meditative activity of the practitioner, aimed especially at detecting the body responses to the treatment, which influences the subsequent treatment step by step. Pressure is applied to all parts of the body along specific pathways (meridians). These are essentially the same meridians that are used in traditional Chinese medicine for acupuncture, though modified and extended by Masunaga (so they are sometimes called Masunaga Meridians; see Figures 3-6). It is understood that this technique stimulates the natural healing powers of the body, wherefore symptoms of disease lessen and vitality is regained. The professional Zen Shiatsu therapist is trained to feel the body's condition, particularly the circulation, by his/her hands in order to find the imbalanced areas in the body. By skillfully stimulating the imbalanced meridians, the therapist attempts to restore the balanced flow. From the Western point of view, shiatsu works directly to calm the autonomic nervous system, which has the effect of calming nervous distress and increasing resistance to stress. By helping with blood and lymph circulation in the body, shiatsu helps to maintain and improve muscle tone and healthy internal organ functions. It is believed that shiatsu can also strengthen the immune system. Regular and consistent shiatsu treatments can become an important aspect of preventive health care as well as treatment for existing symptoms. Zen Shiatsu is ideally performed while the recipient lies on a futon on the floor, allowing the practitioner access from all sides and the ability to apply pressure using body weight (as opposed to pushing just with finger pressure, as may be done with other shiatsu techniques; see Figure 7). The shiatsu recipient should be dressed comfortably with light clothing. No massage oils or lotions are used or needed because the practitioner does not slide along the body surface, but gives a series of presses along the pathways.

BASIC CONCEPTS

Consistent with the basic concepts of traditional Chinese medicine, Zen Shiatsu is grounded in the theory that health problems are attributed to, or at least involve: imbalances in yin and yang; disharmonies between the internal organs; and blockages to the circulation of ki (in Chinese: qi; in English: chi) through the meridians. The unique features of Zen Shiatsu, compared to traditional Chinese medicine techniques such as acupuncture or other shiatsu techniques, are these: For diagnosis, abdominal palpation is the primary technique used. Abdominal diagnosis (in Japan: hara diagnosis) is an ancient Chinese technique that had been largely abandoned in China, but became important in the practice of Kampo (the Japanese practice of Chinese medicine) around the beginning of the 18th century. Abdominal diagnosis is used in Japan for herbal medicine prescribing, acupuncture, and Zen Shiatsu. The diagnosis is primarily aimed at determining whether each meridian is relatively empty (Japanese: kyo, Chinese: xu) or relatively full (Japanese: jitsu; Chinese: shi). At the end of the treatment, the abdominal diagnosis is performed again to ascertain changes (improvements) that have occurred. Pressure is applied at intervals along the meridians that were described by Masunaga. He presented 12 meridians, corresponding to the 12 basic organ-affiliated meridians of the Chinese system. The meridian pathways are similar to, but not the same as, the Chinese ones; the main difference being an extension of each meridian to range from legs to arms, passing through the associated diagnostic region of the abdomen.

The treatment involves brief contact with each point, in a somewhat rhythmic pattern as a portion of a meridian is traced. The contact is with fairly strong pressure that is applied using the movement of the practitioners body, fingers, elbows, and other parts of the body. To attain the proper combination of pressure and movement along the meridian, the practitioner may move frequently around the recipient's body and may even move the recipient (who is instructed to remain passive), such as lifting the head or arms. The actions may include turning or bending the recipient's body parts with the purposes of gaining access to essential points, stretching the meridians, and using gravity or leverage to attain the needed pressure at certain points. The therapy does not focus on one part of the body, even if the health problem is localized; the whole body becomes involved. The practitioner works within a meditative state, focusing on the responses of the recipient so as to properly direct the therapy, as opposed to focusing on selection of pressure points by a theoretical system. To develop this condition of heightened awareness and clear intention, the practitioner practices meditation regularly. Because of its connection to traditional Chinese medicine, Zen Shiatsu serves as an excellent adjunct to acupuncture therapy as well as Chinese or Japanese herb prescribing, fitting well with the theoretical framework. Further, it serves as a complementary therapy for Western methods of manipulation, including chiropractic or standard massage (e.g., Swedish style), providing an entirely different stimulus to the body. Although Masunaga's Zen Shiatsu is considered essential reading for practitioners, the main textbook of Zen Shiatsu used today is Shiatsu Theory and Practice by Carola Beresford-Cooke (first published 1996; revised edition 2002). She has outlined five basic principles of Zen Shiatsu as follows: 1. Relax. The practitioner must be in a comfortable physical and mental condition to convey comfort to the recipient; the arms, hands, neck, and shoulders must be relaxed, not tensed, to give the proper treatment and to perceive the recipient responses. 2. Use penetration rather than pressure. It is understood that the body has spots (called "tsubo") that can receive the pressing by the practitioner; the muscle gives way to the penetrating force to let it enter, rather than being pushed away by pressure. The result is an entirely different experience than mere finger-pressing, and requires that the practitioner have the correct body position in relation to the recipient and be mindful of the technique being used. 3. Perpendicular penetration without side-to-side motion. Unlike many massage techniques where movement across the surface is emphasized, Zen Shiatsu involves penetration at each point, perpendicular to the body surface. Although there are a few exceptions, the treatment does not involve rotation, back-and-forth, or wiggling movements of the hands, but simple direct inward-directed movement. 4. Two handed connectedness. The Zen Shiatsu practitioner maintains two hands on the recipient's body; one hand may be still and holding a part of the body in position, while the other is active, penetrating points on the meridians. The practitioner is advised to give attention to the role of both hands, not just the more active one. 5. Meridian continuity. The focus of the therapy is to treat an entire meridian, not just individual points or regions. This is based on the theory that the imbalances to be addressed are based in the meridians, which require a free flow of ki throughout.

Figure 1. Shizuto Masunaga (1925-1981).

Figure 2. Masunaga's primary text: Zen Shiatsu.

Figure 3. The Meridians Of Masunaga's Zen Shiatsu.

Figure 4. Masunaga's Meridians at the Head.

Figure 5. Hara diagnosis chart based on Mubunsai's text of 1685.

Figure 6. A modern interpretation of a Hara diagnosis chart; a key to the abdominal diagnosis chart on the right is available at: http://www.yogawelt.com/haradiagnosis.html

Figure 7. Demonstration of Modified Zen Shiatsu at the London College of Shiatsu The style used at this college is from Takeo Suzuki who worked with Masunaga and taught Shiatsu at the Iokai Center before starting his own school in Tokyo. Suzuki further refined and developed the work of Masunaga for his own unique style.

December 2002

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AN EPIDEMIC OF SINUS DISORDERS NATURAL TREATMENT WITH AYURVEDIC METHODS Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

There seems to be an “epidemic” of sinus problems in America. Each year, hundreds of thousands undergo surgery to clear sinuses that are so severely blocked, often as the result of infections resistant to drug treatment, that there seems to be no other way out. Millions take antibiotics and other prescription drugs to clear, or attempt to clear, repetitive infections and/or to alleviate the intense congestion caused by irritants and allergies. Prescription decongestant drugs, such as the widely-used Seldane, have been shown to be potentially dangerous when mixed with certain antibiotics. There are tens of millions who purchase over-the-counter (OTC) remedies for their symptoms; some of the OTC drugs, such as those based on pseudoephedrine, can induce insomnia, while others, such as those based on common antihistamines, induce drowsiness. Several possible causes for these sinus problems can be suggested. Direct irritation of the sinuses might be blamed on cigarette smoking, a practice undertaken by 48 million Americans. Sinus irritation also arises from those who have used, or continue to use cocaine by inhalation of the powder (many millions of people in the past twenty-five years). There are those who work daily, or at least frequently, in dusty, dirty, or polluted areas, not just in inner cities, but on some farms, in mines, and in rural factories that refine natural resources. Abnormalities of the immune system, leading to allergy and/or reduced ability to fight sinus infections, may arise from early curtailment of, or the failure to provide any, breast feeding of infants. Immune dysfunction can also be the result of exposure to powerful chemicals and drugs, common nutritional deficiencies, and from irregular habits associated with eating and sleeping. A further contributing factor to sinus problems may be lack of vigorous physical activity: such activity dilates the sinuses and stimulates the circulation of air and cleansing mucus through the sinuses. All of these might be considered life-style and environmental factors that are characteristic of conditions for most people in the U.S. during the second half of the 20th century. Thus, it is not surprising to find the appearance of widespread nagging sinus disorders. There are three problems with the current remedies—such as drugs and surgery—that are most commonly applied to treating the disorder. First, they fail to correct the behaviors that contribute to the sinus problems, or even show direction towards behavioral modifications, so the disorder recurs. Second, they do not improve the body’s own mechanisms for rectifying such disorders; rather, they temporarily force a change that gives symptomatic relief. Third, for some people there are side-effects of drugs and complications from surgery. One avenue towards a possible solution is to rely on traditional medicine: a continually evolving approach to healthy life that can be traced back to ancient times, but which illuminates current options for natural health care. Here is an example. INDIA AND AYURVEDIC MEDICINE India is the ancient source of our own language, the source of great art, and the widespread Buddhist religion. From India we have gained the popular yoga exercises, much of the West’s approach to vegetarian diet, the strategy of non-violent revolutionary change inspired by Ghandi, and the natural medical approach known as Ayurveda. In ancient times, the knowledge of wise living was set down in a group of teachings (vedas: collections of knowledge and wisdom), including the one that is the source of traditional medicine in India—Ayurveda (ayur, meaning to know. Ayurveda is knowing the great wisdom, and, thereby, having a long, healthy life; it is often translated into English as the “science of life”). Today, more than 2,500 years after the earliest records of this medical system were produced, it is a popular means of health care in India and, increasingly, throughout the world (1). Within the system of Ayurveda there is a rich heritage of herbal knowledge (2). This knowledge, when applied with the sophisticated system of diagnostics and therapeutics, can be a powerful tool towards relieving many of the ills that affect us today. As importantly, these effective methods can be a guiding light towards understanding a healthful lifestyle. AYURVEDIC UNDERSTANDING OF SINUS DISORDERS From the point of view of trained Ayurvedic physicians, many of the sinus problems experienced today have their root in the digestive system, especially the stomach and upper small intestine, which directly receives partially-digested food from the stomach. That is to say, the nasal irritants, the immune system disturbances, and other contributors to sinus problems that we can identify, are producing frequent symptoms—some of them quite serious—because of an underlying digestive disorder in many instances. This digestive problem is described more specifically as a weakness in the digestive fire; in Ayurvedic terminology (3), the problem i s manda agni: dampened ability to transform and metabolize. Agni is one of the five elements (bhutas) that combine to form the physical realm and the human body: agni is the fire element. Within the body there are many metabolic processes, or agni, and the one that is particularly of concern here is called the jathar agni, or the metabolic processes of the stomach and upper small intestine. From the modern scientific viewpoint, one might describe the hydrochloric acid and other digestive substances in the stomach, as well as the enzymes fed into the jejunum (upper small intestine) by the pancreas, as the essential components of digestive capability. The insufficient activity of these digestive fluids corresponds, roughly, to manda agni. Why is this a problem in relation to the sinuses? Because the food is not as quickly and as thoroughly digested as it should be, leading to production of byproducts that affect the sinuses. According to the traditional understanding, ingested food becomes divided into two portions: one is pure (aharaprasada) and is the one that is used to nourish the body, while the other is the refuse ( mala), that which remains after the pure portion is drawn off. The result of inadequate digestive fire is that some of the substances that should be separated and removed from the food end up accumulating. This material, called ama, is unusable for normal physiological processes. These substances contribute to an increase in phlegm. In the Ayurvedic system of diagnosis and classification of imbalances, phlegm is the substance associated with one of three transporting systems, or humors, called doshas: kapha, pitta, and vata (see: Basics of Ayurvedic physiology). Kapha is the transporting system for certain fluids (other than blood), collectively called phlegm. These fluids are critical to maintaining health. The normal mucus lining all of the membranes of the body is protective, lubricating, and cleansing. It could be said that because of the weakened

agni of the digestive system, kapha has an overabundance of fluid, including some fluid that is of undesirable nature. An overabundance is an imbalance and is unhealthy: the body needs to get rid of it, but the secretion mechanisms for ridding excess can eventually be overwhelmed. The fluid has several potential sites for accumulation. The reason that it accumulates in the sinuses for some people (but elsewhere for others) is because there is a disturbance there. That disturbance could be the irritation from ragweed pollen, cigarette smoke, or other compounds; it could be from the lack of normal movement of air and mucus due to inadequate exercise; it could be because of the effect of emotions on the respiratory system. Such causes are the immediate disease-inducing factors, known to Ayurvedic physicians as nidanas. Kapha is described as the dosha of phlegm, which is a combination of the water and earth elements (water contributes the fluid quality, earth the murkiness and thickness). The accumulation of phlegm in the sinus area disturbs another of the three transporting systems: vata. Vata is the dosha of air. The lungs and sinuses are directly involved in transport of air, and they regulate the prahna vata (air vata); there are other aspects of vata that affect the body and are regulated elsewhere. The prahna vata becomes agitated by the obstruction of phlegm, as it is unable to maintain smooth flow (it is said to be vitiated). When there is a disturbance, the smooth flow is transformed into an agitated flow, like the wind. Vata is derived from the air and ether elements (air is the substance, and ether is the space through which the air flows to yield its fundamental characteristic: movement). The third transporting system, or dosha, is called pitta, and this is the transporter of metabolic nutrients and the energy of metabolism. One aspect of pitta, called pachak pitta, corresponds to digestive fire. Pitta is described as the dosha of fire. In many cases of sinus problems, there is a weakness or deficiency in pitta (as it manifests in the agni of digestion), an excess in kapha (as it manifests in mucus), and a disturbance of vata (as it manifests in the breath). Thus, all three doshas are imbalanced and contribute to the sinus disorder that is experienced. Over time, if the accumulation of phlegm and disruption of air flow continues, it distorts the entire tissue structure of the face. Muscles become tense, nerves become pinched, and even the bone structure becomes compressed: one experiences tightness and pain. From the viewpoint of Ayurveda, this is because the disturbance of the doshas has led to a distress of the dhatus: the structural components of the body. There are seven dhatus recognized by traditional practitioners, including the mamsa dhatu (muscle), the majja dhatu (nerves), and the ashti dhatu (bone). It is suggested that the distortion of facial structures by chronic sinus problems, in addition to maintaining the sinus congestion, can lead to weakening of vision, premature greying of hair, and wrinkling of the skin. MASSAGE THERAPY An important step in remedying the chronic sinus disorder is external oeliation, or, more simply, oil massage (4). This massage will soften the structures (dhatus) that have been distorted by the imbalanced transporters (doshas). Head massage (champi) is considered very important in the Ayurvedic system and it is used to prevent kapha from accumulating in the head (among other things, used for common cold, sinusitis, and headaches). For sinus disorders, the massage is carried out by applying a medicated oil. Oils in general, and sesame oil in particular, have the ability to calm the agitated vata dosha. That is because the qualities of this oil counter the qualities of vata. In fact, oil massage is sometimes called snehana, which means to apply oil to control vata. Vata is described as having the qualities (among others) of lightness, coldness, irregularity, and dryness. By contrast, the sesame oil is heavy, warming, smooth, and, of course, oily; thus, it counteracts the excessive impact of vata characteristics when the vata is disturbed. Facial massage with oil alleviates the accumulation of kapha and calms the vata. Medicated oil, such as narayan oil or mahanarayan oil, enhances the influence of the massage. The herbs in mahanarayan oil (of which there are about 50) and narayan oil (which has a smaller number of the herbs) are selected to help soften the obstructions (distortions of the dhatus) that occur from long-term dosha imbalances. The main ingredient of the narayan oils is shatavari (Asparagus racemosus). The oil is also used topically to treat rheumatism, stiff neck, hemiplegia, and various nervous system disorders. Mahanarayan oil is selected for the massage treatment when the sinus blockage is extreme; narayan oil is otherwise selected. For maximum effectiveness, the oil is applied warm (which is more comfortable, more fluid, and more able to transport the herb ingredients into the skin than cold oil) to specific points on the face that are the key areas of circulation. These points, called marma points, have been described in the early Ayurvedic literature. They are much like the acupuncture points of Chinese traditional medicine, and, in fact, one can massage both the Indian marma points and Chinese acupoints with good effect. Marma points are juncture points (4, 5), rather than points along meridians as found in Chinese medicine. There are a total of 107 critical marma points on the body, divided into five groups: muscle (11 points), vessels (41 points), ligaments (27 points), bones (8 points), and vulnerable joints (20 points). There are 11 points on each leg and each arm (total of 44), 12 in the region of the chest and abdomen, 14 on the back, and 37 in the region of the neck and head. These points are valuable treatment sites, and, according to traditional understanding, if the junctures are physically damaged it can have significant negative health impact—in some cases, causing death. As has occurred with Chinese acupuncture points, the basic set has been expanded by some practitioners; some, such as Frank Ross (6), have advocated a complete combining and integration of the Chinese and Ayurvedic points. A few drops of oil are sufficient to provide herb extractives and lubrication for the massage. After the facial points (about a dozen or so) are massaged, the oil is spread across the entire face in broad strokes. The massaging of the marma points and the whole face stimulates the body to eliminate accumulations. It helps the dhatus—the structures which hold onto substance—to release. It calms and regulates the vata. For an illustrated guide to the basic facial massage, see Johari’s recent publication on Ayurvedic massage (4). To enhance the action of this massage, the person being treated is kept comfortable by placing a hot water bottle under the neck, on the abdomen (over the intestines), and on the feet. The heat has a relaxing effect and promotes circulation. Further, after applying the oil each time—a process that is repeated three times—a heated towel is placed on the face, helping the blood vessels and pores to expand and accept the herb ingredients. NASYA: NASAL INHALATION OF HERBS After two applications of the oil to the marma points and to the face as a whole, a few drops (typically 5) of medicated oil is placed in each nostril (the person being treated inhales the oil). This portion of the treatment is known as nasya. The hot water bottle under the neck assists the person in comfortably extending the neck so that the nose points up and back, allowing the oils to flow towards the sinuses. For the treatment of sinus congestion, a typical medicated oil is calamus and ginger extract in sesame oil. This oil strongly opens the congested tissues of the sinuses and breaks up the phlegm (in the event that a person has a feverish condition, cooling coconut

oil is sometimes used to replace sesame oil; when the oils are not available, calamus powder can be inhaled as a snuff). Following this, there is the third application of oil to the face, and then the excess oil on the skin can be removed by a warm, moistened towel. The nasal passages can also be massaged on a daily basis by the individual suffering from sinus problems. For this method, Dr. Lad (7) says “Dip the clean little finger into the appropriate oil and insert into each nostril as deeply as possible [he cautions about both sharp fingernails and forceful insertion]. The nasal passage is then lubricated through this gentle massage. Nasal massage helps to relax the deeper tissues and can be done every day or any time one is under stress....By this means, the emotions that are blocked in the respiratory tract are released” For stressful situations, when the sinuses are not overly congested, one can use brahmi oil (which is made from gotu kola or bacopa in sesame oil base) or clarified butter (ghee). Softening the dhatus, cleansing the overflowing kapha (see below), and calming the vata, are the principles of treatment for the symptoms of sinus problems. The treatment, which generally requires having two oils (one for facial massage and one for use in the nose) and a minimum of accessory equipment (hot water bottles, warm towels, dropper), takes about 25 minutes, and it can be selfadministered if necessary. Additionally, small amounts of the medicated nasya oil can be inhaled again at intervals of several hours to give further relief. INGESTING HERBS, REGULATING DIET A key to ultimately eliminating the problem of sinus congestion is to invigorate the jathar agni. To accomplish this, one can swallow small amounts of herb combinations in the form of simple powder (which can be encapsulated or tableted for convenient administration). The most common treatment for dampened digestive fire is the powder known as Hingushtaka, a spicy blend of asafoetida (Ferula asafoetida), ginger, black and long peppers, and other herbs. A modification of this formula, called Shivakashar Panchana, is made by adding haritaki (Terminalia chebula ) and a small amount of sodium bicarbonate, and is selected when there is evidence of obvious lung weakness, such as asthma and bronchitis, when rales are heard through a stethoscope. Either formula will treat indigestion, gas, bloating, and accumulation of ama, the unusable substance that arises when food is not fully digested. For those who are sensitive to spicy herbs (such as persons with ulcers), an alternative formula can be used, such as the combination of licorice and turmeric. Licorice pacifies the overexcited fire (pitta vitiation), while turmeric smoothes and promotes the essential digestive fire (agni). The combination of these two herbs is used to treat hyperacidity, excessive appetite, irritation and inflammation of the stomach and esophagus. The total treatment for the sinus problem is to increase the digestive fire, penetrate the areas of blockage, and eliminate the accumulation by regulating the doshas and modifying the dhatus. To retain the benefits of this treatment, one should be careful in eating habits to avoid weakening the digestive fire. According to Ayurvedic principles, one should avoid chilled foods and foods that are classified as having a cold nature, as these will further reduce the digestive fire while contributing to the vata imbalance. One should also minimize phlegm-increasing foods: milk products and fatty meats, such as pork and lamb, are examples. These foods can exacerbate the kapha accumulation in the head. And, of course, one should be careful to avoid irritating the sinuses with smoke, chemicals, or dust. In this article, one of the most common patterns for development of sinus disorders has been presented, with the basic types of therapy to be applied, using specific examples of massage oils, nasya ingredients, and herb/diet suggestions. For an individual, one must check to see that this pattern is an appropriate depiction, or else adjust the treatment details correspondingly to the results of the analysis. Dr. Vinod Verma (1) presents some alternative approaches for sinusitis, such as jel neti, the yogic method of sinus cleansing by pouring water or milk into the nostrils, and the inhalation of highly aromatic mixtures (e.g., eucalyptus, menthol, camphor, lavender, anise). As one becomes familiar with the basic concepts of Ayurveda, health problems due to imbalances in the body can be detected before they become severe and can be treated easily through herbs, diet, and lifestyle modifications, rather than pursuing an endless course of drugs and surgery. ACKNOWLEDGMENT The treatment method for sinus disorders described in this article, and much of the explanation for its functions, is based on information provided by Kim McCarthy, a massage therapist specializing in Ayurvedic medicine; McCarthy practices and teaches in Portland, Oregon. I wish to thank Husaini Ali, of Universal Medicaments, and Dr. K.S. Kundley, of the Poddar Ayurvedic Hospital, for providing suggestions about the treatment methods, materials used, and Ayurvedic principles, some of them outlined elsewhere (3). REFERENCES 1. Verma V, Ayurveda: A Way of Life, 1995 Samuel Weiser Press, York Beach, ME. 2. Nadkarni KM, Indian Materia Medica, 1908 (revised and enlarged 1954), Bombay Popular Prakashan, Bombay. 3. Dharmananda S, Basic principles of Ayurvedic physiology, 1997 START Group Manuscripts, Portland, OR. 4. Johari H, Ayurvedic Massage, 1996 Healing Arts Press, Rochester, VT. 5. Kutambiah P, Ancient Indian Medicine, 1962 (revised 1969) Orient Longman, Bombay. 6. Ross F, Lost Secrets of Indian Acupuncture, 1994 Lotus Press, Twin Lakes, WI. 7. Lad V, Ayurveda: The Science of Self-Healing, 1984 Lotus Press, Twin Lakes, WI. February 1997





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RESOURCE GUIDE FOR TIBETAN MEDICINE by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The practice of Tibetan medicine has hovered near extinction for the past forty years, though there are increasing efforts under way now to preserve it, with some success. This active tradition was suddenly disrupted in the 1950’s with the Chinese communist invasion of Tibet, followed by destruction of the monasteries, the killing of the Tibetan monks and professionals, and forced exile of the leadership. The main medical school, founded in 1696 A.D., was built on Iron Hill (Chakpori) opposite the Potala Palace in Lhasa; it was reduced to dust by the shelling of the Chinese army when rebellious monks took refuge there in 1959. A second school, Men-TseeKhang, was built in Lhasa in 1916, founded by Kyenrab Norbu (1883–1962), on the plains nearby the Potala. It was intended to adapt Tibetan medical education to the demands of the 20th Century. The school has not been destroyed and continues to operate, though only a few remaining elderly Tibetan doctors are available to provide the original teachings. A combination of Tibetan and Chinese medicine is now taught and practiced, but due to limitations of resources, new doctors graduate with less training than in earlier decades, as they readily admit. Under the direction of the Dalai Lama, the Tibetan Medical and Astrological Institute, also known as Men-Tsee-Khang, was established in Dharamsala in 1961 as a school where Tibetans in exile could receive Tibetan medical training towards becoming a doctor. Dr. Trogawa Rinpoche also established a small school in Darjeeling that was intended to follow the Chakpori tradition, of which he is a lineage holder. This school was eventually incorporated into Men-Tsee-Khang in order to maintain uniformity of the student’s education and evaluation. Most of the older doctors who escaped from Tibet, and who are still able, are constantly traveling in order to maintain some international awareness of Tibetan medicine. The center in Dharamsala is limited by lack of funds and also by lack of access to some of the medicinal plants that grow in Tibet but not in Nepal and north India. Small remnants of the once thriving Tibetan medical tradition live on in Mongolia, Russia, and along the Himalayan range in small nations, such as Ladakh, Bhutan, Sikkim, and Nepal. A major effort to preserve the main body of Tibetan medicine has been undertaken by several individuals, and there is now a more unified effort. Below are listed some of the centers of Tibetan medicine preservation and promotion. GENERAL International Trust for Traditional Medicine (ITTM) Vijnana Niwas Madhuban Kalimpong 734 301 West Bengal, India ITTM (a Public Charitable Trust founded in 1995) publishes a periodical on Indo-Tibetan and allied medical cultures, called Ayurvijnana, twice a year. The articles can be viewed from their excellent internet site at http://www.kreisels.com/ittm. ITTM has its own trial plots of land for the cultivation of traditional medicinal herbs under biodynamic conditions. It brings in scholars and researchers to work on Tibetan medical manuscript translation and related projects, and encourages volunteers with sustained interest in traditional medicine to work on its various projects. The Founder Trustee, Barbara Gerke, who has been researching Tibetan and allied medicine in India for almost ten years, is in charge of the center. Donations will be gratefully acknowledged in its publications and may be sent to the above address, preferably by cashier’s/banker’s check.

The New Yuthok Institute Dr. Pasang Yontan Arya Viala Spagna 77 20099 Sesto S. Giovanni Milano The New Yuthok Institute promotes the study of Tibetan medicine and offers courses for trained medical practitioners in Italy, Switzerland, and Germany. The organization is headed by Dr. Pasang Yontan Arya, who was born in Tibet in 1955 and studied Tibetan medicine at the Tibetan Medical Institute in Dharamsala. Dr. Arya later worked at the Tibetan Medical Institute as a pharmacist, professor, and, eventually, director. In Italy, Dr. Arya is conducting beginner and advanced courses; there are also Swiss and German seminars. 1996 saw the first graduating class of the 4-year course. Phone and Fax in Italy: 0039-02-25 362 66. The New Yuthok Institute has put a “virtual library” of Tibetan medicine on the internet, accessible at: http://home.t-online.de/home/520097278994-0001/yuthog/engl/medicine.html. ACCESS TO TREATMENTS Institute for East-West Medicine 102 East 30th Street New York, New York 10016 The Institute for East-West Medicine is associated with the Meridian Medical Group, which provides medical treatments that include Chinese, Ayurvedic, and Tibetan medical methods. Dr. Choyang Phunstok is the resident Tibetan doctor; he is formerly an instructor at the Tibetan Medical Institute in Dharamsala. Dr. Raymond Chang is the director. For access to treatments at the center, call 212-6831221 (fax: 212-683-1083). Traditional Tibetan Healing, Inc. 231 Holland St. Somerville, MA 02143 This center specializes in Tibetan medicine and also provides other alternative health care services. The clinical director is Keyzom Bhutti, who graduated from the Tibetan Medical Institute; she served as chief physician at the Tibetan Medical and Astrological Clinic in Darjeeling for 25 years. Phone: 1-617-666-8635 COURSES Shang Shung Institute P.O. Box 277 Conway, MA 01341 [also in Italy] The Shang Shung Institute provides courses in Tibetan medicine, featuring Dr. Thubten Phuntsog. A basic curriculum in Tibetan Medicine is tentatively planned to begin in January, 2000. Dr. Phuntsog was born in Eastern Tibet in 1956; he studied medicine at the Pelpung Monastery. He held faculty positions in Sichuan (China) from 1986 until he traveled to the West; he offers courses in the U.S. and Italy. Phone: 413-369-4928; fax: 413-369-4165

Tibetan Medical and Astrological Institute [Men-Tsee-Khang] Gangchen Kyishong Dharamsala 176215, India [also in Darjeeling, see below] TMAI provides full clinical training (five years) towards becoming a traditional Tibetan physician. The courses are taught in the Tibetan language, so fluency is required; however, there are occasional seminars with an interpreter for Westerners. The medical practitioners at the facility include Dr. Tenzin Choedrak (born in Tibet in 1922), Dr. Tenzin Dakpa (born in Himachal Pradesh, India in 1963), and Dr. Dawa (born in Lhasa, 1958). Phone: 91-1892-22618; fax: 91-1892-22457. TMAI also operates 40 outpatient clinics throughout India and Nepal. TMAI has prepared a website giving background information on Tibetan medicine: http://www.tibet.com/Med_Astro/tibmed.html. Chakpori Tibetan Medical Institute Trogawa House North Point Darjeeling 734104 West Bengal, India The Chakpori Institute has a teaching center for Tibetan Medicine, the Three Pillars School (the Three Pillars = school, pharmacy, and clinic), in West Bengal and sponsors lectures in Darjeeling. As with the TMAI school in Dharamsala, the courses are in Tibetan. The Founder and Director of the Chakpori Institute is Lama Dr. Trogowa Rinpoche. The Chakpori Institute has undertaken a project to investigate plant preservation and cultivation in Sikkim and surrounding regions. For more information, contact the Institute and request their newsletter about aims and projects: Chakpori News. PLANT PRESERVATION/CULTIVATION Tibetan Plateau Project 300 Broadway, Suite 28 San Francisco, California 94133 TPP investigates the status of traditional medicine plants and methods of preservation. Membership in TPP can be obtained through their website and features updates and information via an e-mail newsletter. Contact TPP at: http://www.earthisland.org/tpp/tppframes.htm. Institute for Traditional Medicine (ITM) 2017 S.E. Hawthorne Portland, Oregon 97214 ITM provides funding and other support for a Tibetan and Ayurvedic Plant conservation and cultivation project in Nepal, headed by Joy Lawrence. Joy Lawrence graduated from the University of Oregon and has spent several months in Nepal organizing the project. ITM has a website with links to other sites of interest: http://www.itmonline.org.

TIBETAN MEDICINE IN RUSSIA Because of the aversion to religion that the seventy years of communism in Russia manifested, more than 150 Buddhist monasteries and temples of local Mongolian tribes were destroyed and thousands of lamas were killed or imprisoned. Each of the monasteries had a medical department or, at the least, a traditional doctor. The first Buddhist temple in Europe, built about one hundred years ago in St. Petersburg, as well as the Tibetan hospital and drugstore founded by the famous Badmajew family of doctors and translators, were closed. Professors from St. Petersburg University who belonged to the school of Tibetology were sent to Gulag camps. In St. Petersburg, Moscow, and Vladivostok there now are several small Tibetan medical centers where doctors carry on a living tradition that has persisted in Russia, sometimes in hiding, for nearly two centuries. The Siberian department of the Russian Academy of Sciences publishes translations of classical Tibetan medical texts and conducts research on the biochemical properties of Tibetan medicine components. A bibliography of Russian books and journal articles on the subject includes more than 400 titles. The Badmajew family eventually moved West; in Switzerland, a medical factory, Padma AG, has been producing modifications of the formulas brought by the Badmajews and marketing them as drugs in Switzerland. Research on the formulas, especially Padma 28 (called Adaptrin in the U.S.) has been sponsored in several countries, including Italy and Poland. TIBETAN MEDICINE IN THE U.S. Dr. Lobsang Dolma was one of the first to provide teachings of Tibetan medicine in the U.S., traveling and teaching during the 1970’s. Though she has passed away, her daughter, Dolkar Khangkar, has continued her long-standing family tradition of practicing Tibetan medicine, working at clinics in Delhi and Bombay. In 1987, the Society for Tibetan Medicine (established in New York) suffered the loss of one of its main proponents, Dr. Terry Clifford, and has been largely inactive, but Dr. Clifford’s book on Tibetan psychiatry ( The Diamond Healing) has influenced many who might not otherwise have approached this system. Dr. Lobsang Rapgay has worked at the Mind-Body Medical Institute in Los Angeles and has since moved to New York to carry on his work. Dr. Yeshe Donden has been offering formal training in Florida for several years; both Rapgay and Donden have published extensively in English. As noted above, the Shang Shung Institute has taken on the task of providing regular lectures on Tibetan medicine in the U.S. TIBETAN MEDICINE IN EUROPE In Venice and Milan, Italy, there are centers for Tibetan medical study and practice and a large library of Tibetan works. Trogawa Rinpoche, Ganchen Rinpoche, and Namkhai Norbu Rinpoche lecture on different aspects of spiritual and material healing arts, and Tibetan doctors, such as Tenzin Choedrak and Pasang Yonten, practice and teach the tradition in Italy and throughout Europe. At the University of Ulm in Germany, Dr. Juergen Aschoff has been studying the effects of Tibetan medicines on small groups of patients and has helped publish books about Tibetan medicine, including an extensive annotated bibliography on Tibetan medical literature in modern languages (1996). The full text of the bibliography can be read at: http://www.uni-ulm.de/~jaschoff. The New Yuthok Institute has branches in Naples and Rome, and Dr. Pasang Yontan, head of the Institute, also lectures by invitation in Switzerland and Germany. PLANT PRESERVATION EFFORTS Nearly all of Tibet is at high altitude, and although Tibetan doctors utilize many imported materials in making their medicines, the alpine plants that make up some of their treatments are not accessible in large enough quantities to serve as a basis for medical therapies applied to the huge modern population that might be interested in using them. Fortunately, Tibetan doctors believe whole-heartedly in the use of substitute materials with similar therapeutic action. Therefore, it appears possible to mimic Tibetan remedies using materials that are available from China, India, Russia, and the Middle East. Some limited efforts to preserve Tibetan herbs have been undertaken in Nepal and Sikkim. The following is derived from a statement by Tashi Trogawa and other members working at the Chakpori Tibetan Medical Institute regarding a proposal for replanting of wild herbs for cultivation in Sikkim (published in the Chakpori newsletter): Taking care of the rich environment of the Himalayas is the reason behind research, conservation, and replanting. From the point of view of Chakpori Tibetan Medical Institute, not only the biodiversity but also the quality and power of medicinal herbs is extremely important. Medicinal herbs are the raw materials of Tibetan medicines. There is a very long standing tradition in the use, the proper time of collection, the way to prepare, and the assessment of the herbs in this ancient way of healing. Tibetan doctors (Amchis) and pharmacists evaluate the quality of individual plants because not all specimens of a certain medicinal herb have the same quality and power. Depending on the quality, larger or smaller quantities of plants are needed to get the desired effect and result. Because all medicines are a composition of many medicinal plants, quantities of individual herbs within a formulation cannot easily be changed. Thus, as our major aim of replanting, we choose quality instead of quantity. To know which plants are vulnerable, endangered, or close to extinction, detailed studies have to be made. Also, the cause of rarity should be investigated (e.g., environmental causes, over-exploitation by non-expert gathering, etc.). An important decision has to be made to replant not only the economically valuable plants but also the plants that are environmentally valuable and supportive of the total environment. Replanting sites should have the same characteristics as the original habitat. In traditional Tibetan medical texts, the side of the mountain, altitude, climatic condition, soil composition, etc. are mentioned. Research on biodiversity uses models to describe the situation of different species and their abundance: by means of research which uses the most appropriate model, it is possible to describe the natural surroundings of a specific medicinal herb. The research findings are essential guidelines for replanting the herbs in their natural environment. The size of the replanting area is also crucial because of genetic diversity and the problems of insular ecology. Monocultures, like the usual big plantations, should be avoided: mass plantations of certain species will not have the desired quality or power. Herberia, photographic reports, and botanical gardens are needed to show and inform participants in plant preservation projects. Seed banks are to be established. BOOKS ABOUT TIBETAN MEDICINE Following are some resources for the study of Tibetan Medicine from the ITM library that are in the English language. There are numerous other small books available from the same publishers. Most of the Tibetan medical books published in English began to

appear in the mid-1970’s, shortly after Tibetans began to tour the major Western cities to describe their dilemma. Several of the books are now out of print, but may still be found in stores that specialize in used books. Four authors have produced many of the titles: Tsarong, Dash, Donden, and Rapgay; their books are listed first, and they have produced other books as well that are not in the ITM library. Handbook of Traditional Tibetan Drugs by T.J. Tsarong, 1986 Tibetan Medical Publications, Kalimpong, West Bengal, India. Tibetan Medicinal Plants (illustrated) by T.J. Tsarong, Tibetan Medical Publications, Kalimpong, West Bengal, India. Fundamentals of Tibetan Medicine by T.J. Tsarong, 1981 Tibetan Medical Centre, Dharamsala, India. Formulary Of Tibetan Medicine by Vaidya Bhagwan Dash, 1988 Classics India Publications, Delhi, India. Materia Medica of Indo-Tibetan Medicine by Vaidya Bhagwan Dash, Classics India Publications, Delhi, India. Tibetan Medicine with Special Reference to Yoga Sataka by Vaidya Bhagwan Dash, 1985 Library of Tibetan Works and Archives, Dharamsala, India. Health Through Balance by Yeshe Donden, Snow Lion Publications, Ithaca, NY. What Is Tibetan Medicine? by Yeshe Donden and Gyatsho Tshering, Tibetan Review Publications, Delhi, India. Ambrosia Heart Tantra annotated by Yeshe Donden, translated by Jhampa Kelsang, 1977 Library of Tibetan Works and Archives, Dharamsala, India. Tibetan Medicine: A Holistic Approach to Better Health by Lobsang Rapgay, Dharamsala, India. The Tibetan Book of Healing, by Lobsang Rapgay, 1996 Passage Press, Salt Lake City, UT. Tibetan Therapeutic Massage by Lobsang Rapgay, 1986 Dharamsala, India. The Art of Tibetan Medical Urinalysis by Lobsang Rapgay, 1986 Dharamsala, India. Tibetan Buddhist Medicine and Psychiatry by Terry Clifford, 1984 Samuel Weiser, Inc. York Beach, ME. Tibetan Medicine by Rechung Rinpoche, 1976 University of California Press, Berkeley, CA. Studies in Tibetan Medicine by Elisabeth Finckh, 1988 Snow Lion Publications, Ithaca, NY. Lectures on Tibetan Medicine by Lobsang Dolma Khangkar, 1986 Library of Tibetan Works and Archives, Dharamsala, India. Introduction to Tibetan Medicine by Luigi Vitiello, Wisdom Publications, London, England. The Tibetan Art of Healing by Theodore Burang, Robinson and Watkins Books, London. Asceticism and Healing in Ancient India: Medicine in the Buddhist Monastery, by Kenneth Zysk, Oxford University Press, Oxford, England. Healing Herbs, The Heart of Tibetan Medicine by Badmajew, et al., Red Lotus Press, Berkeley, CA. Tibetan Medical Paintings by O. Parfionovich and F. Meyer, Wisdom Publications, London, England [other versions of this book, have been published in Lhasa and Russia; see also Buddha’s Art of Healing: Tibetan Paintings Rediscovered , based on the 17th century Atlas of Tibetan Medicine, with essays by several modern authorities]. Mind and Mental Health in Tibetan Medicine, collection of essays, 1988 Potala Publications, New York. Tibetan Medicine, series of nine booklets (journals) with articles by various authors, Library of Tibetan Works and Archives, Dharamsala, India. The Quintessence Tantras of Tibetan Medicine, translated by Barry Clark, 1995 Snow Lion Publications, Ithaca, NY. WHERE TO GET BOOKS ON TIBETAN MEDICINE · Snow Lion Publications produces a quarterly newsletter and catalogue which is filled with information about the Tibetan people, and about materials for further study, including books on Tibetan medicine. It carries advertising and notices about other publishers and resources and also gives notice for events such as Medicine Buddha retreats. Ask for their free newsletter by writing to Snow Lion, P.O. Box 6483, Ithaca, New York 14851 (607-273-8506; fax: 607-273-8508). · Potala Publications, 107 East 31st Street, New York, New York 10016 (212-213-5010), has an extensive list of titles related to Tibetan culture, including Tibetan medicine. Men-Tsee-Khang Exports, 13 Jaipur Estate, Nizamuddin East, New Delhi, 110013, India (91-11-6212604; fax 91-11-6446826), has a number of books on Tibetan medicine and related topics in Tibetan and in English. September 1999

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TIBETAN HERBAL MEDICINE With examples of treating lung diseases using rhodiola and hippophae by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Tibetan medicine has a rich heritage and is currently practiced not only in Tibet, but also in the adjacent Chinese provinces of Qinghai, Gansu, Sichuan, and Yunnan, and in the neighboring kingdoms of Bhutan, Nepal, Ladakh, and Sikkim, where communities of Tibetan people have long been established. Many non-Tibetans also seek out treatment by this traditional system because of its good reputation. As a result of the flood of refugees from the Chinese military occupation of Tibet, Tibetan medicine extended to India, and, from there, to many countries of the world (especially in Europe and North America) under the guidance of a small number of refugee physicians. One of the most famous of the refugee doctors is Dr. Yeshe Donden, who was the personal physician of the Dalai Lama in exile from 1961-1969. Dr. Donden has spent much time in the U.S., where he has diagnosed and treated patients, given teachings to doctors and laypersons, written books and articles, and answered numerous questions about the Tibetan system of health care. Tibetan medicine has also been popularized by a lineage of the Badmajev family that originated in Russia, near Mongolia; members of the family traveled West during the 20th century. Tibetan herbal formulas they brought with them have been available as pharmaceutical products in Europe since 1980. Tibetan medicine originated with the local folk tradition (known as Bon) that dates back to about 300 B.C. and was formally recorded by Xiepu Chixi, the physician to the Tibetan King Niechi Zanpu, in 126 B.C. Aspects of both the traditional Chinese and Indian (Ayurvedic) medical systems were added later; Ayurveda has had the most profound influence on Tibetan medicine. The medicine of India was introduced to Tibet as early as 254 A.D., with the visit of two Indian physicians. During the following century several physicians from India reinforced the teachings. The greatest influence from India came about when Buddhism was adopted in Tibet as the state religion. This occurred as Tibet was unified under King Songzan Ganbu (618-652 A.D.). Buddhism had great implications for the practice of the Indian approach to medicine that evolved separately in Tibet. The Ayurvedic principles, especially the concept of tridosha, or three faults (in Buddhism, the three poisons) provided the basis for analyzing physical disorders and designing treatments, while Buddhism provided a strong spiritual component. The legend of how Tibetan medicine was introduced to Tibet is relayed in the story The Life of the Great Physician Yuthog Yonten Gonpo [pinyin: Yutuo Yuandan Gongbu ] which has been translated and presented in the book Tibetan Medicine by Rechung Rinpoche (1). The following is the command by Tara (the Buddhist god of compassion, which is identified in the Chinese tradition as the goddess Guan Yin) to two famous physicians of India who are said to have become immortals (now living in the sandalwood jungles of India): It has been prophesied by the Buddha about the country of Tibet; and all the Buddhas have discoursed on Tibet, and Avalokitesvara [also called Chenrezi; a champion of Buddhism: a boddhisatva] was made the special protector of Tibet. Avalokitesvara is the chief protector and I am helping him. When you go to Tibet, you will teach the people medicine, in the way the Buddha comes with his teaching. There is no doubt of success. Go quickly, and I shall look after you with my merciful eyes. And you will have the blessing of Avalokitesvara and great results. By the strength of your former prayers, the teaching of medicine will be kept up by the lineage of your families. Be of good cheer and go to Tibet! The lineage spoken of here involved the birth in Tibet of Yuthog Yonten Gonpo (708-833 A.D.), who studied medicine since an early age and was exposed to Buddhism during his teen years. Yuthog made three trips to India and studied with the great masters of Buddhist and Ayurvedic medicine there, and he eventually wrote 30 classic medical works integrating the local, Indian and Chinese medical traditions (2, 3). The involvement of Chinese medicine came about in 641 A.D. when a Tang Dynasty princess, Wen Cheng, was married to the Tibetan leader Songzan Ganbu (who was also married to a Nepalese princess that introduced him to Buddhism). Wen Cheng brought with her many Chinese books, including the medical books, as well as herbal formulas and medical instruments. Seventy years later, during Yuthog's life, another Chinese princess, Jin Cheng, brought additional medical books, as well as several Chinese physicians, to Tibet. Yuthog is viewed as the father of Tibetan medicine. He became a royal court physician and established the first Tibetan medical school at Congpo Menlong; he also became a monk at the Samye Monastery. A great medical conference was held at Samye during this time, bringing together Indian, Chinese, Persian, and Greek medical experts. Yuthog received the forerunner of the Four Medical Tantras (Sibuyidian; in Tibetan: rGyud-bzhi, ca. 770 A.D.) that serve as the basis of Tibetan medical practice. The original version is thought to have been written in Sanskrit around the 4th Century A.D. and then translated into Tibetan and given to the royal court (4). Yuthog's work in reorganizing and clarifying these books, as well as adding supplemental material (including that from other traditions described at the Samye conference) made him the true author of the Tibetan traditional text. Because of the vast contributions he made, he is considered a reincarnation of the Medicine Buddha, venerated as "the second Medicine Buddha." The Four Medical Tantras were revised (1573 A.D.) by the "younger Yuthog" who was a 14th generation descendent of the original Yuthog, now referred to as the "elder Yuthog." Additional revisions were made during the 17th century to bring forth the current version. The first two medical tantras (called the "root tantra" and the "explanatory tantra") have been translated and annotated by Dr. Yeshi Donden (5) and translated again in expanded

form by Dr. Barry Clark (6). These first two tantras make only brief mention of herbal medicine, and focus instead on behavior, diet, diagnostics, disease categories, and other aspects of traditional medicine. The third tantra ("instructions") details the cause and treatment of each major category of disease, and the fourth tantra ("concluding text") is devoted to the details of diagnosis, herbs, moxibustion, and other techniques. One major obstacle to translating the section on herbs is that the identification of the original materials in this 1,200 year old text is quite difficult. The general methods of diagnosis and therapeutics used by Tibetan doctors follow the Indian tridosha system; that is, being based on three humors (see Table 1). Table 1: The system of three humors adopted into Tibetan medicine from India. English wind bile phlegm

Tibetan rLung mKrhispa Badkan

Pinyin long chiba peigen

Indian vayu pitta kapha

Basic Concept movement, breath, cold metabolism, digestion, fire restraint, lubrication, moistness

The imbalances in an individual are revealed by a combination of reported symptoms, pulse diagnosis, tongue diagnosis, and urine analysis. The overall physical appearance of the person and information about their daily habits, and consideration of seasonal influences also contribute to the analysis. The Tibetan pulse diagnosis appears to be derived from the Chinese system, and is taken at the same artery of each wrist, but the method of feeling the pulse and the interpretations differ. Tongue diagnosis is simplified compared to the Chinese system (long disorders are characterized by red and dry tongue; chiba disorders by a yellowish tongue coating; and peigen disorders by a greyish and sticky coating with a smooth and moist texture). Urine analysis is unique to the Tibetan system and may have been introduced from Persia. Physicians inspect the color, amount of vapor, sediment, smell, and characteristics of the foam generated upon stirring, relying on the first urine excreted in the morning. Traditional Tibetan formulas are described mainly in terms of the diseases and symptoms that they treat, rather than their properties and influences on the humors. For example, in this article, several formulas that treat lung diseases are presented and their description mainly involves characteristic symptoms (cough, coloration of sputum, fever, involvement of the throat). In order to select among various possible remedies, it is important to know if the lung disease is hot or cold in nature, and to know the disturbances of the three humors that form the background to the disease in an individual patient. The humors may either be insufficient and require supplementation (invigoration) or they may be excessive and require pacification. In an attempt to correlate Tibetan and Chinese concepts, it has been suggested (3) that long corresponds roughly to concepts of qi and wind, chiba corresponds to fire or gallbladder, and peigen corresponds to moisture, the earth element, and phlegm. The modern Materia Medica of Tibet is derived from the book Jingzhu Bencao (The Pearl Herbs), published in 1835 by Dumar Danzhenpengcuo (7). This text has been compared to the famous Chinese herbal Bencao Gangmu. Its format includes two sections, one being in the style of the Buddhist sutra with praise of the medicines, and the other being a detailed classification of each substance, giving the material's origin, environmental conditions where it is found, quality, parts used, and properties. The text included 2,294 materials, of which 1,006 are of plant origin, 448 of animal origin, and 840 minerals. The heavier reliance on minerals and animals than on plantscompared to other traditional medical traditions-can readily be understood for a country at such high altitude that is very rocky and supports only small areas of plant growth over much of the terrain. About one-third of the medicinal materials used in Tibetan formulas are unique to the Tibetan region (including the Himalayan area in bordering countries), while the other two-thirds of the materials are obtained from India and China. The Tibetan population that had access to the medicines was relatively small until this century, so the total amount of pills produced were correspondingly small. Bringing herbs from India and China to Tibet has always been difficult and has limited the production of herbal formulas. Today, it is relatively easy to get Chinese herbs into Tibet, and China cultivates most of the herbs indigenous to India that might be needed. Although Tibetan herbal medicine includes the use of decoctions and powders, for the most part, Tibetan doctors utilize pills that are usually made from a large number of herbs (typically 8-25 ingredients). Pills have the advantage of being easy to use and they can be prepared in advance at a medical facility where all the ingredients are gathered together. Due to the vast distances, rough terrain, and limited development of Tibet, it was not possible to have the broad range of ingredients available to individual doctors who might compound formulas for decoction, as was often done in China. Instead, a relatively small variety of pills prepared at central facilities would be carried by the doctors to their patients. For many doctors, a collection of about two dozen principal formulas would have to suffice. In Lhasa, where there was a centralized population, the doctors have had access to about 200 kinds of pills. The traditional Tibetan pills were often large and hard and time consuming to prepare. Dr. Lobsang Dolma Khangkar (8) explained that each herb had to first be processed meticulously and then had to be mixed and preserved properly: If we are using cardamom, we have to use only the inside, because the outside has no value and then we have to peel each one. There is no machine that can do this, it has to be done by hand. After treating each of the ingredients like this, we will mix maybe three, thirteen, or twenty-five ingredients to make one pill. The first step is to mix all of these ingredients together. If this is not done properly, then each of these ingredients will maintain their own potency without combining with the rest. So, first they have to be completely mixed and this takes a long time of grinding and mixing. After that, it has to be left at rest for a whole day. After the rest, the person who is preparing the medicines has to clean his hands and then

begin again with mixing and grinding that medicine. After this, we make the pills. The pills can be made with machines....Then the pills are put into a very long bag made of cotton cloth. Two men hold the cloth from each side and move it back and forth so that the pills roll from one side to the other. This is done for a whole day. This last procedure is what is responsible for making Tibetan medicine pills so hard. This procedure takes out all the air that is still in the pills. If air remains in the pill, then it is prone to bacteria getting in, and for the pills to go bad. In order to make Tibetan medicines available to more people, modern factories have worked out new methods of blending, grinding, and making the pills, as well as producing other forms of the finished materials to make them easier to consume. There are regulations on the production of pills made in Tibet, with 97 different formulas formally recognized; of these 25 are covered under State medical insurance. Many of the formulations that are still in use were established many centuries ago. The principles of herbal combining to yield a traditional formula are not clearly defined in the Tibetan system. There are complex methods of analyzing the qualities of medicinal materials: 6 tastes, 8 properties, and 17 effects (see Table 2), but the precise organizational principles for compounding numerous ingredients into the formulas is lost to history. Table 2: Classification of herbal properties in Tibetan medicine (4). Grouping Six tastes

Eight properties

Seventeen effects

Characteristics sweet (e.g., bamboo, grapes, saffron; pacifies long and chiba; increases peigen); sour (e.g., pomegranate, hippophae, crataegus; pacifies long and peigen; increases chiba); salty (e.g., salt and several minerals; pacifies long and peigen; increases chihba); bitter (e.g., gentiana, aconite, berberis; pacifies chiba, increases long and peigen); acrid (e.g., piper, ginger, garlic; pacifies long and peigen, increases chiba); and astringent (e.g., sandalwood, terminalia, aquilegia; pacifies peigen, increases long and peigen) heavy, smooth (these two treat combat long); cool, soft (these two combat chiba); light, rough, acrid, and sharp (these four combat peigen). To increase long, rough and cool medicines are used; to increase chiba, warm, sharp, and smooth medicines are used; to increase peigen, heavy, smooth, cool, and soft medicines are used. cold, hot, warm, cool, thick, thin, moist, rough, light, heavy, steady, motive, blunt, sharp, tender, dry, and soft. Disease is treated by the opposing effect; a hot disease by a cold effect, stagnant diseases by a motive effect, an accumulation by a sharp effect, a moist condition by a dry effect, etc. Long disorders tend to be dry, light, cool, mobile, subtle, and hard; chiba disorders tend to be oily, sharp, malodorous, purging, hot, flowing, and light; peigen disorders tend to be cold, heavy, blunt, smooth, oily, stable, and sticky.

In general, Tibetan remedies emphasize the use of spicy (acrid), aromatic, and warming herbs. The climate has a substantial influence on these choices: the high altitude of Tibet means that cold and windy conditions prevail. The warm, spicy, aromatic herbs help to compensate for this condition. Ayurvedic medicine relies heavily on spicy herbs for stimulating the digestive system functions, which is understood to be the key to health. Thus, among the commonly used Tibetan herbs are those derived mainly from the Ayurvedic system, such as the peppers, cumins, cardamom, clove, ginger, and other hot spices, complemented by the local aromatics such as saussurea and musk. Also, the Tibetan system emphasizes astringent herbs, possibly representing an attempt to conserve body fluids and alleviate any inflammation of the mucous membranes. The "king" herb of Tibetan medicine is the chebulic myrobalan (Terminalia chebula ), which is an astringent herb, but is said to possess all the tastes (different parts of the fruit have different tastes), properties, and effects. Despite this emphasis on herbs with properties that are generally needed for the Tibetan climate, cooling and bitter herbs are often required to treat the disease manifestation, as inflammatory processes finally result if the pathogenic influences are not conquered or expelled. Tibetan medicines are today prescribed by several thousand Tibetan doctors that have been trained in recent decades in Tibet, Qinghai, Gansu, and Sichuan. Ten cities in China have set-up Tibetan medical facilities (teaching and clinical units), including a large one in Lhasa and an even larger one in Beijing. There are also 57 hospitals of Tibetan medicine throughout China and 30 Tibetan medicine factories. The refugee community in Dharamsala has a medical college and there are several small manufacturers of Tibetan herb products throughout India and Nepal. Tibetan medicine, like other traditional medical systems, is highly complex, and represents a comprehensive effort at dealing with health and disease. Some modern pharmacologists, herb enthusiasts, and product developers have focused on certain herbs that can be used in a general way, thus making them accessible to the world population without having to transmit the medical system itself. Two such herbs are rhodiola and hippophae.

RHODIOLA

Rhodiola is mainly found on rocky slopes at 3,500-5,000 meters (11,000-16,000 feet). The Chinese name hongjingtian refers to the red flowers of the stonecrop-the common name given in the West (hong = red, jingtian = view of heaven or heavenly view, probably referring to its growth on high altitude stone faces). This herb is in the family Crassulaceae, which yields a small number of genera of medicinal plants, mainly rhodiola and sedum. The root of the plant is used in the current medicinal applications. The outer peel of the root has a light golden color, so that the herb is sometimes referred to as golden root; the inside of the root is pink. There are several species of rhodiola collected, with the main ones being Rhodiola rosea and Rhodiola kirilowii; others are being investigated, including R. eoccinca, R. crentinii, R. krifida, and R. atropurpurea.

Tibetan rhodiola has become so popular in recent years that, according to a survey by the Tibet Institute of Biology, 10,000 tons of it are collected annually and six factories make products that have rhodiola as a key ingredient (or sole ingredient). Rather than relying on its traditional applications, rhodiola is presented as a health product of general benefit, described as an adaptogen. The concept of an adaptogen has been attributed to the Russian pharmacologist N.V. Lazarev from his work during the period 1958-1959. Basically, he defined an adaptogen as a substance that has no toxicity or side effects at normal dosages and that non-specifically increases the resistance to disease and to physical and chemical stresses. Put another way, use of an adaptogenic herb will safely assist the body in maintaining its homeostatic balance and recovering from the effects of adverse weather, emotions, and disease influences. The leading advocates of developing natural resources as adaptogens were the Russian researchers I.I. Brekhman and I.V. Dardymov. They reviewed the status of research into adaptogenic agents in the seminal article "New substances of plant origin which increase non-specific resistance," published in 1969 (9). The leading adaptogens identified at that time were eleutherococcus (Eleutherococcus senticosus), ginseng (Panax ginseng), rhaponticum (Rhaponticum carthamoides), and rhodiola (Rhodiola rosea). The Russians went on to develop eleutherococcus (usually simplified to eleuthero) as a major health product, used locally and exported to Western countries. The Chinese developed their own resources of this herb (which grows in abundance in northeast China), eventually becoming the world's main supplier. Ginseng had long been used in the Orient and revered as a health tonic; the Koreans developed the world market for this herb, promoting research into its pharmacology and clinical effects and cultivating huge quantities of the roots. China and the U.S. (providing an American species, P. quinquefolium) eventually became major suppliers as well. Rhaponticum is still being investigated in China and Russia; it is mainly studied in relation to antioxidant activity, but is also reputed to improve circulation and mental acuity. Rhodiola has been researched in Russia and China and has become a common health food product which has been promoted in the West in recent years. The development of rhodiola as an adaptogen represents one aspect of Chinese efforts to promote Tibetan medicine (as one of the Chinese indigenous medical systems). As an adaptogen, rhodiola is considered to be like ginseng (renshen) and eleuthero (ciwujia) in terms of effects and applications; adaptogens from numerous different plant species have the same basic actions (25). Modern promoters of rhodiola have dubbed the herb "Tibetan ginseng." Though some herbalists object to this off hand use of the term ginseng (similarly, ashwaganda is called Indian ginseng, eleuthero is called Siberian ginseng or eleuthero ginseng), it may well represent the current intended use of the herb for consumers who are already familiar with ginseng as a general health tonic. One of the adaptogenic applications of rhodiola that has received considerable research attention recently is for aiding adaptation to high altitudes, thus, as a preventive and treatment for mountain sickness (23, 24, 25). Information about traditional uses of rhodiola remains somewhat limited; it was used for treatment of dysentery, back pain, lung inflammation with expectoration of bloody mucus, painful and irregular menstruation, leukorrhea, and traumatic injuries (25). Based on the indications for use, rhodiola appears to be cooling and detoxifying, and vitalizes blood circulation. By including the related genus Sedum in the discussion, one can get a better understanding of the herb since the two are nearly interchangeable. Some of the Chinese and Tibetan species of Sedum go by the name jingtian that is used for rhodiola: Sedum erythrostictum, is the main species known by this name. Sedum was described (10) during the Song Dynasty as "being sweet in taste, cold and slightly toxic in nature, the plant crawls on stones of the southern side of a mountain and it is tender and lustrous...." Sedum erythrostictum was described in the Bencao Gangmu of the Ming Dynasty (11) as having the reputation of protecting from fire. It was grown in pots on house tops to protect the house (i.e., protecting thatched roofs), and the herb would be used to treat people burned by fire or scalded by hot water, or who suffered from the burning sensation of insect bites. It is used topically much the way we currently use Aloe vera, which has a similar mucilaginous quality to the leaves. Some Chinese species of Sedum are administered as hemostatics; this especially applies to Sedum aizoon, which is known as tushanqi, being named the same as the famous hemostatic notoginseng (sanqi; tu means local variety). The traditional Tibetan use of both sedum and rhodiola is for lung diseases, specifically, lung heat (generally meaning a lung infection). In fact, the two herbs are combined in a simple decoction with licorice and lacca (zicaorong) for treating lung heat (12). In recent years, sedum extracts have been shown to protect the liver from damage due to chemicals and the herb has been used in treatment of viral hepatitis. The most commonly used species for this purpose in China is Sedum sarmentosum (chuipencao). The whole plant is applied in cases of damp-heat and to counteract toxic-heat (13). A tablet made from this herb, containing 8 mg of the glycoside component was used to treat chronic hepatitis at a dosage of 9 tablets per day (72 mg of glycoside). Its main effect was to lower transaminase levels within two weeks (23). In addition to tablets, rhodiola is produced in the form of a wine, oral liquid (that includes other Chinese herbs), capsule, and tea bag. Much of the research on rhodiola has been carried out in Lhasa. The Tibet Institute of High Altitude Biology has done research with rhodiola and confirmed that it is of benefit as an adaptogen, including use against mountain sickness. A capsule with rhodiola and hippophae (plus lycium fruit) is produced by one factory and is promoted as a treatment for altitude sickness. In Chengdu, the West China University of Medical Sciences undertook a review of the research on this herb, which was published in 1988, evaluating 90 reports on the botany, chemistry, pharmacology, toxicology, and clinical effects. They reported that hongjingtian was obtained from the root and rhizome of several species of Rhodiola, with studies conducted on the constituents of 20 of China's 70 species. The active constituents include numerous flavonoids (such as quercetin, rutin, and kaempferol), condensed flavonoids (polyphenols, mainly gallic acid and epigallocatechin), cyanoglycosides (which have histamine-inhibiting activity), and salidroside, which is deemed one of the main active constituents of interest by virtually all authorities. In

concentrated extracts of rhodiola, salidroside makes up about 1-2% of the content. Salidroside is comprised of tyrosol linked to glucose; tyrosol is one of the major flavors and aroma ingredients of the olive which confers notable antioxidant activity to olive oil. Rhodiola also contains sterols, notably daucosterol and sitosterol. According to mouse experiments conducted in China, rhodiola extract has a central stimulant action and increases the tolerance to anoxia, fatigue, microwave irradiation, poisoning by strychnine, tetanin, and other toxins; it regulates brain functions, leukocyte count, blood glucose, and promotes protein hydrolysis; and it enhances the functions of the thyroid gland, adrenals, and ovaries. According to the reports from recent clinical research efforts conducted mainly in Russia, rhodiola may prove helpful in treating depression and its use may result in improvements in mental performance and alleviation of fatigue. All reports suggest that the toxicity of rhodiola is very low and that there are no significant side effects (24). As can be seen, the modern research (both laboratory and clinical) is aimed at the potential of rhodiola as an adaptogen rather than its traditional function as a treatment for lung diseases.

HIPPOPHAE

Hippophae (Chinese: shaji, literally: sand thorn, the English common name is sea buckthorn) is a member of the Elaeagnaceae family, a family that has very few medicinal herbs, mainly Hippophae, Eleaegnus, and Elaeocarpus. There is one dominant species of Hippophae used in China and Russia: H. rhamnoides. Hippophae is usually found at an altitude of 1,200-2,000 meters (4,000-6,500 feet) in cold climates, though it can grow at both higher and lower altitudes, in sandy soil. It has recently been planted in temperate zones worldwide to prevent soil erosion and to serve as a source of food and medicine (15). Hippophae has been developed into a major resource for China, with numerous organizations devoted to the project, including the following three that have sponsored a journal, Hippophae, that has been published (in Chinese) since 1988: China Research and Training Centre on Sea Buckthorn Sea Buckthorn Office of the Yellow River Water Commission Shaanxi Sea Buckthorn Development Office The fruit is the main part used as food and medicine. It is one of the richest sources of vitamin C, with about 6 mg/gram in the fruit and about 5 mg per ml of fruit juice (16), so the juice has been made into a health beverage on that basis. Medicinally, the flavonoids of the fruit and the oil of the seed are deemed the main active constituents. The flavonoid are present in the range of 1-10 mg/gram of fresh fruit. Injected into laboratory animals (17) at a dose in the range of 2-5 mg/kg, they improve non-specific immunity (one of the actions of an adaptogen). In addition, the flavonoids promote bone marrow production of red blood cells, and reduce allergy reactions (26). Both the vitamin C and flavonoids are thought to help protect against carcinogenesis when ingesting food contaminated with carcinogens (18). In a double-blind clinical trial (19) 128 patients with ischemic heart disease were given total flavonoids of hippophae at 10 mg each time, three times daily, for 6 weeks. The patients had a decrease in cholesterol level and improved cardiac function; also they had less angina than those receiving the control drug isosorbide dinitrate. No harmful effect of hippophae flavonoids was noted in renal functions or hepatic functions. Hippophae seed oil is rich in vitamin E and essential fatty acids, including several that inhibit inflammation. One ingredient, palmitoleic acid, is a component of skin that is considered very valuable in treating burns and healing wounds. The oil is used alone or in various preparations topically applied for a wide range of skin ailments, including burns, scalds, ulcerations, infections, and as an aid in promoting regeneration of tissues and protectant in sunblocks (hippophae oil itself has UV-blocking activity). The seed oil and the bark of the plant have been found to possess anti-tumor effects in preliminary laboratory studies (15). For internal use, the oil is put into soft gelatin capsules, which are used for treating gastric and duodenal ulcers, liver inflammation, and skin disorders, such as atopic dermatitis. Both the seed oil and flavonoids have been used in laboratory animal studies aimed at revealing adaptogenic properties, such as protection against harmful effects of radiation, cold, fatigue from excessive activity demands, and oxygen deficits (26). In the Indian Materia Medica, hippophae is mentioned briefly, the fruit being used for lung diseases (20). In Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (21), hippophae fruit is described as sour, astringent, and warm in nature, and used to eliminate phlegm, stop cough, improve digestion and remove accumulations, and to move blood and remove blood stasis. Examples of uses are: cough with profuse sputum; abdominal pain due to accumulation of food and indigestion; amenorrhea due to blood stasis; and swelling and stagnation in trauma. These functions and applications are similar to those described in Tibetan medicine, where hippophae is used for lung-heat disorders and stomach-intestine disorders with bleeding. However, the emphasis of modern research and product development is on its nutritional and general health benefits rather than the traditional medical applications. Some simple formulas with more specific applications have been developed recently; for example, there is a liquid preparation of hippophae, carthamus, and licorice intended for use in treatment coronary heart disease and sequelae of heart attack and stroke, based on improving blood circulation.

TRADITIONAL TIBETAN FORMULAS WITH RHODIOLA AND HIPPOPHAE

T.J. Tsarong outlined 175 important Tibetan formulas in his Handbook of Traditional Tibetan Drugs (22). In the next two tables, formulas with rhodiola and/or hippophae are mentioned; other herbs commonly included in these

formulas are: sandalwood, saussurea, carthamus, bamboo, terminalia, licorice; geranium, emblica, gentiana, inula, and grapes (see also Tables 5 & 6). Of these, all are used in Chinese medicine except emblica and grapes, both used extensively in Indian medicine. Tsarong included 12 formulas that utilize rhodiola, all of which are used for lung disorders (see Tables 3 & 4). Table 3: Traditional Tibetan formulas with rhodiola. The number of herbs in the formula is indicated in the formula name or added in parenthesis after the formula name. Formula Blue Garuda Bird (9)

Main Uses in Tibetan Tradition acute inflammation of the lungs and throat, as well as fever and dysentery coughing, infections, fever and diarrhea (this formula is usually used for pediatric cases)

Bamboo 9 Pulmonary Medicine of Death Healing Nectar (15) Eliminator of Lung Inflammation (13) Eliminator of All Lung Imbalances (11) Blood Gentian Pill (18) Gentiana 15 Sandalwood 8 Sandalwood 9 (add cinnamon to above) Yuthog's Bamboo 25 Copper Calcine 25

acute and chronic cough and sputum streaked with pus (formula includes hippophae) inflammation of the lungs, cough, chest congestion chronic cough with expectoration of phlegm, and fever antipyretic and expectorant for inflammation of the lungs and cough cough, shortness of breath, hoarseness, blood in sputum inflammation of the lungs, blood and pus in the sputum inflammation of the lungs, pus in the sputum, fever pain and inflammation of the lungs, blood in the sputum, inflammation of the respiratory tract (formula includes hippophae) all types of lung inflammation; difficulty breathing, coughing

A representative rhodiola formula is the Eliminator of Lung Inflammation. Its ingredients, in addition to rhodiola, are bamboo, carthamus, clove, white and red sandalwoods, geranium, terminalia, aconite, myrrh, musk, saussurea, and cinnabar (vermilion). Though this is considered a valuable remedy by the Tibetans, it is not a suitable preparation for use in the West, as it contains raw aconite (a toxic substance, though used in small amounts), musk (obtained from the musk deer, an endangered species), saussurea (collected from wild sources; it is an endangered species), and cinnabar (contains mercury). The main characteristic of the formula is that it is very fragrant, mainly due to the clove, saussurea, sandalwood, geranium, myrrh, and musk; it has a bitter, acrid, astringent taste (sandalwood, saussurea, and terminalia are the main astringents); and the overall action is cooling. When interpreting its effects and uses, it must be understood that the classification of the herbs are often different in the Tibetan system compared to the Chinese system. As examples, both carthamus and sandalwood are deemed warming in the Chinese system but cooling in the Tibetan system; sandalwood is used to regulate qi in the Chinese system, but is applied as an astringent in the Tibetan system; carthamus is used in the Chinese system to vitalize blood circulation, but it is used to stop bleeding and nourish blood in the Tibetan system. In this formulation, phlegm-fire (chiba; bile) is controlled by ingredients such as white sandalwood, carthamus, and bamboo, while phlegm-damp (peigen) is controlled by aconite and penetrated by the fragrant herbs. This formula is suited to treating lung diseases in which there is considerable difficulty breathing due to sticky phlegm. Two of the formulas in Table 3 include hippophae; there are also 6 formulas with hippophae that do not include rhodiola (see Table 4). Most of these are also used for lung diseases and phlegm accumulation problems, but hippophae is also included in formulas for treating blood-heat disorders (these usually manifest as bleeding disorders). Table 4: Traditional Tibetan formulas with hippophae (see Table 3 for two additional formulas). Formula Blue Poppy 8 Balancing Comforter (17) Reed of Comfort (17)

White Nectar Pill (5) Amla 25 Hippophae 5

Main Uses in Tibetan Tradition to control excess blood from the liver into the stomach lining (hematemesis) for all types of phlegm accumulation with lack of stomach heat (symptoms of anorexia, indigestion, stomach tumors), discomfort of stomach and liver, hematamesis, lymphatic disorders, skin disorders (including itching) for phlegm accumulation, pain along with emesis of sour and watery vomitus, inflammation of the stomach, indigestion, hematemesis, irregular menstruation, painful menstruation to promote digestion (increases stomach fire), disintegrates stomach tumors and mucus, removes phlegm accumulations, acts like a nectar for colic and cold parasites removes bad blood, reduces blood pressure, treats dryness of throat and mouth, and redness of eyes for chronic inflammation of the lungs, with discharge of pus and blood; it suppresses coughing and treats hidden fever

A representative formula with hippophae is Hippophae 5; which also contains licorice, grape, emblica, and saussurea. This is a formula compatible with Western requirements in terms of safety of the herbal materials, though the main Tibetan source for saussurea, S. lappa, is on the endangered species list (cultivated sources and a related herb used as a common substitute, Vladimiria souliei, can resolve this problem). Hippophae 5 has the characteristic

of being sweet (mainly due to licorice and grape) and sour (mainly due to the hippophae and emblica) with only modest fragrance (mainly contributed by saussurea) and a cooling quality (not compensated by spicy warm herbs). Sweet herbs are considered useful for controlling chiba (phlegm-fire), while peigen (phlegm) is controlled both by sour herbs and those that are coarse (hippophae). This formula is given for lung disorders with accompanying fever, and with free flowing mucus. Comparing the two formulas-Eliminator of Lung Inflammation and Hippophae 5-the former is more suited for lung disorders dominated by stuffiness and the latter is more suited for lung problems associated with fever and infection (which can lead to discharge of copious mucus including pus and blood), while both are good for the most general category of lung inflammation.

TIBETAN HERBS COMMONLY COMBINED WITH RHODIOLA AND HIPPOPHAE

In traditional Tibetan formulas, rhodiola and hippophae are combined in complex formulas, as depicted above, for treatment of lung diseases. Table 5 presents these two key herbs along with several of the other herbs commonly included in the formulas. Table 6 presents information about the inclusion of these herbs in the same formulas that are listed in Table 3 and Table 4. Other herbs, that are in some of these formulas but mentioned less frequently, include geranium, emblica, gentiana, inula, and grapes. Table 5: Tibetan herbs commonly used in formulas for treating lung diseases. The Tibetan name is presented according to the transliteration system used in the Quintessence Tantras of Tibetan Medicine (6), and the Indian name is presented according to Indian Materia Medica (20). Herb (common name); Tibetan name; Sanskrit name; (botanical name) Part used Bengal name Bamboo resin chu-gang vansa Bambusa sp. or Phyllostachys sp. resin bans Carthamus* gur-kum kamalottera; kusumba Carthamus tinctorius flower kajireh Hippophae star-bu dhurchuk (Hindi) Hippophae rhamnoides fruit dhurchuk Licorice shing-mngar madhuka, yashti-madhu Glycyrrhiza glabra or G. uralensis root yashto-madhu Rhodiola sro-lo Not included Rhodiola sp. whole plant Sandalwood (red) tsan-dan dmar-po rakta chandana Pterocarpus santalinus heart wood pit-sal Sandalwood (white) tsan-dan dkar-po chandanam; srigandha Santalum alba heart wood sada-chandan Saussurea ru-rta puskara, kushta kashmirjagada pachak Saussurea lappa root Terminalia a-ru-ra haritaki, abhaya, pathya, etc. Terminalia chebula fruit hirda *common substitute for saffron, the originally-specified ingredient

Chinese name; Category tianzhuhuang resolve phlegm honghua vitalize blood shaji resolve phlegm gancao tonify qi hongjingtian tonify qi hongtanxiang regulate qi tanxiang regulate qi guangmuxiang regulate qi hezi astringent

Table 6: The inclusion of common Tibetan herbs in the formulas with rhodiola and/or hippophae. Formula

Rhodiola

Hippophae

Sandalwood

Saussurea

Carthamus

Bamboo

Terminalia

Licorice

• •



•



•

•

•



Pulmonary Medicine of Death Healing Nectar

•

•

•

•

•

•



•

Eliminator of Lung Inflammation

•



•

•

•

•

•



Eliminator of All Lung Imbalances

•



•







•



Blood Gentiana Pill Sandalwood 8 & 9

• • •



• •

• •

•

• • •

• •

• • •

Yuthog's Bamboo 25

•

•

•

•

•

•

•

•

Copper Calcine 25 Blue Poppy 8

•

•

•



• •

• •



• •

Balancing Comforter



•

•



•

•





Reed of Comfort



• • • •

•

• • •

• •

•

• •

•

Blue Garuda Bird Bamboo 9

Gentiana 15

White Nectar Pill Amla 25 Hippophae 5

SUMMARY

Tibetan medicine is a derivative of the Indian and Chinese medical systems, with a dominant Buddhist influence, especially that carried over as a translation and revision of the Four Medical Tantras during the 8th Century A.D. Tibetan herbal medicine represents a complex system that involves a large number of medicinal substances, about a third of which are high altitude plants (especially those that grow in dry sandy or rocky areas). The classical Tibetan Materia Medica was developed in the 19th Century, and remains the primary source of pre-scientific herb information. Rhodiola and hippophae are examples of herbs frequently included in traditional Tibetan formulas, especially for treatment of lung diseases. They have been developed into health products apart from the Tibetan tradition, with rhodiola promoted as an adaptogenic agent, and hippophae as a nutritious beverage, a treatment for circulatory disorders, and as a skin protectant and healer. Tibetan medicine has been promoted and further developed in recent years both by China and by Tibetan refugee physicians. The main Tibetan texts are being translated into other languages (mainly Chinese and English) and scholars are investigating archeological sites and lost texts. The Tibetan medical system is experiencing a revival as the growing world population seeks solutions for difficult medical problems for which the modern system lacks adequate remedies. However, there are not enough trained physicians to support the demand. It is likely that more of the individual Tibetan herbs will be taken from this tradition and developed as health products as further research is undertaken. These general health products may stimulate interest in the preservation and further development of this unique medical tradition.

REFERENCES

1. Rechung Rinpoche, Tibetan Medicine, 1976 University of California Press, Berkeley, California. 2. Anonymous, Survey of Tibetan Medicine, Chinese Journal of Ethnomedicine and Ethnopharmacy, 1992; (1): 40-41. 3. Guo Jiening, et al., Tibetan medicine: historical development and theoretical system, Chinese Journal of Ethnomedicine and Ethnopharmacy, 1995; (14): 1-5. 4. Tsarong TJ (translator and editor), Fundamentals of Tibetan Medicine, 1981 Tibetan Medical Center, Dharamsala, India. 5. Donden Y (annotator) and Keisang J (translator), The Ambrosia Heart Tantra, 1977 Library of Tibetan Works and Archives, Dharamsala, India. 6. Clark B (translator), The Quintessence Tantras of Tibetan Medicine, 1995 Snow Lion Press, Ithica, New York. 7. Wang Jinhui, The characteristics of the Jingzhu Bencao, Chinese Journal of Ethnomedicine and Ethnopharmacy, 1995; (13): 4-5. 8. Khangkar LD, Lectures on Tibetan Medicine, 1986 Library of Tibetan Works and Archives, Dharamsala. 9. Brekhman II and Dardymov IV, New substances of plant origin which increase non-specific resistance, Annual Review of Pharmacology, 1969; 9: 419-430.

10. Chang Minyi, Anticancer Medicinal Herbs, 1992 Hunan Science and Technology Publishing House, Changsha. 11. Smith FP and Stuart GA, Chinese Medicinal Herbs, 1973 Georgetown Press, San Francisco, CA. 12. Li Yingcun, The characteristics of Tibetan medicine preparation in Sibu Yidian, Chinese Journal of Ethnomedicine and Ethnopharmacy, 1995 (14): 16-19. 13. Pharmacopoeia Commission of the Ministry of Public Health, Colored Atlas of the Chinese Materia Medica, 1995 Guangdong Science and Technology Press, Guangzhou. 14. Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore. 15. Li TSC and Schroeder WR, Sea buckthorn (Hippophae rhamnoides): A multipurpose plant, Horticultural Technology 1996; 6(4): 370-378. 16. Ji Lanju, Free amino acids and vitamin C in the fruits of Hippophae rhamnoides, Nitraria tangutorum, and Berberis dasystachya, ACTA Botanica Sinica 1989; 31(6): 487-488. 17. Zhong Fei, et al., Effects of the total flavonoid of Hippophae rhamnoides on nonspecific immunity in animals, Shanxi Medical Journal 1989; 18(1): 9-10. 18. Li Yong and Liu Huang, Blocking effect of the juice of Hippophae rhamnoides on synthesis of nitrosodimethylamine in rat, ACTA Nutrmenta Sinica, 1989; 11(1): 47-53. 19. Zhang Maoshun, et al., Treatment of ischemic heart diseases with flavonoids of Hippophae rhamnoides, Chinese Journal of Cardiology, 1987; 15(2): 97-99. 20. Nadkarni AK, Indian Materia Medica, 1908 (revised 1954), Popular Prakashan Private LTD, Bombay. 21. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, 1993 Heilongjiang Education Press, Harbin, China. 22. Tsarong TJ, Handbook of Traditional Tibetan Drugs, 1986 Tibetan Medical Publications, Kalimpong. 23. Zhang Weiyun, Recent development on application of Rhodiola spp. and its preparations, Journal of the Gansu College of Traditional Chinese Medicine 1997; 14(4); 41-42.

24. Wang Liang, Progress of research on the pharmacology of rhodiola, Li Shizhen Medicine and Materia Medica Research 1999; 10(4): 295-296. 25. Qian Yancong, et al., Survey of research on Rhodiola kirilowii, Acta Chinese Medicine and Pharmacology 1999; (5): 34-35. 26. Diao Jingli, et al., Pharmacological actions of Hippophae rhamnoides, Li Shizhen Medicine and Materia Medica Research 1999; 10(12): 956-957. May 2001

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UNANI MEDICINE with Reference to Hamdard of Pakistan and India by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Unani medicine is ancient Greek medicine that has evolved within the Muslim world for the past 13 centuries (Unani is an Arabic spelling of Ionian, meaning Greek). Greek medicine, greatly simplified for presentation here, was based on the concept of balancing body humors. They either fell out of balance, which might yield diseases (depending on circumstances), or were restored to balance to heal diseases. The system involved four elements, thus differing from the Ayurvedic system of three doshas and the Chinese system of five elements. The original Greek and the resulting Unani systems involve these four elements: earth, air, water, and fire; along with four natures: cold, hot, wet, and dry; and four humors: blood (which is hot/wet), phlegm (cold/wet), yellow bile (hot/dry), and black bile (cold/dry).

Unani medicine, like Western medicine (which also arose from the Greek background) owes its origination to Hippocrates (460-377 B.C.) and his numerous followers. Other Greek medical masters, such as Dioscorides and Galen, who we recognize as the forerunners of Western herbal medicine, are also considered founders of Unani medicine. The adoption of Greek medicine into the Islamic culture was depicted by Husain F. Nagamia MD, Chairman International Institute of Islamic Medicine, and former President of the Islamic Medical Association, as arising in the ancient city of Jundishapur (near Baghdad). The timing of events is described in relation to rule of caliphs, the civil and religious leaders of Muslim states, who are considered to be successors of Mohammed: Jundishapur (or 'Gondeshapur') was a city in Khuzistan founded by a Sasnid Emperor Shapur I (241-272 A.D.) before the advent of Islam. It was to settle Greek prisoners....The town was taken by Muslims during the caliphate of Hadrat Umar, by Abu Musa Al-Ashari in 738 A.D. At this time it already had a well established hospital and medical school. It was during the Abbasid Caliphate (754-775 A.D.) that Caliph al-Mansur, the founder of the city of Baghdad, invited the then head of the Jundishapur School to treat him. This physician was Jirjis Bukhtishu, a Christian whose name meant 'Jesus has saved.' He treated the Caliph successfully and got appointed to the court. He did not stay permanently in Baghdad, returning to Jundishapur before his death, but the migration to Baghdad had begun. Thus, his son Jibrail Bukhtishu established his practice in the city and became a prominent physician [he was invited to head the first Islamic hospital, built under direction of the Caliph]. Another family that migrated from Jundishapur to Baghdad was that of Masawayh, who went at the invitation of Caliph Harun-ul-Rashid (786-809 A.D.) and became a famous ophthalmologist. Most famous amongst his three sons who were all physicians was Yuhanna ibn Masawayh (known as Mesue Senior in the West). He wrote prolifically and 42 works are attributed to him [he also translated the Greek works into Arabic]. By this time (the 8th century A.D.) the fame of Baghdad began to rise as did the political power of the caliphate. Many hospitals and medical centers were established and tremendous intellectual activity was recorded. This culminated into the period of Islamic Renaissance and the golden era of Islamic Medicine….. One of the largest hospitals ever built was the Mansuri Hospital in Cairo, completed in 1248 AD under the rule of the Mameluke ruler of Egypt, Mansur Qalaun….The Mansuri Hospital had its own pharmacy, library and lecture halls. There was also a mosque for Muslim patients and a chapel for Christian patients. The most influential historical figure in this golden era of Unani medicine was Avicenna (980-1037 A.D.), born in Kharmaitan. He began studying medicine at the age of 13 and started treating patients three years later. He gained a very good reputation, such that the ruler of the Samanid Empire (in what is now Iran), Nuh ibn Mansur (reign: 976-997A.D.), sought him out to treat an illness that was unsuccessfully treated by his court physicians. Avicenna was successful and stayed on as court physician; however, the Empire soon fell, and Avicenna became a wandering physician and teacher. Eventually, he moved to Hamadan (in west-central Iran), where he worked as a court physician. He began writing several works on philosophy and medicine, and, through further political upheaval, ended up in Isfahan, where he was able to complete his books. He died soon after, while serving as a court physician on a military campaign back to Hamadan, suffering an illness he was unable to cure. His writings included diverse subjects such as mathematics, astronomy, geology, and logic. His most important medical work was The Canon of Medicine (Qunun), which remained a valued text throughout Europe and the mid-East for several centuries after his death.

Isfahan today

Avicenna

The Unani medical system flourished in Persia and India. Today, it is especially strong in Pakistan, which was partitioned as a separate Islamic country with the independence of India from Britain in 1947. The Unani system is sometimes called Hikmat or UnaniTibb. Its medical practitioners are called Hakims.

Page from a 15th Century Islamic medical text Portion of page from same book showing some medical instruments (The Arrangement of Bodies for Treatment), used for piercing, as blood letting was one of the important methods showing the four-fold layout of diseases as per the for letting out excesses of the humors. original Greek four-fold system of elements, qualities, and humors. This page is devoted to illnesses of the brain.

THE 20th CENTURY AND HAMDARD

Hakim Abdul Majid (1883-1922) founded an organization called Hamdard in Delhi in 1906; at the time, it was a small clinic and herbal medicine shop. Abdul had come from a family that included many herbal doctors, and he joined the herbal pharmacy of the renowned Unani physician Ajmal Khan. As he developed his knowledge of medicine, he too became a doctor (Hakim) and decided to establish his own pharmacy and clinic, which he called Hamdard Dawakhana. Hamdard, meaning sympathy, refers here to "one who shares the pain of others and is willing to mitigate it" (Dawakhana means clinic). As a result of Hamdard's success, it was moved to a new larger building in 1922; unfortunately, Abdul suffered a serious illness and died that year. The responsibility for Hamdard fell to his wife and his eldest son (in a family of five children), Abdul Hamid, who was only 13 at the time and already studying medicine.

Hakim Abdul Majid Hamdard would undertake its biggest growth and development once Majid's youngest son, Mohammad Said, agreed to study medicine (he had originally wanted to be a journalist). In 1940 he undertook studies of both Ayurvedic medicine and Unani medicine. After graduation, he participated in the Hamdard pharmacy and clinic with his older brother. Soon, however, the state of Pakistan was formed and many Muslims from India migrated there, including Mohammad Said, who was a devout Muslim. In 1948, he moved to Karachi, and set up a branch of Hamdard there, with both clinical facilities and herb manufacturing. In keeping with its aim to serve the people, it was turned into a charitable trust in 1953. Meanwhile, the original facilities in India, devoted exclusively to Unani medicine, continued to expand; under its director, Hakim Abdul Hamid, it became world famous and is likely the largest facility on earth for research and training in herbal medicine. One of Hamdard's first products, formulated in 1907 and commercially produced since 1908, was a beverage made of herbs, fruits, and vegetables called Rooh Afza. The drink derived its name from its function of giving enlightenment (Afza) to the soul (Rooh). It became a major product in India and Pakistan and remains well-known today, having world-wide distribution. Among Hamdard's other products are Ayurvedic and Unani internal remedies and topical applications for dozens of common ailments (see Appendix 2 for some examples). In Pakistan, under the leadership of Mohammed Said, Hamdard expanded its mission; in addition large foundation, it eventually generated an academy that became a major University (that includes a department of Eastern Medicine as well as other medical sciences), and a trust to house scholars and students. The pharmaceuticals branches in Delhi and Karachi became the world's largest producers of Unani products. There are nearly 30 other major herbal companies in Pakistan that follow Hamdard's lead.

Hakim Mohammad Said

Sadia Rashid

Unfortunately, Said, who had become a prominent person in Pakistan, was assassinated in 1998 by terrorists when he arrived at his usual Sunday morning clinic shift. It is speculated that he was killed because he was speaking out about corruption in Pakastani institutions. His daughter, Sadia Rashid, has taken over his position as chairperson of Hamdard Foundation in Pakistan. Mohammad Said's life and works is commemorated on a website: (http://spider.tm/jan2003/top5.shtml) Mohammad Said traveled to various clinics in Pakistan, and provided free consultations and often provided free medicines. He was an avid reader and collector of books; he brought 300 books with him when he arrived in Pakistan in 1948, and eventually collected 75,000 books while there, which he donated to the Hamdard University library. Others followed his example of donating to the library, which now has nearly 500,000 books. The Hamdard Foundation has published 300 books. One of Said's books, Medicine in China, was based on a visit he made to China in 1963. His book recounts the history of Chinese medicine and focuses mainly on the developments since the Chinese revolution in 1949. He had visited hospitals, research centers, and pharmaceutical factories. He also consulted a large number of books, pamphlets, and periodicals to put together the information for his book. The illustrations in the book, paintings of famous traditional Chinese medicine doctors that hang at the Academy of Traditional Chinese Medicine in Beijing, are featured on the Institute for Traditional Medicine website: http://www.itmonline.org/docs/famous.htm Dr. Said had been in contact with ITM in the 1980s, as part of an effort to promote Eastern medicine.

APPENDIX 1: Unani Medicine Resources in India and Pakistan

India has 18 colleges of Unani medicine, two of them with postgraduate departments (one being Hamdard Tibbi College in Delhi; (see Appendix 3 about another major contributor to India's Unani system). The annual new admissions in the undergraduate courses is about

700 students, and 30 students in the postgraduate courses. A National Institute of Unani Medicine is in Bangalore. There are about 100 Unani hospitals in India, with nearly 1,400 beds for inpatients. In addition, there were nearly 900 dispensaries of Unani medicines and about 30,000 registered practitioners. Unfortunately, details of the overall medical situation in Pakistan are not available. However, a report on the most commonly used herbs for Unani medicine in Pakistan has been provided by the American Institute of Unani Medicine, as follows:

Botanical Name Terminalia species Emblica spp. Ptychotis ajowan Cassia angustifolia Foeniculum vulgare Cinnamomum zeylanicum Sesamum indicum Piper nigrum Coriandum sativum Glycyrrhiza glabra Mentha spp. Viola odorata Rosa damascena Zingiber officinale Malva sylvestris Adhatoda vasica Nymphaea lotus Rheum emodi Cuminum spp. Elettaria cardamomum Althea officinalis

Unani Herbs in Pakistan Clinics, Ranked by Quantity Used Common Name Unani Class* Beleric myrobalans Cold 1, Dry 2 Myrobalans Cold 2, Dry 3 Ajowan Senna Fennel Cinnamon Hot 2, Dry 2 Sesame seed Black pepper Hot 2, Dry 2 Coriander Licorice root Hot 2, Dry 1 Peppermint Violet Red rose Ginger root Hot 2, Dry 2 Mallow leaves Malabar nut, adhatoda Hot 2, Dry 2 Water lily Rhubarb Cumin seed Hot 2, Dry 3 Cardamom seed Marshmallow

*The Unani classification of the herb is presented where available from Indian Materia Medica by Nadkarni. The herbs are classified by the four natures of hot, cold, dry, or moist, and then by degrees, which can range from 1 to 4. Common foods and very mild herbs are usually classified as being in the first degree; the frequently used herbs of relatively mild nature (such as those listed above) are usually classed in the second degree, strong-acting herbs are classed in the third degree, and toxic herbs reach the fourth degree. These depictions, especially of hot and cold, differ from those used in the Chinese system, and refer to the effects on the four humors. One of the more extreme natured herbs is Ipomoea turpethum (not commonly used), a powerful purgative, rated as 3rd degree hot and 3rd degree dry. The wet quality is usually attributed to things that are actually wet, such as fresh fruits and vegetables and beverages; cucumbers, for example, are both cold and wet. The herbs for which classification is available in the table above are all of dry nature. Most of the herbs are of hot nature; there are relatively few that are cold. An example of a cold natured herb is white sandalwood, which is classified as 3rd degree cold and 2nd degree dry; it is used for high fevers. The myrobalans fruits (first two items in the table above) are by far the most commonly used cooling herbs. The hot and dry natured herbs help to dispel excess of the phlegm humor, which is cold and moist. In the Ayurvedic system, it is common to use spicy herbs to stimulate the digestive system, and these same herbs, being hot and dry, are used extensively in the Unani medicine of India and Pakistan with a similar benefit attributed to them. The disorder of the humors is diagnosed through questioning, examination of pulse and tongue, and urine and stool analysis. Appropriate food preparation and selection is an important first step to correcting an imbalance in the humors. If the condition is more advanced, a series of herbal formulations are employed to "ripen" and then "purge" the offending humor.

APPENDIX 2: Sample Products of Hamdard Rooh Afza A popular summer drink that quenches thirst, maintains the water-electrolyte balance, and acts as an instant source of energy for the body. Ingredients: Citrus medica, Rosa damascena, Coriandrum sativum, Daucus carota, Portulaca oleracea, Citrullus vulgaris, Spinacea oleracea, Mentha arvenis, Luffa cylindrica, Cichorium intybus, Vitis vinefera, Vitiveria zizaniodes. Uses / Prevents: A 90-year-old summer drink that is used effectively as an oral rehydration therapy in heat strokes, chronic diarrhea, etc. It provides instant energy and quenches the summer thirst. Directions for usage: Mix 50 ml Rooh Afza with ice cold water and use as and when required. Joshina

A remedy for catarrh, cough, cold, sore throat or nasal congestion. Ingredients: Viola odorata, Onosma bracteatum, Althea officinalis, Malva rotundifolia, Glycyrrhiza glabra, Zizyphus vulgaris, Cordia latifolia. Uses / Prevents: Joshina is a ready-made convenient and more effective variation of Joshanda-the age old, tried and trusted remedy for cold, catarrh and sore throat. Directions for usage: 10 ml of Joshina mixed with 100 ml warm water to be taken before breakfast and at bed time

Safi: Blood Purifier A 60-year-old famous blood purifier that improves complexion and removes skin troubles. Ingredients: Cassia angustifolia, Rheum emodi, Ipomoea terpethum, Nelumbo nucifera, Rosa damaascena, Dalbergia sisoo, Pterocarpus santalinus, Tinospora cordifolia, Terminalia chebula, Curcuma cassia, Swertia chirata, Andrographis paniculata, Cassia occidentalis, Spaeranthus indicus, Chrozophora plicata, Fumaria parviflora, Bauhinia variegata, Azadirachta indica, Ocimum basillium, Clitoria ternata, Artesmia absenthum. Uses / Prevents: The herbal remedy for skin diseases such as acne vulgaris, boils, skin rashes, blemishes. Checks nose bleeding, cures constipation, corrects indigestion, improves complexion. Directions for usage: 10 ml once daily Pachnol A great remedy for stomach disorders and indigestions, loss of appetite, etc. It strengthens the digestive juices and removes gastric troubles. Ingredients: Piper longum, potassium carbonate, Zingiber officinale, borax, Piper nigrum, Eugenia caryophyllata, Calotropis gigantia, Acacia arabica gum, sulphur, black salt, potassium nitrate, ammonium chloride, Ferula assafoetida, citric acid. Uses / Prevents: Digestive tablets-strengthens digestive juices, aids in the digestion of rich food and relieves gastric troubles. Directions for usage: Two tablets after meals. Hair Oil A multi purpose oil that prevents dandruff, premature greying and falling of hair and provides shine and gloss to the hair. Ingredients: Nardostachys jatamansi, Eclipta alba, Lawsonia alba, Sesamum indicum oil. Uses / Prevents: A very useful oil that helps in all-round nourishment of the hair and stimulates the growth of the hair. It helps removing the split-ends in the hair, dandruff and provides strength to hair follicles. Directions for usage: Massage gently on scalp, leave overnight, shampoo next morning with Zulamia. Hamdogen

It is an ideal medicine for sexual impotence and frigidity in men of all ages and acts as a powerful sex stimulant. Ingredients: Allium cepa, Mesua ferrea, Myristica fragrans, Myrtus caryophyllus, Alpinia galanga, Piper longum, Zingiber officinale, Cinnamomum zeylanicum, Trigonela foenum-graeceum , Mucuna pruriens, Crocus sativus. Uses / Prevents: It acts as a restorative and recuperative for entire human body. It also removes debility, symptoms of fatigue and exhaustion and is the ideal tonic for improving sexual performance and increasing sexual desire. Directions for usage: Two capsules once a day.

APPENDIX 3: Unani Medicine in India: Hakim Ajmal Khan

Ajmal Khan was born in India in 1864, and is generally acknowledged to be the most significant 20th Century contributor to Unani medicine in India. His life in India was something like that of Mohammed Said's in Pakistan; both were humanitarians of the first order who became important leaders and were versed not only in medicine, but in other academic areas, with an intense interest in providing educational opportunities. Ajmal Khan came from the famous Sharif Khani family of Delhi, known best for his great grandfather who made an immense contribution in keeping alive the two age-old native medical systems of India-Unani and Ayurveda-at a time when these systems were in decline as a result of widespread introduction of Western medicine by India's British rulers. Ajmal Kahn established the Hindustani Dawakhana in Delhi in 1905 (photo below right, as it was in the 1930s) to manufacture Unani and Ayurvedic medicines (thus, it was founded at about the same time and in the same city as Hamdard was founded by Abdul Majid). The dispensary took out patents for 84 herbal formulas. From the 1930s through 1960s, the Dawakhana employed up to 300 workers; today, it is in serious disrepair, and there are calls to preserve it as a magnificent historical structure.

Unani Tibba College

Ajmal Khan

Hindustani Dawakhana in Delhi, as it was in the 30s

Three years after founding the Hundisutani Dawakhana, Ajmal Kahn started a Unani Medical School for Women, and after many years more of hard work he helped establish Jamia Millia Islamia (National Islamic Univeristy, in Delhi) and also established the Ayurvedic and Unani Tibba College (pictured above left), inaugurated by Mahatma Gandhi in 1921. These organizations were partly funded by the proceeds from the Dawakhana. Ajmal Khan also worked politically in close association with Mahatma Gandhi as well as Motilal Nehru and many others and emerged to be a symbol of Hindu-Muslim unity. As a result, in 1921 he also rose to become the President of Indian National Congress. The herb Rauwolfia serpentina, which Ajmal Kahn had used extensively, was analyzed under his supervision, with the contribution of Dr. Salimuzzaman Siddiquil, the primary research scientist. This work eventually led to the production of modern drugs of great importance, such as reserpine (a sedative and antihypertensive agent that was highly effective, though no longer available in North America). Another compound isolated that has anti-arrhythmia activity is named Ajmaline, in commemoration of Ajmal Khan, who died at the end of 1927 after having lived a life of great accomplishments.

An Ajmal Khan Memorial Society has been established. A book about his life and works has been written in English by Zafar Ahmad. An award given to dedicated physicians of highest quality (in Ayurvedic, Unani, or Allopathic medicines) and for high quality

manufacturers of Ayurvedic and Unani medicines in India is named after Ajmal Khan and awarded by the Memorial Society. One of the recipients of the award, Universal Medicaments, provides medicinal materials to ITM.

APPENDIX 4: Black Seed-Unani Herb Gains International Recognition.

Nigella sativa is the source of a black seed that has a unique reputation in Eastern medicine. It is sometimes simply called "black seed," and sometimes called black cumin. It is not botanically related to the common cumins (Cuminum spp.) used as spices, but it is similarly used in foods. These seeds were found in ancient Egyptian tombs, mentioned in the Bible, and, most influentially, alluded to in the Qur'an, where Mohammed relays the saying that "black seed can cure anything but death." The seeds are used today to treat asthma and other lung disorders, digestive disturbance (e.g., indigestion, diarrhea), and hyperlipidemia. They are also recognized for antioxidant effects and immune regulating activity.

Nigella sativa The unusual flower of this plant in the Ranunculaceae family varies from white to light blue, to deep blue (as pictured above). Extensive analysis has been done on the active constituents and pharmacological actions. There are two major groups of active ingredients, terpenes (making up the essential oil) and alkaloids. The seeds also contain small amounts of saponins and a significant amount of fixed oil (rich in linolenic and linoleic acids). The terpenes are derivatives of thymol: mainly thymoquinone and its polymers (such as dithymoquinone), and p-cymene and αpinene. These are volatile compounds.

Recent studies of the steam distilled essential oil of black seed (which makes up 0.4% of the seed) showed that the major components were p-cymene (37%) and thymoquinone (14%). In pharmacology tests, the essential oil was shown to have antiinflammatory and analgesic effects, and thymoquinone was proposed to be the most significant contributor to that effect. Isolated thymoquinone was also shown to have anticonvulsant activity and anthihypertensive action. In an evaluation of thymoquinone as a protective antioxidant, it was demonstrated that it could reduce the cardiotoxicity of the cancer drug doxorubicin (also called adriamycin) without impairing the antitumor activity of the drug. This component also has protective activity against toxic chemicals that affect the liver or kidneys. At least two patents have been granted for pharmaceutical preparations of black seed to be used as an adjunct to cancer therapy to protect against side effects, provide additional anti-tumor action, and enhance the immune responses. Other patents have been given for black seed as a component of complex herbal therapies for hepatitis and diabetes. The seed oil was evaluated for its immune regulating effects in a clinical trial of patients with various allergic conditions (e.g., allergic rhinitis, asthma, atopic eczema). The subjective experience of allergic symptoms were noted to decrease with doses of 40-80 mg/kg. The main alkaloids of black seed are diterpene alkaloids called nigellamines. In pharmacology experiments, the isolated alkaloids have been shown to lower cholesterol and triglycerides to an extent comparable to the drug clofibrate.

May 2004





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Veterinarian Guide To get onto our veterinarian list, practitioners must fill out and submit a questionnaire we have prepared to become an ITM member, and their information is reviewed to assure they have knowledge of traditional Chinese medicine. A record of their training and granted degrees as well as their medical specialties is retained at ITM. These veterinarians do not pay for their listing in this guide; this is not an advertisement for their practices, rather it is a service provided by ITM for people seeking alternative health care for their animals. Application for inclusion in the ITM Veterinary Guide Revised December 2015 ALABAMA Eclectic Mary S. Battistella ALASKA North Pole Jean Olson Wasilla Joanne Rehn

334-857-1816 907-488-2906 907-376-7930

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520-494-9571 520-625-0433

Judy Stolz Cornville James C. Armer Jr. Mesa Carolyn Tyau Phoenix William Peterson, DVM Sedona Deborah Mallu Tucson Candy Burton Paula Medler

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310-659-2260 408-402-3071 818-957-5834 415-664-0191

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510-339-8600

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805-646-9695

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209-664-1764

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858-276-1616

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828-272-2342 619-584-8418

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619-276-5900

Jeffrey N. Bryan San Raefael

415-664-0191

Pamela Bouchard

415-454-4994

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408-489-8613

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707-887-2261

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818-761-0787

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818-761-0787

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707-462-8833

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818-271-7960

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310-268-2275

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303-456-4136

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303-816-6006

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303-530-2500

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303-499-8626

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303-494-7877

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303-761-7063

Colin L. Combs Littleton

970-330-7283

Laura Deloatch, DVM Longmont

303-229-5261

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303-702-1986

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970-249-8022

Clarissa A. Meeks

970-881-2672

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Allen Schoen

203-354-2287

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203-484-0736

West Hartford Petcare Veterinary Services

860-232-6060

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203-227-4943

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Wilminton Jeanne Wordley FLORIDA

302-762-2694

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904-462-7017

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407-924-4240

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VCA Boca Del Mar Animal Clinic Clearwater

561-395-4668

John H. Fudens Clermont

813-787-6010

Constance DiNatale Dunedin

407-644-0080

Gregory Todd Melbourne

727-733-9351

Joseph Demers Miami

321-752-0140

Lois Sargent North Redington Beach

305-264-2439

John Mead, DVM Reddick

727-526-0918

Bruce Ferguson

352-317-1111

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941-925-2262

Dr. Robert Katz GEORGIA Alpharetta

772-287-2242

Allison M. Howell

770-475-9659

Carrolton Taffy Shields Rhyne

770-834-1000

Madison



Dr. Luli de Guzman Watkinsville Charlene Kickbush, DVM

706-342-1232 706-769-1533

Woodstock Susan Wynn

770-516-5954

HAWAII Kailua Kimberly Steinberg Kaneohe

808-262-7257

Sharman Elison Kapaa Ihor Basko

808-235-6405 808-822-4229

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208-939-4800

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208-442-7205

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208-442-7205

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312-458-0969 312-405-6444

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630-963-0424 708-423-3200

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947-932-1840 708-383-5997

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815-678-4700 847-891-8944

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217-344-1017 847-256-1131

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815-728-7381

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219-763-3311 765-966-0015

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515-386-3600

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785-843-4338

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859-281-1183

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504-834-2023

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207-338-6700

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207-799-6952 207-743-6384

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207-712-8134

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301-656-2882 410-992-7087

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301-812-0315 301-972-9730

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301-603-1223

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Boston Randy Caviness Duxbury

978-779-2955

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781-789-3386 413-528-8020

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704-734-0061 781-585-6525

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508-839-2293 508-358-8100

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413-268-3000 508-798-3463

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508-798-0400

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952-473-1239

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Omaha Troy Everson, D.V.M.

402-330-3096

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702-735-7184 702-617-3285

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732-972-3201

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732-842-8266 609-953-3502

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609-953-3502 973-644-3211

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505-888-5777

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516-242-7209

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845-356-3838

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212-481-7999

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828-277-6635 828-295-9181 704-370-0767 704-542-2000

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513-931-9127 614-888-2100 513-367-4111

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740-353-5758 503-579-3300 541-312-2360 541-383-2569

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503-233-2332 503-239-5670

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503-556-3084 503-385-6701 503-363-6465 503-397-9190

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503-655-1722 717-677-9543 724-774-8047

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610-558-1616

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610-466-0501

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717-872-0674 724-758-8882

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New Britain Susan Yatsky Nottingham Judith Shoemaker Yardley Deva Khalsa SOUTH CAROLINA

215-340-0345 717-529-0526 213-493-0621

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843-437-0063 843-881-9915 864-834-7334

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915-886-3201 281-440-4441 817-572-2400 713-522-2700

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281-440-4441 281-440-5243 409-755-7216 210-641-4447

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435-644-2400 435-647-0807

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802-375-9491

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802-259-2286 802-888-4201 802-747-4076

W. Halifax Susan M. Kelly, DVM VIRGINIA Alexandria Harold Alterman

802-368-2244 703-823-5646

Arlington Jane Morse

703-528-2776

Charlottesville Albert Smith Daleville Cheryl Caputo

434-973-4341 540-992-4550

Falls Church



Animal Holistic Home Care Flint Hill Joyce C. Harman Hartfield Steven Skinner Locust Grove Anna Walton

703-578-6017 540-675-1855 804-776-9219 540-972-3869

Middleburg Janet McKim New Castle Marjorie Lewter Norfolk Constance Pozniak Richmond Tracy Agostino Lord, DVM

540-687-6144 540-544-6971 757-461-4416 757-291-2202

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540-343-8021 703-752-9105 703-670-6181

WASHINGTON Bellingham Michelle C. Schraeder Olympia Patti Schaefer Pasco Charles Coleman, DVM Port Townsend

360-592-5113 360-923-5759 509-545-4931

Abbie Doll, DVM, CVA Redmond Larry Siegler Renton Michael Lemmon Seattle Naomi Bierman

360-379-1133 425-885-5400 425-226-8418 206-715-1059

Masami Seplow Spokane Rosemarie Asterino Kerry Fisher Vancouver Brenda K. Smith WISCONSIN

206-723-3809 509-327-2062 509-468-0443 360-694-9514

Eau Claire Lindalu Vognar Glendale Maria Glinski Granton

715-579-9472 414-228-7655

Granton Jean Liljegren Madison

715-238-7686

Cynthia Smith Mike Kohn

608-827-3023 608-255-1239

Naomi Bierman Sturtevant Pedro Luis & Michelle Rivera

608-255-2977 414-886-1100

Waunokee Julie James-Blindt WYOMING Laramie Vicki Burton, DVM CANADA

608-850-7387 307-742-2488

St. Albert, Alberta Gail Beniuk Campbell Toronto, Ontario Rona Sherebrin, DVM

403-458-6051 416-486-1700

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About the Institute for Traditional Medicine The Institute for Traditional Medicine and Preventive Health Care, Inc. (ITM), is a non-profit 501(c)(3) organization established in 1979, incorporated in 1983, and moved to its current head office in 1988. ITM was founded by and is directed by Subhuti Dharmananda, Ph.D. Traditional medicine refers to ideas, experiences, and substances that have been handed down generation to generation from ancient times, where the origins are obscure but where the continuity of basic understanding has been assured by a formal structure. Among the primary traditional medical systems still active today are the Chinese, Tibetan, and Indian (Ayurvedic). ITM enriches the lives of people seeking traditional medicine knowledge and services by clarifying the nature of traditional medicine and demonstrating how it can be utilized in the modern setting. To accomplish its goals, the Institute performs 6 basic functions: 1. It operates two clinical facilities, the Immune Enhancement Project (IEP) and the An Hao Natural Health Care Clinic (An Hao). IEP is a low cost treatment center providing acupuncture, Chinese herb therapies, and Zen shiatsu primarily for patients with serious ailments (such as cancer and HIV) that can clearly benefit from effective adjunctive therapies, though all are welcome so long as they follow program protocol. IEP serves as a charitable outlet for ITM's clinical activities. An Hao is a mixed therapies clinic offering naturopathic medicine, acupuncture, chiropractic, Zen shiatsu, Chinese herbs, and modern medicine. It is a demonstration clinic that illustrates a potential new model for integrative health care. In addition, ITM provides consulting to other clinics that wish to follow the presentation method or the therapies that are available at these clinics. Selected students at local acupuncture colleges, particularly of the Chinese medical department of the National College of Naturopathic Medicine, can get advanced training at these clinics. 2. It provides numerous educational materials, primarily articles written by Subhuti Dharmananda. Currently, over 2,000 pages of such articles are in the ITM archive. Dr. Dharmananda provides free consulting to practitioners who are members of the START Group, to aid in their understanding of



herbs, issues related to traditional medicine, individual patients, and practice methods. 3. It conducts background research in traditional medicine, including medical journal searches in China (carried out by Dr. Fu Kezhi in Harbin) and computer searches here in the U.S. 4. It provides specially designed herbal formulations (most in tablet form) for use in the ITM clinics and by practitioners who read ITM's literature. These formulas are described in the ITM book A Bag of Pearls, and belong to the overall educational and training method of ITM which is to integrate the study of Chinese medicine into the practice of Chinese medicine. A Bag of Pearls describes 200 formulas, most of them based on traditional Chinese medicine principles. ITM also maintains a pharmacy of dried extracts, following the method of herb use that is dominant in Japan, Korea, and Taiwan. These dried extracts (granules) are used to make personalized formulations or formulas that are used in doses higher than suited to tablets. 5. ITM supports traditional environments where traditional medicine can be preserved. As funds are available, ITM has aided Tibetan, Indian, Chinese, Native American, Central and South American groups that represent potential reservoirs of traditional medicine culture and resources. Most notably, ITM has provided funds to construct a health care clinic at the Drepung Gomang Monastic refugee camp in southern India and has helped this group of about 1,700 refugees in maintaining their traditional culture. A doctor trained in Tibet works at the clinic. ITM has also supported a licorice cultivation project in a remote area of China where the capability to develop herb cultivation is strong. Herb materials have been given to practitioners traveling to Hondurus, Guatamala, East Europe, India, and other destinations to provide traditional Chinese health care in areas of desperate need. ITM funds have aided the International Trust of Traditional Medicine in India. 6. It provides information to other organizations, such as the American Botanical Council, and to magazines, news reporters, and researchers, upon request. ITM is frequently cited as a source for reliable information on herbal therapies. ITM has 24 employees: about half are part-time health professionals (mainly acupuncturists and massage therapists); about half are full time office workers. ITM has affiliate organizations in Belgium and China. ITM is not a school and does not offer courses, certifications, or diplomas; it does not conduct clinical or laboratory research; it is not a foundation (e.g., that might provide funding to students or others working in the

field of traditional medicine). To better understand the work of ITM, please read several of the articles posted here.

About Subhuti Dharmananda Subhuti Dharmananda received his Ph.D. in Biology from the University of California in 1980. He traveled to China several times, the first visit in 1977 and most recent in 2001, and has collected a large library of books and journals involved with traditional medicine. In addition to ITM, Subhuti Dharmananda helped initiate People's Herbs Incorporated, All-The-Tea Company, and Dharma Consulting International, and has been a consultant to several major herb companies, including Fmali Herbs (maker of Good Earth Teas), Health Concerns (maker of Chinese Traditionals), and Sen (maker of Sen traditional herbal formulae and other products). He has been an editor, reviewer, and contributor to several journals involved with traditional medicine, including the International Journal of Oriental Medicine, the Protocol Journal of Botanical Medicine, and Herbalgram. Home | About | Articles | Formulas | Practitioner Guide | Veterinarian Guide | Acupuncture Schools | Famous Doctors



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A BRIEF REVIEW OF AYURVEDIC CONCEPTS with examples of essential Ayurvedic herbs and useful formulas by Subhuti Dharmananda, Ph.D., Institute for Traditional Medicine, Portland, OR

Ayurvedic medicine is one of the major traditional medicine systems of the world, second only to Chinese medicine in terms of the extent to which it is used today. It has influenced Chinese medicine by virtue of the transfer of several herbs native to India to China for incorporation into the Chinese system. Much of that transfer was accomplished over a thousand years ago. Chinese medicine and India's medicine have been combined into Tibetan medicine to help produce yet another major traditional medical system. India's tradition has also combined with that of the Greeks to help form the modern Unani medicine as practiced in Pakistan and surrounding areas. There is no licensing for the practice of Ayurvedic medicine in the United States (or most other countries outside those where it has been a central part of the healing tradition for centuries). It is provided by health professionals who have studied the subject independently (a few medical doctors, naturopathic physicians, acupuncturists, etc.), or interested persons may obtain herbs and formulas on their own by self-selection of remedies sold in stores or via the internet. Ayurvedic medicine is of some interest to these practitioners and the general public for several reasons, aside from its long history of use, such as: Ayurvedic suppliers are becoming a strong force in the nutriceutical industry, providing concentrated extracts or isolated components from major Ayurvedic herbs. These are coming to the attention of the public at large as well as many practitioners. While all traditional medical systems emphasize the importance of diet in health and use of certain foods as medicines, the Ayurvedic system is especially known for this and offers some practical advice. The modern emphasis on scientific evaluation of traditional remedies means that there is increasing desire to use "proven" substances, regardless of which medical system they have been derived from. Thus, those who have studied Chinese medicine or Western herbs will still find any well-studied Ayurvedic herbs of value to know, understand, and possibly use. In trying to grasp the meaning and application of traditional and modern medicine concepts, it is helpful to see the differences between medical approaches around the world so that one does not become confined to a single cultural model. In this document, there are a few pages devoted to depicting the basic Ayurvedic system, with focus on the dominant tridosha framework. This is followed by an exposition of 12 of the key Ayurvedic herbs, with examples of one formula each that have them as their primary ingredients. These formulas are available for use in convenient tablet form. Many other Ayurvedic formulas, both traditional and modern, also rely on these key herbs, so that the explanations provided here should be helpful in understanding other formulations that may be encountered.





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A Bag of Pearls 2004 Edition Featuring: Many new & revised formulas Reformulations based on current safety concerns Expanded traditional formulas section Expanded granule formula section Extensive introduction and background materials View the Table of Contents Only $20.00 + $9.00 shipping (shipping costs may vary) To order, call: 503-233-4907 (in Oregon) or 1-800-544-7504 Home | About | Articles | Formulas | Practitioner Guide | Veterinarian Guide | Acupuncture Schools | Famous Doctors



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CHINESE DYNASTIES by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Chinese history is normally described in relation to Dynasties. The first historical emperor of China was Qinshi Huangdi, or the Yellow Emperor of the Qin clan. His tomb has become the famous archeological site at Xian, best known for its hundreds of terra cotta guards and horses. Before him, there were diverse tribes forming confederations, depicted as the Xia, Shang, and Zhou Dynasties. Dating of the Xia and Shang Dynasties are based on archeological finds; dating of the Zhou Dynasty is influenced by historical records that are imprecise. Before that time, one encounters stories of a mythical period, projecting back to 5,000 years before the present, which gives the commonly-cited figure for the age of many Chinese cultural activities, including the frequently recited statement: "Chinese medicine has a 5,000-year history." Beginning with the Qin Dynasty, the common characteristic of Chinese rule is that there was one primary leader of China, the head of the Dynasty. Each leader was succeeded by another, usually by birthright, until an opposing group took power (at times, two or more Dynasties coexisted in different parts of China). It was common for a Chinese Dynasty to follow a basic pattern: begin with a very powerful leader taking over a weakened country; develop over several generations to a highly successful and vital civilization; and then degrade to the point that an opponent could take over. Some historical periods were highly unstable, in which there was frequent or nearly continuous upheaval. Thus, before the Tang Dynasty, there was the Six Dynasties period, followed by the short-lived Sui Dynasty (all together 7 Dynasties in 140 years). For those who are interested in China, the famous Han, Tang, Song, Ming, and Qing Dynasties particularly stand out; each of these lasted for about 300 years and ruled a vast territory. In Chinese historical documents, it is common to identify a person's life and accomplishments by the Dynasty in which he (or she) lived, and, frequently, according to the Emperor who lived at that time. For precision, a person's birth date, date of a publication or accomplishment, or date of death might be given as the "16th year of the Kangxi Emperor of the Qing Dynasty," thus allowing modern historians to translate to a specific year of the calendar. Major historical developments are described in relation to the Dynastic period in which they took place. In the medical field, it is common to refer to medical works that arose during the Han, Song, Ming, or Qing Dynasties; one particularly productive period is known as the Jin-Yuan; referring to the Southern Song (corresponding to Jin) and Mongolian (Yuan) Dynastic periods. While the Chinese people, as well as scholars who specialize in Chinese history, are well aware of these Dynasties by name and when they occurred, those who have a more cursory interest in things Chinese may not gain much insight by typical references to "the Warring States period," or the Manchu Dynasty (the Qing Dynasty). In order to assist readers in understanding the timeline of Chinese history, the following table (on two pages) is offered. It should be understood that there are some disagreements among scholars about the dates involved, particularly before about 300 A.D. In the table, some alternative dates are presented in brackets. Often times, the transition would not be a clean one; an emperor of one Dynasty might retreat to a different part of China and continue on for some years; or, a new Dynasty might begin in a remote part of China and then take over the capitol. The question arises: what date is chosen to define when the Dynasty starts and ends? There can also be slight discrepancies in the year assigned due to uncertainties in the historical records; these usually involve only a year or two of difference from the years cited here. To help further elucidate the nature of a Dynasty, details of the Qing Dynasty, China's last, are presented in a separate table, showing each of the Emperors, and depicting some events that took place during their reign that influenced the future development of China. Several books about individual Chinese Emperors and the events taking place during their rule are available. Examples are: The First Emperor of China (1), A Year of No Significance (2; about the Wangli Emperor of the Ming Dynasty), and Emperor of China (3; about the Kangxi Emperor of the Qing Dynasty). Table 1: Chinese Dynasties. Designation of Dynasty, Subdivisions, and Years

Years of Dynastic Period

Mythical Rulers Fu Xi (Tai Hao): 2953 B.C. Shen Nong (Yan Di): 2838 B.C. Five Emperors* 1. You Xiong (Huang Di): 2698-2599 B.C. 2. Jin Tian (Shao Han): 2598-2515 B.C. 3. Gao Yang (Zhuan Xu): 2514-2437 B.C. 4. Gao Xin (Di Ku): 2436-2367 B.C. 5. Gao Xin (Di Zhi): 2366-2357 B.C.

2953-2357 B.C.

Patriarchs Tao Tang (Yao): 2357-2258 B.C. You Yu (Shun): 2255-2205 B.C.

2357-2205 B.C.

Xia Dynasty Dating estimates from archeological sites

2205-1766 [1806] B.C. [~2000-1500 B.C.] [~2100-1600 B.C.]

Shang Dynasty Dating estimates from archeological sites

1766-1121 B.C. [1700-1027 B.C.] [1600-1066 B.C.]

Zhou Dynasty Kingdom of Zhou (Eastern Zhou): 1121 [1027/1134]-770 B.C. Chun Qiu (Period of the Annals; Spring and Autumn): 770-464 [476] B.C. Zhan Guo (Warring States): 464 [475]-221 B.C. Qin Dynasty Qin Shi Huang Di [first emperor]: 221-210 B.C.

1121-255 B.C. [1066-221 B.C.] [770-221 B.C.] 221-206 B.C.

Han Dynasty** Western Han: 206 B.C.-25 A.D. [9 A.D.] Eastern Han: 25 A.D.-220 A.D.

206 B.C.-220 A.D.

Three Kingdoms Wei (North): 220-265 A.D. Shu (West): 221-265 A.D. Wu (South): 222 [229]-280 A.D.

220-280 A.D.

Jin Dynasty Western Jin: 265-317 A.D. Eastern Jin: 317-420 A.D.

265-420 A.D.

Song Dynasty

420-479 A.D.

Six Dynasties 1. Qi Dynasty: 479-502 A.D. 2. Liang Dynasty: 502-557 A.D. 3. Chen Dynasty: 557-589 A.D. 4. Wei Dynasty: 386-557 [533] A.D. Northern Wei Dynasty: 386-535 A.D. Western Wei Dynasty: 535-557 A.D. Eastern Wei Dynasty: 534-550 A.D. 5. Northern Qi Dynasty: 550-589 [577] A.D. 6. Northern Zhou Dynasty: 557-589 A.D.

479-589 A.D.

Sui Dynasty

589 [581]-618 A.D.

Tang Dynasty

618-907 A.D.

Five Dynasties and Ten Kingdoms *** 1. Later Liang: 907-923 A.D. 2. Later Tang: 923-936 A.D. 3. Later Jin: 936-947 A.D. 4. Later Han: 947-951 A.D. 5. Later Zhou: 951-960 A.D.

907-960 A.D.

Song Dynasty Northern Song: 960-1127 A.D. Southern Song: 1127-1280 A.D. (Jin)

960-1280 A.D.

Yuan Dynasty (Mongol)

1280-1368 A.D.

Ming Dynasty

1368-1644 A.D.

Qing Dynasty (Manchu)

1644-1911 A.D.

* Historians have not agreed on who were the Five Kings, as the literature is ambiguous and conflicting. The basic list is Huang Di, Shao Hao, Zhuan Xu, Di Yao [or Di Ku], and Di Shun [or Di Zhi]. ** The transition between the Western (or former) and Eastern (or later) Han Dynasties is marked by the rule of the Xin king Wang Mang, from 9 A.D. [6 A.D.] to 23 A.D. and the usurper Xuan for one or two more years; they are often subsumed under the Western Han period. At the end of the Eastern Han Dynasty, Emperor Liu Shan ruled in exile from 224-263 A.D. *** The Ten Kingdoms were the Wu, Nan Tang (Southern Tang), Wu Yue, Chu, Min, Nan Han (Southern Han), Qian Shu (Former Shu), Hou Shu (Later Shu), Jing Nan (Southern Jing), and Bei Han (Northern Han). There were also two Dynasties that overlapped with this period and the Song Dynasty as follows: Liao 916-1125 A.D.; Western Xia 1038 [1032]-1227 A.D. After the Qing Dynasty, the Republic of China was founded by Sun Yatsen; the Republic of China continues today on Taiwan. In 1949, the People's Republic of China was founded by Mao Zedong; the communist PRC is the current governmental structure for all of China except Taiwan. Table 2: Emperors of the Qing Dynasty. Emperors*

Events

Qing Shi Zu (Sun Zhi) (1644-1662)

Shi Zu occupied Beijing; Li Zi Cheng defeated (1644). Zheng Cheng Gong took over Taiwan (1661).

Qing Sheng Zu (Kang Xi) (1662-1723)

England began trading with China (1680). Taiwan captured (1683). Boundary between Russia and China is delineated (1689). Mongolia incorportated into Qing's territory (1697). Tibet's rebellion suppressed (1720).

Qing Shi Zong (Yong Zheng) (1723-1736)

Sunu tried to crown Emperor Kang Xi's eighth son Yun Yi to be Emperor, but failed. Qing Hai captured (1723). Christianity banned in China (1723). Emperor issues first anti-opium edict.

Qing Gao Zong (Qian Long) (1736-1796)

Conquered Turkestan (1755). Initiated the Closed Door Policy. Tea trade with Europe established (1760 - 1770). Vietnam conquered by China (1787).

Qing Ren Zong (Jia Qing) (1796-1821)

Christian literature banned (1805). Opium trade, forced by Britain, starts to expand rapidly (1820).

Qing Xuan Zong (Dao Guan) (1821-1851)

Opium War: Britain captured Zhou Shan and attacked Ning Po (1840). War ended with the signing of Nanjing Treaty that opened up five trading ports and ceded Hong Kong to England (1842).

Qing Wen Zong (Xian Feng) (1851-1862)

Hong Xiu Quan led the Taiping Rebellion (1851). Joint forces of England and France attacked China over banning of opium (1857) and occupied Beijing; Summer Palace looted. China signed Beijing treaty with England, France, and Russia to end the war by paying indemnity and giving up more land (1860).

Qing Mu Zong (Tong Zhi) (1862-1875)

When Xiang Feng died Tong Zhi was only 6 years old. Empress Dowager Cixi (Tong Zhi's mother) ruled China behind the scenes until Tong Zhi was 17. Taiping troops defeated in Shanghai (1862). Japan occupied Taiwan (1874).

Qing De Zong (Guan Xu) (1875-1909)

Empress Dowager Cixi ruled China (1875-1908). Civil war in Korea: China sent troops to help and sparked the Sino-Japanese war (1894) that ended with China giving Taiwan to Japan (1895). England took Kowloon; America forced China to open its door (1899). Boxer Rebellion sparked the mass invasion by eight countries including England, America, Germany, France, and Russia (1900).

Qing Xuan Tong Di (1909-1911)

Japan conquered Korea (1910). Rebellion started in Wu Chang (1911), leading to overthrow of last Chinese Dynasty, "ruled" by a young child, Pu Yi.

* The Emperors name is given first, followed by the name for the Emperor's reign. Hence, Qing Shi Zu is the name of the Sun Zhi Emperor; Qing Sheng Zu is the name of the Kang Xi Emperor.

REFERENCES. 1. Guisso RWL, Pagani C, and Miller D, The First Emperor of China, 1989 Sidgwick and Jackson, London. 2. Huang R, 1587 A Year of No Significance: The Ming Dynasty in Decline, 1981 Yale University Press, New Haven, CT. 3. Spence JD, Emperor of China: Self Portrait of Kang-Hsi, 1974 Vintage Books, New York.

Figure 1: The First Emperor of China: Qinshi (221-210 B.C.).

Figure 2: Hongwu, Founder of the Ming Dynasty (1369-1398 A.D.).

Figure 3: Wanli, 14th Emperor of the Ming Dynasty (1573-1619 A.D.).

Figure 4: Kangxi, 2nd Emperor of the Qing Dynasty (1662-1722 A.D.).

KIDNEY ESSENCE AND THE HUMAN BODY: An Exploration of Chinese Embryology by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

First, there is essence, the intertwining of yin and yang that makes up all things. It has-this time-manifested as a human, the ultimate meeting of heaven (yang) and earth (yin). The essence, as a manifestation from earlier existence through the continuing cycle of death and rebirth, gains its new chamber, the kidney, which retains it and allows it to slowly emerge in form. From this precious chamber sprouts the skeleton, and within the spine, the spinal cord and brain and from the brain the retina and hearing mechanism. Within the bones is the marrow which generates blood. Also from the kidney emerges the reproductive organs, so as to help assure another part of the linkage between earlier existence and later existence. The kidney has the nature of and is the source of water. From the kidney rises the water vapors that fill the sky and cover it with clouds. From the clouds come the falling rains. From the kidney emerges the bladder which contains the returning water and then drains it. The hearing mechanism responds to the universal sounds, which reverberate through the water, and from this vibration of the water there develops the liver, which is the nature of wood. The liver stores the blood generated by the marrow, and sprouts the tendons and ligaments from the edges of the bones. It produces the eyes that attach to the retina. The liver is the source of wind. The wind disperses the water vapors and clouds and lets spaces develop, through which the great yang, the sun, can shine and the wood can grow. The penetrating and reflecting light enters through the eyes and the images then restrain or agitate the wind. The blood is dried by the wind and the dried blood is drained into the gallbladder. The sight mechanism responds to universal signs, which provide the initial spark that is whipped by the wind to generate the heart, which is of the nature of fire. The heart circulates the blood and opens to the mind so that the wind may generate its own signs. From the heart sprouts the blood vessels through which the blood circulates, and there develops the tongue which will allow the human to communicate the images of the mind. The fire generates heat, which is carried by the water and wind and dispersed through the three heated spaces, the upper body, the middle body, and the lower body. The heart is in the upper body, the liver is in the middle body, and the kidney is in the lower body. From the tongue there develops the ability to taste and the desire to take in food: from that desire emerges the spleen, which is of the nature of earth. The spleen takes from the food the clear essence (qi) which is used to replenish the blood that has dried, and to produce the flesh and muscles that attach to the tendons, and to circulate the moisture that has been warmed by the heart and the kidney. From the spleen develops the mouth to take in the food and the stomach in which the food is briefly stored and then prepared for the body. The spleen has the nature of earth which is moist and heavy; the earth forms ponds and streams and rivers and oceans. The wetness is cold, but the fire of the sun is warm, and so there is balance. But it is a dynamic balance-with movement. The movement is made possible by the muscles empowered by the spleen and the extracted essence of food. The food, like the earth, is heavy; the yin and yang of the body desires balance, so from the spleen which is the nature of earth, arises the lungs. The lungs take in the air, which is light, and which invigorates the heavy qi with light qi. The lungs generate the nose to help bring in the air and the fragrances it carries. The lungs have the nature of metal. Metal, which is the condensation of materials within the earth, helps the water vapors to return to the kidney, to assure that the entire organism is maintained through recycling of the essences. The lungs sit on the top of the organs and protect them from the outside forces. They produce the defensive qi that keeps out unfavorable external influences penetrating from the surface (yang) to the interior (yin) and from the upper body (yang) to the lower body (yin). They expand and contract and help to bring in the favorable influences and to expel the unfavorable. In this, the metal helps the spleen, especially as it needs assistance in expelling the waste from food through the intestine. From the beautiful and pungent fragrances, especially, but also from the sight, sound, taste, feel, and speech, the human body is attracted to another human body and the kidney essence of the male is merged with the kidney essence of the female to produce the new human body. The new human body, which has the nature of substance, attracts the floating spirit which has no substance but which needs a place to rest. The spirit entices the blending of the particular human bodies to meet its direction in the new life, still dependent on the actions of the earlier life. In the blending of spiritual direction and human material essence, the process continues.

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Ethics in Modern Practice of Traditional Chinese Medicine (TCM) by Subhuti Dharmananda, Ph.D.

Background There are numerous matters that fall under the category of medical ethics, and I have selected three of them in order to illustrate an approach to pursuing a higher ethical standard for the modern practice of TCM. The three categories are: Educational Responsibilities of TCM Practitioners Scope of Responsible Practice for TCM Claims for Success and Efficacy These three areas are intimately connected. Well-educated practitioners are more likely to keep to the scope of practice for which they are licensed, while poorly educated practitioners are more likely to fall prey to a variety of kinds of alternative practices that are (or should be) outside their scope of training and licensure. Well-educated practitioners who work within their scope of practice are less likely to make claims that are unsubstantiated and misleading, while less educated practitioners who journey outside their scope of practice are more likely to make proclamations of capability and success that are not based on any objective assessment. Patients’ health and wellbeing, as well as their wallets, are affected by weak ethical standards, and the entire profession can be tainted by failing to adhere to high standards. While there exists, within all professions, a risk of unethical practices by individuals who lack a strong sense of right and wrong, what is to be addressed here are areas of susceptibility within the structure of the modern TCM community that may encourage practitioners to pursue methods not of suitable ethical standard, and, more importantly, that give no indication that anything is awry. Too often, these ethical issues become couched in terms that dissuade challenges: there is a purported clash in “paradigms.” The matter is eventually described in terms of power: how—and by whom—does a determination get made as to what is valid, true, or acceptable? Objections are raised to those who are perceived as being closed minded about what goes on in TCM practices. But, there is a difference between having a critical mind, one that challenges appropriately and demands some accountability, and having a closed mind that is not able to consider an alternate viewpoint. In this presentation, I will offer some judgments on activities that have taken place in this field, and hope that these are seen as tackling the problem of invasive movements rather than raising barriers to valid approaches. One of the ways to address the matter with some fairness is to turn to ethical principles that are espoused in the community of Chinese medicine practitioners in China, such as presented in the book Medical Ethics in Imperial China, and to supplement that with the ethical considerations that belong to a western culture, such as associated with the scientific community. There are two towering figures—Sun Simiao in China and Hippocrates in the west—that provide beacons to guide us. In the end, some will agree and others disagree with the selection of issues and determinations as made here. Yet, it is hoped that the points raised will serve as a basis for further work in this area that might lead to a consensus, at least amongst those who are in a leadership role. The particular concerns addressed in my essay are about practitioners of Chinese medicine who were trained in the west, especially in the U.S.

Sun Simiao The subject to ethics in Chinese society was first dealt with in a formal manner by Confucius (Kong Fuzi; his life usually dated 551-479 B.C.). He did not address medical ethics, but, instead, focused on relations within society: its governments, communities, and families. In a summarization of Confucian ethics, the terms ren; yi versus li and li (different character) together with xiao form the basis: Rén: The fundamental virtue of Confucianism; it refers to benevolence, charity, humanity, love, and kindness. Confucius defines the principle Aì rén: to love others. Yì; involves right conduct, morality, duty to one’s neighbor, and righteousness, whereas Lì, involves profit, gain, and advantage, which are not proper motivation for actions affecting others. It is put this way: “The gentleman (junzi) understands yì; the small man (xiaoren) understands lì.” Yì may be broken down into two components: zhōng, doing one’s best, conscientiousness, and loyalty; and shù, reciprocity, altruism, and consideration for others. There is also the general manner of living within a family, it includes Lĭ (an entirely different word than Lìabove) meaning propriety, good manners, politeness, ceremony and worship; and another important principle which is Xiào, to honor one’s parents, known as filial piety. While some forms of medicine were present since the most ancient times, the system we become familiar with was organized during the Han Dynasty period, with preliminary work done during the Eastern Han and the formation of essential texts, like the Nei Jing and Shang Han Lun, during the Western Han period (25-220 A.D.), mainly during the last half of that period. Chinese medical historians recognize that a period of disorganization of the medical field occurred from time to time, and Sun Simiao played a big part in the revitalization of Chinese medicine that took place after China had gone through a time of great divisiveness and war, with reunification occurring in the Sui Dynasty (589-618), and China flourishing during the Tang Dynasty (618-907). The website ChinaCulture.org presented information on Sun Simiao, emphasizing his contribution to ethics. Here is a portion of their presentation (1):

Sun Simiao (581-682) was a great medical scientist of China in the Tang Dynasty (618-907)….Sun Simiao's viewpoint on medical ethics was very important in the history of Chinese medicine. In his Qianjin Yaofang (Essential Prescriptions Worth a Thousand Pieces of Gold), he put forward the notion of “good faith of a great doctor” for the first time, offering an all-round argumentation on the guiding rules of medical ethics a doctor must hold to. “Human life is of paramount importance, more precious than a thousand pieces of gold; to save it with one prescription is to show your great virtue.” His book was just a manifestation of such a noble moral character. He gathered and studied the medical data before the Tang Dynasty, with reference to his own clinical experience of several decades, wrote Beiji Qianjin Yaofang (Essential Prescriptions Worth a Thousand Pieces of Gold for Emergencies) and Qianjin Yifang (Additions to the Prescriptions Worth a Thousand Pieces of Gold), which have 30 volumes each....Sun Simiao paid great attention to women and children's care and wrote The Prescriptions for Women in three volumes and the Prescriptions for Children and Infants in two volumes….Sun Simiao’s study on health care was very profound. He advocated putting prevention of diseases at the first place, stressed the importance of “restraining the desires [in order] to cultivate mental poise”, “caution in speech,” and “moderate in eating.” Among the things to note in this presentation is that he took care of those in great need, including saving the lives of those who were too weak or ill to be cared for by their own families, giving attention to the needs of women and children (who were in a secondary position of the society), and paying attention to moderate behavior as a means of both preventing disease and maintaining a healthy community. His dedication, displayed by the lengthy studies and tireless writings, offers guidance for others who wish to contribute to a high standard of medical ethics.

Hippocrates In the West, we have the basis for medical ethics established by Hippocrates a thousand years before Sun Simiao. He summarized his ethical views in his famous “oath,” for which many people know it by name, but are not familiar with its content (2): I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot! We may note here the emphasis on education, including the honor to one’s teacher and passing on of what has been learned; the protection of the patient and, as one example, not stepping outside the scope of practice but leaving certain actions to those who are specialists; and abstaining from mischief and that which is mischievous, which would include giving information that is misleading, such as comments about health and disease and claims of success that are not substantiated

Part I. Educational Responsibilities of TCM Practitioners Principle: It is vital that persons who offer professional services in the field of TCM maintain adequate knowledge of all the relevant subjects in order to give a level of service consistent with the current state of the art. Problem: There are a number of deficiencies in education related to TCM, especially to its application in the modern setting, that need to be rectified. Examples of these deficiencies include the following four areas. a) In China until recent years, persons who provided Chinese medical services grew up in a culture in which basic philosophical concepts, such as yin/yang, five elements, and jing-qi-shen (essence, qi, and spirit), had a broad meaning that could be learned through education and daily experiences. By contrast, Western practitioners of TCM are usually introduced to these concepts later in life, in a didactic manner, and with a minimum of exposure to their historical and cultural significance, as well as limited description of their meaning and relevance in the medical system. Additionally, students of TCM are often given scant exposure to the ancient texts that are required reading for practitioners in Asia, and rarely presented with biographies of model medical men and scholars that can inspire deep study of the field. As a result, the fundamental concepts and original ideas that form the basis of TCM are often improperly used by today’s practitioners to the detriment of the field and, potentially, as a barrier to effective utilization of TCM. b) Today, modern medicine, which is the standard and orthodox form of treatment, and modern science (including, but not limited to: clinical trials, laboratory studies, and the theoretical frameworks of biology and physiology) are the means of presentation of concepts and information that are expected by most patients. Insufficient training in the sciences and modern medicine, and outright prejudice against these aspects of our knowledge base expressed by some educators (particularly writers of articles and books) can lead practitioners to provide incorrect, misleading, and potentially harmful information and recommendations, as well as suboptimal treatments. c) Teaching of TCM often focuses on conveying the ancient dogma and the assignment of properties and effects for acupuncture points and herbs without adequate attention to essential details of their practical applications. As a result, those who are licensed to practice Chinese medicine frequently do not have adequate training in key matters affecting outcomes such as frequency of acupuncture therapy and the recommended techniques of maintaining stimulus; herbal dosage and duration of therapy; issues of herbal safety (including the meaning of contraindications); and true TCM concepts of how life style influences healing. As a result, practitioners may offer therapies that have reduced value even though these are provided at great expense to patients (both in terms of cost and time). d) The method of self-learning and in-depth pursuit of knowledge following the initial TCM training is often ignored; practitioners are not encouraged to vigorously gain deeper understanding. To undertake such additional learning, graduating students must be taught to distinguish between valuable resources and those that are deceptive and useless. There is an unfortunate abundance of intellectual dishonesty in the broad field of “alternative medicine,” a field to which TCM, as practiced in the West, often attaches itself. To quote a useful definition (3): “Intellectual dishonesty is the creation of misleading impressions through the use of rhetoric, logical fallacy, fraud, or misrepresented evidence. It may stem from an ulterior motive, haste, sloppiness, or external pressure to reach a certain conclusion. The unwary reader [or hearer] may be deceived as a result.” TCM practitioners may be led into beliefs that have little relevance to either TCM or modern medicine, and which have little or no basis anywhere, giving patients a false sense of hope and contributing to their confusion about health matters. Resolution: It is first necessary that members of the profession become aware of these deficiencies and to recognize that the deficits are widespread and to some extent affect all TCM practitioners today to varying degrees (indeed, all people face related challenges in their various professions). Once the deficits are acknowledged, educational institutions—their directors and faculty—must together find ways to address the problem. Practitioners, informed of the need from the outset of their training, must be willing to put aside a certain amount of time towards study and contemplation that will narrow the knowledge gap. This is accomplished through active and ongoing critical study by the practitioner, and not limited to symposia that are utilized for continuing education credits or for attaining additional techniques or certifications. Critical study is a never ending process, because the subjects involved have a great depth and the medical situation is ever changing. A process of examining sources of information and ideas with good judgment must be established. The relevant materials must be accessed, studied, and then given consideration as to how they might apply to actual situations. In China, there is a concept of “cultivating” oneself, one’s moral and ethical principles, and one’s qi. This is accomplished by a three-fold process of study, living a life style that is consistent with the underlying principles, and putting the fruits of study and daily experience into practice. This ideal of self-cultivation serves as a model for the TCM practitioner. Much of Chinese medical practice originates with Taoist philosophy. I would like to quote briefly from a statement on ethics provided by the Taoism Culture and Information Center (4): Taoism [Daoism] considers ethical education and practice as its fundamental task. On the one hand, Taoism tries to publicize its theory and doctrine in society, leading people to be good in the hope of creating an ethical society. This is Taoism’s ethical education. On the other hand, Taoism encourages ethical practice, which is to lead human beings to good behavior. Ethical practice aims at accomplishing one's duties and accumulating merits, which is to bring forth one’s spiritual release, instead of seeking to win compliments.

I think most people will see that these principles exist with similar form in the Judeo-Christian tradition, in Buddhism, and, in fact, all religious and spiritual traditions. Taoism is an especially useful reference point because of its close relation to the development of TCM. In an article I wrote on the essentials of Taoism and the Taoist influence on medical literature (5), I included this quotation from Xu Dachun (6), writing about 250 years ago, on the need for physicians to continually study: Today’s physicians possess no skills. They do not read a single book. Hence those who merely browse through the medical literature [become prevalent]....Those browsers believe themselves to be increasingly right after some time. [Yet], in the beginning they harm other people through mistaken treatments; then they harm their relatives through their mistaken treatments; in the end, they harm themselves through mistaken treatments. Physicians whose training is insufficient may still avoid harming people as long as they are able to follow proper principles. And if they are able to remain modest, and if they attach great importance to studying, their knowledge will progress every day, and each of their therapies will result in a cure. Hence their fame and reputation will increase and many people will seek their help as a consequencewith riches following them. If one searches for nothing but riches, one will miss both fame and riches. Why do the physicians increase their own problems by neglecting one [studying] and going for the other [seeking rewards]? Gong Xin (ca 1600 A.D.) had written about the proper approach used by enlightened physicians and what is too often the actual case—the methods of common physicians—as relayed in the book on medical ethics in Imperial China (7): The enlightened physicians of today cultivate humaneness and righteousness in their attitude. Their study is extensive and embraces all of the writings in their entirety. For this reason, they are well versed in theoretical medicine and its practical use. They know yin and yang, and understand the macrocosmic phases [yün] and the types of climate [qi]….They ponder over their best procedures, are flexible in their treatments, and do not cling mechanically to any formulas….Today’s common physicians brag about the unusual and the strange. They do not study the classic writings, neither do they understand the meaning of the words. They praise themselves into the forefront in order to deceive the world around them….they being a confused treatment without having searched for the origin of the disease....” In quoting these writers from centuries ago, I am demonstrating that the problems of today were the problems of all times. We have a somewhat organized system of college education of practitioners, so we should be getting past these problems rather than passing them on. In quoting these writings, I do not wish to put too much emphasis on the need to know yin and yang, yün and qi, or even the classical writings; there is just as much, if not more, need to know the relevant aspects of modern medicine, the modern understanding of herbs, and other parts of the knowledge base that were unknown in their times. I also wish to point to the Gong’s caution about the “unusual and strange.” It is unfortunately common today for many practitioners to adopt devices and techniques that are, in relation to both TCM and modern medicine, truly “unusual and strange.” In China, students of TCM are presented with biographies of numerous famous physicians; these biographies are not so much accurate portrayals of their lives as stories to encourage the students towards great things. In every biography, there is mention of the intensive study of the classics and the great efforts to pursue knowledge of medicine. As an example, Hua Tuo (which many practitioners know for the acupuncture points named after him) has this story, which I summarized from various Chinese sources and relayed in my article about him (8): Hua Tuo studied and mastered various classics, especially those related to medical and health measures, but also astronomy, geography, literature, history, and agriculture, when he was young. He was stimulated to pursue a career in medicine after seeing so many people die of epidemics, famines, and injuries from wars. His father had died when Hua Tuo was seven. His family lived in poverty and his mother wanted him to pursue a career. So, he walked hundreds of kilometers to Xuzhou to access all the medical classics retained there and learned from a famous physician named Cai. He studied tirelessly while practicing medicine, and became expert in several fields, including acupuncture, gynecology, pediatrics, and surgery. Studying tirelessly is often the only way to catch-up on the needs of patients, especially when the training in TCM is so limited. Ethically, it is a requirement. One could say, also, that this intensive study “keeps one out of trouble,” that is, from straying too far from the area of expertise.

Part II. Scope of Responsible Practice for TCM Principle: It is essential that practitioners maintain and actively promote the integrity of Chinese medicine and be scrupulous in evaluating any diagnostic or therapeutic approach which is not an authentic part of TCM that might be incorporated into a TCM practice. Problem: Many practitioners in the West have quickly added to their TCM practice both diagnostic and therapeutic methods that have these characteristics: they have no basis in TCM; they have no support in modern medicine (the accepted medical system in the Western culture); and they can taint the field of TCM for all practitioners. a) One of the primary attractions of TCM is that it has a long history of use, that it has been and continues to be extensively used in its country of origin, and that its component parts are unified by a relatively consistent dogma. Patients going to practitioners of Chinese medicine have a reasonable expectation of being provided authentic TCM services, reflecting the best and safest practices from China (or, under the heading Oriental medicine, from Japan, Korea, and other countries that adopted Chinese medical concepts and practices). Chinese medicine is recognized as being a system that, like other health care systems, is liable to be adversely affected by deception, quackery, practice by untrained people, and similar problems whereby patients might be exploited by practitioners either wilfully or without realizing it (even with best of intentions). Traditional Chinese medicine literature refers to many instances where these problems arose in China. Patients going to practitioners who are licensed by their respective State governments have a reasonable expectation that such fraudulent and non-authentic or amateur practices have been weeded out via the required educational process, the testing and licensing processes, and monitoring of practitioners once they have set up their medical business. However, there are defects in the current system that allow practitioners to ignore their scope of practice and incorporate techniques not consistent with authentic TCM and not consistent with the high standards of education and monitoring that are expected. b) Patients can reasonably expect that practitioners of TCM have undergone rigorous, prolonged training and appropriate internship in order to understand their field of expertise and carry out its techniques with adequate knowledge and skill. Practitioners usually graduate from accredited schools, work (while being students) in professionally supervised clinics, and meet requirements for competence and understanding that are to be maintained and expanded through approved continuing education, as established by state and national organizations. Unfortunately, when adding other techniques to the practice of TCM, a practitioner might receive little training and the training might be provided by a person who would not meet qualifications consistent with accreditation of schools; the techniques may be ones that are not acceptable within the approved programs or in accordance with their standards, or the board responsible for monitoring and approving such courses may fail to do its important duty of careful oversight. Practitioners and their patients will not have a means for evaluating the training that is received nor the level of competence gained in use of these methods. c) TCM is regarded, by most practitioners and educators in the field, as a system of great depth, one which requires years of effort to master, far beyond the basics learned in a college program. By adopting non-TCM approaches into the clinical work, the practitioner may be diverted from further investigation of his/her field of expertise and licensing, particularly if the adopted methods are proclaimed (usually without proof) to resolve difficulties of practice that would otherwise require much study and effort. The problem is compounded when practitioners adopt non-TCM methods soon after completing their basic training, before getting a depth of knowledge and experience from working with TCM; because of limited experience, they may not be able to distinguish between authentic TCM and other methods that are popular fads. That these basic issues are not new and not unique to the Western situation can be illustrated by quoting from Qing Dynasty authors. Huai Yuan wrote a warning to physicians of his day, in a book dating from 1808 (7): In medical practice one cannot act at one’s own discretion. Patients entrust physicians with the decision over their life and their death….[the physician] searches for the causes and considers the consequences. He knows the normal and understands the changes….A physician plans in detail and thinks comprehensively. He observes a disease and takes precautions against it to avoid a second. He is glad over a success and yet he is aware that one cannot repose on this…Those, however, who surrender to fashionable trends do not carry out their practice conscientiously. They place themselves in the greatest light and make use of the need of others in order to appropriate their material goods to themselves….A physician has to love and respect himself; only then will he, when he faces a grave disease, possess enough trust in himself. I have studied at great length and in any diagnosis of a disease, I proceed with exactitude and conscientiousness; how could I carelessly acquit myself of that which others have entrusted to me and which I have promised to them?....Every patient has to consider the practicing physician a trustworthy person. A physician may examine the respectable [methods] without any further consideration. Yet, if he meets with the disreputable, he is first to assure himself of all the details related to it before making a decision. Xu Dachun, (writing 50 years earlier, in 1757), also warned physicians about the ease of deceiving patients with wrong ideas (6): The fact is that patients are people who do not know anything about medicine….When the patients meet someone who knows a little about medical principles, and [who] offers clear-cut discourse and discussion, they will believe what they hear, especially if he displays extraordinary concern and if emotions and face are involved. Who knows that this talk is based on superficial reading and stands for nothing but gossip? Before the people offering [these things] have considered what will happen to the patients following their advice, the patients will have already followed them…..As a result, they recklessly treat people’s illnesses and if these illnesses heal, they consider this their own achievement. If the patient dies, they have done no wrong. They cling only more strongly to their one-sided views….they go on and write books and establish doctrines of their own, and thusly bequeath harm even

to later generations. There are so many such people—one cannot count them. Although Xu mentions the extreme case of a person dying, which is usually not the situation in modern times, he gives a good analysis; it is easy for a person to claim credit for any improvements that a patient has, and to disregard failures: in the modern situation, a patient doesn’t die but simply decides not to come back for another treatment; the practitioner doesn’t see a failure because of keeping awareness only of those who come back again and again. Huai, Xu, and other Chinese commentators were aware that many practitioners of TCM could easily be distracted from their medicine by promulgators of disreputable techniques and from hearing presentations by charismatic speakers. They worried about people doing superficial investigations and introducing methods that were based on gossip and emotion-based claims. The same can and does happen in the modern world. Practitioners of TCM in the West are particularly susceptible because they are working within a culture that is not inherently supportive of their efforts, where the medicine they are licensed to practice is already considered an alternative to what is widely accepted. As a result, the ethical barrier to invasive, superficial, and distracting ideas, a valuable barrier that should exist, is sometimes left too porous or removed altogether. The requirement for an ethical barrier is not a matter of having a closed mind, but rather a matter of maintaining appropriate and necessary ethical restrictions under difficult circumstances. In the following presentation of examples in the current setting, I rely primarily on talks I have had with practitioners of TCM during the past two decades for information about how techniques are entering into TCM practices. I have written extensively about the problems with incorporating such techniques and about the importance of challenging claims made for them. For purposes of discussion, I will give as examples the “diagnostic” technique of applied kinesiology (muscle testing) and the “therapeutic” technique of NAET (allergyclearing therapy). Applied kinesiology has been widely introduced into Western TCM practices; it is unproven (and easily disproved by using blinded samples); it has no basis in or consistency with TCM (it was devised by a chiropractor who had no TCM experience); and may divert practitioners from study of their field. Learning the technique may require only a few hours (if that) and it can be taught by anyone who is a self-proclaimed expert. For those not familiar with this practice, a common method of application is for the patient to hold some material (e.g., a bottle of herb pills) to their naval, and then hold out one arm parallel to the ground or hold their thumb and first finger together in a circle; the practitioner then presses down on the outstretched arm while the patient resists, or pulls on the two fingers held together with the patient resisting; if the muscles seem to give way easily, the remedy is deemed wrong, while if the muscles seem to resist well, the remedy is deemed correct. For the average educated person, this technique—used for medical purposes rather than entertainment—may seem silly in the extreme; for practitioners who adopt it, this is a serious method based on the concept that the body does not lie, and that the body will accurately reflect the relative value of the remedy as detected through its “energy field” which then influences the strength of the tested muscles. The role of the practitioner is to apply the counter-pressure to the patient’s applied muscular tension; the result seems equally obvious to the patient and the practitioner, so there is no expertise required. In speaking with and challenging practitioners who use the technique, defences for its use in a TCM practice include keeping its use restricted (e.g., to cases where it is difficult to decide between two herbal formulations that might seem equally suitable); not relying solely on its use (e.g., using it only as a final “check” for decisions made on the basis of TCM); or claiming that it evidently helps the practitioner get good results, so its application is justified (e.g., “my practice is much more effective with it”). In all three instances, there is no established basis for determining that applied kinesiology is of benefit whether it is widely applied or only for limited cases; in the last instance, the claim of benefit is made without considering the generally accepted means of making such judgments (that is, established methods of modern science, which has its foundation in evaluating the veracity of claimed outcomes). In a few cases, practitioners are swept into working with an entire theoretical framework of “body energetics” in which applied kinesiology plays a substantial role, and the practitioner no longer presents what he or she is doing in standard TCM terminology. As an example, one chiropractor-acupuncturist lists on his website the services he offers, saying that the therapeutic approach involves “acupuncture together with other methods” and includes homeopathy (another non-TCM practice, which is also not part of chiropractic), described this way: “the use of homeopathic remedies to enhance the body's ability to heal itself. We stock highly effective European homeopathics. Bach Flower Remedies are dispensed according to applied kinesiological testing to assure effectiveness.” An especially notable example of offering TCM and then “other” techniques, is a clinic of three acupuncturists who describe how their work “evolved” (Three Rivers Clinic, accessed June 2006): “The medical philosophy of Three Rivers Clinic is based on Traditional Chinese Medicine (TCM) with acupuncture as the cornerstone of that philosophy…..As Three Rivers Clinic has evolved, our practitioners have embraced new forms of energetic healing. BioSET Allergy Elimination treatments and the Jaffe-Mellor Technique are two examples of this new energetic healing. Both use acupuncture and Traditional Chinese Medicine concepts, yet they bring them to a new level of assessment and treatment by implementing the modern discovery of muscle resistance testing (or applied kinesiology) as a way to obtain information directly from the body. These exciting new techniques have offered us new and powerful tools to help us reach our goal of healing the body, mind, and spirit!” Practitioners who embrace the self-proclaimed higher level techniques often become involved further with nonTCM methods, using various electromagnetic testing devices, pursuing the angle that the body’s field can be measured to determine a treatment. The possible divergences from TCM practice are endless; applied kinesiology may be described as a first step onto the “slippery slope.” A retort by some of those who use applied kinesiology is to challenge the TCM system this way: ‘if kinesiology is questioned, then why not question pulse diagnosis as well?’ Although a diversion from the true question, this point of potential dispute is raised because pulse diagnosis presents certain difficulties: it is claimed that by touching

the body (mainly the wrist) in certain ways (i.e., holding three fingers at the radial artery and placing differing amounts of pressure), one can determine imbalances of the internal organ systems. This seems an incredible claim, and somewhat like the claim for kinesiology. In fact, pulse diagnosis is an unproven method. However, it differs from applied kinesiology in significant ways; in regard to the ethical question at hand, it is a different situation because it is an authentic aspect of TCM. A practitioner may decide not to rely heavily on pulse diagnosis or not to use it at all if he or she questions its value in the modern setting. However, the practitioner who utilizes it in a manner consistent with its use in TCM is relying on a part of the official training that is given for the original medical system. Using traditional medicine systems does not require that each component of the system be proven valid or effective, because traditional medicine is a cultural construct that is being retained; however, introducing a non-traditional technique places an ethical burden on the one introducing it, especially if that person claims that, in fact, “it works.” Not only is patient care at stake, but also the reputation of the entire profession. A related problem is introduction of therapeutics (in contrast to diagnostics) that have little or no connection to TCM. Mentioned briefly above was homeopathics (and one of the recent derivatives called Bach Flower Remedies). A particularly insidious example affecting the TCM profession is NAET, which became popular a few years ago, though it is now waning (thankfully). Initially, it was claimed that this technique applied to allergy patients could cure allergies permanently within 24 hours. The therapy was developed by a young practitioner of chiropractic who was studying acupuncture. She incorporated the concepts of NLP (neurolinguistic programming), a bizarre system that was developed in California about thirty years ago, which has been widely adopted by chiropractors, the same group that initiated and has extensively used applied kinesiology (NLP has also been used in some other areas, such as popularized negotiating strategies, because it involves trying to change people’s ideas, attitudes, and behaviours). Naturally, NAET failed to meet the initial claim, but it did attract many practitioners to offer prolonged, expensive treatment regimens to patients; the financial rewards has been cited by practitioners who still offer NAET as one of the reasons for retaining it. The practitioners would, in many instances, even claim to cure an allergy that they themselves diagnosed, through methods such as applied kinesiology, thus making an internally self-satisfying system. Spin-offs of this technique (such as BioSET and Jaffe-Mellor Technique (JMT), mentioned by Three Rivers Clinic) were then promulgated to offer cures not only of allergies, but of autoimmune diseases and numerous other recalcitrant health problems. Although use of acupuncture needles is a usual component of the therapy, no in-depth knowledge of TCM is required to apply NAET, BioSET, or JMT. Thus, these methods could give the external appearance of being authentic TCM, while actually being an unrelated practice. Claims of its effectiveness were arrived at easily by interpreting patient responses and case histories in unusual and limited ways. There are no reputable studies demonstrating the effectiveness of either applied kinesiology or NAET that might be relied upon to help justify a need for them to be incorporated into a TCM practice. The explanations of how these techniques “work”—as given by proponents—is based on descriptions of the body that are not consistent with what has been established through modern investigations; though they might remotely sound like explanations of TCM, they are, in fact, only superficially of any similarity. While the lack of studies or the non-standard explanation by themselves does not rule out the possible reality and effectiveness of the techniques, neither do the claims for them have any basis on which one could ethically introduce them into a licensed TCM practice. As with comparisons of applied kinesiology with pulse diagnosis, the theories behind NAET might be compared with certain concepts of the flow of qi and the concept of unblocking qi to resolve diseases. As before, the proper description of qi circulation falls within the realm of authentic TCM, and practitioners can minimize or avoid the use of this description if they question its suitability in the modern context (for example, acupuncture effects can be described in terms of manipulations of the nervous system, circulatory system, and various signalling substances in the blood). Thus, comparisons to somewhat esoteric TCM concepts do not excuse the unchallenged introduction of a non-TCM technique that lacks both authenticity and valid proof of efficacy. Practitioners who have used these techniques will no doubt find some patients who believe that it is these techniques that have helped them (rather than other, equally logical explanations for changes that they experienced). However, a closer examination will show a more complex story. In their enthusiasm for offering these new techniques, practitioners may not realize that they are providing a certain deception. Patients may be attracted by the statements like these: “Acupuncture is a 5,000 year old medical science that is used worldwide; I am a licensed acupuncturist and studied 3 years [or more] at [name of college], an accredited institution.” Their action, however, may actually be this (if defined honestly): “I am going to offer you a technique that is not anywhere near 5,000 years old, nor 500 years old, but less than 50 years old, for which I am not licensed by the State and which was not taught at an accredited college.” There are some instances where a non-TCM approach might be incorporated into a practice. The example I usually give is this: if a practitioner has a good grasp of TCM dietetics and modern nutritional knowledge as well as expertise in Chinese herbs and corresponding understanding of herbal constituents, it may be reasonable to recommend nutritional supplements to patients in the TCM setting. This is because certain selections of TCM dietary and herb formula ingredients and dosage levels are made in such a way that they actually provide high levels of substances found in these supplements, which may then serve as substitutes for unavailable or difficult to use original ingredients. The possible addition of such “prescribing” is dependent on the knowledge base and the connection of the activity to a TCM fundamental approach. Resolution: It is essential that practitioners of Chinese medicine give serious consideration to the introduction of non-TCM techniques into their practice before including them. Schools of Chinese medicine and teachers in the field need to explicitly define what constitutes TCM and emphasize that it has characteristics which patients expect to encounter, including authenticity of the technique as part of TCM, training of the practitioner in the techniques they apply within the accredited courses, and reasonable interpretation of the scope of practice. The method for evaluating claims of effectiveness and evaluating patient responses to treatments need to become part of the TCM curriculum.

Part III. Claims of efficacy and safety Principle: Educators, researchers, and practitioners must relay honest, carefully considered, educated assessments of efficacy and safety when describing the services and treatments in a setting where TCM is offered. Problem: Frequently, claims of success are made on the basis of cursory observations and by relaying information from sources that have not been properly scrutinized. Assurances of safety are sometimes given on a theoretical basis rather than from consulting the evidence. As a result, potential and existing users of TCM services may be misled, with impact on their financial expenditures and time commitments. It is not in the interest of patients to rely on uninformed or inadequately informed decision-making for determining their health care priorities. a) As a traditional medicine system, TCM developed over the centuries under the influences of the culture and historical experiences of China. Prior to the 20th century, no systematic method of determining therapeutic efficacy and safety existed. Highly acclaimed texts of Chinese medicine typically described which therapies were indicated for certain disease conditions, but did not give information about their efficacy. Sometimes, suggestions were made for a next step in the therapeutic process if the treatment failed or if an adverse consequence occurred. During the first half of the 20th century, laboratory research was conducted on active components of Chinese herbs, and some evidence was gained to indicate that pharmacological activity of the herb or one or more components correlated with traditional therapeutic claims. However, the large gap between laboratory work and detailed study of human clinical applications was not bridged. During the second half of the 20th century, thousands of studies were carried out in China, examining the full array of TCM modalities, including acupuncture, massage, moxibustion, qi gong, and herbal formulae (orally consumed, topical, injection, and other routes). It has been demonstrated by careful evaluation of the published reports, that virtually all such studies were conducted with inadequate techniques and that the stated results were not reliable. Therefore, few of the conclusions of efficacy derived from the vast collection of Chinese medical reports during this period can be utilized to make statements about Chinese medicine. At the beginning of the 21st century, efforts are being made to correct this situation, but success in this area has been limited. Thus, reliable information about efficacy is still difficult to obtain. b) Patients have the need to make rational decisions about their health care. Health care costs are spiralling upward, including for various natural, alternative, and complementary health care methods. Expenditures for even minimal TCM intervention, such as an initial office visit and a few follow-up visits plus cost of herbs can involve hundreds of dollars. Time commitments for TCM therapies (including transportation to and from a practitioner office) can involve several hours per month. Sometimes decisions must be made by patients, such as whether to schedule undesirable therapies, such as surgery, or to initiate a drug therapy which would otherwise be avoided, that will depend on the potential for success of TCM methods. In order to make rational decisions, patients must have a reasonable estimate of costs, time, therapeutic efficacy, and risks involved with TCM. c) The field of TCM is still in its infancy in the West, leaving it vulnerable to negative impressions. For example, in the U.S., there was little access to TCM just 30 years ago; not all states in the country have provision for licensing practitioners; and the total number of licensed practitioners is relatively small; there are about 40 medical doctors for every licensed acupuncturist in the U.S. Similar conditions prevail in Europe and other regions where TCM was introduced in the 20th Century. Therefore, the reputation of TCM is still uncertain. False claims of efficacy and safety, even when made by a relatively small number of practitioners, can impose a heavy burden on the profession by conveying a negative impression. While all false or exaggerated claims are potentially harmful, the ones that are especially damaging are those for which it is claimed that a disease which is not known to be curable can be cured, perhaps even easily cured. This has been done, for example, with cases of cancer, autoimmune diseases, and neurodegenerative diseases. There are a number of reasons why a person makes such a claim and the basis for such actions today runs parallel to causes that have been the basis of cautionary advice in the past. Huai Yuan, a Qing Dynasty medical ethicist, wrote a warning to physicians of his day, in a book dating from 1808 (7), addressing this issue under the heading “decisions.” Although he talks about accepting or rejecting the patient who can not be cured, the discussion can be adapted to the current situation. He makes the clear point about the necessity for an honest assessment: If I am faced with the case of a disease which cannot be cured under any circumstances, and I attempt to save the patient in spite of this fact, I must have accumulated knowledge in regard to the “middle” [that is, the affairs of men] and experience with similar cases in the past. Yet, when I examine the results of my attempts at saving, I will come to the conclusion that it does not correspond to my expectations. There was, in fact, no other possibility. Is it not better to decide immediately in such hopeless cases to give up the case? Two reasons are responsible for such decisions not being made. For one thing, the emotional ties with relatives play a part. Because one can not bear their loss, one thinks up a hundred plans to protect them, in the hope that ultimately one will fortunately lead to success. Yet, thereby the physician merely causes the patient to become angry. The second reason for reluctance quickly to reject the treatment of an incurable case lies in the hope of great profit. In such cases magnanimous words are to cover everything, until chance will perhaps bring about a success. Yet, thereby, a physician attracts only slander. Therefore, if in a situation of danger the physician has clearly recognized the course of the phenomena, he should preferably make the decision early not to treat, and not worry about profits and emotional ties. This statement is quite rich in teachings about ethical behaviour, so it will be analyzed further here. It should not be taken from this passage that a person who can not be cured of their disease or whose life can not be saved by the practitioner should simply be turned away; instead, it is important not to entice the patient or falsely proclaim to the patient that the offered services will yield results that can not properly be promised. It is clear from Yuan’s discourse that making the claim that one can cure this person is unethical. The guidelines for accepting a patient

with such an incurable condition are given: the first is to have accumulated knowledge—and this would imply also wisdom, spiritual discipline, intensive study, and dedication to practice—that prepares one to guide the person through this difficult medical situation in an entirely open and honest manner. And, one has to have sufficient experience with cases of similar nature to be able to understand and explain the process, without deception. In the absence of such qualities, the patient should either be referred to someone who possesses them or should be offered only the limited palliative care that can be reasonably claimed and provided at an expense that is appropriately restricted. There are situations where practitioners may make claims that are not within these bounds because they are relying upon a rather cursory analysis of their own experiences. Thus, there are many instances where a patient with an incurable disease will come for treatment and express gratitude for the offering and describe a certain alleviation of symptoms. This may be interpreted as success in treatment of the disease by the practitioner (and it represents a type of success, no doubt). But, if the patient stops coming for treatment because the benefits have not been sufficient or because they become too debilitated, and then their disease progresses and/or they succumb to it, any claims of success must be greatly tempered. If the practitioner does not take time to learn about this end result, and consider it in the prognosis to be given to the next patient, then any positive rendition of the treatment is dishonest by virtue of the failure to examine the case fully. Indeed, when people have claimed to cure cancer with various natural and alternative remedies, those who sought to actually follow-up the results find the patients were not cured. In some instances, a patient may be “diagnosed” with the cancer by an alternative method that is not recognized anywhere else as being valid, and then similarly proclaim a “cure,” but such self-contained situations are not of value in evaluating the outcomes. It is essential that practitioners learn to detect unsupported claims in the literature and how to avoid making such claims themselves. As an example of bizarre methods of interpreting cases that have been utilized, I was contacted by a practitioner who claimed to have cured a patient of cancer, and in response I pressed for details. It turned out that the patient had undergone standard medical therapies, including chemotherapy, as well as pursuing the alternative treatment. When asked why this practitioner determined that the therapy he had provided was the successful one and not the medical treatment that produced the “success,” I was told [paraphrasing]: “Chemotherapy never works; cancer can only be cured by natural means.” By refusing to look at the entire picture, practitioners can become convinced that they do have experience of successful treatment. Only when a patient is given an honest assessment, such as: “symptoms may be alleviated for a period of time, but that there is not evidence for a cure,” will the patient be in a good position to make a judgement about how to proceed. Huai Yuan gives two reasons that practitioners end up deceiving the patients. One is the emotional response to the plight of the patient and, especially, the patient’s relatives who are desperately seeking to save their loved one. Out of sympathy for them, one shrinks away from the bad prognosis and instead wishes to offer hope. However, false hope is not what they seek, and the failure to gain ultimate success can lead to anger, by the patient, and by the relatives; at other times, they may feel sorry for the practitioner who seems to be a victim of the failure as well. At risk, though, is the fact that the practitioner, who had been viewed as a saviour, may now be seen instead as a fraud, and the field of medicine he/she practices may be deemed a sham even if it has legitimate applications. The other reason for making untenable claims is the simple self-serving desire to gain patients, retain patients, and hope to have a success that will bring more fame. The services are rendered, the money is collected, but the result is that the practitioner and the profession become open to slander. One need not quash all hopes of benefits in order to give a reasonable description that includes the expected limitations of treatment. Unfortunately, a too common response to this ethical issue is for practitioners to speak only among themselves and discuss the closed-mindedness of those who question their claims, actions, and motives, while bolstering one another’s impression of competence and assuredness in success. This approach is contrary to that recommended by the majority of practitioners, which is to work in conjunction with the modern medical profession and bring the standards of TCM research and practice to acceptable levels. Making valid claims should be the goal of all. Chen Keji, one of the leading international proponents of TCM and its integration with modern medicine observed: “the evaluation of efficacy [for TCM] should seek truth from facts, should stand up to current international criteria” (9). He also notes that with all its benefits, “TCM fails to provide cure from many diseases” (10). These views, expressed by a spokesperson for this field, are consistent with the need for an honest assessment, as opposed to claims that lack a firm basis. By acknowledging the limitations in prior studies and the limitations of TCM for certain diseases, he is not withdrawing support for TCM; rather, he is calling for a strengthening of this traditional medical system and for its integration with the rapidly developing modern medical system.

Learning from prior examples In an attempt to demonstrate how claims that turn out to be unjustified develop and persist, I had written about the example of a purported cancer cure known as laetrile. It is worth mentioning this failed therapy in this context of discussing Chinese medicine for a couple of reasons. First, when Chinese medicine was becoming popularized in the U.S. several proponents of laetrile treatment contacted me with the hope of confirming their story through examples of traditional use in China. Laetrile (amygdalin) is an apricot seed derivative, and apricot seed (kuxingren) has been used in China for 2,000 years. It turned out that Chinese historical use of the herb was mainly focused on treatment of cough (e.g., in asthma, bronchitis, influenza) and secondarily for constipation (as a source of lubricating oil), but there was no mention of treatment of cancer. Second, I was provided with information that was part of a recent flurry of interest over the proclaimed anticancer activity of artemisinin and artesunate, a modified active component from a Chinese herb used for malaria: qinghao. The pattern of development of the claims is similar to that which occurred with Laetrile, even the proposed mode of action is parallel. This story of this remedy has spread among some practitioners of Chinese medicine without apparent concern for the veracity of the testing and claims. Yet, when I attempted to pin down the claims being made, many of which were difficult to believe, I was given no further details by the practitioners spreading them. The University of Washington (Seattle) where two workers in the bioengineering department had done some of the initial work and had not hesitated to make provocative claims, has found it necessary to make a disclaimer, such as this one they posted on their web site (2006 University of Washington): “IMPORTANT NOTE: The Department of Bioengineering and University of Washington do not advocate the use of artemisinin to treat cancer. The US Food and Drug Administration does not currently approve the use of artemisinin for the treatment of any disease. Research on artemisinin and cancer is still in very early stages. Human use of artemisinin should be considered experimental and taking artemisinin or any other drug should be approached with extreme caution and responsibility.” Another case that I wrote about was the claimed successful therapy for prostate cancer, PC-SPES, which was described as a combination of traditional Chinese herbs. Just days before PC-SPES was pulled from the market— because it was found to have a number of drugs in it—a medical doctor in New York City proclaimed in a national news interview that this was a successful natural treatment for prostate cancer. The mechanism of action of this formulation turned out to be a reliance on an estrogen analogue to temporarily shrink the prostate cancer (which also lowers the PSA marker), while utilizing a small does of warfarin to prevent clots due to estrogen therapy. Hormone therapy for prostate cancer is already widely used for limited benefits in modern medicine. A number of other cancer-related scams have come from China, including one based on a soy bean extract sold (sometimes by TCM practitioners) to unsuspecting patients for a very high cost. The promulgation of false medical claims often follows from lack of critical thinking. Too often, proponents of natural therapies will immediately, and without question, disseminate information and hearsay about a therapy when a study is supportive, but will demand and pursue intensive investigation and debunking of any study that gives a negative result. For a negative study on herbs, questions about botanical identification, dosage, controls, statistical analysis, and interpretation of results are raised to help assure that the study is rejected; while for a positive study the benefits are merely explained and even elaborated with projections of broader usage. I have written about the problem of lack of critical thinking, which is a fault that must be laid primarily at the doorstep of the colleges that train practitioners and researchers. While a large effort is given to teaching the acupuncture points and indications, herbs and their uses, little time is given to analyzing the information that is to be utilized, its source, and whether any claim is verified. The other side What has been discussed thus far is the problem of implying, confirming, or assuring efficacy of treatments when, in fact, the treatment may lack adequate evidence to support those statements. There is the other side of the ethical issue that is also quite important. If one does, in fact, have an efficacious remedy, a treatment that does not merely alleviate a minor problem but, for example, cures a disease thought to be incurable or difficult to cure, then there are responsibilities that fall to the person who has encountered or invented such a wonderful gift for humanity. A practitioner who has actually accomplished a medical feat, particularly something that is reproducible (that is, not just involving one extremely rare case), has the obligation of making a concerted effort to have the results verified and disseminated so that others suffering from the disease condition can benefit. It is not sufficient to simply say: “come to my clinic, and I will cure you,” restricting such a great potential benefit to a small group of those privileged to learn about and be able to access such a therapy or, worse, prolonging a false claim for personal aggrandizement. During the Qing Dynasty, Xu Dachun wrote about this very issue, under the heading “On prescriptions that are kept secret,” saying (6): “The virtue of heaven and earth lies in their appreciation of life. The mind of the Sages is characterized by their devotion to the interests of the public. When the latter established prescriptions to cure an illness, they saw to it that these prescriptions became known to everyone throughout the world. To spread their knowledge has been the utmost desire of heaven and earth and of the Sages….Dishonest persons, who have nothing but profit in mind, falsely claim to possess secret prescriptions. They cheat the world and delude the masses.” Once a person claims to be able to cure a disease that is normally incurable, or that is normally only curable by the most difficult and risky means, it becomes a duty to proceed to a next step. Today, that means something far more technical than merely making a simple disclosure and spreading it widely. Rather, the claim must be subjected to full scrutiny. There are patents and other means of protecting a reasonable financial interest in such discoveries, but there is no ethical basis to restrict access through keeping a therapy secret even from scientific scrutiny. In this presentation, I have stuck to the discussion of the efficacy of treatment. However, the same concerns to issues of treatment safety, where unsupported claims of safety can be detrimental. A further discussion about safety

of treatment is planned for a future article. Resolution: It is essential that educators, practitioners, and proponents of Chinese medicine make the effort to critically challenge claims that are made—or that they wish to declare—about TCM efficacy and safety so that potential and current patients can be given accurate information and reasonable prognosis in order make decisions about their health care. It is essential that claims be subjected to rational evaluation and scientific scrutiny so that those treatments claimed and then proven effective can be spread widely to benefit mankind.

References 1. Sun Simiao: http://www1.chinaculture.org/library/2008-01/31/content_26674.htm 2. The Oath, Hippocrates: http://evans-experientialism.freewebspace.com/hippocrates.htm 3. Wikipedia definition: http://en.wikipedia.org/wiki/Intellectual_dishonesty 4. Taoism Culture and Information Centre: http://www.eng.taoism.org.hk/daoist-beliefs/ethicaleducation&practise/pg2-6-intro.asp 5. Dharmananda S, Essentials of Taoism and the Taoist influence on Chinese medicine literature, http://www.itmonline.org/arts/taoism.htm 6. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. 7. Unschuld PU, Medical Ethics in Imperial China, 1979 University of California Press, Berkeley, CA. 8. Dharmananda S, Hua Tuo, http://www.itmonline.org/arts/huatuo.htm 9. Chen K.J. (2002), The principle and practice of integrative Chinese and Western medicine: Chinese Journal of Integrated Traditional and Western Medicine 8(2): 82-84. 10. Chen K.J. (2005), Study of Chinese medicine—Which is after all the right way? : Chinese Journal of Integrated Traditional and Western Medicine 11(4): 241-242. July 2010





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FENG: The Meaning of Wind in Chinese Medicine with special attention to acupoint fengchi (GB-20) by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

A term in the field of traditional Chinese medicine that causes considerable difficulty for modern practitioners is wind (feng). It is known as: one of the six external causes of disease (six qi or six yin); one of the conditions associated with the five elements systematic correspondences (wind associated with the wood element); an entity that has an external and an internal origin, associated with diagnostic categories; and one of the terms used in acupuncture point names, such as fengchi (GB-20), fengfu (GV-16), fengmen (BL-12), and fengshi (GB-31). The use of this term feng is so widespread and mysterious that a modern text on the underlying meaning of acupuncture point names is titled: “Grasping the Wind (1).” Certainly, to understand basic Chinese medical thinking sufficiently to carry out an Oriental medicine practice, one must grasp the meaning of wind. A difficulty with the term wind is that it is widely and freely used in the Orient in relation to health and disease, while it has no equivalent meaning or implication for Westerners in the medical field. A patient unfamiliar with the use of the term may be told, “your condition involves wind,” or this treatment is for “wind-heat.” The puzzling reference to a weather condition may call for explanation. An appropriate depiction of the Chinese concept can set the stage for better appreciation of the Chinese tradition. On the other hand, an unacceptable depiction can lead to even greater suspicion of the foreign concepts employed in the sometimes bizarre medical tradition that includes cupping, blood letting, inserting over a dozen needles in the body, and ingestion of large combinations of herbs. One approach that has been taken in describing wind in relation to disease is to rely on a strict interpretation of wind as a “pernicious influence:” that exposure to windy weather can cause disease. Another approach is to use an analogy, such as that when symptoms appear in different parts of the body at different times, this suggests movement that is like the wind, so there is a “wind disease.” The best explanation for wind may come from dividing its role in the medical system into two: etiology (cause of disease) and manifestation (characteristics of disease), each of which can be separately described. The purpose of this article is to reveal the basis of the Chinese concept and suggest a modern description. Before delineating the historical development of the term wind and its representation as a pictograph, applications of the term in traditional Chinese medicine, as it comes to us today, may be of value: diseases involving excess movement of the body: epilepsy (rare convulsions) and Parkinson’s disease; diseases involving symptoms appearing in different parts of the body at different times: early stage rheumatism involving differing joints or skin rashes that appear in different places; diseases involving loss of movement: stroke, paralysis, tetany, and coma; various pain, numbness, and spastic syndromes, sometimes referred to as bi syndromes, including headache, toothache, limb numbness, tendon spasms, arthritis, deep bone pain; diseases that are acute: common cold, influenza, sinus infection, skin eruption, sore throat, cough, eye disorders; and diseases that affect the surface of the body (skin or flesh, rather than viscera): chronic eczema, leprosy, scrofula, hair loss. In the field of modern medicine, a number of causative factors have been identified for the “wind” disorders of concern, including infectious agents, neurological problems, and autoimmune diseases. Despite progress in scientific analysis, the reason that a disease has arisen in any individual may remain difficult to pin down; further, the manifestations among different patients varies, sometimes markedly. None of the modern explanations for the cause or manifestation of the diseases and disorders inherently contradicts the traditional Chinese concept that they are caused by wind or somehow involve wind, but the explanations do seem more detailed and up to date. The availability of modern explanations raises the question of how useful the ancient terminology is when it comes to understanding the disease and deciding upon the method of treatment. Thus, it is important to get a sense of how much reliance there is upon the basic concept of wind in the Chinese system. THE CHARACTER FOR FENG: Insights into meaning The Chinese character feng, is usually explained on the basis of the conjunction of two pictographs. One of them depicts an insect (chong; originally hui, a type of snake; see Figure 1), which is placed inside the character fan, which means the origin (see Figure 2). The resulting character (see Figure 3) is explained in an ancient Chinese text describing the meaning of written characters (2), the Shuowen Jiezi (ca. 120 A.D.). It makes reference to the Chinese idea: “when the wind blows, insects are born.” In this interpretation, the character feng represents the origin of insects, but it also means exactly what it means in the West, namely a weather condition: the movement of the air. The simplified version of the character (Figure 4) retains the meaning of a weather condition, movement of the air, to this day. Fengbiao is a weather vane (used for measuring wind direction), fengche is a windmill, and fengshan is an electric fan.

Perhaps the image of flying insects, some of which appear rather suddenly as the seasons change and which might seem to come along the path of the wind, gave rise to the notion that the wind was their origin. There are also ideas in ancient Chinese literature that wind “resides” in caves before it explodes out as gusts in the atmosphere, and caves are where some insects congregate in large numbers. Insects and other small crawling animals would have been viewed negatively, as a source of destruction; similarly, the wind is often a destructive force. Therefore, the connection between insects and wind may have found its way into the development of written characters as a result of several conceptual connections drawn between the two.

Figure 1. Chong or hui.

Figure 2. Fan.

Figure 3. Feng; traditional version.

Figure 4. Feng; simplified version.

The manifestation of the wind, particularly its direction, was long considered important. In particular, it was observed that the wind conditions at each seasonal change (e.g., from winter to spring) and at mid-season seemed to have a different fundamental nature, and so there were, all together, eight winds that were specified. The type of wind that was actually encountered at any of these eight points in the year was thought to have prognostic value for a variety of outcomes, including crop yields. The concept that wind was a pathological agent appears to have correlated with divination practices. In ancient times, the eight winds were related to the bagua (the 8 triagrams of the Yijing) and they came from the eight directions, such as northeast, northwest, etc. In the Lingshu (3), the influences of these winds were categorized as follows:

Name of Wind

Internally Affects

South Southwest West Northwest

great feathery wind scheming wind hard wind breaking wind

heart spleen lungs small intestine

North

great hard wind

kidneys

Northeast

unfortunate wind

large intestine

East Southeast

children’s wind feathery wind

liver stomach

Externally Affects

channels muscles skin arm major yang channel bones, shoulder, back muscles sides of ribs, armpits, lower bones, limb joints thick muscles muscles, flesh

Its Qi Causes

heat weakness dryness blockage in channel coldness [not stated in text]

dampness body weight

According to the Lingshu, the adverse influence was so great that “the sages avoided the winds like avoiding arrows and stones.” In particular, they were concerned about sudden death from what corresponds in the traditional descriptions to a stroke (zhongfeng). Zhongfeng, meaning struck [penetrated] by wind, is mentioned in the Huangdi Neijing (Suwen and Lingshu), Shanghan Lun, and Jingui Yaolue, where the descriptions often, though not always, suggest a stroke; in modern Chinese medicine, zhongfeng still means stroke. This zhongfeng is a dominant concern about the effect of wind for centuries, into the modern era.

AVOIDING WIND AND ITS EFFECTS How did the sages avoid the winds? This is not overtly outlined in the Lingshu or in other sources. Originally, various rituals and incantations may have been the methods relied upon (4). A reading of traditional literature will show that avoiding the wind could mean not having any exposure to blowing air (especially when the body was in certain conditions, such as sleep) and not allowing oneself to become susceptible to the influence of wind (as occurs when one has drunk too much wine or eaten rich food). Gao Ling, a 16th century medical scholar, warned against summer time practice of sleeping outdoors under the stars, as noxious wind could invade the body; he also recommended that cracks in the home be filled in to avoid drafts, especially in summer. A perspective on the early Chinese understanding of wind may be gleaned from the art of fengshui (literally: wind and water), sometimes translated as “geomancy.” Wind is generally considered a malevolent force. According to Eva Wong (14), these are guidelines for avoiding adverse influences of wind: 1. Do not live in areas where it is windy all the time. These include open coastline, lakefront, wide stretches of flatland, and exposed ridges and slopes. Wind tunnels are also undesirable, and these are generally found in narrow valleys and canyons. 2. Winds that swirl or create funnels are destructive, for they uproot energy and carry it away, leaving the earth “barren.” 3. Even if the top of a ridge is covered with trees, a house located there is still buffeted by wind. In fact, when wind lashes at the trees, the trees will sway as if they too are “beating” the house. Thus, like the sages mentioned in the Lingshu, we are all cautioned to avoid the wind by not living in a place that is exposed to severe wind or wind occurring on a regular basis. As an example of how Chinese physicians view windy weather as a cause of disease, in a 1994 teaching round at the Beijing Institute of Acupuncture and Moxibustion (15), a case was presented in which a female patient had headaches since she was 10 years old. The author explains: On the eve of spring festival, when people were celebrating on the grassland, she suddenly felt a severe headache that made her fall to the ground, possibly because of pathogenic wind and cold.... Falling to the ground (apoplexy) is characteristic of zhongfeng, which, in this case is probably not a stroke, but some other cerebral event. That this occurred at the spring festival may be of significance, because this is the time of one of the eight winds, and the weather is still cold. In a review of methods of health preservation presented by the Beijing College of Traditional Chinese Medicine in 1982 (16), it is said that: One should not sleep in a draft lest one be attacked by evil wind during sound sleep. This is true even in the very hot summer season. The mention of “even in” hot summer conditions is important because in much of the traditional literature the conjunction of wind and cold (as in the previous example) is considered to be the main wind-related pathology; wind and heat are also problematic. Today, it is common to hear Western acupuncturists caution patients to avoid sitting in the cold draft of air conditioning vents, a recommendation based on this traditional Chinese reasoning. When it comes to avoiding the influence of wind, that is, not being adversely affected if one is exposed to wind, then these are steps to be taken: 1. One should be careful to avoid having the pores open excessively. The pores are the entry point for wind; they are open when one is sweating profusely. They are open when the wei qi is weak and cannot hold them closed. Wind, as a pathological agent, will further act to open the pores. The Lingshu states (page 216): “When the hollow evil attacks man beginning in the skin, the result is the skin slows and the foundation between skin and flesh and the pores open. These openings allow the evil to follow the hair, to penetrate, and to enter. This entry reaches deeply....This causes a transmission to the location of the channels.” 2. One should be careful to avoid having the channels become deficient. The wind enters the pores and proceeds to the channels. The wind cannot easily enter the channels if they are replete of healthy qi and blood, that is, when the ying qi is well nourished. The Lingshu states (page 216): “When suddenly encountering the quick wind and violent rain and there is no illness, it means one is covered and there is no hollowness. Consequently, these evils singly cannot injure man. Disease must originate in the wind’s hollow evil and in the body’s form.” 3. One should be careful to avoid the channels becoming full of phlegm and heat, as occurs with excessive eating of rich food and drinking wine. Then, the wind combines with phlegm and fire and causes severe obstruction and stroke. Examples of this will be given in the following section. 4. One should quickly remove wind from the body if it enters. This is accomplished by using wind-dispelling herbs (see Table 1), herbs that induce perspiration (such as ma-huang and cinnamon twig), and by acupuncture performed at certain sites (see Table 4). In the Rumen Shiqin (1228 A.D.) it says: “All evil influences resulting from the impact of wind or cold assemble in the skin; they are stored inside the conduits and network vessels [jingluo]; they remain there and do not leave the body by themselves. In some cases, they cause pain that moves through the body, or numbness and loss of sensitivity, and also swellings, itching, and cramps in one’s four limbs. In all of these cases, the evil influences responsible can be eliminated through therapies causing perspiration.” Although not all wind-dispelling herbs induce sweating, sweating therapies are one of the methods for dispelling wind. The reference to hollow wind or its hollow evil in the Lingshu goes back to the process of divination. As

explained by Unschuld (4): If the wind on these days [the divination days, such as first day of each season] came from the direction in which Taiyi [the head of the demon spirits] happened to be residing, it was the so-called wind of repletion and was considered an auspicious omen. If the wind blew from the opposite direction [being the wind of depletion; hollow], it was regarded as an unfavorable sign. This “hollow” (or “deficiency”) wind had an adverse effect on crops, weather, and the health of humans. As to the latter, the Lingshu states further: Eight are the winds. For the winds, man has the eight joints of the legs and arms [hip, knee, shoulder, and elbow]. The eight primaries, the beginning and middle of each season [four seasons], can possess hollow winds. These eight winds can injure man. When sheltered in the inner being, they make deep rheumatism in the bones, and may be released among the loins, the backbone, the joints, and in the area between the skin and flesh. Therefore, to cure with acupuncture, one must use the needles with a long body and a sharp tip. This can be used to grasp the deep evil and distant rheumatism. That is, these long sharp needles can grasp the wind, hence the title of the acupuncture book. There is also another traditional Chinese reference to wind that should be considered in order to fully understand the context in which the term is used medically. Around 200 A.D., a book called Fengsu Tongyi was published; the term feng in the title is the same as that for wind, but the compound fengsu means manners and customs (7). In the preface to the book, the author discusses the meanings of feng and su: Feng includes such things as the warmth or coldness of the air, the treacherousness or gentleness of the land, the perfection or imperfection of waters and springs, the toughness or suppleness of wood and fibers. Su includes those classes of beings with blood in them.... From this explanation, one can see that feng had the connotation of a quality, nature, or characteristic; thus it has a meaning somewhat similar to that of qi. Unschuld has argued that the concept of wind in Chinese medicine was, in fact, a transitional one (4): previously, the main pathological phenomena were evil spirits and ghosts, and, later, the main pathological phenomena were the six qi (of which wind is one). The term feng is still used to suggest qualities and influences in several modern expressions: fengdu is bearing, manner, behavior; fenghua is to change or reform by example; fengsu still means customs and manners; fengtu means the local climate or natural features. The importance of feng among the six qi (environmental qualities that have influence) that appears in subsequent medical texts implies that feng and qi were viewed in somewhat similar fashion. OTHER PORTRAYALS OF THE PATHOLOGY OF WIND While the Lingshu focuses on the eight winds, in the Suwen (5) there is a chapter devoted to the pathological effects of wind based on the Five Elements. Thus, there is a depiction of wind influences on each of the internal organs. As an example, it is said that: Kidney wind manifests as excess sweating and aversion to wind. There is a dull gray cast to the face and swelling of the eyes. The face may even have a charcoal hue. There is back pain and an inability to straighten. There may be obstruction of the urinary tract. One should look for a dark black color and hue in the flesh. Here, as is also found in the 4th century book Zhong Zang Jing (17), are the common correspondences of the five element system; black color is associated with the water element, the kidney, lower back, and urinary obstruction. Wind causes obstruction, stiffness, and accumulation. In this same chapter, it is said that: Wind is the cause of many illnesses. Once it penetrates the body, its nature is dynamic and changeable, and it has many pathological manifestations. But the cause is always the same: pathogenic wind attacking the body. Once wind enters the body it can cause a progression or transmission of disease. For example, in the Suwen, it is said that: “When wind travels from the yangming channel into the stomach, it then follows the channel up to the eyes.” Depending on whether the person is obese or thin, this movement to the eyes will result in yellowing or constant tearing, respectively. The dynamism mentioned here involves transmission of disease from one site to another, along a certain path that is set down explicitly, rather than random movement. This particular route of transmission from stomach to eyes is elaborated in the Yinhai Jingwei, a 7th century ophthalmology text attributed to Sun Simiao: In the case of the condition called ‘wind pulls the lower lid outward,’ spleen and stomach have received wind, and this poison accumulates and becomes manifest at the upper and lower lids. When the lower lid is affected by wind, its skin tightens, and when the spleen is affected by wind, the muscle flesh is blocked...Irrespective of the four seasons, tears flow because the earth yields and cannot dike the water any longer. Water accumulates at the lower lid, which appears soggy and rotten. The excess fluid is related to the weakening of the stomach and spleen by the action of wind on those organs. The earth element is imaged as a dike that controls the flow of water. In a situation that is evidently related to having a stroke, it is explained in this same text that:

When, after excessive drinking [of alcohol] and eating one sits or lies facing the wind longing for cool air, one’s right or left side may suddenly receive wind, which pulls one’s mouth and one eye into a slanting position....in serious cases, one side of the body fails to follow one’s will. Here, it is explained that exposure to wind serves as a trigger to the ailment; it is not a strong wind, nor a wind from the wrong direction, but rather a gentle breeze that one longs for to cool a body overheated by food and drink. Nonetheless, the gentle breeze either contains some evil component that causes a severe reaction or it becomes malevolent simply by combination with internal factors that are pathological. The text recommends various topical treatments, such as ointment to rub the wind away, scraping the affected side of the body (i.e., the technique known a s guasha), burning moxa, and applying a poultice of magnetite. In explanation of how the wind causes the deviation of eye and mouth it is said that: “they were drawn that way because the liver conduit has received windevil; this causes the tendons to become tardy and to shrink and lose their swiftness.” The adverse influence of wine and rich food is mentioned also by Zhu Danxi (18). In a short chapter on wind damage, a single case is relayed in which “a male who was addicted to wine felt fatigued because of having worn thin clothing in face of wind cold.” In his chapter on head wind, he describes a person being susceptible to this condition “who used to take fat meat and fine grains.” As opposed to these cases of excess due to food and drink, in the text Zhubing Yuanhou Lun (610 A.D.), the chapter on fengbihou (wind and bi disease) also points to deficiency (depletion); it is said that (6): The three influences of wind, cold, and dampness arrive together, unite, and constitute bi illness. Its appearance is such that the muscles and flesh turn clumsy and thick. Occasionally one may feel pain. The human body may receive wind-evil if the pores have opened because of depletion. When the illness affects the yang regions of the body, it is called wind; if it affects the yin regions, it is called bi. If both yin and yang regions of the body are affected at once, one speaks of a wind-bi illness. As indicated here, openness of the pores resulting from an internal depletion is what allows the wind to cause disease. The wind illness is the one that affects the yang region, which includes the back and upper part of the body (example: shoulders), while bi syndrome is the name given to a similar disorder that affects the yin portion of the body, which includes the front and lower part of the body (e.g., knees). This division between wind and bi is not followed in most modern texts, though it is sometimes stated in passing. Most often, a bi syndrome is described as one in which wind is accompanied by another pathological factor, such as dampness and/or cold; the impact is a blockage, which then causes the various symptoms. In a discussion of facial paralysis (mainly Bell’s palsy), the following depiction of wind entering deficient meridians is presented (23): According to TCM theory, this disease results from derangement of zangfu, deficiency of vital qi, and feebleness of channels and collaterals [jingluo]; all this allows the invasion of exogenous pathogenic wind-cold, leading to stagnancy of qi, blood stasis, and excessive atony of the yangming channels. PROGRESSION OF THE CONCEPTS Later in the development of Chinese medical literature, the nature and role of wind was described somewhat differently than in any of the previous texts. For example, the emphasis on the eight winds or on the direct influence of wind on each of the five viscera is no longer prevalent; internal wind, distinct from external wind, becomes an issue of importance. It is mentioned in the 18th century text, Yixue Yuanliu Lun , that the influence of wind from the outside can induce a wind from the inside, and together these produce a heat syndrome (8): When wind enters the conduits and the network vessels, internal winds and the wind intruding from the outside excite each other until suddenly phlegm-fire emerges and causes obstructions. In such a situation, there is no other way but to first expel the wind from the body, then cool the phlegm-fire, and, finally, harmonize the body’s qi and blood. As a result, the conduits and vessels will gradually become passable again. The book’s author, Xu Dajun, further explains the progressive course of a wind-induced ailment, which is from skin to lungs, and the complex treatment needed to fully resolve the disorder: The fact is that the illnesses of harm caused by wind start from the skin and its hair to enter the lung. The lung is a delicate viscus; it is compatible with neither hot nor cold....As the proverb goes, ‘If one does not pay attention to harm caused by wind, the illness will change to fatigue.’ Well said! But how to conduct treatment? First, the wind is to be expelled with drugs like perilla leaf and schizonepeta. Second the phlegm is to be dissolved with drugs like pinellia and fritillaria; third the qi is to be brought down with herbs like perilla seed and peucedanum. Fourth the ying and wei qi are to be harmonized with drugs like cinnamon twig and peony. Fifth, the body’s liquids are to be enriched with drugs like trichosanthes seed and scrophularia. Sixth, the blood is to be nourished with drugs like tang-kuei and gelatin. Seventh, the fire is to be cooled with drugs like scute and gardenia. Eighth, the lungs are to be regulated with drugs like morus bark and arctium. MODERN CHINESE DESCRIPTIONS OF WIND Modern sources of information on Chinese medicine reveal the difficulties of relying on traditional terms, making use of them giving a cursory definition. For example, in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (9), wind is included as one of the six external factors and its influence is summarized this way as being very important, yet not subject of detailed analysis:

Pathogenic wind is the leading cause of many diseases. Of the six excesses, wind is the primary exogenous pathogenic factor, since cold, damp, dryness, and heat may all depend on wind to attack the body. Here, the exogenous wind is the carrier for other exogenous factors to help them penetrate the surface of the body and cause disease. As to the internal wind, according to the textbook, this is one of the “five evils” (the others being internal cold, damp, dryness, and fire). The internal wind is described as being closely related to the liver, having four causative factors: liver yang excess and yin deficiency generating endogenous wind (mainly the result of emotional frustration); extreme heat (usually in the advanced stage of febrile diseases); yin deficiency (usually due to prolonged illness that consumes body fluids); and blood deficiency (usually from insufficient blood production or from excess blood loss). Internal wind is said to be the cause of tremor, dizziness, and spasm; it is the primary factor in Parkinson’s disease, for example (26). It is said to be a common problem of old age, because deficiency of yin natural develops with aging, giving rise to liver yang agitation, which can produce internal wind. Unlike the description centuries ago, there is no mention in modern texts of the internal wind being stirred up by the exogenous wind. There is some tendency in modern guides to Chinese medicine to use a simple analogy to explain wind and thereby avoid some of the difficult questions raised by the historical and cultural usage of the term. The analogy basically goes like this: wind occurs in gusts and is characterized by rapid changes; symptoms and diseases that have similar character, namely arising suddenly or involving rapid change and movement, are wind diseases. With this analogy, experience of an acute ailment, a headache or the common cold, for example, and experience of excessive movement, as with Parkinson’s, falls into the wind category. Having a stroke will also fit, because of its sudden onset. Paralysis, considered a type of wind disease in the Chinese system, is more difficult to explain. For example, in a modern discussion of wind as one of the causes of disease, it is said that (27): “Wind is characterized by constant movement, causing abnormal motion or rigidity of the trunk or limbs.” This doesn’t seem to make sense, since the wind characteristic is not related to rigidity. But the analogy system then works this way: diseases characterized by excessive movement, or by the opposite extreme, restricted movement, are of the same type, namely wind diseases. The traditional view, however, was that when wind enters the body it could impede the function of the muscles (perhaps directly or systemically be afflicting the spleen that controls the muscles), and thereby cause paralysis. The method of analogy for wind is perhaps best stated in Manual of Dermatology in Chinese Medicine: The etiology and symptomotology of wind-related disorders reflect the characteristics of wind as a force of nature. Wind is a yang excess characterized by an ‘opening up,’ and by an upward and outward nature. Wind diseases usually affect the upper body first, producing sores and ulcers of the head and face. Wind has the propensity to move and change, thus there is usually no predictable location for diseases caused by wind. Urticaria, known in Chinese as ‘wind-type concealed rash,’ is such a skin condition. Diseases caused by wind are characterized by rapid onset and resolution, and a short course; a propensity to move about, without a fixed location in the body; itching (in skin disorders); a tendency to attack the surface of the body and the head; an aversion to wind; and, like the spreading and dispersing nature of wind itself, by the opening of the pores, with sweating. Gone from such explanations are the ideas of eight winds, the influence of wind direction on disease, the association of wind with each of the organs, progression of wind disease from skin to lungs, and numerous other concepts about wind that belong to the Chinese tradition. The system of simple analogy removes any need to describe how wind might cause an ailment and replaces that with a classification scheme: if the ailment has the nature of yang (opening, upward, outward, movement, change), then it is a wind illness. Although the term etiology is mentioned in the description above, it is an aspect that is, in fact, entirely deleted from the explanation. Wind becomes, instead, a label for certain diseases. An attempt to explain the apparent disparity among traditional texts describing wind invading the surface of the body, via the meridians, and wind entering the internal organs (zangfu) was made by a professor at the Academy of Traditional Chinese Medicine in response to questions about the cause of wind-stroke (25). He indicated that: Zhang Zhongjing [author of Shanghan Lun] had already offered his classification method [for wind diseases], i.e. ‘Invasion of collaterals by pathogenic factors leads to numbness of the skin; invasion of the channels leads to paralysis of limbs; invasion of fu organs leads to unconsciousness; and that of the zang organs to aphasia and leaking of salivation.’ This method of classification is still being used. In our clinical practice, the distinction between involvement of the zangfu organs and that of the channels and collaterals lies mainly in whether there is a coma, which suggests involvement of the former [zangfu], otherwise, the latter [meridians]. It can be seen here that in modern practice if someone experiences a stroke, it is labeled a wind disease, and then if it causes a coma it is labeled a wind disease affecting the zangfu. This is labeling, rather than an understanding of etiology, and it is simply retention of a term from 2,000 years ago. The above quoted comments were delivered after several doctors at the Academy analyzed a particular case of wind-stroke (Western diagnosis: cerebral thrombosis) and came up with the following causative factors, none of which involved invasion of wind into meridians or zangfu:

Long years of working by bending over the desk has consumed his yin essence, which results in hyperactivity of the liver yang due to consumption of the yin essence failing to check the exuberant yang, hence the occurrence of wind-stroke. Long years of mental strain has insidiously consumed his yin-essence that first leads to deficiency of kidney yin which, in turn, leads to deficiency of the liver yin, resulting in hyperactivity of the liver yang. Deficiency of the kidney yin fails to nourish the heart, contributing to hyperactivity of the heart yang, hence the occurrence of wind-stroke, a result of the liver yang transforming into wind. Apart from the affected heart, liver, and kidney, the spleen is also involved, characterized by the patient’s clinical manifestations of fatigue and changeable appetite, all indication of depression of the spleen-qi. A more comprehensive conclusion can be made by combining the above three analyses, namely: Derangement of yin and yang of the zangfu organs due to accumulation of dampness turning into phlegm, resulting from dysfunction of the spleen in transportation caused by immoderate food intake, which, when attacked by anxiety, anger, or over-strain and stress, may lead to hyperactivity of the liver-yang stirring up the wind and exuberant heart fire, as a result, wind and fire mutually stirring up and qi and blood mixed up with phlegm ascending together making transverse attack of the channels and colaterals [jingluo] and cloudiness of the mind. In this brief discussion of the case, four of the five zang organs (all but the lungs) are said to be involved. Exuberant liver yang and heart yang are said to be the immediate causative factors, with liver wind (internal wind) brought into play briefly among the numerous factors. In this patient, because there was no coma, it was to be treated as a case of jingluo being affected by wind. One can observe that these experts at China’s leading Academy are clearly having difficulty translating a case of “being hit by wind” (wind stroke) into a coherent traditional medical analysis, requiring them to bring in diet, emotion, mental activity, physical position at the job, yin and yang, qi, blood, essence, moisture and phlegm, heat and wind, zangfu and jingluo—nearly the whole of the medical system terminology. Thus, the difficulties are not merely those of translation into Western languages, but are also inherent in the traditional Chinese analysis of cause and manifestation of disease. Indeed, one may conclude from an examination of the literature that the nature of wind remains poorly understood though widely invoked. In the book Chinese Medical Terminology (10), Frank Liu and Liu Yan Mau (who studied Western and Traditional Chinese Medicine, respectively) expressed their frustration with the cavalier use of the term by Chinese doctors: Again, as in the case of qi, feng—wind—may also be regarded as being entirely immaterial, perhaps only more so. Nobody, of course, has even been able to demonstrate what wind is! Adoption of the term may well have been based on the inherent nature of the word wind: indefinite, indeterminable, wandering and changeable. It is listed as the number one climatic evil. When Chinese doctors are confronted with symptoms of malaise (especially feelings of discomfort on the part of the patient) without clear signs of a particular disease, they often attribute such to wind—some sort of evil air. There are, of course, specific maladies which doctors do point out, though quite unintelligibly to the layman, as the effects of ill wind: fainting spells, convulsions, epileptoid tremor, palsy trembling, paralysis agitans (Parkinson’s disease), etc. Most pains, like severe headache, are the inevitable accompaniment of feng. A stroke is to be the invasion of evil wind into the brain, causing immediate swooning and unconsciousness. One of the more familiar ailments associated with wind is fengshi, which may be rheumatism or a type of arthritis caused by the evil wind dampness. The common cold, and even influenza, are spoken of as evil wind injuries. And, eczema is but manifestation of the devilish damp wind that has succeeded to get out of the body by eruption through the skin. PROPOSAL FOR AN APPROPRIATE INTERPRETATION OF WIND It may be necessary to explain the term wind by first explicitly dividing it into two different areas of concern. This is not unlike dividing external and internal wind, but the basis of the division is different. On the one hand, wind is a term used to describe etiology of disease and, on the other, it is a term used to describe the nature of a disease that has occurred. There is a linkage between the two, but it is a tenuous one, so it may be best to minimize the connection. As to disease causation, the term wind serves best for unexplained etiology rather than as a specific explanation. Western physicians and researchers may state that “the cause of [disease name] is not known,” and this is regarded as an honest and valid, if not very satisfying, explanation for several diseases. Sometimes the term idiopathic is used in such cases, and it is as though something has “come out of the air” to cause the disease, while a more complex explanation is presumed to await the results of further research. The Chinese physician can state that the cause of a disease or symptom pattern is wind, which is also deemed valid (within the tradition) and can only seem satisfying if one accepts “wind” as a specific etiologic agent (e.g., windy weather caused the disease). Thus, if a person suddenly passes out, it can be said—without fear of contradiction—that he or she has been “struck by wind” (zhongfeng). On the other hand, if a detailed medical examination shows that this person has clogged arteries (atherosclerosis), rapid platelet aggregation (sticky blood), high blood pressure, and evidence of a blood clot in the brain leading to ischemia (death of local tissues), then it would be better to say that the person has suffered from a stoke due to a blood clot. The latter explanation is better because there is little doubt as to the factors that contributed to the fainting. If this person, as the one described above from the ophthalmology text, had been eating a rich meal and drinking too much wine, one might feel satisfied that the effect of this meal was to thicken the blood and lead to the clot, and the supposed effect of the cool breeze sought thereafter might well be ignored. On the other hand, in the absence of knowledge of how a stroke occurs, one seeks a causative agent, and wind has been invoked throughout the pre-modern era.

At first, this use of the term wind to mean unexplained etiology may seem like an evasion of the problem at hand: namely, the Chinese postulated a specific cause of disease, called wind, but we are having difficulty pinning it down: therefore, we bypass the issue by not pinning it down. After all, it would be difficult in modern times to explain the pathological role of “hollow winds coming from a direction other than that in which Taiyi resides.” So, instead, we remove the specificity of wind altogether (a resolution that is tidy but evasive). This possible resolution of the problem may coincide quite well with the actual interpretation that has been put forth in China. The Chinese system of medicine may not, at any time, have intended wind to designate a specific entity in terms of its nature, quality, source, and action. It was always a great unknown: immaterial, changing, and causing all kinds of havoc. The southwest wind which, according to the Lingshu, affected the muscles and caused weakness, was not necessarily a wind from the southwest that a person was exposed to and then suffered this disease. Instead, the wind from the southwest was blowing on a certain day and this predicted that ailments characterized by muscular weakness were going to be more prevalent during the coming months, just as it predicted the crop yields (something like seeing a groundhog’s shadow on groundhog’s day, and deducing the future weather patterns). In texts that associated wind ailments with the spring (as per the five element system), it is almost always stated that such ailments are more prevalent during the spring, but that they are not limited to this time period. The disorder may be induced during the spring, but not show up at any time of year or show up during the next season. A person who was said to be “struck by wind”, having suddenly suffered fainting or paralysis, could have been affected on a day when the wind was still, because the Chinese did not intend that the “wind evil” was always a specific entity, such as a gust of wind, but was, instead, some unknown entity that had been carried by the wind. While individual commentators have tried to pin down what this term really meant, or how wind really behaved, the diversity of opinions (such as described in this article) merely reflect the fundamental difficulty of grasping the wind. Therefore, when explaining wind to a patient who is curious about your diagnosis and treatment strategy, it might suffice to say that: “The nature of your disease suggests that it involves what has been called wind, namely some unknown etiologic agent. The treatment strategy, in such cases, usually involves nourishing deficiencies (mainly qi, blood, and yin) to make less room for such an agent to impose itself, and including herbs that ‘dispel’ or ‘settle’ wind. The ‘wind-dispelling’ herbs have the properties of improving circulation, relaxing tension, alleviating pain, and reducing inflammation. The wind-settling herbs have the properties of inhibiting excessive nervous energy, relieving spasms, and relaxing tension. These actions are likely to produce some benefits regardless of the specific cause that can not, at this time, be identified more precisely.” It is probably of no benefit to describe a case that is clearly influenza as “wind-heat” or a case that is clearly the common cold as “wind-cold,” because the shift in naming does not enlighten one as to the cause or nature of the disease. The idea of wind exposure does not correlate with the recommendation of better hand washing. A case that presents like influenza but can not be identified, could be called wind-heat without appearing to dismiss all the developments of modern medicine that might otherwise give it a specific cause. Such an explanation is no worse than saying, as a modern physician might: “it is probably a viral infection, but I can’t be sure.” As a description for diseases (rather than their cause), those that have an unpredictable, changing course might be said to have the characteristic of wind. Sensitivity of the skin to slight touch would also fit in this category, since the light touch is like the blowing wind and the disorder comes and goes depending on the presence of the stimulus. The reason for the variation remains unknown, so this explanation, as with that for etiology, fits the concept of a description for the unexplainable. The Chinese physicians that write about wind do not make the claim that by using herbs that treat wind disorders, such diseases will change from an unpredictable course to one that is fixed or regular as a result of suppressing or dispelling the wind. Instead, the underlying suggestion is that if a disorder is changeable, then the wind-dispelling or wind suppressing herbs will help it go away. Disorders that have the characteristic of changing their site of symptom manifestation or which come and go are thought to generally involve those aspects of the physiology that can change easily, such as the nervous system and the immune system. Such disorders usually do not involve structural changes, as this would imply a fixed disease location. Thus, herbs that calm the nervous system and reduce hyperactivity of the immune system (perhaps relieving inflammation) would be the ones most likely to be of assistance. Using a disease description such as wind is of value so long as treatments that have been traditionally defined as treating wind conditions actually benefit the people who have such diseases. Unless any of these herbal actions are entirely inappropriate to the disease treatment, these explanations should suffice to continue use of the term wind in modern practice, if one so chooses. On the other hand, it is not an essential term. Here is a presentation of trigeminal neuralgia from the Journal of Traditional Chinese Medicine (19) that depicts a wind-like illness but circumvents using the word wind: Trigeminal neuralgia is characterized by severe paroxysmal pain in the area of trigeminal distribution that feels like cutting with a knife, an electric shock, the pricking of a needle, or burning. The onset is usually precipitated by brushing the teeth, washing the face, speaking, or eating food. The duration of attack is short, from a few seconds to several minutes. The etiology is unknown and the onsets can be frequent. The traditional description is that one possible cause is invasion of wind and heat (the heat component has to do with the burning sensation that is produced); the coming and going of the disorder in a short time and easy triggering of attacks is characteristic of wind diseases. Although the area of pain is fixed, the site of pain may wander within that area. In the above description, instead of using the term wind, the etiology is said to be unknown and the manifestations are simply listed.

Practitioners who rely on the term wind to describe disease conditions should be very familiar with the herbs and acupuncture points that are said to treat the conditions. Table 1 is a partial listing of well-known herbs that are reputed to dispel wind. The actions and uses of the herbs are from Oriental Materia Medica (11), with only those aspects that are directly or indirectly related to wind included. The uses of wind-dispelling herbs are diverse, but mainly include pain, spasms, skin disorders, and a variety of acute diseases involving infection and/or inflammation affecting the upper part of the body (sinuses, eyes, throat); stroke and paralysis is also included among wind disorders; see Table 2 for summary of applications of these herbs. Table 3 presents the separate category of herbs for internal wind, which, upon examination, will reveal a remarkable similarity to the others, in terms of conditions that they treat. Acupuncture points for treating wind are listed in Tables 4 (those with the term feng in their name) and 5 (other points that have a reputation for treating wind ailments) and two physician’s experience in using important wind points is presented in Appendices 1 and 2.

Table 1: Herbs that Dispel Wind. Herb Name/Pinyin acanthopanax wujiapi agkistrodon baihuashe angelica baizhi arctium niubangzi asarum xixin chiang-huo jianghuo chin-chiu qinjiu chrysanthemum juhua cicada chantui cinnamon twig guizhi clematis weilingxian clerodendron chouwutong cnidium chuanxiong equisetum muzei erythrinia haidongpi

Properties Related to Wind removes wind and dampness

Uses Related to Wind spasms of tendons and bones, numbness and pain in loins and legs, pudendal pruritis

removes wind-dampness, promotes flow of meridians, stabilizes convulsions and epilepsy removes wind, dissolves surface, controls pain, removes swelling

paralysis due to rheumatism, arthralgia, hemiplegia, stroke syndrome, epilepsy

disperses wind-heat, removes swellings

cough due to wind-heat, sore throat, un-erupted erythema, swelling ulcer, carbuncle

dispels cold and wind, warms the lung to resolve accumulated fluids

sinusitis, toothache, rheumatoid arthritis due to wind and dampness

dispels wind, resolves, surface, expels wind-damp, controls pain

common cold due to wind-cold, headache, generalized aching

removes wind and dampness

rheumatism, painful spasms, contraction of the tendons and bones

disperses wind-heat, clears vision, cleanses heat, removes toxin

headache, ocular inflammation, dizziness, deeprooted furuncle

dissolves wind-heat, moistens throat, stabilizes convulsion

headache, cough, laryngitis, epilepsy, obscured vision, un-erupted measles, rubella, pruritis

induces perspiration, resolves exterior

“exterior confirmation of wind cold,” aching in shoulder, arms, and joints

headache, toothache, ocular irritation, rhinorrhea, pruritis

removes wind-dampness, promotes rheumatism, gout, pain in the loins, knees, and meridian flow, controls pain limbs, apoplexy, migraine removes wind-dampness

rheumatic arthritis due to wind and dampness, hemiplegia, carbuncle

dispels wind, controls pain

headache, arthralgia due to cold, spasm of tendons

disperses wind-heat, removes film

hyperemia, excessive tearing nebula

removes wind, promotes the flow of meridians

rheumatic arthritis due to wind and dampness, pain in the loins and knees, toothache, scabies

dispels wind, disperses cold, controls pain

headache due to wind-cold, tinea

ma-huang mahuang magnolia flower xinyi mentha bohe

induces perspiration, resolves surface disperses wind, opens cavities

febrile disease due to exterior-excess

disperses wind-heat, cleanses throat, promotes eruption

morus twig sangzhi perilla leaf zisuye pueraria gegen schizonepeta jingjie siegesbeckia xiqiancao

dispels wind, promotes the flow of meridians

fever due to exogenous pathogenic factors, headaches, hyperemia, sore throat, oral and dermal lesions, rash, toothache arthralgia due to wind, cold, and heat, contraction of the limbs

induces perspiration

common cold

resolves surface

febrile diseases, stiff neck, unerupted rash

dispels wind, resolves surface

fever due to common cold, headache, laryngitis, carbuncle

siler fangfeng tu-huo duhuo vitex manjingzi xanthium cangerzi zaocys wushaoshe

anodyne and sedative for headache, sinusitis, and nasal suppuration

removes wind and dampness

rheumatoid arthritis due to wind and dampness, aching and numbness of the limbs, suppurative infection of the body surface dispels wind, resolves surface, common cold due to wind-cold, headache, removes dampness, relieves generalized aching, arthralgia due to wind, cold, convulsions and dampness, ostealgia, limbic spasms removes wind-dampness, promotes headache due to common cold, aching and pain circulation of meridians in the loins and knees, arthralgia due to dampness, wind, and cold, pruritis, convulsive pain in the hands and feet disperses wind-heat, cleanses head heaviness of head, ocular pain, headache, and eyes common cold removes wind and dampness, opens the nose

headache due to wind and dampness, cramping and numbness of the limbs, sinusitis, pruritis

removes wind-dampness

arthralgia, ostealgia, numbness of the skin, rash due to wind, scabies, leprosy, urticaria

Table 2: Summary of Uses for Wind-dispelling Herbs. Wind-induced Disorders pain of the joints (arthralgia) or bones (ostealgia); gout, generalized aching headache, migraine, stiff neck

toothache spasms, contraction, cramping affecting tendons, bones, limbs, including painful spasms numbness and/or pain of limbs convulsions, epilepsy skin rashes, itching (pruritis), numbness, scabies, tinea, leprosy skin eruptions (furuncles, carbuncles); ulcerations unerupted rashes sinusitis, rhinitis

eye irritation, swelling, visual obstruction cough, sore throat, laryngitis common cold, fever due to common cold*

stroke (apoplexy; hemiplegia), paralysis

Herbs Used for Treatment agkistrodon, asarum, chiang-huo, chin-chiu, cinnamon twig, clematis, clerodendron, cnidium, erythrinia, morus twig, siegesbeckia, siler, tu-huo, zaocys angelica, chiang-huo, chrysanthemum, cicada, clematis, cnidium, kao-pen, magnolia flower, mentha, pueraria, schizonepeta, siler, tu-huo, vitex, xanthium angelica, asarum, erythrinia, mentha acanthopanax, chin-chiu, cnidium, morus twig, siler, tu-huo, xanthium

Comments Most of these medicinal agents have anti-inflammatory actions.

These herbs may normalize blood circulation and alleviate inflammation and pain. These herbs are antiinflammatory. These herbs have antispasmodic ingredients.

acanthopanax, siegesbeckia

These two herbs are commonly used for arthralgia (bi syndrome). agkistrodon, cicada These are animal agents that may inhibit nerve transmission. acanthopanax, angelica, cicada, erythrinia, These herbs have antikao-pen, mentha, tu-huo, xanthium, zaocys inflammatory effects; they probably cannot eradicate the infecting organisms. arctium, chrysanthemum, clerodendron, These herbs have antibacterial mentha, schizonepeta, siegesbeckia effects. arctium, cicada, pueraria The mechanism of action is unknown. angelica, asarum, magnolia flower, xanthium These herbs have decongesting essential oils and some antiallergy effects. angelica, chrysanthemum, cicada, The mechanism of action is equisetum, mentha, vitex unknown. arctium, cicada, mentha, schizonepeta These herbs have antiinflammatory actions. chiang-huo, cinnamon twig, mentha, perilla The common cold is not leaf, pueraria, schizonepeta, siler, vitex accompanied by fever; reference is to a wind-disease. The herbs have anti-inflammatory and antipyretic effects. agkistrodon, clematis, clerodendron The mechanism of action is unknown.

Table 3: Herbs that Settle Wind. Herbs that nourish the liver yin and blood can settle wind; the following herbs are described as having a direct action on inhibiting wind. Note that the properties are almost the same as those described for the herbs in Table 1, but there is greater emphasis on treatment of convulsions and epilepsy, especially in children. Herb Name/Pinyin antelope horn lingyangjiao [no longer used; endangered] centipede wugong earthworm dilong

Properties Related to Wind subdues liver wind, calms fright

Uses Related to Wind loss of consciousness, delirium, mania, ocular irritation, headache, epilepsy induced by fright

subdues wind, suppresses convulsions

epilepsy, spasm, tetanus, scrofula

suppresses convulsions

eretmochelys daimao [no longer used; endangered]

suppresses liver wind

irritability and restlessness, hyperemia, sore throat, rheumatism, arthralgia, hemiplegia, convulsions in infants febrile diseases, epilepsy induced by fright, delirium, childhood convulsions, carbuncle, abscess, excessive tearing

gastrodia tianma [Armillaria, the gastrodia mushroom, sometimes used as substitute]

dispels wind, controls convulsions, controls pain

headache, dizziness, vertigo, convulsions, epilepsy, hemiplegia, contracture of the limbs, sore and painful knees and waist, loss of voice, arthralgia due to wind, cold, and dampness, convulsions in children

haliotis shijueming

causes yang to descend, suppresses liver wind, clears vision removes wind, relieves convulsions

vertigo due to liver wind, glaucoma

suppresses wind, subdues convulsions, dispels wind, controls pain extinguishes wind, subdues convulsions

convulsions in young children, muscular spasms of apoplexy in adults, hemiplegia, tetanus, scrofula

pi-hu bihu scorpion quanxie silkworm baijiangcan tribulus baijili uncaria gouteng

soothes the liver and suppresses wind, clears vision, controls itching calms the liver, controls convulsions, calms nervous excitement due to wind

apoplexy, paralysis, arthritis, epilepsy, tetanus, arthralgia, scrofula

epilepsy, apoplexy, convulsions, headache, painful swelling of the throat, loss of voice, erysipelas, scrofula headache, swollen red eyes

dizziness, epilepsy in children

Table 4: Major Wind Acupuncture Points. The acupuncture points listed here have wind (feng) in their traditional point name. The meaning of the point names come from the book Grasping the Wind (1), the title referring to the name and action of the point bingfeng (SI-12). The uses of the points are from A Manual of Acupuncture (12). Point Name fengchi (GB-20)

Interpretation of Point Name Wind pool; the depression in which GB-20 is located resembles a pool in the landscape of the body. Wind pathogens are said to collect in this depression, and the point is used in the treatment of wind disease.

fengmen (BL-12)

Wind gate; BL-12 is called wind gate both because wind pathogens enter the body there, and because the point can be used to treat exterior wind patterns.

fengfu (GV-16)

Wind mansion; this point is used to treat wind disorders such as wind strike, stiff neck, headache, aversion to cold, visual dizziness, hemiplegia, heat wind and wind cold. It treats both endogenous and exogenous wind, especially when that wind affects the brain. GV-16 is further considered to be a point at which wind pathogens enter the body.

Uses of the Acupuncture Point headache, head wind, one-sided and generalized headache, dizziness, visual dizziness, hypertension, hemiplegia, deviation of the mouth and eye, goiter, lockjaw, insomnia, loss of memory, epilepsy, loss of speech following windstroke, injury by cold, redness and pain of the eyes, blurred vision, lacrimation (especially on exposure to wind), nosebleed, rhinitis, nasal congestion, deafness, tinnitus, stiffness and pain of the neck with inability to turn the head, pain of the shoulder and back, and pain of the lumbar spine attack of wind with fever, cold, shivering, dislike of wind and cold, headache, injury by cold with rigidity of the head and neck, flaccidity of the interstices with frequent coughing and clear watery nasal discharge, desire to keep the eyes closed, wind dizziness, visual dizziness; also: lumbar pain, stiff neck, urticaria, carbuncles of the back, shoulder pain, and restless sleep heaviness of the body with aversion to cold, cold shivering with sweating, swelling and pain of the throat, wind painful obstruction, all types of wind disease, injury by wind, headache, head wind, the hundred diseases of the head, visual dizziness, dizziness, blurred vision, nosebleed, upward staring of the eyes, sudden loss of voice, sudden inability to speak following windstroke, flaccid tongue with inability to speak, numbness of the legs, hemeplegia, hypertension, mania, incessant talking, difficulty in breathing, heat in the chest, and pain in the neck with inability to turn the head

fengshi (GB-31)

Wind market; wind disorders can be treated by applying acupuncture or moxibustion at this point. Furthermore, wind qi may gather in this area like people gathering at a market or fair.

hemiplegia, atrophy disorder and painful obstruction of the lower limb, cold painful obstructions, sciatica, leg qi, numbness of the leg, weakness and feebleness of the legs, heavy sensation of the legs with difficulty sitting, contraction and pain of the knees, itching of the whole body, and urticaria

bingfeng (SI-12)

Grasping the wind; a deep depression is found at this spot when the arm is raised. An invasion of external wind can get caught in this depression and cause shoulder disorders. In a manner of speaking, the point catches or “grasps” the wind. SI-12 is treated to relieve this type of shoulder pain accompanied by inability to raise the arm. It can literally “grasp the wind” and relieve the pain. Wind screen; this point is located behind the ear, which acts as a screen for the point, shading it and protecting it from the wind. In addition, the point may be utilized to dispel wind, thus screening the body from wind pathogens.

pain of the shoulder and scapula with inability to raise the arm, stiff neck with inability to turn the head, pain and numbness of the upper arm, and cough with stubborn phlegm

yifeng (TB-17)

deafness, tinnitus, damp itching of the inside of the ear, redness pain and swelling of the ear, earache, deviation of the mouth and eye, loss of speech, tetany with inability to speak, lockjaw, pain and swelling of the cheek, toothache of the lower jaw, visual obstruction, mania, clonic spasm

Table 5: Additional Wind Points. These acupuncture points are mentioned in Golden Needle Wang Le-ting (20) for treating wind. Most of the points treat wind anywhere in the body, but also have a specific focal area for wind diseases that is used in the process of point selection. Point Name baihui (GV-20) xinhui (GV-22) shuigou (GV-26) quchi (LI-11) jianyu (LI-15) huantiao (GB-30) yanglingquan (GB-34) yangfu (GB-38) weizhong (BL-40) jiache (ST-6) zusanli (ST-36) dadun (LV-1) xingjian (LV-2) xiguan (LV-7) yuji (LU-10) shaoshang (LU-11) sanyinjiao (SP-6) rangu (KI-2) laogong (PC-8) bafeng (M-LED-8) baxie (M-UE-22)

Treats Wind at the Following Locations: head and vertex head [especially nose] head and face [note: treats internal and external wind] extremities and blood vessels extremities and the jingluo four extremities, low back, legs tendons, joints, jingluo of the four extremities four extremities jingluo, head, neck, back, legs [especially knees] mouth and face four extremities [calms internal wind] tendons knees legs and knees lungs throat blood; four extremities umbilicus hand (palm) legs and feet [note: this is a collection of eight points between the toes] hands and arms [note: this is a collection of eight points between the knuckles]

APPENDIX 1: Professor Wei Fengpo’s Clinical Experience with Four “Feng” Points Following is the text of an article presented in the Journal of Traditional Chinese Medicine (21); only the case examples have been deleted from the original article: The author of this article followed professor Wei Fengpo for more than 10 years and saw him use four feng acupoints for treatment of many kinds of diseases. The therapeutic results were quite good. The clinical experience in application of four feng acupoints was summarized and reported as follows. The four feng acupoints refer to fengfu (GV-16), fengchi (GB-20), yifeng (TB-17) and fengmen (UB-12). They are located respectively at nucha [nape of the neck], posterior lower margin of the earlobe, and upper back, which are easily attacked by pathogenic wind. Therefore, all these acupoints are named with one of the words being feng

(wind), and they have the functions of expelling and dispersing the pathogenic wind, not only the exogenous wind but also the endogenous wind. So they are the important acupoints for treatment of both the endogenous and exogenous wind syndromes. Clinically they are used in treatment of the exogenous wind syndrome intermingled with cold or heat caused by the attack of exogenous pathogenic wind, with the following symptoms: aversion to cold, aversion to wind, fever, nasal obstruction and discharge, discomfort and pain in the head, nucha, shoulder and back; and they can also be applied for treatment of convulsion, epilepsy, and hysteria induced by endogenous wind, with the symptoms of aphasia from apoplexy, dizziness, tremor, and ocular and auditory disorders. Although the four feng acupoints have similar functions, they have their own specialties. These are introduced as follows Fengfu (GV-16) It is located at the middle of the nucha, 1 cun above the hairline, where the Governing Vessel, Yangwei, and Foot-Taiyang Channels meet. Fu means a place for accumulation, and fengfu implies the place for accumulation of wind evil. Therefore, fengfu is primarily used for treatment of various wind syndromes. 1. Fengfu acupoints can be applied for expelling pathogenic wind, dispersing cold and clearing away heat in the treatment of exogenous pathogenic wind-induced symptoms such as common cold, headache, neck stiffness, aversion to cold, and fever. When fengfu acupoint is applied with fengchi (GB-20) as an adjunct acupoint, the therapeutic effect can be enhanced. It is described in the Shanghan Lun that if disorders of taiyang channel can not be relieved by initially taking Guizhi Tang (Cinnamon Combination), acupuncture at fengchi and fengfu acupoints should be first applied, and then the disease can be cured by the decoction. In Tong Xuan Zhi Yao Fu, it is said that when the pathogenic wind acutely attacks the nucha, one should firstly seek the help of fengfu. Professor Wei considers that no matter whether the exogenous pathogenic wind inducedsyndrome is wind-cold or wind-heat, fengfu is the main effective acupoint for the initial selection. 2. For treatment of endogenous wind-induced syndromes, such as aphasia and coma from apoplexy, hemiplegia, or tremor of four limbs, fengfu acupoint can be used, or alternately applied with yamen (GV-15). For patients with coma, renzhong (GV-26) and baihui (GV-20) can be added for waking up from unconsciousness, clearing away heat and tranquilizing the endogenous wind. For patients with aphasia, lianquan (CV-23) and tongli (HT-5) acupoints can be added to promote the functions of larynx and tongue for restoring the voice. For patients with limb paralysis, acupoints of the Yangming Channel can be selected as adjuvant acupoints; while for patients with tremor of four limbs, taichong (LV-3) and for patients with opisthotonus [hyperextension and spasticity] dazhui (GV-14) can be added. In recent years, fengfu has been used in treatment of pseudobulbar paralysis due to cerebral hemorrhage and multiple cerebral vascular accidents with excellent therapeutic effects. Professor Wei considers that during the performance of acupuncture, the depth, degree of angle, and direction of the needle insertion should be strictly held, and attention should be paid to the patient’s reaction. The method: take the needle with the right hand, and it is safe to perpendicularly insert the needle about 0.8 cun deep (external to the dura mater) to induce the feeling of needling sensation. Generally, after manipulating the needle at fengfu 2–4 times, the needling sensation will arrive, therapeutic effect thus can be obtained, and the needle should be immediately taken out; if no needling sensation is felt, lifting and thrusting the needle slowly in small amplitude may help to induce it. Fengchi (GB-20) Fengchi points are located at the bilateral sides of fengfu, where Hand- and Foot-Shaoyang, Yangqiao, and Yangwei Channels meet. Their functions are multiple and indications extensive. For internal and external ocular diseases, acupoints situated at periocular areas can be selected, such as jingming (UB-1), tongziliao (GB-1), and sibai (ST-2). For internal ocular diseases (fundus diseases: retinal hemorrhage, optic nerve atrophy), qiuhou (Extra-4) should be added. Professor Wei’s manipulation at bilateral fengchi points has unique characteristics. He uses both hands simultaneously to insert and manipulate the needles at both fengchi acupoints, that is, lifting, thrusting, twisting and twirling the needles on both sides at the same time. In manipulation of acupuncture, the feeling of needling sensation with its transmission is of importance no matter whether the depth of needle insertion is shallow or deep. The direction of the needle tip is towards the contralateral eyeball or zygomatic bone. If the needling sensation with its transmission is not felt, the direction and angle of the needling should be modified. The depth of acupuncture is about 5 fen to 1 cun. The transmission of needling sensation is from fengchi acupoint along the occipital, posterior parietal, temporal and anterior frontal areas, occasionally reaching the ocular region. The needling sensation varies among different individuals and the therapeutic effect is related to the needling sensation and its transmission. Professor Wei observed a great number of youth and children with myopia treated by acupuncture, and their shortterm therapeutic results were marked. Some adults also felt a better visual acuity with their ocular fatigue ameliorated. Professor Wei used two sentences to summarize the therapeutic effects of fengchi acupoints: “The faster the needling sensation comes, the better the therapeutic effects” and “The farther the transmission of the needling sensation, the greater the therapeutic effects.” Fengmen (UB-12) Fengmen acupoint is located below and 1.5 cun lateral to the spinous process of the second thoracic vertebra, where the Foot-Taiyang and Governing Channels meet. Because heat is accumulated at fengmen, it is also named “refu.” It has the functions of dispersing wind, purgating heat, ventilating the lungs, and relieving cough and asthma. When the external pathogenic factors invade the body, they first enter into fengmen and are transmitted along the Foot-Taiyang Channel to the neck and back, and further affect the other zang-fu organs. This acupoint is often used for common cold (including epidemic influenza), aversion to wind and cold, fever, acute and chronic bronchitis, cough and asthma. For patients with chronic deficiency-cold syndrome, moxibustion is applied. In other conditions, acupuncture is primarily used. Professor Wei often selects fengmen with feishu (UB-13) as the adjuvant point for treatment of acute and chronic bronchitis and asthma with good therapeutic results. When Professor Wei performs fengmen acupuncture, the patient is in the sitting position. The needle is perpendicularly inserted into fengmen 8 fen deep to induce needling sensation, and the needle is retained for 15 minutes and manipulated twice by lifting, thrusting, twisting and twirling with the uniform reinforcing-reducing method. For part of the patients, while the

needle is being retained, mild moxibustion is applied. Yifeng (TB-17) Yifeng is located antero-inferiorly to the mastoid process and at the level of posterior lower margin of the earlobe, which belongs to the Triple Burner Channel and is the place where Hand- and Foot-Shaoyang Channels meet. Generally, in medical books, it is recorded that deafness or psychic deafness can be treated by this acupoint, because it is near the ear. Professor Wei often used this acupoint for treatment of Shaoyang headache (angioneurotic headache and migraine). The therapeutic effects were excellent. In clinical practice for many years, Professor Wei accumulated experience in manipulation with his own unique approach. He used both hands to simultaneously insert two needles into bilateral yifeng points 1.5–2 c u n deep towards the contralateral mastoid process. His basic manipulation was frequent twisting and twirling with less lifting and thrusting. Most of the patients experience marked needling sensation, and the sensation could be transmitted to the pharynx, larynx or the root of tongue, showing that the depth and angle of the needling were correct. The needles were manipulated twice during retention of the needles for 20 minutes. If the needling sensation is not significant, or the transmission could not reach the pharynx, larynx or root of tongue, electrostimulation is used to induce a stronger needling sensation. APPENDIX 2: Professor Wei Jia’s Experience Using Fengchi (GB-20) The following is the text (except for the illustrative cases) from an article in the Journal of Traditional Chinese Medicine (28) about use of one of the most important wind points, fengchi: As students of Professor Wei Jia for two years, we have witnessed his success in treating a variety of diseases by needling acupoint fengchi (GB-20). The following is a brief account of his experience. Generally, acupuncturists asked the patient to sit facing the operator or leaning over the back of a chair for locating fengchi (GB-20). Professor Wei, however, locates the point with the patient lying prone, as he believes this allows the acupuncturist to locate the point more accurately with the patient feeling relaxed and comfortable, which could prevent fainting during the acupuncture. Another feature of his locating method is repeated pressing of the area around fengchi (GB-20) with the thumb in locating the point, which is very sensitive to pressure. In applying this acupoint, Professor Wei emphasizes the importance of the depth of needling, which must never reach the medullary bulb. In children, the needling depth never exceeds 0.5 cun, and there is no retention of the needle. In thin adults, one cun is suitable, while in obese cases the insertion depth is within 1.5 cun, with needle retention for 30 minutes in either case. The direction in which the needle is pressed after it has reached a suitable depth varies with the treatment of various diseases. In treating ear disorders, direct the needle toward yifeng (TB17); in treating eye disorders, direct the needle toward the eyes alternately; for cerebrovascular and nervous system diseases, direct the needle toward yintang (Extra-1); and in cases of up-stirring of liver wind, direct the needle toward the left and right alternately. Professor Wei believes that this method of point penetration not only has the double function of treating disease by needling two acupoints at once (by enabling the needling sensation to extend easily to the vertex, temples, forehead, or the ears and eyes), but it also avoids piercing the foramen occipitale magnum or the spinal cord. Combining his own experience with that of his predecessors, Professor Wei developed a therapy for treating over ten diseases using fengchi (GB-20) as the main acupoint, supplemented by certain auxiliary acupoints, as indicated below:

Adjunct Point Accompanying Fengchi (GB-20)

Headaches neuroheadache headache due to hypertension headache due to wind-cold headache due to wind-heat wind-phlegm headache headache due to blood stasis Other disorders of the head facial spasm facial paralysis nervous tinnitus nervous deafness rhinitis myopia optic atrophy hemiparalysis due to stroke sequelae of epidemic encephalitis sequalae of encephalitis B alopecia parotitis herpes zoster halitosis tonsillitis toothache due to wind-fire Abdominal and chest disorders phrenospasm (spasm of diaphragm) biliary colic gastrointestinal spasm ulcer dysmenorrhea bronchitis bronchial asthma Miscellaneous other disorders insomnia

shuaigu (GB-8) quchi (LI-11) lieque (LU-7) hegu (LI-4) fenglong (ST-40) baihui (GV-20); with blood letting taiyang (Extra-2) quanliao (SI-18) plus dicang (ST-4) yifeng (TB-17) tinghui (GB-2) yingxiang (LI-20) jingming (UB-1) yiming (Extra-7) quchi (LI-11) plus fengshi (GB-31) hegu (LI-4) plus yanglingquan (GB-34) jianyu (LI-15) plus yanglingquan (GB-34) shenting (GV-24) jiache (ST-6) zhongzhu (TB-3) renzhong (GV-26) shaoshang (LU-11); with blood letting local tender point shangwan (CV-13) yanglingquan (GB-34) zhongwan (CV-12) zusanli (ST-36) chengshan (UB-57) feishu (UB-13) dingchuan (Extra-17) shenmen (HT-7)

epilepsy schizophrenia vasospasm sciatica menopausal syndrome cervical spondylotic syndrome

baihui (GV-20) xinshu (UB-20) taichong (LV-3) huantiao (GB-30) taixi (KI-3) plus sanyinjiao (SP-6) cervical vertebrae

Prof. Wei holds that fengchi (GB-20) has seven functions: 1. Expelling pathogenic wind: The point belongs to the Gallbladder Channel of Foot-Shaoyang. Since there exists an exterior-interior relationship between gallbladder and the liver, and the liver is in charge of wind, puncturing fengchi soothes the liver and suppresses wind. It is also at the juncture of the Yangwei and Gallbladder Channels of Foot-Shaoyang. As the Yangwei Channel is in charge of the exterior, and most exterior syndromes are related to exogenous pathogenic wind, therefore all syndromes connected with wind pathogen may be treated by puncturing fengchi. 2. Purging pathogenic fire: Fengchi has the function of removing pathogenic fire from the liver and gallbladder, and is often selected in treating patients with yin-deficiency and yang-excess. The treatment of menopausal syndrome is an example of using it for purging the gallbladder of pathogenic fire. 3. Regulating qi by alleviation of mental depression: The liver and gallbladder both pertain to wind and wood, and therefore prefer cheerfulness to depression, while depression may lead to various diseases. This is the principle upon which the treatment of gastralgia due to disharmony between the liver and gallbladder and the treatment of sciatica due to stagnation of liver-qi are based. 4. Resolving phlegm: Most unusual diseases involve profuse phlegm. Professor Wei excels in the application of fengchi in treating such diseases as those caused by phlegm-fire. He holds that there are two reasons why fengchi is useful in resolving phlegm: first, it regulates the functioning of qi, and so dispels phlegm; second, it lowers intense heat so that body fluid is not concentrated into phlegm. 5. Stimulating the circulation of blood: Stagnancy of qi leads to blood stasis, active circulation of qi leads to fluent blood circulation. Fengchi is useful in treating many stubborn diseases related to blood stasis. This is because fengchi acts upon the Shaoyang Channel, regulating the functioning of qi and activating blood circulation. It was with this function of fengchi in mind that Professor Wei used it in treating cerebritis and hemiparalysis due to cerebral infarction. 6. Tranquilizing the mind: Since fengchi is fairly effective in tranquilizing the mind, it is often selected for treating various kinds of insomnia due to mental depression and restlessness. 7. Relieving spasm: The spasm-relieving property of fengchi is markedly manifested in the following three ways: it relieves cerebrovascular spasm, and hence is often selected in treating neurovascular headache as well as headaches due to hypertension; secondly, it can relieve bronchospasm, and is therefore effective in relieving asthma; and thirdly, it can relieve gastrointestinal spasm causing abdominal pain. APPENDIX 3: Additional reports on Fengchi (GB-20) Professor Chen Sancai (29) made a short report on clinical application of fengchi (GB-20) for treating a condition of heel pain (plantar fasciitis is a likely diagnosis for the condition he described), in which case he also treated taixi (KI-3), and for treating depression, in which case he also treated neiguan (PC-6) and sanyinjiao (SP-6). His comments, after describing successful therapy, are of potential interest: Fengchi is the crossing point where Shaoyang Channel, Yangwei Channel, and Yangqiao Channel meet; it is effective for alleviating pain….Fengchi is indicated for obstinate insomnia, epilepsy, and climacteric syndrome (menopausal syndrome) by its action of soothing the liver, normalizing bile secretion, promoting the flow of qi and blood, and regulating the emotions. Chen Yuelai and his colleagues (30) provided examples of using needling of fengchi, accompanied by other points, in treatment of blepharoptosis (eye lids do not lift), dysosmia (loss of sense of smell), and migraine accompanied by hypotension. Regarding this particular acupuncture point, they noted: Fengchi is a point of the Gallbladder Channel of Foot Shaoyang. Just as its name implies, it is a place where the pathogenic wind converges. So, the point is regarded as an important point to dispel wind since it has the functions of clearing heat and brightening the eye, dispelling wind and inducing resuscitation. Clinically, the point is widely used to treat cerebrovascular diseases, five sense organ disorders, and exogenous syndromes….. Generally speaking, the patient usually feels sensitive when fengchi is punctured. Yet, routine needling technique can only cause the local sensation of soreness and distention without needling transmission, and this might affect the therapeutic effect. Ancient physicians said “Acupuncture is effective when qi arrives.” So, to promote needling sensation running right to the affected area is very important to improve the therapeutic effect….Proper needling is able to transmit the needling sensation to the eye, ear, frontal, and temporal regions along the running course of the Shaoyang, Yangwei, and Yangqiao channels. This is why fengchi can be used to treat diseases of the five sense organs. Being close to the brain, fengchi serves as an important point to reduce liver fire and dispel liver wind when the head and brain functions are disturbed, which is especially effective to treat headache caused by qi and blood disorders. So, clinically, fengchi is often selected to treat diseases of the head and neck for regulating qi, activating blood, and improving the brain functions.

APPENDIX 4: Wind in Ayurvedic Medicine The Chinese description of wind influence is remarkably similar to the one used in other parts of Southeast Asia, which may be the result of communications between the cultures. For example, Mervyn Jaspan (13) describes the causes of disease, including wind, in traditional medicine in Sumatra: A further method of categorizing maladies [aside from the division of cold and hot] is based on four principal pathogenic forces: wind, spirits, poison, and worms. If a patient has a severe chill, with thin nasal mucus and a painful head and joints, he is diagnosed as ‘entered by wind’ (masuk angien), a concept that includes catching a chill or draft, or getting a cramp or a stiff neck. All such ailments require heat treatment, and the patient is instructed to stay indoors near a fire and to take hot drinks and sudatory drugs [those that induce sweating]. The absence of sweat in a patient ‘entered by wind’ is regarded as a negative, and sometimes dangerous, symptom. The sudatory dosage may be increased, and the patient brought nearer the fire. Wind takes an even more prominent role in the Ayurvedic tradition of India, in which it is one of the three doshas that have a pivotal role in disease etiology, manifestation, and determination of treatment strategy (see Appendix 3). Yet, several of the descriptions for wind and its action on the body very closely parallel that provided by the Chinese. There was some interaction between India and China during the consolidation of their medical traditions, with increased interchange during the 7th and 8th centuries A.D. Data on the diagnosis of diseases by traditional category in the Ayurvedic system was presented in an article on the impact of Ayurvedic ideas on the culture in Sri Lanka (24). More than 100,000 patient visits to six Ayurvedic clinics in Kandy, Sri Lanka were analyzed. Ten diagnostic categories accounted for nearly 64% of all cases presented. Wind-caused diseases, mostly described as aches, pains, and trouble with the joints, comprised three of the ten categories (vata vyadi, vatrakta, amavata) and constituted the main diagnosis. Graduating students of an Ayurvedic medical college were surveyed to find out which diseases they thought were most likely to be treated effectively by Ayurvedic medicines. Five conditions were considered most amenable to treatment: two wind ailments (amavata and vatarakta), skin diseases (rashes, eczema), paralysis, and hemorrhoids. In a government hospital featuring Ayurvedic medicine, these ailments were the dominant ones treated, with wind-related conditions comprising over half of the cases that fell into these categories. In the Chinese system, many cases of skin diseases and paralysis are also attributed to the influence of wind. One of the most important Ayurvedic texts is the Caraka-Samhita. In the first volume of the English language translation, there is a chapter on wind (vata), called Vatakalakaliyam, meaning the merits and faults of wind, which is reproduced in its entirety below (22). As will be seen, wind that functions within the body may have a positive effect, but if it becomes excited or provoked (“vitiated” is the term often used by Western authors), then it causes harm. At the end of the section, there is a short discourse on the influences of bile and phlegm. Here is the translation, which is presented in its entirety so that readers will fully appreciate the context of traditional medical presentation:

Vatakalakaliyam [Merits and Faults of Wind] The great Rsis (sages) seated at their ease, and desirous of ascertaining the truth about the merits and faults of the wind, asked one another: What are the virtues of the wind? What is meant by provocation of the wind? What, again, are those things that can allay that provocation? The wind is never stationary (being ceaselessly mobile). It is also impalpable (i.e., neither solid nor liquid). Those things that are said to provoke and allay it cannot come in contact with it. How then, without coming in contact with it, can they provoke or allay it? The provoked or unprovoked wind moves within the body and without the body. What, indeed, is its action within the body and what outside the body? The questions being propounded, Krsa, the son of Sankrti, answered: The wind has six qualities; these are dryness, lightness, coldness, fierceness, heat, and poisonousness. Hearing these words, Kumarasira-Bharadvaja said: It is even so as the illustrious one has said. Truly, these are the attributes of the wind. By frequent recourse to objects possessed of similar attributes, and acts productive of similar attributes, the wind becomes excited. The presence of objects possessed of similar properties is the cause of the increase of each of these elements of wind, bile, and phlegm. Hearing those words, Vadisa-Dhamargava said: It is even so as the illustrious one has said. These (objects and acts) are excitants and mitigating causes of the wind. We shall presently expound how these excitants and mitigating causes achieve their respective functions of exciting and mitigating, without actually coming into contact with the wind which is impalpable and unstable. Without doubt, things that are dry, light, cold, fierce, hot, poisonous, and wasting are excitants of the wind in the body. The wind occurring in bodies fed with substances of such attributes, increases in consequence thereof and becomes excited. Substances, again that mitigate or allay the wind in the body are those that are juicy, heavy, hot, jelly-like, soft, oily and constipating. The wind occurring in bodies fed with such substances, moves in contact therewith and becomes mitigated or allayed. Hearing these words of Vadisa that were just and approved by all the Rsis, the royal sage Varyovida said: It is even so as the illustrious one has said. All this is faultless. Bowing unto the wind, I shall, according to my lights, declare with the aid of direct perception, of inference, and of authority, the nature of those functions which the excited and unexcited wind, dwelling in the body and out of it, accomplishes while moving within the body and out of it. The wind upholds the constituents of the body (such as blood, flesh, marrow, fat, etc.) and their courses through the body. It exists in the five-fold form of Prana, Udana, Samana, Vyana and Apana. It is the urging cause of

movements of diverse kinds. It restrains the mind (from all undesirable objects) and concentrates it (on objects that are desirable). It causes all the (ten) senses (of knowledge and action) to perform their functions. It bears all the objects of the senses (after contact with the senses) to the mind. It holds together all the elements of the body. It assists the cohesion of the particles of the body. It causes speech. It is the prime cause of touch and sound, and the root of scent and touch. It is the origin of joy and cheerfulness. It excites the heat of fire. It dries up all faults. It throws out all impurities. It pierces through all the ducts of the body, gross and fine. It gives form to the embryo in the womb. It furnishes evidence of the existence of life. The wind, when unexcited, achieves all these functions. When excited within the body, it pains the body with diverse afflictions. It destroys and injures strength, complexion, happiness, and duration of life. It agitates the mind. It injures all the senses. It kills the embryo and causes miscarriage. It maims the embryo (by suspending the development of particular parts). It holds the fetus longer than usual. It causes fear, grief, stupefication, cheerlessness, and delusions. It destroys life. As regards the wind that blows out of the body, when it is in its normal condition, it achieves the following functions: it upholds the Earth (in space); it causes the fire to blaze forth; it causes the sun, the moon, the stars and the planets to move ceaselessly in their respective orbits. It creates the clouds. It causes the clouds to pour rain. It causes all currents or streams to flow. It causes all flowers and fruits to appear. It causes all vegetables to grow. It causes the change of seasons. It causes all solid substances to assume different forms. It ordains the density of different substances as also their shapes. It causes seeds to sprout forth, and produces the kernel in fruit and crops. It protects crops and fruits from putrefaction while unripe and dries up crops when ripe. It prevents things from putrefying. When moving in the world in an excited state, without doubt, it achieves the following functions: It breaks the summit of mountains. It uproots trees. It agitates seas. It swells the waters of lakes causing them to rise upwards. It causes the currents of rivers to run in opposite directions. It makes the Earth tremble. It urges the clouds. It causes frost, thunder, dust, sand, fish, frogs, snakes, ashes, blood, stones, lightning to fall down on the Earth. It causes excess of virtues, absence of virtues, and contrariety of virtues in respect of the six seasons. It causes failure of crops. It produces disease and plagues. It destroys many objects. It causes those clouds, suns, fire and winds which bring about a universal dissolution at the end of the four Yugas. Possessed of divine attributes, the wind is the cause of both production and destruction (of the universe). It causes all existent objects to start into life and also brings about their destruction. It ordains both happiness and misery. It is Mrtyu, Yama, Niyantr, Prajapati, Aditi and Visvakarman [Mrtyu is a goddess who sprang from Brahman the Creator: when asked to destroy all creatures, she refused to do so, moved by compassion, but was ultimately prevailed upon by the Creator to accomplish her divine purpose. Yama is the infernal Judge: it is his province to judge of all persons after death, and to award punishments to those that deserve them of different grades of severity. Niyantr is a male deity that is employed in ordaining the occurrences of the lives of every person. Prajapati is the Regent that supervises the world. Aditi is the mother of the celestials. Visvakarman is the divine artificer.]. It is of universal form. It is capable of going everywhere. It is the ordainer of all acts or rules. Of all existent objects it is exceedingly subtle, exceedingly gross, omnipresent and, therefore, embraces all things. The wind is a divine object. Hearing these word (about the virtues and nature of the wind) by (the royal sage) Varyovida, the son of Marci said: If it be as you say, what power can medical knowledge possess in the matter of either understanding or describing this topic of discourse? Or, why has our discourse on this topic commenced in connection with medical arts? Varyovida said: If the physician does not hear that the wind is possessed of great might, that it is very fierce, that it is characterized by great celerity in respect of all its operations, and that it is productive of evil, why shall he make haste, with concentrated faculties, to restrain it at the outset when it becomes suddenly excited? Indeed, the physician should, at the very outset, seek to allay or restrain the wind from fear of the injury it is capable of doing. The just propitiation of the wind leads to health, the growth of strength and complexion; energy, the increase of vitality, the growth of knowledge, and extension of the period of life.’“ The son of Marci said: The heat dwelling in the body, within the bile, when excited, produces evil and when in its normal condition leads to beneficial consequences. This is as follows: In its normal condition, it aids digestion, vision, the proper measure of warmth (of body), propriety of complexion, courage, cheerfulness, and free play of the faculties, etc. When excited, it produces indigestion, weakness of vision, an improper measure of warmth, an unhealthy complexion, fear, wrath, error, etc. Excited and unmixed, it produces similar pairs of opposites. Hearing these words of Marci’s son, Kasyapa said: Soma that dwells in the body with the phlegm, unexcited and excited, produces beneficial and evil consequences. They are as follows: Tightness of limbs and their relaxation; growth and weakness; exertion and languor; virility and its reverse; knowledge and ignorance; understanding and stupidity, and similar other pairs of opposite virtues. Hearing these words of Kasyapa, the illustrious Punarvasu, the son of Atri, said: All of your illustrious selves have said what is sufficient and proper in respect of what is beneficial and what is injurious for man. Without doubt, all the (three) elements, wind, bile and phlegm, when in their normal condition, keep a man’s senses in good order; bring about an accession of strength, complexion, and happiness; and bestow length of life upon him, even as religion, wealth and pleasure, judiciously sought, unite one, both here and hereafter, with what is highly beneficial. When wind, bile and phlegm become abnormal. they bring about an accession of immeasurable evil upon him even as the three seasons, when fraught with abnormal manifestations, bring about an accession of much evil upon the world, when their calamities begin to develop themselves. All these words of the illustrious son of Atri were fully

accepted by the Rsis and approved of by them. Hearing these words of Atri’s son, all the Rsis (there present) accepted and approved of them even as the deities accept and approve the words of Indra. The six qualities of the wind, the two kinds of causes (excitement and unexcitement), the diverse functions of the wind when excited and unexcited, the four kinds of functions of bile and phlegm, the opinions of the several Rsis and the opinions of Punarvasu, have all been expounded in this lesson on the merits and faults of the wind. REFERENCES 1. Ellis A, Wiseman N, and Boss K, Grasping the Wind, 1989 Paradigm Publications, Brookline, MA. 2. Wieger L, Chinese Characters: Their Origin, Etymology, History, Classification, and Signification, 1965 Dover Publications, NY. 3. Wu Jing-Nuan (translator), Lingshu, or The Spiritual Pivot, 1993 Taoist Center, Washington, D.C. 4. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. 5. Maoshing Ni, The Yellow Emperor’s Classic of Medicine: A New Translation of the Neijing Su Wen with Commentary, 1995 Shambhala, Boston, MA. 6. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988, Kluwer Academic Publishers, Holland. 7. Campany RF, Strange Writing, 1996 State University of New York Press, Albany, NY. 8. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. 9. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (4 vol.) 1995–6 New World Press, Beijing. 10. Liu F and Liu YM, Chinese Medical Terminology, 1980 Commercial Press, Hong Kong. 11. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA. 12. Deadman P and Al-Khafaji M, A Manual of Acupuncture, 1998 Journal of Chinese Medicine Publications, Hove, England. 13. Jaspan MY, The social organization of indigenous and modern medical practices in southwest Sumatra, in Leslie C (editor), Asian Medical Systems, 1976 University of California Press, Berkeley, CA. 14. Wong E, Fengshui, 1996 Shambala Publications, Boston, MA. 15. Hu Jinsheng, Teaching round: headache, Journal of Traditional Chinese Medicine 1994; 14(3): 237–240. 16. Yuan Liren and Liu Xiaoming, Traditional Chinese methods of health preservation (2), 1992; 12(3): 220–223. 17. Yang Shouzhong (translator), Master Hua’s Classic of the Central Viscera, 1993 Blue Poppy Press, Boulder, CO. 18. Yang Shouzhong (translator), The Heart and Essence of Danxi’s Methods of Treatment, 1993 Blue Poppy Press, Boulder, CO. 19. Ge Shuhan, Xu Benren, and Zhang Yuhuan, Treatment of primary trigeminal neuralgia with acupuncture in 1500 cases, Journal of Traditional Chinese Medicine 1991; 11(1): 3–6. 20. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1996 Blue Poppy Press, Boulder, CO. 21. Wei Bo, Professor Wei Fengpo’s clinical experience in application of four feng points, Journal of Traditional Chinese Medicine 1996; 16(2): 112–116. 22. Kaviratna AC and Sharma P (translators), Caraka-Samhita, 1996 Sri Satgu Publications, Delhi, India. 23. Ren Xiaoqun, A survey of acupuncture treatment for peripheral facial paralysis, Journal of Traditional Chinese Medicine 1994; 14(2): 139–146. 24. Obeyesekere G, The impact of Ayurvedic ideas on the culture and the individual in Sri Lanka, in Leslie C (editor), Asian Medical Systems, 1976 University of California Press, Berkeley, CA. 25. Hu Jinsheng, Teaching round: Acupuncture treatment of wind stroke, Journal of Traditional Chinese Medicine 1996: 307–311. 26. Ji Xiaoping, Teaching round: Parkinson’s disease, Journal of Traditional Chinese Medicine 1986: 52–54. 27. Anonymous, Lectures on essentials of traditional Chinese medicine: etiology, Journal of Traditional Chinese Medicine 1982; 2(3): 243–248. 28. Zhang Qiaobao and Xie Qiang, Experience of Professor Wei Jia in using acupoint fengchi, Journal of Traditional Chinese Medicine 1995; 15(4): 265–269. 29. Chen Sancai, Clinical application of Fengchi point, Journal of Traditional Chinese Medicine 2003; 23(2): 140. 30. Chen Yuelai, Zhang Tiansong and Zheng Kuishan, Examples of clinical application of Fengchi, Journal of Traditional Chinese Medicine 2002; 22(2): 128–131. October 2010

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PROMOTING HEALTH DURING THE FOUR SEASONS translated and introduced by Heiner Fruehauf, Ph.D., L.Ac., Institute for Traditional Medicine, Portland, OR introduction edited and amended by Subhuti Dharmananda, Ph.D., Institute for Traditional Medicine, Portland, OR

INTRODUCTION The following is a presentation by Gao Lian, a 16th century poet and medical scholar who was an ardent proponent of the art of nourishing life. The four presentations on the seasons originally appeared in Gao’s book, Eight Pieces on Observing the Fundamental Principles of Life (Zunsheng Bajian; 1575 A.D.), which Chinese physicians have regarded as a comprehensive source of lifestyle-related information. Elaborating upon one of the main themes of the Yellow Emperor’s Internal Classic (Huangdi Neijing), these seasonal portraits can be read as an attempt to translate the densely-crafted teachings of the classic into more contemporary language. Gao cautioned against some common habits while providing careful explanations for changing them. Gao Lian exemplifies the classical type of Chinese scholar who saw the cultivation of art, music, and poetry as a gateway to the mysteries of the body and the mind. While recognizing the medicine of poetry, he was also intrigued by the poetry of medicine. His delight in the rich cultural aspects of Chinese medicine and his efforts to collect medicinal recipes, herbal prescriptions, and therapeutic exercises put him in the company of other famous poets devoted to the pursuit of medical studies, such as the Song Dynasty master lyricist Su Dongbo (also known as Su Shi; 1036-1101 A.D.). For both of these distinguished literati, medicine represented the realization of the artistic quest in the realm of the physical: humankind’s age-old search to reconnect and resonate with its cosmic origins. Gao’s writings thus reflect the conviction of the poet-philosopher class of dynastic China that one cannot successfully treat a patient without cultivating this vital connection to the macrocosm. More specifically, the following four pieces are intended to remind the technique-oriented physician that, in the Neijing, medicine was primarily introduced as the art of celebrating the healthy body and preventing any detachment from the vitalityimbuing cycles of nature. In the Chinese medicine system, five seasons are mentioned, one for each of the elements. This division of the year has been a matter of contention and it is not surprising that Gao, an expert in many other fields, chooses to describe four seasons, as is most commonly done. One of the ways in which this division is correlated with the five element system is either to have the earth element as a common feature of all the seasons or to have the earth element dominate during the transitions between seasons. To aid in understanding Gao’s recommendations as they are read, a brief summary of main points is helpful. First, he recognizes that the element associated with each of the seasons tends to have a stronger energy manifesting in the body at that time. To attain balance, one must be careful about eating foods that would further enhance that energy, while increasing the intake of those foods that would boost the strength of the element (and organ system) suppressed by the dominant element. So, for spring, sour foods are minimized, as they promote the energy of the dominant wood element (liver), while mildly sweet foods would be increased because they promote the energy of the earth element (spleen), which is suppressed by the wood element. A brief table may help: Season Spring Summer Autumn Winter

Dominant Element/Organ Wood (Liver); eat less sour foods Fire (Heart); eat less bitter foods Metal (Lungs); eat less pungent foods Water (Kidneys); eat less salty foods

Affected Element/Organ Earth (Spleen); eat more mildly sweet foods Metal (Lungs); eat more pungent foods Wood (Liver); eat more sour foods Fire (Heart); eat more bitter foods

Gao cautions against the typical responses people make to characteristic weather of each season: in the winter, be careful not to hover near the stove and eat aged and preserved foods (in ancient societies, fresh foods were not readily available during the winter, so various means of preservation were utilized to make foods easier to get at that time). Though staying very warm and eating these kinds of strong tasting foods seem normal during the winter, these practices may end up causing disease in the spring when the weather starts to warm because of the accumulated internal heat. He also cautions against hot baths for those who have cold in the lower body, but heat above. In similar manner, during the summer, one should not be eating all kinds of cold and cooling foods and beverages, because, though it seems appropriate at the time, when the cooler weather arrives in Autumn, diseases may arise as a result. In fact, he suggests taking mildly warming tonics in the summer. He also cautions about being in drafty places and sleeping out in the open, due to risk of invasion of pathogenic wind. Thus, be careful not to contradict the power and influence of the natural weather condition: not too much warming to counter cold of winter or too much cooling to counter heat of summer. As he sums up for the erratic and changing conditions of spring and fall: “one should take special care to attend to the tranquil practices of nourishing life…and to conduct both one’s daily life and the treatment of patients in accordance with the predominant qi of the respective season.” In terms of behavior, Gao is a dedicated naturalist and believes that people should harmonize their actions to the weather. In Spring, get up early and do a morning stroll; in summer, be more calm, use selected sounds and hair strokes to stimulate the body rather than pursuing vigorous activities; in autumn, do some qigong exercises, like clicking of teeth and generating warmth; in winter, be careful not to sit around and get depressed! He mainly favors getting up early, except in winter, when one should be careful of the early morning cold. As to medical therapies, Gao offers some advice, sometimes of general nature and other times in relation to

specific symptoms or medical conditions. A table will help sum up: Season Spring

Summer

Autumn

Winter

Examples of Cautions Do not simply use herbs to overcome stagnation. If there is no sign of disease, there is no need to take any medicine Avoid draining yin qi, either by laxatives that induce diarrhea or by draining methods of acupuncture or moxibustion Avoid using dispersing therapies such as emetics or strong diaphoretics Warm diaphoretics should not be used excessively

Some Methods to Use When a disease is coming on, extinguish [or dispel] wind, harmonize qi, cool the diaphragm Ingest warm substances during the summer solstice, and take tonics for the kidneys use acupuncture/moxibustion and some herbal decoctions or powders which assist the patient’s yang qi Dispel existing pathogens with emetics. Take a combination of tonic materials steeped in wine; dioscorea wine is also good

Following is the translation of Gao’s essays. Please give attention not only to the specific analysis of the seasons and their effects or to his detailed recommendations, but also observe his love for the dynamics of the seasons. His attitude can be adopted even in modern times when some of the methods might need to be adjusted according to new circumstances. SPRING The three months of spring are the time of renewal: the old and stale dissipates, heaven and earth come to life, and everything blossoms. Rest at night and get up early, stride freely through the courtyard, let your hair down and indulge in the leisurely feeling of a morning stroll; this is how you should raise your spirits in spring. Foster all life and do not kill, be generous and agreeable, give freely and do not punish. This is the way of honoring the qi of spring and nourishing life during this season. Going against these characteristics of the seasonal flow will have harmful affects on the liver. The flavor of liver wood is sour. Wood can overcome earth, the dynamic element governing the spleen, which in turn is influenced by sweet flavors. In spring, therefore, one should eat less sour foods and increase one’s intake of mildly sweet foods to nourish spleen qi. The warming rays of the new sun of spring kindle everything into sprouting growth, including certain diseases that have been hiding beneath the body’s surface. The weather is quite erratic during the first and second lunar month [February to April], cold at one moment and hot the next, and since most of the elderly suffer from some kind of chronic ailment, the advancing qi of spring may cause those people to feel tired and weak. Chronic ailments flare up easily under these conditions. Also, during the winter months people tend to hover near the smoky stove and eat aged and preserved foods, and these detrimental influences gradually accumulate in the body until they finally come out in Spring. They will make the body feel hot and the head dizzy, the diaphragm will plug up and the mouth turn sticky, the arms will lose strength and the legs and lower back will become weak. All of these are ailments which have accumulated during the winter season. When the body exhibits signs of change and one senses that a disease may be coming on, it would be wrong to simply use moving herbs to straighten out apparent stagnation, because remedies of this nature may actually harm the organs at this time and cause other diseases to crop up. The appropriate way is to use remedies that extinguish wind and harmonize qi, cool the diaphragm and transform smoldering disease. If one chooses to employ dietary measures, one should select foods that have a nature that is neither too hot nor too cold, possibly slightly cooling, and which prevent stagnation by benefiting the smooth transformation of food and drink. In this manner, all of the body processes will flow naturally. If there are no signs of disease, there is no need to take any medicine. Spring is the season of harmony. This is the time to roam through gardens and forests, to sit leisurely in scenic kiosks and take in the tranquil sights of nature. Open up your heart, get rid of all stagnant energy, and thus encourage the budding qi (of birth, life, and renewal) to flow. At this time, it would be against the dynamics of nature to sit around dwelling on things and grow stagnant and depressed. Avoid drinking a lot of alcohol, and show some restraint with those commonly-eaten flour products that have a tendency to harm the spleen and stomach networks. They are truly hard to digest. Old people, especially, should not give in to the temptation of oral gratification and overeat on an empty stomach; otherwise their health will almost certainly suffer. Also, since the weather switches from cold to warm and from warm to cold, it would be a mistake for them to put their padded winter clothing away. Old people typically have weak qi, brittle bones, and a frail body that is highly susceptible to wind cold. Since their surface is invaded easily, they should always have an extra set of clothing ready which can be laid aside when the sun comes out. Decrease layer by layer: don’t get rid of everything all at once! SUMMER The three months of summer are governed by the energy of fire, and are thus in charge of the process of growing and ripening. The heart’s qi is abundant with fire energy, and its associated flavor is bitter. According to the controlling cycle of relationships between the five elements, fire can distress metal; metal energy governs the lung, and the flavor associated with the lung network is pungent. During the summertime, therefore, one should decrease bitter foods and increase pungent flavors to nourish the lung. At the same time, one should use the sound “haaaaa” to course stagnant heart qi, and “shhhhh” to harmonize its flow.

During the days when the hot summer temperatures are at their peak, the abdomen actually has a tendency to get cold. During this period it would be especially unhealthy to succumb to diarrhea, for this disorder drains out precious yin qi. If this should happen, do not use the draining methods of acupuncture or moxibustion, but use diaphoretic herbs instead. It would be best to look ahead and prevent this and other disorders by ingesting some warming substances during the summer solstice, when the wintry forces of yin energy start making their erstwhile hidden comeback at the midnight hour. Also, a decoction that is tonic to the kidneys should be taken at this time. The heart is exuberant during the summer months, but the kidney is in its weakest state. Despite the heat, therefore, it would be unsuitable to fill up one’s belly with frosted snacks, sweetened cold drinks, cold noodles, or cold cereals. These dietary habits easily lead to abdominal cold, which in turn will cause summer diarrhea. By the same token, don’t eat any summer squash, eggplant, uncooked vegetables, or other excessively yin foods, because at this time there is already plenty of yin qi present in the abdomen, and the ingestion of coagulating foods like this may promote the formation of abdominal masses. Old people, in particular, and people with a tendency for heat-phlegm disorders that are due to their cold constitution should abide by these principles and avoid those foods. For the same reason, don’t seek relief from the heat of summer in drafty and busy places. Although you may find temporary coolness under the awning, in the corridor, in the busy outer courtyard, or near a broken window, it is in places like this that noxious winds can most easily invade the body. Seek out the tranquility of a clean and spacious room, or the pure yin nature of an open water kiosk, to achieve a natural state of coolness. Even more important, regulate your breath and put your heart at ease. Keep in mind that holding icy crystals in your heart and stomach will cause heat to flare rather than to diminish. Don’t just assume that hot things are heating and therefore will fuel an already abundant heat. Rather, make it a habit to regularly take warming tonics in pill or powder form during the summer months, in order to assure a smooth functioning of the body’s qi flow. Drink warm liquids and eat warm food; never fill yourself up to the brim, but eat smaller portions in shorter intervals. Drink cinnamon tea, cook with cardamom, use boiled rather than fresh water, and avoid the intake of greasy dishes and fatty animal food. Also, do not sleep under the light of the stars and the moon, because if you camp out in the open you will be prone to wind invasion. Although you may feel an initial rush of exhilaration, the wind will most certainly make its way through your pores. This particular kind of wind invasion is truly the kind that will cause the most distressing symptoms. Somebody, for instance, who ingests cold food and then retires his or her sweaty body for the night in a drafty place will easily contract wind block syndrome resulting in numbness of the hands and feet, inhibited speech, and paralysis of the limbs. Admittedly, not everybody will contract this disorder; one could say that there are people who will become afflicted right away, while others seem hardly affected at all. This is because if a young and strong person does this during a full moon, s/he is supported by nature’s cosmic forces and will most probably remain symptom free. If, however, an old and weak person does this during a new moon when the time related forces of nature are not only unable to compensate for unhealthful behavior, but are putting additional stress on the system, then s/he will most certainly have to suffer the consequences. Since the head is the meeting point of all yang channels, special care should be taken to protect it from the noxious influence of wind. All of the little cracks in your bedroom wall should therefore be mended at this time, so as to prevent injury to the head. Also, selecting a place to do so that is free of draft, comb your head daily 100–200 times during the summer months, taking care not to injure the scalp. This is a natural method to expel wind and brighten the eyes. AUTUMN The three months of autumn are in charge of withering and of decelerating the momentum of growth. The organ network associated with this season is the lung; this organ is abundant with qi, and it has a particular affinity to pungent flavors. When viewing the lung in the context of the other organs, it is important to note that metal can have an overbearing action on wood. Since the organ system associated with wood is the liver, and since this system is particularly affected by sour flavors, one should decrease the intake of pungent flavors in the fall while increasing sour ones, since this will nourish and protect liver qi. If the lung network is in a state of pathological excess, one should use the sound “ssssssss” to drain this excess from the system. During the three months following the beginning of autumn, it is important to keep body and mind in a state of quiet harmony and to not drain one’s energy. Both spring and autumn are seasons of change, and it is particularly then that diseases will surface. Therefore, one should take special care to attend to the tranquil practices of nourishing life during those times, and to conduct both one’s daily life and the treatment of patients in accordance with the predominant qi of the respective season. In autumn, for instance, it would be inappropriate to use dispersing therapies such as emetics or strong diaphoretics, since measures like these cause people to feel drained and create restlessness in the organs. In cases of diarrhea, for example, one should only use acupuncture/moxibustion and some herbal decoctions or powders which assist the patient’s yang qi. People, moreover, who suffer from taxation fatigue or hemorrhoids or wasting-thirst syndrome [diabetes], etc., should avoid eating fried rice, deep fried foods, and beef from cows that died without being slaughtered, as well as raw fish, chicken, pork, wine, fermented foods, salty foods, vinegar, and all things that are sticky and hard to digest. People with those conditions should also avoid raw vegetables, seeds, and fermented soy bean products. The same is true for people suffering from cold syndrome due to wind qi, or people with masses below the ribcage. It is also advisable to engage in the following exercise right after waking up in the morning: close your eyes, click your teeth twenty-one times, swallow your saliva, rub your hands together and let the heat from your palms penetrate into your eyeballs. Rub your hands and cup your eyeballs repeatedly. If one practices this exercise regularly during the three months of autumn, the eyes will become bright and illuminated.

The Neijing states: “Go to bed early and get up with the chickens [at dawn]. This will cause all mental faculties to become calm and peaceful, and moderate the downward blow of autumn. Reel in your mental energy to be in harmony with the condensing quality of autumn qi. Do not disperse your energies, and the lung qi will be clear. This is the way of nourishing life in accordance with the nourishing and constricting qi of the autumnal harvest season. Going against these principles will harm the lung network, eventually causing diarrhea in winter, when things should really be in a state of storage rather than leakage. The qi of Autumn is dry, and so it is advisable to consume some moistening sesame to counteract the dryness. Avoid cold drinks, and do not wear damp and cold clothing close to your skin.” WINTER During the three months of winter, heaven and earth shut down and go into a state of storage. Water turns to ice and earth splits open, while the yang qi of nature stays unperturbed. Go to bed early, therefore, and get up only after the warming rays of the sun have appeared in the morning. Avoid cold and seek out warmth, and be careful not to purge the body’s skin layer [with extreme diaphoretic measures]. Otherwise harm to the kidneys will occur, and consequently the germinating forces of Spring will be impaired. During the following season of Spring, then, offenders may suffer from diseases like muscular atrophy, paralysis, or stroke. In winter, the yang is submerged within. If somebody suffers from an ailment, therefore, it is advisable to dispel existing pathogens from the body with emetic methods. Warm diaphoretics should not be used excessively during this time, since they easily drain out precious yang qi; the heart and diaphragm region, moreover, tend to easily accumulate heat in winter. This is the season to take a combination of tonic materials steeped in wine, or to drink 1–2 small cups of dioscorea wine (shanyao jiu) every day to foster yang qi. At night, do not immediately collapse into bed, but settle down with leisure. Wear padded winter clothes during the coldest time, but add them gradually and not all at once; stop increasing the layers just when you have added enough to not feel cold anymore. Do not warm yourself in front of a roaring fire, since this winter habit may bring about particularly harmful consequences. The hands and feet, namely, have an affinity to the heart network, and should therefore never be toasted over a fire. The fire may otherwise be enticed into the heart and create symptoms of restlessness. For the same reasons, avoid grilling food over an open fire. Keep in mind that just as cooling medicines are not effective against extremely hot disorders, warming medicines do not work for extremely cold diseases—the nature of water is damp, while fire is dry. One should nourish heart qi by decreasing salty foods and increasing bitter ones. This is because the winter months are associated with kidney water which in turn is affected by salty flavors. To prevent water from developing an overbearing influence on fire and thereby plunging the heart into a state of disharmony, it is best to nourish heart qi in a preventive manner. Also, it is best to withdraw to a tightly sealed dwelling in winter, and to make sure that one’s food intake is regulated and the clothing adjusted to the changes in temperature. Do not try to be daring and expose yourself to cold wind, especially if you are old, because Winter poses an increased risk of catching wind cold, which will result in symptoms such as coughing, numbness of the extremities, dizziness, etc. In winter, the earth’s yang qi resides within, while the yin qi is at the surface. Old people, who often tend to exhibit heat symptoms above and cold symptoms below, should, therefore, not take hot baths during this time. At a time when the yang smolders inside, extreme sweating may occur when one is exposed to scorching heat. At an advanced age the bones are brittle and the flesh is frail, and the body is thus easily influenced by stimuli of this sort. Since winter is the time when external disorders are easily contracted, do not go outside at an early hour, or you will be in danger of being assaulted by frost. Drink a small cup of wine in the morning to expel the cold; in the evening take some herbs that eliminate internal heat. In this fashion, you will harmonize your heart qi and prevent pathological heat qi from flushing up. In winter, avoid sex and avoid excessive consumption of baked foods, meat, and flour products (e.g., won-ton dumplings, etc.). October 2010

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THE QI KEEPS THE BLOOD WITHIN THE VESSELS The story of Gui Pi Tang by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

This article is presented in an effort to help practitioners avoid a common error: linking a symptom to a traditional diagnostic category without considering the totality of the available evidence. The discussion, which eventually focuses on the symptom of uterine bleeding, is presented because I have noted that many Western practitioners of Chinese medicine automatically assign cases of uterine bleeding to the diagnostic category of qi failing to keep the blood within the vessels. Even when a woman presents some signs of qi deficiency (e.g., failures in the transformation and transportation of food essence, or weakness and pallor), I believe one should not necessarily assign to this observation the interpretation that this deficiency is the immediate and principal cause of bleeding. Instead, it is valuable to observe the full realm of symptoms and to take into account the practices of modern Chinese physicians and information obtained from the application of Western medical diagnostics.

QI CONTROLS BLOOD The functions of qi are many. One of those reported in all standard modern texts is maintaining the flow of blood within the vessels. This function of qi is deemed a direct outcome of the spleen's activities. I n The Five Organ Networks of Chinese Medicine (Heiner Fruehauf, ITM, 1998), it is stated that: Qi does not only move body essences, but it also holds them in place. The fact that the blood circulates in the vessels without leaving its proper path is particularly attributed to the restraining function of spleen qi. The Classic of Difficulties (Nanjing) simply states: "The spleen contains the blood [Pi tong xue]." This function of the spleen [associated with the earth element or phase] is evocative of the characteristics of earth: just as the rivers and streams are contained by an earthen bed, the body's blood is contained in the channels. The term "contains" has been used in this particular translation, but it is not the only possible meaning. Pi tong xue literally states: spleen [pi] commands, unifies, draws together, controls, rules [tong] blood [xue] . The meaning of the character tong is rendered in various ways (only some of the versions are given here), usually with the help of a second character following it to give it more specific meaning. As presented in the medical classics, without modification, the statement does not inherently imply retaining the blood within vessels, but that can be one of its interpretations. In fact, this interpretation has been relied upon for some time, though probably not during the centuries immediately following the writing of the Neijing (ca. 100 B.C.) and Nanjing (ca. 100 A.D.), when the phrase was first used. Thus, for example, the book Zhong Zang Jing (probably published around 500 A.D.) has a chapter about diseases of the spleen; despite lengthy mention of numerous serious consequences of spleen disorders, including spleen deficiency syndromes, bleeding is not one of them (1). In the 1984 Dictionary of Traditional Chinese Medicine (2) the phrase Pi tong xue is accompanied by this simple explanation: "The spleen has the function of keeping the blood flowing within the vessels. Its impairment usually leads to chronic hemorrhagic diseases." The persistence of bleeding is one of the factors frequently, though not always, mentioned as a signifier of this type of syndrome. The modern interpretation of the ancient words is widely reported in similar ways, as in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (3): "With the assistance of the spleen, blood circulates inside the vessels, and no blood extravasation [leakage from the vessels] occurs, therefore, 'the spleen controls blood [Pi tong xue].'"

APPLYING THE PRINCIPLE The application of the Pi tong xue principle can be understood from analysis of the historical records and from modern medical journal reporting of contemporary practice of traditional Chinese medicine, especially herbal medicine. It will be noted, upon such examination, that one particular type of blood escaping the vessels is treated by tonifying spleen qi and is mentioned in relation to qi failing to hold the blood within the vessels: uterine bleeding. A second type of bleeding, intestinal bleeding, is also treated by tonifying the spleen qi, but that does not appear (in most instances) to be a direct application of the Pi tong xue principle; rather, it is a consequence of the general practice of treating intestinal disorders by tonifying the spleen, whether or not bleeding occurs. The phrase "blood escaping from the vessels" is designated in Chinese by: "xue bu gui jing." Literally, this means that the blood [xue] does not [bu] return [gui] to the vessels [jing; this is the term that is often translated as meridians; originally, meridians and blood vessels were considered the same; see: Jingluo: Drawing a concept]. In other words, the original concept may have been that the blood was not rigidly contained within vessels, but flowed mainly within them, being able to seep out and seep back. Modern medicine recognizes that, in fact, blood constituents do leave the small vessels (capillaries) and return. A Western approach to treating bleeding is to utilize flavonoids (a plant constituent found in many hemostatic herbs) that reduce the leakage from capillaries. The larger vessels, such as arteries and veins that were depicted as jing and luo by the Chinese, normally do not have direct exchange of fluids across the vessel walls. When there is bleeding from other sites, such as the nose, gums, or lungs, and when there is discharge of blood in the urine, or spontaneous appearance of bleeding beneath the skin (purpura), this is most often interpreted as the result of an excess of heat. This heat excess may be associated with a deficiency of yin and/or blood, so that it is depicted as "deficiency heat"; but that term means that the heat, which is an excess, arises from a deficiency. These symptoms of bleeding usually reflect the traditional principle that heat can cause the blood to run wild and escape from the vessels (unable to return, due to its disorderly exit). Many textbooks will list potential causes for bleeding at these other sites, and include a section on qi deficiency as one potential cause (depicting the patient as having characteristic qi and blood deficiency symptoms and signs), but it is not common to find clinical reports of treatments actually based on this principle, unlike the situation for prolonged uterine bleeding. It is stated in The Foundations of Chinese Medicine (4) that:

When spleen qi is deficient, it can not hold the blood in the vessels and bleeding appears from various sources, such as under the skin, in the stools or urine, or from the uterus. This is bleeding of deficient nature, as opposed to the bleeding from heat in the blood which is of an excess nature. When describing bleeding of "deficient nature," the author is not referring to deficiency heat, but rather, spleen qi deficiency only. The Advanced Textbook... states: "If the spleen and stomach are deficient and affected by cold, or if the qi of the middle jiao is insufficient, either bloody stools or uterine bleeding will occur." Under the subsection of the chapter on bleeding, with the heading "deficiency of qi and blood," it says the clinical manifestations are: "bleeding in the nose or gums, or pores in severe cases...." There is something amiss here in these text book descriptions that is mirrored in the Western practice of Chinese medicine, and I propose it is the spontaneous adherence to a simple traditional statement without due consideration of the full spectrum of clinical presentation. The textbook passages reveal two deviations from what is frequently reported clinically: 1. Most practitioners of traditional medicine encounter numerous patients with spleen-qi deficiency who show no signs of "bleeding from various sources," even though the above statements suggest that the weakened spleen qi "can not hold the blood in the vessels" and that "bleeding will occur." Most other books describing traditional theory correspond to the above statements, implying that there will be bleeding if the spleen qi is weak, even though clinical experience shows that bleeding is only sometimes found in persons with spleen qi weakness. 2. Although some experienced Chinese practitioners have applied spleen-qi tonification principles to treating the conditions mentioned in these two texts, including bleeding under the skin, fecal blood, urinary bleeding, nose and gum bleeding, and bleeding through the pores (probably thrombocytopenic purpura in extreme cases), this is not the dominant approach. While patients with deficiency syndrome are certainly treated with tonic herbs, qi tonics are not frequently employed as the focus of therapy when the patients present bleeding of these types.

GUI PI TANG The best known traditional formula for addressing bleeding that is attributed to spleen-qi deficiency is Gui Pi Tang (Ginseng and Longan Combination). In fact, this formula (or a modification of it) is prominently featured in virtually every text that mentions the herbal treatment of bleeding disorders associated with qi deficiency following the principle of Pi tong xue. One of the few exceptions is a passing mention in the Advanced Textbook... of both Gui Pi Tang and Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination). In some books on formula applications, Buzhong Yiqi Tang (Ginseng and Astragalus Combination) is said to treat this type of bleeding. These three formulas all have the following herbs in common: astragalus, ginseng (with codonopsis often used in modern China as a substitute), atractylodes, licorice; this basic combination of four herbs tonifies qi. The three formulas also contain tang-kuei (danggui), but this is a minor ingredient of Gui Pi Tang. Gui Pi Tang (5, 6) Coarsely grind the ingredients, use 12 grams each time, with 5 slices of fresh ginger and a piece of jujube, and decoct. The recipe is for a two week supply, which is a standard course of therapy for this formula. astragalus ginseng atractylodes hoelen licorice (baked) zizyphus tang-kuei polygala saussurea

30 g 15 g 30 g 30 g 8 g 30 g 3 g 3 g 15 g

The origin of Gui Pi Tang is attributed to the book Ji Sheng Fang (Formulas for Saving Lives) by Yan Yonghe (1253 A.D.). Gui means to return or restore; the formula name appears to mean "the decoction [tang] for restoring the vitality of the spleen [pi]." The original formula did not contain tang-kuei or polygala (yuanzhi); these two ingredients were added in small amounts about 300 years later when the formula was listed in a book on treating women's disorders (Jiaozhu Furen Liangfang). The indication of the formula to treat bleeding was first added about 100 years after the formula was written (6). It is not entirely clear, however, whether the actual effect of this formula is to stop the bleeding by helping the qi to control the blood, as would be implied by the Pi tong xue principle, or to compensate for the blood loss that occurs with bleeding, by generating more blood. Modern interpretations of the formula's actions more often focus on generation of blood. The formula is sometimes described in English as "the decoction for invigorating the spleen and nourishing the heart," referring its ability to nourish heart blood rather than on its antihemorrhagic action. Many times, patients categorized with spleen-qi deficiency who have a bleeding disorder (usually uterine bleeding) receive a modified version of this Gui Pi Tang containing herbs with specific hemostatic properties. In those cases, the hemostatic herbs (common additions are gelatin and fulonggan, also called zaoxintu, the oxidized clay from heating stoves) may have the primary function to halt the blood flow, while the rest of the formula nourishes the depleted blood and quickly restores the vitality of the individual. As an example, in the treatment of metrorrhagia in a women with spleen-qi-deficiency diagnosis, Shang Xianmin recommends (7) a slightly modified Gui Pi Tang as the base formula, with the following comments: "For cases with profuse bleeding, add agrimony and gall, and omit tang-kuei; for cases with prolonged dripping bleeding, add typha and sepia bone." Domei Yakazu (8) reported these indications for Gui Pi Tang, relaying the information recorded in Ji Shi Chuan Su: Hemorrhage of the spleen meridian [bleeding associated with weakness of spleen qi]; insomnia with fever and profuse perspiration; a spleen injured by over worry which in turn leads to poor blood transformation and the resultant reckless acts;

amnesia and melancholy; over palpitation [heart stimulation] causing sleeplessness; the pains of an injured spleen and heart that result in a fondness for lying in bed and poor appetite; a spleen injured by over worry that results in fever and insufficiency of blood; pains in the limbs and trunk; irregular bowel movements; menoxemia; fever in the chest or the interior; scrofula which is suppurating and can't be dispersed, outbursted, or astringed. Relaying information from the Nü Shan Fang Gao, a summary of applications of this formula is given: 1. It is a wonderful prescription used mainly to treat a spleen and heart that are exhausted and injured by excessive thinking and worrying, resulting in amnesia and reckless acts or destructive behavior. 2. For those with insufficient blood in the heart, or for intestinal wind and bloody stools; hematemesis, epistaxis, spermatorrhea, white turbid urine, or dripping and painful urination, or for the strong-willed deep thinkers who have withered, yellow complexions, the prescription has a miraculous effect. 3. It is used for women who are peevish and irritable, can't be satisfied by any man, and can't get what they want. This mental condition leads to jealousy and hostility, resulting in weak and depressed spleen and heart with the accompanying symptoms of reckless acts, palpitation, flare-up of weak fire, white dandruff, paralysis in the feet and hands, fondness of lying in bed, poor appetite, thirst, itching and feverish skin heat, body odor, and pain and swelling or leukorrhea in the genital area. 4. It has an excellent effect in treating all diseases of the female genitalia. For bleeding during coitus, add cimicifuga [shengma] and peony [baishao] to the formula [note: shengma raises qi and peony astringes blood, so this combination is intended to prevent the falling of blood]. 5. It has a marvelous effect in curing the weakness in widows and virgins who are sexually frustrated and, as a consequence, suffer depression and anxiety. Summing up his views on the use of Gui Pi Tang, Domei Yakazu states: It is especially effective for those who have been so worn out in body and mind that they have reached an extremity of exhaustion and fatigue. It is also good for those who have had ceaseless superior and inferior [upper and lower body] hemorrhages, rendering an extreme anemia; for those with amnesia and nervous excitement such that the palpitation and anxiety make them unable to sleep.... From all this description, it remains somewhat unclear whether Gui Pi Tang, the formula almost universally selected to treat patients who are diagnosed with the spleen-deficiency-type bleeding, actually stops the bleeding or treats the "extreme anemia" that occurs as the result of chronic bleeding disorders. Clinical trials conducted in recent years have not shed much light on this subject.

UTERINE BLEEDING Uterine bleeding associated with a qi-deficiency syndrome is characterized in Chinese medical texts by prolonged bleeding (sometimes incessant bleeding), of thin, pale blood (indicates blood deficiency), usually accompanied by chilly sensations (affecting the lower abdomen and legs/feet). Although one can simply state that the cause of the prolonged bleeding is due to the qi deficiency, this is merely a restatement of the Pi tong xue dogma that has developed. What were the causes, as we describe them in modern terms, of such bleeding? Unfortunately, we cannot know with any certainty the reason why women in China, particularly in ancient China (when Pi tong xue was established as a principle related to bleeding disorders), experienced unusual uterine bleeding. Certainly, the conditions that the Chinese women were exposed to differed markedly from those of modern Western women. For example, there were different diets with markedly different levels of important nutrients, there were fewer STD's (sexually transmitted diseases), no use of high-dosage hormone therapies (there may have been some limited use of herbal therapies that affected hormones, but that is not likely to be prevalent), and more and earlier childbirths. These factors and others mean that the particular manifestation of diseases and disorders of the uterus would likely be different than today, even when the symptoms are similar. From the modern perspective, we understand that blood escapes the vessels as a result of the following general causes: 1. The vessels are broken either by physical injury or the result of pathological process such as infection, inflammation, or other swelling. 2. The blood fails to clot properly due to lack of platelets (e.g., as occurs with ITP-idiopathic thrombocytopenic purpura, leukemia, or aplastic anemia), vitamin-K (from dietary deficiency or intestinal flora imbalance), or some other clotting factor (as occurs with hemophilia). As to the first category of causation, injuries were understood in traditional China much as they are today, and the bleeding wasn't correlated with failure of spleen-qi function. Infection, inflammation, and swelling often have a parallel to the traditional concept of heat syndrome (e.g., a lung-heat syndrome leading to hemoptysis would correspond, roughly, to a modern description of lung infection with inflammation, with some bleeding at the site of inflamed and damaged vessels). As to the second category, these particular disorders were probably quite rare; the incidence of ITP, leukemia, and hemophilia have apparently increased markedly during recent decades and were unlikely to be common disorders in ancient times. However, bleeding may also occur as the result of various nutritional deficiencies that rarely affect the modern population, except during illness, but may have been a problem from time to time in China's history even in the absence of illness. In a study of spleen-qi deficiency patients (10), comprised mainly of individuals with chronic gastro-intestinal diseases, it was found that the blood status differed from that of normal patients. Not surprisingly, there was a lower hematocrit, indicating a nutritional deficiency condition, but there was also a reduction in blood viscosity. In such cases, if there is a potential for bleeding, such as when there are distended, inflamed, or damaged capillaries, then it is more likely that bleeding will occur. If Gui Pi Tang helps reduce the gastro-intestinal inflammation, thereby rendering food nutrients more absorbable, the blood viscosity may return to normal and bleeding will be reduced. This may reflect the fundamental mechanism whereby qi-deficiency patients with bleeding report less bleeding after qitonifying and blood-nourishing prescriptions are administered.

Uterine bleeding presents some unique considerations. From the modern perspective, there are three major causes: 1. A uterine fibroid increases the surface area of the uterine lining and the amount of tissue shed during menstruation; they also cause the blood vessels to stretch and become exposed, thus weakening their structural integrity. The weakened vessels can then break easily and cause excessive blood flow. Uterine cancer, uterine polyps, and endometriosis with cysts near the uterine wall, are causes of a similar nature, but are much less common. 2. A disorder of the endometrium (usually a thickening, often caused by a sustained excess level of estrogen or deficiency of progesterone) leading to repeated pulling on blood vessels, breaking them open to bleed. Post-partum hemorrhage is sometimes a related problem. 3. A hormonal imbalance leading to mid-cycle bleeding or persistent bleeding. Perimenopausal bleeding disorders are of this nature. It is estimated that about 25% of the cases of abnormal uterine bleeding (in the West) are due to uterine fibroids. These occur with high frequency in women who are about 35-50 years old (fibroids tend to grow substantially during the years just prior to menopause, and then tend to shrink with menopause), affecting about 20% of all women. These abdominal masses are interpreted from the traditional Chinese viewpoint as a blood-stasis syndrome (usually secondary to a qi-stagnation syndrome). There is also a traditional principle that bleeding occurs at sites of blood stasis because the static blood impairs the normal flow of blood and therefore causes it to exit from the vessels under duress. This traditional principle is reasonably close to our modern understanding of fibroids. The other 75% of cases of abnormal bleeding are related to hormonal imbalances. The thickening of the endometrium is treated in Western medical practice by removing it (d & c procedure) and then administering hormonal pills; this condition would usually be treated by traditional Chinese physicians using blood-vitalizing herbs (with some hemostatics to address the immediate problem of bleeding) followed by a "female formula," that has the effect of regulating menstruation. Modern physicians treat the hormonal imbalance that leads directly to bleeding by using hormone pills (e.g., birth control pills) or by other measures, in some cases, by hysterectomy in women who are approaching menopause. From the Chinese perspective, the treatment would vary depending upon the constitution of the patient and manifestation of the bleeding. Only in cases of weakness and pallor (indicating spleen-qi deficiency) would the imbalance likely be treated with qi-nourishing herbs: specifically, with Gui Pi Tang (weakness and pallor could be the result of the excessive bleeding, rather than the cause). For example, Gui Pi Tang is indicated for the treatment of "preceded menstrual cycle with pale blood," (pale blood indicates a qi and blood deficiency syndrome; darker red blood would suggest a heat syndrome as cause of the bleeding, a condition of short menstrual cycling that corresponds to hormonal imbalance.) The modern Chinese medical practice of utilizing Gui Pi Tang more frequently for treatment of uterine bleeding than other types of bleeding is illustrated by the descriptions in some recent texts. For example, applications of Gui Pi Tang in the book Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (5) are: "...for poor memory due to heart and spleen deficiency, anxiety impairing the heart and spleen, and deficiency of qi and blood, manifesting palpitation, insomnia, night sweating, decreased intake of food, fatigue, sallow complexion, uterine bleeding or menorrhagia, whitish tongue, with thin white coating and thready weak pulse." In an article on spleen disorders by Zhang Hai Feng (10), the section on "tonifying spleen and holding blood in the vessels," states that "It generally occurs in gynecological hemorrhages." Gui Pi Tang is mentioned as the formula of choice. Of course, not all of the Chinese literature focuses on uterine bleeding; this is only the dominant clinical application for the formula (or its modification) in relation to bleeding. In A Comprehensive Guide to Chinese Herbal Medicine (11), the section on bleeding problems lists numerous causes from the traditional viewpoint, as well as the associated therapies. With regard to spleen-qi deficiency, it specifically lists "spitting up of dark or reddish blood" [indicating bleeding in the stomach, hematemesis; bright red blood would indicates bleeding from the lungs] and "melena" [dark feces, usually caused by having bleeding in the intestines]. These are the only bleeding conditions mentioned, implicating bleeding in the gastro-intestinal tract. This focus may have been the result of associating stomach/spleen deficiency, in modern terms, primarily with the gastro-intestinal tract. New Practical Syndrome Differentiation of TCM (12) mentions, under failure of qi in controlling blood, manifestations of "hematemesis, bloody stool, subcutaneous ecchymosis, and metrorrhagia [uterine bleeding that persists apart from the normal menstrual bleeding]." In actual practice, hematemesis, mentioned in both texts, is almost never treated by tonifying qi as the principle of therapy. Before choosing failure of spleen to control the blood as the mechanism involved in a patient experiencing uterine bleeding, one must consider the other causes of uterine bleeding, most notably fibroids, and the appropriate treatment. Fibroids can certainly occur in women with qi deficiency (chronic qi deficiency is one of the traditionally-recognized ways in which pathological processes are able to arise). However, according to Chinese clinical reports, fibroids and resulting uterine bleeding are rarely, if ever, treated by focusing on qi tonification therapy (at least by herbal prescription). In a review I conducted of the Chinese medical literature on clinical experience treating fibroids and uterine bleeding (Treatment of uterine myoma with Chinese herbs ), I found that qi-tonification therapies were briefly mentioned but almost never utilized, with the exception that after the uterine bleeding was controlled via other methods, Gui Pi Wan (the pill form of Gui Pi Tang) was sometimes recommended as a follow-up. A case presentation was made by Shao Nian-fang in his book Treatment of Knotty Diseases... (13), after describing the main categories of concern for functional uterine bleeding, of which deficiency of spleen and kidney was the last one mentioned. A 44-yearold woman presented with menstruation twice per month, each time lasting ten days, with a large amount of blood of light color and no evidence of pathological conditions such as uterine tumors. Today, we would probably describe this as a likely case of perimenopausal menstrual irregularity due to hormonal changes, though this possibility was not mentioned by the author. The woman's constitutional condition was that of qi and blood weakness. The physician's diagnosis was "over strain and over fatigue with impairment of spleen qi, inability to govern the blood, and the debility of the chong a n d re n channels (conception and governor vessels). The formula administered was a modification of Gui Pi Tang, with gelatin (donkey hide extract), cardamon, barley sprout, and magnetite added, and with zizyphus, polygala, and licorice deleted. She took this formula as a decoction for three weeks, and did not have any uterine bleeding during this time. She then took Gui Pi Wan as follow-up for one month (about 6 grams each time, three times daily). The result, according to the author of the report, was that she had normal menstruation for the next six months. Some questions arise: Did the formula restore the ability of qi to control blood? Did the formula alter the woman's hormones to delay a case of premature menopause or prolonged perimenopausal menstrual irregularity? Is there a difference? These questions may be considered by the Western practitioner in defining their own utilization of and reliance upon different models for interpreting symptoms, determining therapies, and

evaluating results of treatment.

CONCLUSION The situation outlined in this article represents one of several cases where modern diagnosis (e.g., gynecological examination, something not done in traditional Chinese medicine until this century) might help to offer guidance in ultimately reaching the correct traditional diagnosis and resulting treatment plan. While a highly skilled practitioner of traditional medicine might be able to make the correct diagnosis without the assistance of modern diagnostic techniques, the more limited training of traditional practitioners in the West makes it imperative that they avoid jumping to conclusions, which seem to be reinforced in several textbooks, based on common phrases (e.g., qi keeps the blood in the vessels). Modern diagnostics may help us get past such natural tendencies of the human mind that lead to erroneous conclusions. I am not proposing that spleen-qi deficiency is never the cause of uterine bleeding (or other bleeding disorder), rather: 1. The finding of spleen-qi deficiency in a patient with bleeding disorder does not necessarily mean that the bleeding disorder is directly caused by that deficiency (to be simply corrected by tonifying spleen qi); and 2. A bleeding disorder, especially chronic uterine bleeding in women past the age of 35, does not automatically qualify as a sign that the patient suffers from spleen-qi deficiency. For the past 650 years Gui Pi Tang has been repeatedly suggested as the remedy for bleeding, especially uterine bleeding, in persons with qi deficiency syndrome. This persistent response suggests that relatively little effort has been expended by Chinese physicians in further analyzing the Pi tong xue principle and the therapeutic methods of addressing it in light of the large number of spleen-qi-invigorating herbs that are available. Modern analyses of the traditionally-defined spleen system have largely focused on its relevance to the digestive system, metabolism, autonomic nervous system, blood constituents, and immune functions (9, 14). Modern analyses of the pharmacological properties and applications of qi-tonic herbs have focused on these same areas (15), without investigating their potential role in treating bleeding disorders.

REFERENCES 1. Yang Shouzhong, Zhong Zang Jing: Master Hua's Classic of the Central Viscera, 1993 Blue Poppy Press, Boulder, CO. 2. Xie Zhufan and Huang Xiokai (eds.), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong. 3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (4 vol.) 1995-6 New World Press, Beijing. 4. Maciocia G, The Foundations of Chinese Medicine, 1989, Churchill Livingstone, London. 5. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. 6. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. 7. Shang Xianmin, et al., Practical Traditional Chinese Medicine and Pharmacology: Clinical Experiences, 1990 New World Press, Beijing. 8. Domei Yakazu, The application of Gui Pi Tang, Bulletin of the Oriental Healing Arts Institute of U.S.A., 1980; 5(3): 21-28. 9. Kuang Yuanliang, et al., A study on hemorrheology in patients with spleen qi deficiency, Journal of Traditional Chinese Medicine, 1988; 8(4): 235-238. 10. Zhang Hai Feng, Spleen and stomach in traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine; 1983; (3): 43-81. 11. Ze-lin Chen and Mei-fang Chen, A Comprehensive Guide to Chinese Herbal Medicine, 1992 Oriental Healing Arts Institute, Long Beach, CA. 12. Wang Qi and Dong Zhi Lin, New Practical Syndrome Differentiation of T.C.M., 1992 China Ocean Press, Beijing. 13. Shao Nian-fang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine, 1990 Shandong Science and Technology Press, Jinan. 14. Wang Jianhua, Modern investigation on the nature of pi (spleen) in traditional Chinese medicine, in Zhou Jinhuang and Liu Ganzhong (eds.), Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing. 15. Dong Zhilin and Yu Shufang, Modern Study and Application of Materia Medica, 1990 China Ocean Press, Beijing.

September 1998

AN INTRODUCTION TO CHINESE HERBS by Subhuti Dharmananda, Ph.D., Institute for Traditional Medicine, Portland, Oregon

The herbal tradition of China is valued scientifically, as well as being a fascinating and popular tradition. Scientists working in China and Japan during the past four decades have demonstrated that the herb materials contain active components that can explain many of their claimed actions. Modern drugs have been developed from the herbs, such as treatments for asthma and hay fever from Chinese ephedra, hepatitis remedies from schizandra fruits and licorice roots, and a number of anticancer agents from trees and shrubs. Several popular formulations produced in China, called "patent medicines," are relied upon daily by millions of Chinese (in China and abroad), such as the Bupleurum Sedative Pills and Women's Precious Pills that invigorate the energy, nourish the blood, calm tension, and regulate menstruation, and Yin Chiao Jie Du Pian, which is a reliable treatment for the early stages of common cold, sore throat, and influenza. More than three hundred herbs that are commonly used today have a history of use that goes back at least 2,000 years. Over that time, a vast amount of experience has been gained that has gone towards perfecting their clinical applications. According to Chinese clinical studies, these herbs, and others that have been added to the list of useful items over the centuries, can greatly increase the effectiveness of modern drug treatments, reduce their side-effects, and sometimes replace them completely. In China, the two most common methods of applying herb therapies are to make a decoction (a strong tea that must be simmered for about an hour or more) and to make large honey-bound pills. Both of these forms meet with considerable resistance in Western countries. The teas are deemed too time-consuming, smelly, and awful-tasting to justify their use, and the honey pills (boluses) are sticky, difficult to chew, and bad tasting. Thus, modern forms that are more acceptable have been developed for most applications. The two popular forms to replace the standard Chinese preparations are extract powders (or granules) and smooth, easy-to-swallow tablets or capsules. The extracts are made by producing a large batch of tea and then removing the water and producing a powder or tiny pellets; the resulting material is swallowed down with some water or mixed with hot water to make a tea. Tablets and capsules contain either powdered herbs or dried extracts or a combination of the two. Despite the convenience, one must take a substantial quantity of these prepared forms (compared to the amount of drugs one takes). For example, doses of the dried extracts range from 1-2 teaspoons each time, two to three times per day, and the tablets or capsules range from about 3-8 units each time, two to three times per day. The herb materials used in all these preparations are gathered from wild supplies or cultivated, usually in China (some come from India, the Mid-East, or elsewhere). There are an estimated 6,000 species in use, including nearly 1,000 materials derived from animal sources and over 100 minerals, all of them categorized under the general heading "herbs." Herbs are processed in various ways, such as cleaning, soaking, slicing, and drying, according to the methods that have been reported to be most useful. These materials are then combined in a formulation; the ingredients and amounts of each item depend on the nature of the condition to be treated. In some cases, a practitioner of Chinese medicine will design a specific formulation for an individual patient, which might be changed frequently over a course of treatment. In other cases, one or more formulas already prepared for ingestion without modification are selected for use. The outcome is monitored, and the determination of whether to continue the current formula, change to another, or discontinue use is made on the basis of actual versus desired outcomes and the obvious or subtle effects of using the herbs. As a general rule, acute ailments (those that arise suddenly and are to be treated right away) are treated for a period of 1-30 days. If an outbreak of influenza or eruption of herpes virus is caught early enough, a one or two day treatment will prevent further development of the disease. In the case of acute active hepatitis causing jaundice, a treatment of 15-30 days may be necessary. For chronic diseases (those that have persisted for several months or years), the treatment time is often dependent on the dosage used and the ability of the individual to undertake all necessary steps to overcome the disease (perhaps changing diet, lowering stress, and increasing exercise). When a high-dosage therapy is applied, most chronic ailments can come under control (and some are cured) by a treatment of about three months duration. If the daily dosage is lowered (because of inability to take the higher doses), the treatment time increases-perhaps to 612 months. Examples of chronic ailments are autoimmune disorders and degenerative diseases associated with aging. In some cases, herbs are taken daily, for an indefinite period, just as some drugs are taken daily. This is typically the situation when there are genetic disorders or permanent damage that cannot be entirely reversed, problems of aging, and ailments that have been left for too long without effective treatment. The main reason that more Westerners are turning to Chinese herbs rather than local herbs is because of the vast scope of experience in using the Chinese materials. In every province of China, there are large schools of traditional Chinese medicine, research institutes, and teaching hospitals, where thousands of practitioners each year gain training in the use of herbs. The written heritage of Chinese medicine is quite rich. Ancient books are retained, with increasing numbers of commentaries. New books are written by practitioners who have had several decades of personal experience or by compilers who scan the vast diverse modern literature and arrange the results of clinical trials into neat categories. American practitioners are usually trained at any one of about 45 colleges in the U.S., with a three- or four-year series of courses that include basic Oriental medical theory, acupuncture, and herb prescribing. Certification is offered at the national level and licensing or registration is offered now by most states. Many doctors from China have come to the U.S. and currently offer professional services throughout the country, but most often in the larger cities. Continuing education is provided through numerous symposia offered by the colleges and professional organizations devoted to Oriental medicine. Often, these meetings focus on the treatment of specific diseases or training in the use of a specialized acupuncture technique or valuable herb formula. Chinese herbs are provided in the U.S. as food supplements, not as drugs. Thus, they are not strictly regulated by the FDA except for monitoring the cleanliness of manufacturing facilities (for those materials made in the U.S.; for the imported items, FDA monitors only the listing of ingredients to help ensure no toxic herbs are being used). Random testing of crude herb materials and herb products made in the U.S. indicate that they are free of harmful bacteria and chemical contaminants. Imported products must be used with some caution, as some of them are problematic, yet get past the investigators. There are a few patent remedies that are labeled with only herb

ingredients, but also contain several Western drugs. Some patents from China contain only Western drugs (and say so on the box, in Chinese), but purchasers may be unaware of this because they are told only that this is an effective remedy that came from China. Thus, imported Chinese herb products should be taken solely on the basis of a prescription from a trained health professional. Adverse responses to Chinese herbs are monitored at the Institute for Traditional Medicine through its contacts with numerous practitioners around the country and subscriptions to technical journals published in China and Japan. Negative interactions with Western drugs have not been noted for any of the common herb materials when used in the normal dosage range. A few people experience allergic reaction to individual herbs, a problem that often cannot be predicted in advance since these are idiosyncratic responses. A more common reaction is a gastro-intestinal response, which might include constipation or diarrhea, nausea or bloating. Such reactions may occur if the individual has poor digestive functions, or if the herbal formula is not quite right for the needs of the individual. Taking the herbs at a different time in relation to meals may be helpful in resolving some of the gastro-intestinal reactions. In a few cases, use of Chinese herb formulas may cause dizziness, headache, agitation, sleepiness, hungry feeling, lowered appetite, sensation of heat or cold, or other sensory reactions. If such responses persist after about three days of using the herbs, it may be necessary to change formulas. Successful treatments based on the application of Chinese herbs are also monitored at the Institute. However, most American practitioners find themselves too busy (because of the small number of practitioners in this country) to prepare detailed reports of their successful cases; thus, it is necessary to rely primarily on the large-scale clinical trials conducted in China for the purpose of learning about the success rates. Such clinical reports, published in the Chinese language, are abstracted and published in English by the Chinese University of Hong Kong. These reports, and other translated materials, are compiled by the Institute and sent to practitioners in a variety of formats, including a technical series called Clinical Tips. Trials supported by the Institute for Traditional Medicine in the U.S. that have generated successful outcomes include treatment of HIV/AIDS, multiple sclerosis, and endometriosis. Following are some examples of common ingredients of Chinese formulas that have become widely used because of their reliable action, the quick results usually experienced, and the diversity of therapeutic activities that can be obtained from each. These reviews serve as examples of what Chinese doctors must know. It will be noted that the dosage range is often very large, reflecting various uses and different methods of application.

FIFTEEN COMMONLY-USED CHINESE HERBS Astragalus (huangqi) The long tap roots of astragalus are, today, the most commonly used herb material in China. Astragalus normalizes immune responses (used for immune deficiency, allergies, and autoimmunity), benefits digestive functions, and treats disorders of the skin from burns to carbuncles. Astragalus is used as a promoter of the functions of several other herbs, such as salvia and tang-kuei (mentioned below). It is used in the treatment of AIDS and hepatitis, for chronic colitis, senility, and cardiovascular diseases. Cancer patients who take this herb can often avoid the white blood cell deficiencies (leukopenia) that occur with chemotherapy. The root is rich in polysaccharides and flavonoids that produce the beneficial effects. Astragalus may be used by itself, usually as a liquid extract, or in combination with other herbs in the form of teas, pills, or tablets. Dosage is from 1-60 grams per day, depending on the application and form. Caution: some individuals may experience flatulence and abdominal bloating from use of astragalus. Atractylodes (baizhu) The rhizomes of atractylodes are considered very important to the treatment of digestive disorders and problems of moisture accumulation. The herb helps move moisture (and nutrients) from the digestive tract to the blood, reducing problems of diarrhea, gas, and bloating, and helps move moisture from the body tissues to the bladder for elimination, alleviating edema. The herb is frequently included in tonic prescriptions, and the herb is rarely used by itself. Dosage is from 200 milligrams in capsules and tablets to 15 grams per day in the form of decoction. Caution: persons suffering from a hot and dry condition may experience worsening of those symptoms if large amounts of atractylodes are used. Bupleurum (chaihu) The thin roots of bupleurum are one of the most frequently used herbs in the Japanese practice of Oriental medicine. Doctors in Japan have found it useful in the treatment of liver diseases, skin ailments, arthritis, menopausal syndrome, withdrawal from corticosteroid use, nephritis, stress-induced ulcers, and mental disorders. The roots are rich in saponins that reduce inflammation and regulate hormone levels. The herb is not used by itself, but rather in formulas with about four to twelve ingredients, made as teas, pills, or tablets. Dosage ranges from a few hundred milligrams of powder to about 15 grams in tea per day. Caution: some individuals may experience dizziness or headaches from use of bupleurum. Cinnamon (guizhi and rougi) The twigs (guizhi) and bark (rougi) of this large tropical tree are said to warm the body, invigorate the circulation, and harmonize the energy of the upper and lower body. Modern studies demonstrate that cinnamon reduces allergy reactions. Traditionally, cinnamon twig is used when the peripheral circulation is poor and cinnamon bark is used when the entire body is cold. If the upper body is warm and the lower body is cold, then cinnamon will correct the imbalance. Cinnamon is usually cooked together with other herbs to make a warming tea, or powdered with other herbs to make a pill or tablet that regulates circulation of blood. Dosage is 0.3-3 grams of bark and up to 9 grams of twig per day. Caution: large amounts of cinnamon are irritating to the liver and should not be used by those with inflammatory liver disorders. Coptis (huanglian) This rhizome (underground stem) is one of the most bitter herbs used in Chinese medicine. It is rich in alkaloids that inhibit infections and calm nervous agitation; it is usually combined with other bitter-tasting herbs, such as phellodendron, scute, and gardenia, to promote these actions. Examples of its many uses include treatment of skin diseases, intestinal infections, hypertension, and insomnia. Coptis is a close relative of an extremely bitter and very useful American herb, goldenseal. Because of its taste, coptis is most often used in the form of pills or tablets. Typical dosage is from a few hundred milligrams of powder to 3 grams in decoction per day. Caution: regular use of coptis in large dosage may cause diarrhea. Ginger (jiang)

The fibrous rhizome of this herb is highly spicy and said to benefit digestion, neutralize poisons in food, ventilate the lungs, and warm the circulation to the limbs. Today, ginger is commonly used as a spice in cooking; as a medicine it has been shown helpful in counteracting nausea from various causes including morning sickness, motion sickness, and food contamination. Many herbalists use ginger in the treatment of cough (it acts as an expectorant) and common cold. Ginger is used in making teas and the powder is encapsulated for easy consumption. Typical dosage is from a few milligrams used as an assistant in herb formulas to about 3 grams per day in making decoctions. Instant tea granules (sugar or honey base) are available. Caution: persons who suffer from dryness-dry cough, thirst, dry constipation, etc.-may find that ginger worsens the condition. Ginseng (renshen) The root has long been cherished as a disease-preventive and a life preserver. It calms the spirit, nourishes the viscera, and helps one gain wisdom. Modern applications include normalizing blood pressure, regulating blood sugar, resisting fatigue, increasing oxygen utilization, and enhancing immune functions. Traditionally, the root is cooked in a double boiler to make a tea, used either alone or with several other herbs. Today, teas can be made quickly from carefully prepared extracts in liquid or dry form; ginseng powder is made into tablets or encapsulated, and ginseng formulas are available in numerous forms for easy consumption. Typical dosage is 0.5-3.0 grams. Higher doses may be used over the short term for specific therapeutic actions: in China 30 grams is recommended to treat shock (sudden hypotension). Caution: excessive consumption of ginseng can lead to nervousness and may produce hormonal imbalance in women. Hoelen (fuling) This herb is a large fungus that grows on pine roots. It is used to alleviate irritation of the gastro-intestinal system and, like atractylodes, it helps transport moisture out of the digestive system into the blood stream and from the various body tissues to the bladder. When bits of the pine root are included in the herb material it is called fushen; the combination of the fungus and pine produces a mild sedative action. This herb, because it is quite mild, is mostly used in making decoctions or dried decoctions, with a dosage equivalent of about 1015 grams per day. The herb is non-toxic and rarely causes any adverse effects. Licorice (gancao) The roots have an extremely sweet taste (but are also bitter) and are said to neutralize toxins, relieve inflammation, and enhance digestion. In Europe, a drug has been made from licorice extract that heals gastric ulcers. Licorice is used by Chinese doctors in the treatment of hepatitis, sore throat, muscle spasms, and, when baked with honey, for treatment hyperthyroidism and heart valve diseases. Traditionally, licorice is thought to enhance the effectiveness of herb formulas and is used to moderate the flavor of herb teas; as a result, it is found in about one-third of all Chinese herb prescriptions. Licorice powder is encapsulated for easy consumption or mixed with other herbs and tableted. Dosage is from very small amounts (a few hundred milligrams) to 15 grams per day in decoction used to treat viral hepatitis. Caution: excessive consumption of licorice over an extended period to time can cause sodium/potassium imbalance with symptoms of tachycardia and/or edema. Ma-huang (mahuang) The stem-like leaves when taken in a dose of several grams stimulate perspiration, open the breathing passages, and invigorate the central nervous system energy. It has been shown that most of these effects are due to two alkaloid components, ephedrine and pseudoephedrine, both of them having been made into modern drugs (for asthma and sinus congestion, respectively). In addition, the stimulating action of ma-huang has led to its use as a metabolic enhancer (burns calories more quickly) for those who are trying to lose weight. Ma-huang also has anti-inflammatory actions useful in treating some cases of arthralgia and myalgia. Ma-huang can be made into a tea, or used in extract form; powdered ma-huang is rarely used. Dosage range is 1-9 grams/day, usually in two or three divided doses. Caution: the stimulant effect of ma-huang can cause insomnia and agitation; persons with very high blood pressure may find this symptom worsened by use of ma-huang. Peony (baishao and chihshao) The root of this common flower is used to regulate the blood. It relaxes the blood vessels, reduces platelet sticking, nourishes the blood, and promotes circulation to the skin and extremities. The root of both wild and cultivated peonies are used. The wild peony yields "red peony" (chihshao) a fibrous root that is especially used for stimulating blood circulation. The cultivated peony yields "white peony" (baishao) a dense root that nourishes the blood. Peony is often combined with tang-kuei, licorice, or other herbs mentioned here to enhance or control their effects. The dosage range is from 0.5-15 grams per day. Peony rarely causes any adverse reactions. Rehmannia (dihuang) The root of this herb is a dark, moist herb that is extensively used to nourish the blood and the hormonal system. It is frequently used in the treatment of problems of aging, because of its ability to restore the levels of several declining hormones. There are two forms of the herb that are currently used: one, designated shengdihuang or raw rehmannia, is given to reduce inflammation and is included in many formulas for autoimmune disorders; the other is designated shoudihuang or cooked rehmannia, and is used as a nourishing tonic. Often, the two forms are combined together in equal proportions to address inflammatory problems that are related to the lack of adequate levels of regulating hormones. The herb is mainly used in making decoctions or dried decoctions, with a dosage of 10-30 grams per day. Caution: persons with weak digestion and tendency to experience loose stool or diarrhea may find that this herb, especially cooked rehmannia, worsens those symptoms. Rhubarb (dahuang) This large root was one of the first herbs that the Western world imported from China. It serves as a very reliable laxative, and also has other benefits: enhancing appetite when taken before meals in small amounts, promoting blood circulation and relieving pain in cases of injury or inflammation, and inhibiting intestinal infections. Rhubarb also reduces autoimmune reactions. The impact of rhubarb is influenced by how it is prepared; if it is cooked for a long period of time, the laxative actions are reduced but other actions are retained. Typical dosage is 0.5-3 grams per day. Caution: rhubarb, alone or in formulas, should not be used by those with irritable bowel conditions, as it may cause cramping and diarrhea. Salvia (danshen) The deep red roots of this Chinese sage plant have become an important herb during the past two decades even though it was used for centuries before that. It is applied in almost all cases where the body tissues have been damaged by disease or injury; thus, it is given for post-stroke syndrome, traumatic injury, chronic inflammation and/or infection, and degenerative diseases. It is best known for its ability

to promote circulation in the capillary beds-the so-called microcirculation system. In addition, salvia lowers blood pressure, helps reduce cholesterol, and enhances function of the liver. It may be consumed alone or with other herbs, in wines, teas, pills, or tablets; dosage is 120 grams per day. Salvia rarely causes any adverse reactions. Tang-kuei (danggui) The root has been long respected as a blood-nourishing agent. It has its highest rate of use among women because tang-kuei will help to regulate uterine blood flow and contraction, but when employed in complex formulas it can be used by both men and women to nourish the blood, moisten the intestines, improve the circulation, calm tension, and relieve pain. Tang-kuei is frequently said to have estrogenic effects, but this is not a valid claim. The recommended dosage for tang-kuei is 0.5-9 grams per day. Tang-kuei may be made as a tea or cooked with chicken to make soup (the taste is quite strong), but it is often used today as a powder, encapsulated or made into tablets, alone or with other herbs. Caution: some individuals find that tang-kuei causes nausea or loose stool.

EXAMPLES OF HERB COMBINING TO MAKE AN EFFECTIVE TREATMENT An ancient formula prescribed for the initial stage of an infectious disease is Cinnamon Combination. It includes cinnamon, peony, licorice, and ginger. It is said that the cinnamon (twig) and peony coordinate the circulation at the surface of the body (where disease is believed to enter) and relaxes tense muscles. Ginger and licorice improve the digestive functions and improve the body's healing energy. An ancient formula used to treat chronic illness is Ginseng and Tang-kuei Ten Combination. It includes astragalus, ginseng, atractylodes, hoelen, licorice, cinnamon, tang-kuei, peony, and rehmannia. Astragalus, ginseng, atractylodes, hoelen, and licorice promote digestive functions, increase the energy, nourish the internal organs, and enhance weakened immune responses. Cinnamon (bark) warms up the weakened metabolism. Tang-kuei, peony, and rehmannia nourish the blood. Another ancient formula, used for a variety of diseases and function disorders, is Minor Bupleurum Combination. It includes bupleurum, ginseng, ginger, hoelen, and licorice. Bupleurum harmonizes the circulation between the internal organs and the body surface, it alleviates stress in the chest and abdomen, and it reduces inflammation. As indicated above, ginseng, ginger, hoelen, and licorice benefit the digestive processes and increase energy. All of these formulas are widely used today, often by making some slight modifications to address the particular needs of the individual or the characteristics of the disease. For example, Cinnamon Combination (with appropriate modifications) has been used in Chinese clinical trials for treatment of frostbite, pernicious vomiting of pregnancy, and appendicitis. Ginseng and Tang-kuei Ten Combination has been applied to treatment of side-effects of cancer therapy and for prevention of cancer recurrence after successful treatment. Minor Bupleurum Combination is one of the formulas frequently given in cases of chronic hepatitis B infection, and it is also used for inflammation of the stomach and pancreas.

November 1996

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ON THE BEST TIME OF DAY TO TAKE HERBAL REMEDIES by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

GENERAL CONSIDERATIONS OF TIME AND TREATMENT The role of time in relation to health and disease has been a major concern of traditional Chinese culture. It has been incorporated into specific rules for treatment, but these rules are not often followed, especially in the modern era. Still, it is of interest to learn the traditional concepts and the procedures that are still recommended today. The influences of time of day on the human body are encompassed in the traditional subdivision of one day into 12 units of two hours each, with each unit associated with an internal organ system (zang and fu) . Based on this concept, it has been proposed that acupuncture therapy for a specific organ system (or associated meridian) would produce optimal results if given at the time indicated. In most cases, this rule isn't followed because it is too inconvenient. The basic concept can be utilized, nonetheless, at all times of day since there are points on each meridian that affect the other zang, and one can rely on the five element relationships (nurturing and controlling) to access elements whose time, so to speak, has not come. Modern science has revealed circadian (daily) cycles in hormone levels and numerous other physiological aspects, suggesting that the body will respond differently to herbs (or modern drugs) at one time of day versus another. A few studies with herbs provide some support for the notion that time of administration can alter the effect. For women, the menstrual cycle clearly illustrates that there are physiological changes that follow the lunar month. In the realm of herbal medicine, it has been proposed that there be corresponding cyclic treatments for women's menstrual disorders, with different formulas given prior to menstruation, after menstruation, during ovulation, and, either no formula or yet another formula, during menstruation. Such adjustments according to time in the cycle are usually applied only in cases of disorders that are associated with menstruation, including infertility, irregular menstrual cycle, or ailments that arise during a specific cycle phase (e.g., premenstrual tension, menstrual headaches, post-menstrual weakness). Nonetheless, the inconvenience of adjusting formulas two to four times per month often leads to recommendations for simpler treatments, with only one main formula throughout the cycle or for a portion of the cycle. The relationship between seasons and the initiation and development of disease is clearly laid out in the Nei Jing. The terminology associated with this way of thinking still persists, as in the application of the term "summer heat" to certain syndromes. This seasonal basis of change has been incorporated into the five elements system, especially via the idea of yunxing, or cyclic elements (phases). In evaluating the pulses for acupuncture treatment, seasonal influences are to be taken into account. When prescribing herbs for chronic diseases or for prevention of disease, the seasonal influence on the body is also deemed an important consideration. Still, it is more difficult to rationally incorporate such concerns in an age when indoor heating and cooling, artificial lighting, imported foods, and extensive travel alter the environmental experience compared to what nature usually presents to persons living in a more primitive situation (as found in China when the theoretical framework for seasonal influences and medical responses was developed). Beyond these levels of timing (days, months, seasons), periods of seven years (for women) or eight years (for men) have been described in the Nei Jing for human developmental cycles having to do with maturation and aging. A cycle of twelve years (that is somewhat comparable in its conception to the monthly zodiac of Western astrologers), enters the mythology of Chinese culture and persists through modern times. These long cycles are not as frequently taken into account in standard medical practice, but they do influence some of the shamanic practices (especially rituals) that have been an important part of Chinese healing.

TIME OF DAY TO TAKE HERBS There are a few descriptions in the Chinese medical literature about the best time to take herbal remedies. These generally have to do with timing in relation to meals and the differences between morning and evening treatments.

Rule 1: Light herbs after meals, heavy herbs before meals. In Introductory Readings in Classical Chinese Medicine (Unschuld, 1988) the following is translated from the Shou Shi Bao Yuan (Achieving Longevity by Guarding the Source; 1616 AD): When an illness is located in the upper part of the body, small pills are suitable. One should always take such pills after meals. In some cases, one crushes these pills with one's teeth into powders, in this way regulating a health problem by means of light drugs....When an illness is located in the lower part of the body, large pills are suitable. One should always take such pills before the meals. In some cases the fact that one takes one's meal after the drugs has the effect that the food presses the drugs downwards in the body. This statement follows the idea that herbs of light nature rise up and treat symptoms in the upper body-they are taken after meals so that they are reflected upward by the mass of food in the center. By lightness, it is seen that one speaks literally: tiny pills or herbs crushed to powder are deemed lighter than whole large pills. In other texts, it is indicated that herbs that have low density (flowers, leaves, stems, and branches) are similarly regarded as likely to float upward. In contrast, heavy materials sink downward and they are taken before meals so that they can sink down unimpeded by a mass of food and can even be pushed down by the food. Again, other texts refer to the dense materials, such as roots, rhizomes, and minerals, as acting on the lower body.

Rule 2: Tonics in the morning, quick-acting herbs in the evening. The statement in the Shou Shi Bao Yuan continues: "Prescriptions formulated to supplement are to be swallowed early in the morning before one has said a word; and drugs that are supposed to act quickly should be taken when one has undressed and goes to sleep." Tonics (supplementing agents that do not invoke movement of the humors) are generally thought to be slow-acting and have a heavier nature than those herbs that are supposed to act quickly. Dr. Hong-yen Hsu, speaking of tonics, simply says that "they must be taken on an empty stomach," referring especially to the time before any meals have been eaten. Quick acting drugs, if taken before bedtime, are consumed after all of the day's meals.

In Forgotten Traditions of Ancient Chinese Medicine (Unschuld, 1990), Xu Dachun is quoted from his work Yixue Yuan Liu Lun (1757): "Decoctions move fast, their substance is light; their strength quickly subsides and does not stay...." This statement contrasts decoctions with the other standard preparations-pills, powders, and pastes-which are deemed heavier and longer lasting. In accordance with the previous statements, such decoctions would be taken after meals (because of their lightness) and toward the end of the day (because of their quick action).

Rule 3: Penetrating and resolving herbs should not be taken with foods. In another section of his book, Xu Dachun says: By treating a patient with penetrating drugs, one intends to take advantage of their ability to transform accumulations and cause them to move downwards. Such drugs must be taken on an empty stomach, and all at once, so that their qualities can be set in motion. As a result, they will push the filth out of the body by releasing it together with the stools. If, however, one brings such drugs into the body together with beverages or food, new and old will be mixed, and the influences of the drugs will be confused with those of the food [the qi of the drugs and the qi of the food will combine]. As a result, the qualities of the drugs cannot exert their effects and the accumulations of food will be increasingly obstinate. This passage refers to penetrating, obstruction-resolving agents which include dispersing and purging therapies. Their action, as described here, is to remove accumulations (filth) by a downward push through the intestines. They are taken on an empty stomach, so that the herbs can quickly disperse through the system and can push out the old accumulations before the food is ingested. If taken with the meal (or close to a meal so that food and herbs can intermingle), the herbs will act on the newly ingested material, the influence of the herbs will be altered by the foods, and the herbs may be slowed down. To have the full effect (strong dispersing and clearing action), the dose of herbs is to be taken all at one time, rather than spread through the day, as is often done with other remedies. Accordingly, early morning would seem most appropriate for this type of therapy. Taken together, these statements from ancient texts suggest that both tonifying and eliminating therapies and all those that must act on the lower part of the body are best taken early in the day and generally before meals, while quick acting and light therapies are taken after meals and later in the day. Decocted tonics, being quick acting by virtue of the decoction form, could be taken later in the day, while tonics in pill form would be taken early in the day. There are some potential conflicts among the few statements quoted here, but this is minor compared to those that have arisen in modern times.

INCONSISTENCIES IN MODERN LITERATURE Today, most practitioners (including traditional herbalists in China) frequently ignore the rules described in earlier centuries. Patent medicines produced in China rarely carry instructions for timing of the doses. Some items are taken once per day, others twice, and the majority three times, but instructions for before or after meal ingestion have largely been eliminated; before meals was the main suggestion on packaging before such descriptions were removed. Similarly, clinicians often divide the dose of a prescribed decoction into two portions to be taken early and late, without regard to the nature of the preparation being consumed. From the modern perspective, the idea that herb materials rise up or sink down in the body is difficult to explain by simplistic ideas of herbal density, pill size, or proximity to ingestion of food. There persists some limited attention to the use of "directing" herbs to focus the effects of a formula on a certain region of the body (e.g., achyranthes to entice the action downward, cimicifuga upward), but the potential action of such agents might be explained by a slight influence on regional microcirculation rather than any actual targeting of organs or tissues. In other words, the first rule listed above may be ignored because the modern ideas don't correspond to the older ideas. Dr. Hong-yen Hsu, in the introduction to his book Commonly Used Chinese Herb Formulas with Illustrations (1980), reiterates the ancient rule of taking formulas after meals for treatment of the upper body and before meals for treatment of the lower, but he specifies that these rules apply generally to those cases where the formula is to be taken for an extended period of time, suggesting that one may not need to pursue this timing in the treatment of an acute ailment. There are only two references to timing of herb consumption in relation to meals conveyed by T.Y. Pang in his book Chinese Herbal (1982). The ingestion of Cnidium and Tea Formula (Chuanxiong Cha Tiao San) and a modified version of Platycodon and Fritillaria Combination (Qing Fei Tang) are both recommended after meals. The former treats headache and the latter treats facial acne and lung disorders; thus, the suggestion is consistent with taking after meals those formulas that treat the upper body. These ailments might be classified as acute, and the remedies would usually be taken for a relatively short period of time. According to Zhu Chunhan, in his book Clinical Handbook of Chinese Prepared Medicines (1989), the patent Xi Ling Jie Du Pian is to be taken before meals when used for treating cases of influenza, a disease of the upper body. The formula is comprised mainly of light ingredients, so this recommendation is exactly opposite to the traditional method. In contrast, the patent Ji Gu Cao Wan for hepatitis is to be taken after meals. It contains several heavy ingredients, including pearl, and treats a disorder of the lower body (according to traditional doctors, the liver system is part of the lower abdomen). Again, this is opposite to the ancient suggestions. It may be that in cases of hepatitis, people are sensitive to taking herbs on an empty stomach, hence the after-meals recommendation. An examination of recommendations for the supplementing formulas mentioned in Zhu's book shows that they are usually suggested to be taken three times daily, as opposed to being taken only first thing in the morning. Timing in relation to meals is rarely mentioned. A case where it is said that the specific timing relative to meals is important is in the use of Sai Mei An, a formula made up mainly of calcium carbonate sources used to neutralize hyperacidity of the stomach. According to Zhu: "It is important to administer on an empty stomach only, at least one half hour before a meal, to give the medicine a chance to form a membrane and line the stomach wall and protect the ulcer from contact with food and gastric secretions." In texts of recent origin, most digestive formulas are recommended to be taken before meals, if any recommendation is given at all. However, when the main purpose is to remove food stagnation, a condition of improperly digested foods, the material is usually taken 30-60 minutes after meals, as suggested for Jian Pi Wan. Still, for Chen Xiang Hua Qi Wan , used for food stagnation, it is suggested to be taken either one-half hour before or after meals, further demonstrating the difficulty of pinning down a specific time for any class of herb remedies. Richard Hyatt, writing on the basis of Kanpo practice, says in his book Chinese Herbal Medicine (1978) that "Prescriptions are usually taken once a day, preferably in the morning on an empty stomach, and should not be followed by any food for one-half hour."

Clearly, this idea is contrary to practices in mainland China where many formulas are taken in divided doses, though it is consistent with the recommendations given in China if the formula is to be taken only once per day. In more recent books on Kanpo medicine, the ingestion of herbs two to three times per day appears to be the rule. The prepared medicines of Japan, dried extracts that substitute directly for decoctions, are usually recommended to be taken two to three times per day. In his small booklet Chinese Herbs and Formulas (1978), Hong-yen Hsu describes the use of these prepared formulas as being taken three times a day "between or after meals." In the Handbook of Commonly Used Chinese Herbal Prescriptions (translated from the Japanese by Oriental Healing Arts Institute) Tang-kuei Four Combination is to be taken one time per day if consumed as a powder, but a similar prescription, Tang-kuei Formula (with rehmannia deleted and atractylodes and scute added), as a draft (powder in hot water) is to be taken three times daily. Both prescriptions would be classified as tonics. The 1988 Pharmacopoeia of the People's Republic of China describes the uses and dosage of dozens of patents. In most cases, the pills are to be taken twice daily, though several items are suggested to be taken in the range of 1-2 times and others 2-3 times. In only one case is the timing of the dosage specified: Wuwei Shexiang Wan is to be taken once a day at bedtime. This formula is a quick acting and somewhat toxic preparation intended for treatment of acute inflammatory conditions. The recommendation is consistent with the ancient idea of taking quick acting remedies at bedtime. However, other remedies listed in the text that have a similar nature are not accompanied by this instruction. In clinical studies, herb formulas used for treating intestinal parasites are usually given in the morning, on an empty stomach, following the idea that the materials will enter the intestines alone, prior to the food taken in during the day. Such methods are in keeping with the ancient ideas. In contrast, in a recent clinical trial of herb decoctions used for treating amyotrophic lateral sclerosis (ALS, an autoimmune disease) made up mostly of heavier drugs such as aconite, cinnamon bark, rehmannia, and tang-kuei, the decoction was recommended to be taken three times daily after meals. This recommendation was made regardless of the main site of the symptoms, such as the upper limbs versus the lower limbs. In the majority of clinical reports published in China, the timing of the dosage is not specified.

NEW RULES One difficulty in pursuing the traditional ideas is that modern prescriptions are rarely comprised of only light or heavy materials or only tonic or dispersing therapies, making the formulas less easy to categorize for purposes of following timing rules. Many diseases cannot be localized in one part of the body or another; indeed, it is not uncommon for symptoms of the upper body to be due to abnormal conditions in the lower body and treated with herb formulas designed to correct the root problem and the branch manifestation simultaneously. Further, an increasing number of prescriptions are made in multiple forms-such as decoctions, powders, and pills-to be used according to a variety of considerations other than their heavy or light, or quick or slow nature, such as according to convenience or cost. Therefore, new rules might apply, as suggested here.

New Rule 1: Take herbs before meals, except when they cause irritation. Taking herbs before meals is often convenient and the practice usually assures that herbs and foods are not mixed. However, taking herbs after meals may be necessary if the before meal dosing yields adverse gastric reactions. The primary difference (as recognized by modern research) between before-meal dosing and after-meal dosing is the higher activity of the digestive system for an hour or more after meals, compared to that before meals. The ingestion of food stimulates the release of digestive juices (including many enzymes and bile acids) and activates the intestinal absorption mechanisms and peristalsis. The herb decoction or pills ingested on an empty stomach, especially if the dosage is small, may produce a limited stimulation of this system and hence result in a slower action during the assimilation of herb materials. Those who have weak digestive action or a sensitive digestive system may find the herb material irritating or difficult to digest in such circumstances. The traditional suggestion of consuming tonics on an empty stomach may indeed be helpful in promoting the assimilative functions of the stomach and spleen, but it may be difficult for the individual to tolerate the herb ingredients early in the morning before the digestive activity has been fully awakened by a meal. Blood-vitalizing herbs are an increasingly important part of Chinese medical practice. Formulas that are mainly comprised of bloodvitalizing herbs and used in large quantity tend to produce nausea when consumed on an empty stomach and might be best taken after meals (but not too long after) to avoid that response. This is contrary to the advice to make sure dispersing and resolving therapies are taken on an empty stomach. In several clinical trials reported in modern Chinese journals, it is stated that herbs are prescribed before meals and then the recommendation is switched for certain individuals to after meals: in response to the experience of gastric distress (and sometimes other reactions) upon ingestion of the herbs. It is reported that this change in timing solves the problem in almost all cases.

New Rule 2. Separate foods, drugs, and herbs, unless there is good reason to do otherwise. Modern experience with drugs shows that simultaneous ingestion of a drug with a food or beverage can sometimes cause changes in absorption and effects. For example, ingestion of tetracycline with milk (a food not used in China until recently) results in reduced absorption of the drug. People relying on protease inhibitor drugs (for HIV treatment) are well aware of the significant restrictions placed on the relationship of meals and drug dose timing because of lowered absorption when food is present. By contrast, ingestion of vitamin C (or other vitamins) along with foods can enhance absorption and utilization of both the vitamins and any minerals that are present. Ingestion of certain pharmaceutical products with alcohol can cause adverse reactions because both produce a pharmacologic effect on the liver; in the practice of Chinese herbal medicine, the simultaneous ingestion of alcohol and herbs is recommended in particular casesblood-vitalizing therapies especially-and avoided in other cases, for example, treatments of damp-heat (this restriction is also because of effects on the liver). It is possible that food components bind-up and therefore inhibit the absorption of various herb ingredients. The relatively low volume of herb materials consumed at one time (especially when not taking a high-dosage decoction) compared to the amount of food materials consumed suggests that it is possible for foods to inhibit the absorption of some herb components. For example, in the case of the concentrated extracts used in Japan and Taiwan, ingesting a small amount of concentrated extract (1.5 to 2.0 grams each time) with the simultaneous ingestion of food might lead to unacceptable losses of herbs. It is known that the reverse happens: herbs can inhibit absorption of food constituents, sometimes in a manner that is desired: As an example, some herbs inhibit the absorption of cholesterol

and thus reduce blood cholesterol levels after meals. High fiber meals may move herbal ingredients through the intestinal system faster than they can be absorbed. This may be a problem when using the large honey pills intended for slow absorption. Similarly, eating too soon after ingesting the herbs (within about half an hour) may mix the herbs with the food mass or push them through the intestinal tract too rapidly. Rich foods with many fats may coat the herb ingredients and make them less amenable to absorption if taken together. In the event that consumption of the herbs with meals is deemed necessary, it might be beneficial to increase the dosage somewhat to compensate for losses. The exact amounts of losses cannot be known, however. A method of herb administration that is increasingly popular is the use of tablets. The tablets, whether manufactured in China or the U.S., may be comprised of powdered herbs, extracts, or a combination of the two. Tablet manufacturers in the U.S. test the tablets for dissolution time by standardized methods that employ digestive juices. A dissolution time of sixty minutes is the maximum allowed but most tablets become a fine powder in considerably less time (20 minutes). If tablets are taken before meals, an allowance of about 30-45 minutes will be sufficient to permit complete disintegration and initial stages of uptake. Maximum absorption of active components into the blood stream is usually expected between 45 and 90 minutes after ingestion (absorption occurs mainly in the small intestine; nonabsorbed materials may have action in the large intestine, such as treating inflammation of the colon). As can be seen from the suggestions of many authors, both ancient and modern, taking herbs on an empty stomach or between meals is the common ground. In the Dictionary of Chinese Medicine (1984), three terms relating to the timing of herb ingestion are listed. Shiyuanfu means to be taken away from mealtime; linshiuqianfu means to be taken before bedtime; and kongfufu means to be taken with an empty stomach (e.g., before breakfast). The consistent feature of these terms is that the herbs are not taken with meals or very close to meals. It has been pointed out by many observers that Americans today rarely consume three regular meals but instead eat several small meals. This makes the term "empty stomach" or "between meals" less definitive. On the other hand, several herbs are recommended to be consumed with specific foods or types of foods, and such recommendations might be retained. For example, tonic herbs can be taken with chicken, pork kidney, or other meats for the purpose of enhancing their effects. Lung disorders are sometimes treated by combining herbs with pears or other fruits. Diarrhea and other disorders are treated by consuming herbs with grains. This suggests that the ingestion of herbs with meals may, in many situations, be satisfactory. In the Shang Han Lun, some formulas, such as Cinnamon Combination, were to be consumed in decoction form followed (after waiting for a "short time") by ingestion of rice gruel for the purpose of enhancing the effect of the herb treatment. By contrast, a wide range of foods are not to be taken during the course of therapy with Cinnamon Combination, including fruit, meat, noodles, garlic, onions, wine, cheese, and all foods that are raw, glutinous, slippery, cold, malodorous or fatty. This leaves the herb decoction and simple rice with a few vegetables as the only things to be consumed.

New Rule 3: Use stimulants in the morning, insomnia remedies at night. Many formulas that treat insomnia will have an immediate effect if taken about one-half hour before going to sleep as well as potentially providing a long-term solution with regular ingestion over a period of several weeks or months. Other formulas will release body energy and will cause insomnia at night; in sensitive individuals, it may be necessary to take no herbs for four hours prior to bedtime. Similarly, energy stimulating formulas might be best taken in the early morning, much like one consumes coffee at that time. However, one should be careful to avoid confusion about the classification of herbal formulas. Sedative formulas rarely have the extreme effects that are common to modern sleeping pills, and they can usually be taken without causing drowsiness early in the day. Some of them calm nervous energy, which can yield improved directed energy. Zizyphus is an example of an herb that can be taken throughout the day, but if one is seeking help in falling asleep, it will be helpful to take it within half an hour of planned sleep time. Energizing formulas also need not cause insomnia at night. They may enhance energy by improving organ system functions, something that will also enhance sleep. However, some herbs, such as ginseng and ma-huang, can cause insomnia in sensitive individuals and for almost anyone if the dose is high enough. Herbal wines prescribed on a regular basis (usually for tonic or for antirheumatic purposes), are best taken before bed because of the sleep-inducing action of the alcohol base. Unlike Western tinctures that are often prescribed in doses of a few drops (and often ineffective at those low doses), these Chinese wines are usually prescribed by the soup spoon, which provides a substantial amount of alcohol (enough for a sedative effect, not enough to disturb sleep). Some practitioners adopt the practice of giving one remedy early in the day and another later in the day. Yet, the experienced Japanese herbalist Keisetsu Otsuka, in Natural Healing with Chinese Herbs (1980), says that he believes the prescribing of different remedies at different times is just a sign of inadequate understanding. He says: "Some doctors adopt the regimen...in the morning Pueraria Combination and in the evening Bupleurum and Schizonepeta Combination. This procedure is followed because the prescriber is incapable of making a clear-cut diagnosis and does not know the indicative prescription." It might be necessary to follow such a regimen to satisfy the individual's sensibilities nonetheless. In Otsuka's example, Pueraria Combination, containing ma-huang, is a stimulant prescription, and Bupleurum and Schizonepeta Combination has sedative properties. Both are used for surface disorders, such as skin ailments. In Tibetan medical practice, physicians often prescribe different medicines for morning, noon, and night (further, the medicines are to be collected and prepared at certain astrologically-defined auspicious moments). By contrast, traditional Chinese texts usually refer to ingestion of a single remedy in one day, in keeping with Otsuka's idea.

New Rule 4: Encourage getting a full daily dose of herbs even if timing is ignored. In the modern situation, there is an issue which may not have been a dominant concern for traditional doctors: the importance of ingestion of adequate doses of herbs on a regular basis. With today's busy schedules and irregular eating habits, some people find restrictive timing a significant impairment to taking herbs, resulting in no herb usage or highly irregular ingestion (herbs being taken when the time requirements can be met, but skipped otherwise). The experience of using modern drugs, where very small amounts are taken and one often desires to minimize the ingestion of the drugs may lead individuals to minimize the use of herbs, especially if the dosage is large and the rules are strict. Therefore, one might have to leave the timing to the convenience of the person who must consume the materials.

Avoidance of adverse reactions may be an equally important concern, since many people are not used to the experience of taking herbs and become highly concerned about any reaction, even if tolerable. These concerns can lead to cessation of using the herbs that might otherwise help them. Hence, in addition to the suggestion of taking herbs after meals, it is possible to gain some advantages by dividing the daily dosage into several smaller doses taken throughout the day. On the other hand, if a person has no problem taking large amounts of herbs at one time, a single dosage may prove to be the only recommendation the individual finds convenient enough to be acceptable. Thus, while an herb combination might be recommended to be taken all at once on the basis of traditional ideas of eliminating accumulations more effectively, this suggestion could be offered instead to assure compliance. On the other hand, the daily dose might be subdivided to avoid reactions to the large amount of herb materials (including difficulty swallowing large numbers of pills) that would otherwise be consumed at once. In attempting to simplify and modernize the traditional recommendations, the Advanced Textbook on Traditional Chinese Medicine and Pharmacology simply sums up the matter this way: "With regard to time of administration, tonic drugs should be taken before meals, those irritant to the stomach and intestine after meals. Anthelmintics should be taken when the stomach is empty, and drugs for calming the mind should be taken before sleep. Antimalarial drugs should be taken two hours before the attack. For acute diseases, there is no restriction as to the time of administration."

May 1997

HUA TUO by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Biographical information about Hua Tuo has been summarized and presented in English in three works: an article in the Journal of Traditional Chinese Medicine (1), a monograph in Chen's History of Chinese Medical Science (2), and an extensive report in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (3). The following has been derived primarily from those sources, except as noted. Hua Tuo is a famous physician of the Han Dynasty who is so widely respected that his name and image adorn numerous products (e.g., as a brand name for acupuncture needles and for medicated plasters) and a set of frequently used acupuncture points (called Hua Tuo Jiaji, see Appendix). He is known for the early qi gong exercise set known as the frolics of the five animals, in which one imitates the actions of tigers, deer, bears, apes, and birds; these practices were later incorporated into various health promoting martial arts practices, such as taijiquan. His name is always mentioned in relation to surgery, as he was considered the first surgeon of China, and one of the last famous surgeons of ancient China. He has been compared, in this regard, to Jivaka of India, who lived at the time of Buddha (about 500 B.C.) and was renowned for surgery, but had no significant successors until the modern era when surgery was reintroduced by Western doctors (4). Legends of Hua Tuo's work are mentioned in historical novels, such as Romance of the Three Kingdoms and Taiping's Comprehensive Anthology of Stories. It was a tradition in the past that when a patient had recovered due to the efforts of a competent physician, the family would present a congratulatory board to the doctor inscribed with the words: A Second Hua Tuo. Hua Tuo was born around 110 A.D., in Qiao of Peiguo (today called Haoxian or Bo) county, in what is now Anhui Province, one of the four major herb distribution centers of modern China. He lived for about 100 years, having died around 207 A.D. He was an older contemporary of China's famous herbalist Zhang Zhongjing, who died around 220 A.D. In the Chronicles of the Later Han Dynasty, it is said that: "Knowing well the way to keep one in good health, Hua Tuo still appeared in the prime of his life when he was almost 100, and so was regarded as immortal." It is said that Cao Cao, ruler of the state of Wei, had Hua Tuo put to death for reasons that are unclear. Cao Cao summoned him to serve as his personal physician, and either became enraged with Hua Tuo's hesitancy to return again later to provide more treatments or suspected an assassination attempt when Hua Tuo suggested brain surgery as a treatment for his severe headaches. According to the Records of the Wei Dynasty (Wei Zhi), Cao Cao had Hua Tuo killed in 207 A.D. at age 97. Cao Cao's second son, Cao Pi (187-226 A.D.), became Emperor of the Wei Dynasty, taking over China upon the forced abdication of Emperor Xian; China then collapsed into chaos, and Cao Pi was left only a few years rule of Wei, the northern kingdom of the "three kingdoms" that resulted from the breakdown. According to the limited existing reports of his life, it is said that Hua Tuo studied and mastered various classics, especially those related to medical and health measures, but also astronomy, geography, literature, history, and agriculture, when he was young. He was stimulated to pursue a career in medicine after seeing so many people die of epidemics, famines, and injuries from wars (Zhang Zhongjing also mentioned the epidemics as leading him to undertake medicine as a career). His father had died when Hua Tuo was seven. His family lived in poverty and his mother wanted him to pursue a career. So, he walked hundreds of kilometers to Xuzhou to access all the medical classics retained there and learned from a famous physician named Cai. He studied tirelessly while practicing medicine, and became expert in several fields, including acupuncture, gynecology, pediatrics, and surgery. For the latter, he invented various herbal anesthetics. One, known as numbing powder (Mafai San), was taken with alcohol before surgery. His ancient prescriptions are lost, but the ingredients are thought to include cannabis and datura, which had been recorded later, during the Song Dynasty, as an anesthetic. Two specific cases of abdominal operations were relayed in Hua Tuo's official biography: A patient who went to Hua Tuo was told: 'Your disease has been chronic, and you should receive an abdominal operation, but even that could lengthen your life by not more than ten years.' The patient, being in great pain, consented to the surgery and was cured immediately, but he died exactly ten years later. A patient who suffered from abdominal pain for more than 10 days and had depilation of his beard and eyebrows asked Hua Tuo for treatment. The doctor diagnosed him as having a deterioration in the abdomen, asked him to drink the anesthesia, then explored his abdomen and removed the deteriorated part, sutured and plastered the abdomen, and administered some herbs. The patient recovered after 100 days. The latter story is believed to be a treatment of acute appendicitis. In the Wei Zhi (5), it was reported that for intestinal diseases Hua Tuo "would cut them out, wash them, sew up the abdomen, and rub on an ointment; the illness would remit if four to five days." There is also the story of general Guan Yu, whose arm was pierced by a poisoned arrow during a battle; General Guan calmly sat playing a board game as he allowed Hua Tuo to clean his flesh down to the bone to remove necrosis, with no anesthetic. This event is a popular historical subject in Chinese art. Hua Tuo has been called the "miracle working doctor" (also translated as divine physician; shenyi) because of his emphasis on using a small number of acupuncture points or small number of herbs in a prescription to attain good results. Some sayings have been attributed to him; for example, in advocating that people exercise to stay healthy, he said: "The body needs exercise, but it should not be excessive. Motion consumes energy produced by food and promotes blood circulation so that the body will be free of diseases just as a door hinge is never worm eaten." Being an accomplished Taoist (Anhui was the birthplace also of the legendary Taoist founders Laozi and Zhuangzi) and following its principles, he did not seek fame or fortune, though much praise was heaped upon him. He served as a physician in what are now Jiangsu and Shandong Provinces adjacent to his home Province of Anhui, and turned down offers for government service. It is said that Hua Tuo wrote several books, but none of them has been handed down, so his teachings remain largely unknown. One story is that while in prison awaiting his death, Hua Tuo handed over his works, collectively referred to as the Book of the Black Bag, to

the prison ward and asked him to help save people's lives with his medical books, but the warden dared not accept it, and Hua Tuo burned it. Another story is that the warden took the volume home, but that his wife, afraid of the trouble it might bring them, burned it. Either way, the lasting story is that his written teachings went up in smoke. It is thought that some of Hua Tuo's teachings have been preserved within other books that came out in subsequent centuries, such as the Pulse Classic, Prescriptions Worth a Thousand Gold , and Medical Secrets of an Official. An existent book was ascribed to him, but it has been determined to be from a much later writer; it was translated to English under the title Master Hua's Classic of the Central Viscera (Zhong Zang Jing), with the unsubstantiated claim that only one of Hua's scrolls was burned and this came through unscathed (6). Similarly, a book called Prescriptions of Surgery was attributed to Hua Tuo, but is believed to have been compiled at least a century or two after his death (7). Despite Hua Tuo's reputation in the field, the loss of his works resulted in the first monographs on surgery being erroneously attributed to others. There were many short documents produced during the time from the end of the Han Dynasty through the 5th century, of which one survives, called Liu Junzi's Mysterious Remedies. Like the other documents of this time, it mainly focused on lancing of carbuncles and cleaning out deep ulcers, as well as some other superficial surgeries, not the abdominal surgery that Hua Tuo is said to have done. Hua Tuo had several disciples, including Wu Pu, Fan E, and Li Dangzhi, all of whom were excellent physicians. They also practiced qi gong, acupuncture, herbal medicine, and other things learned from Hua Tuo. It is said that Wu Pu wrote an herb guide and that Fan lived to be over 100, thanks to the exercises he practiced regularly.

REFERENCES 1. Zheng Bocheng, The miracle-working doctor, Journal of Traditional Chinese Medicine, 1985; 5 (4): 311-312. 2. Hong-yen Hsu and William G. Peacher, Chen's History of Chinese Medical Science, 1977 Oriental Healing Arts Institute, Long Beach, CA. 3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, volume 1, 1995 New World Press, Beijing, China. 4. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, Ca. 5. Sivin N, Chinese Alchemy: Preliminary Studies, 1968 Harvard University Press, Cambridge, MA 6. Yang Shouzhong (translator), Master Hua's Classic of the Central Viscera, 1993 Blue Poppy Press, Boulder, Co. 7. Wang Jaixiu, The first monograph on surgery, Journal of Traditional Chinese Medicine, 1986; 6(2): 136. 8. O'Connor J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981, Eastland Press, Seattle, WA. 9. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1996 Blue Poppy Press, Boulder, CO. 10. Shen Xueyong, Xu Xingsheng, and Zhuang Wei, 23 cases of summer fever treated by needling huatuojiaji points, Journal of Traditional Chinese Medicine 1995; 15(3): 192-194. 11. He Shuhuai, Huatuo jiaji ponts for migraine: 70 cases, Journal of Traditional Chinese Medicine 1983; 3(3): 231-232.

APPENDIX: HUA TUO ACUPUNCTURE POINTS. The Hua Tuo acupuncture points, known as Hua Tuo Jiaji (jia = lining; ji = spine), are located in a row along side the spine, bilaterally. The points are attributed to Huo Tuo because it is said that he preferred treating certain conditions with these points. For example, there is a story that a patient having problems with his feet couldn't walk, so he went to Hua Tuo, who applied moxibustion to points on his back along the spine. Soon, the patient was able to walk again. Historical records of these points are few. The Zhenjiu Jicheng (Comprehensive Collection of Acupuncture-Moxibustion; published in 1847) says: The jiaji treat sudden chaos twisted sinews. Order the patient to lie in prone position and extend their two hands to touch the body. Then use a string to connect the tips of the two elbows. The points are located 1.5 cun bilateral to the spine below the point where the string crosses the spine. Moxa 100 cones and nothing will fall short. This is Hua Tuo's method. The "twisted sinews" may refer to tendons and muscles that have become stiff or paralyzed, causing one to be unable to walk, and this statement may simply be a reflection of the original story linking these points to Hua Tuo. The initial descriptions refer to use of moxibustion, but needling is emphasized in modern texts. The general use of points near the spine was eventually organized into a set of 17 specific points in a row (see figure) with specific relation to the vertebrae, but these have been increased to 24 bilateral points by extending the set upward on the neck and downward on the sacrum (8). The points are located between the single row of Governing Vessel points that run directly along the spinal column and the inner set of bilateral Bladder meridian points. The Bladder meridian runs in two lines parallel to the spine; the inner row being 1.5 cun lateral to the spine. The Huo Tuo Jiaji are usually said to be located 0.5 cun lateral to the lower border of each spinous process; some authors locate the points slightly closer to the spine, and others as far as 1 cun from the spine. The points lie along the interspinous transverse ligaments and muscles. Each point has its related posterior branch of the spinal nerve starting from below the vertebra and the accompanying artery and vein. It is understood that the stimulation of these points will treat problems of the organs and body parts that are located in the same general region. Their functions correspond, roughly, to those of the Bladder-associated shu points. Hence, the points in the upper portion of the thorax are used to treat diseases of the throat, heart, lung, and upper extremities; the points in the lower portion of the thorax are used to treat diseases of the liver, gallbladder, spleen, and stomach; points in the lumbar region are used to treat diseases of the urogenital system, the intestinal tract, lumbosacral region, and lower extremities. From the modern viewpoint, needling the nerves extending from the spinal column to the associated regions could explain these recommendations. Location of the points, in terms of distance from the spine, has been an issue of some contention. The physician Wang Leting (1894-1990) preferred needling the points slightly closer to the spine (9). He moved the location inward so that the points were just 0.3 cun lateral to the spinous processes. Wang cited the satisfactory needle response as one basis for selecting this location and expressed the

view that treating the jiaji would have the effect of simultaneously improving the flow of qi in both the Governing Vessel and Bladder meridian. Such treatment would be of particular benefit for many cases of paralysis; Wang also recommended these points for relieving pain syndromes, including lumbar pain, gastrointestinal disease with pain, herpes zoster, and intercostal neuralgia. In an article on using the Hua Tuo jiaji points for treatment of summer fever (with weakness in the lower extremities, fatigue, and stiffness in the back), the authors indicate that these points are used to regulate the functions of the internal organs and relieve the stiffness (10). As to location, the authors stated: Originally, all the points along both sides of the spinal column were designated jiaji, without fixed location. Later, three main ways for location of jiaji points were used according to the clinicians' experiences. The first and most popular way is 0.5 cun; the second way is 1.0 cun, and the third way, 0.8 cun bilateral to the midpoint between each two vertebral spinous processes. From our experience, it is dangerous to apply acupuncture at 1.0 cun bilateral to the spinal column, 0.5 cun is safe but the needling sensation would not be strong enough. Perpendicular insertion of the needles in the third way [0.8 cun] is not only safe, but also more effective because needling sensation would be elicited easily. In regard to the depth, it is common to insert the needle perpendicularly 0.3-0.5 cun deep at the point 0.5 cun lateral to the midpoint between each two spinous processes. But we consider that this depth is not enough, so that no promising needling response could be elicited. Therefore, no good effect could be expected by shallow needling. For this reason we have adopted deep needling [0.5-1.0 cun for upper thoracic points; 1.0-1.5 cun for lower thoracic and lumbar points] to treat summer fever for a better result. Wang also relied on deep insertion, which was easier to perform and safely done closer to the spine, with 1.5 cun depth except for thin people, who he would needle at 1.0-1.5 cun. He recommended perpendicular needle insertion. In an article on treatment of migraine with Hua Tuo jiaji plus fengchi (GB-20), He Shuhai indicated that needles should be inserted into the points to a depth of 1 cun or a little more or less depending on the fatness or thinness of the patient, using a slight oblique angle of 75 degrees to the skin toward the spine (12). Thus, it appears that one of the considerations for treatment of this region is to needle close enough to the spine to avoid the danger of puncturing the internal organs (specifically to avoid pneumothorax), while puncturing deeply enough to attain an adequate qi response and therapeutic effect. Yet, the points need to be far enough from established points (those of the Governing Vessel and inner Bladder meridian line) to be considered a separate treatment method. Thus, points are selected at a distance from 0.3-0.8 cun lateral to the spinous processes, with a needling depth of 0.5-1.5 cun, using perpendicular or slight oblique needling angle. Needle retention time is 20-30 minutes, with stimulation by reducing or tonifying method as appropriate to the point (e.g., reducing therapy for liver, tonifying for spleen). The points are mainly used to regulate the internal organs and alleviate stiffness, paralysis, and pain syndromes.

August 2002

Location of the Hua Tuo Jiaji. This illustration shows the 17 basic points, which can be expanded to 24 points by extending along the spine upward and downward. The Hua Tuo points are bilateral, that is, on both sides of the spine, even though only one row is displayed

here.

20th century painting of Hua Tuo at Academy of Traditional Chinese Medicine in Beijing.

Painting of Hua Tuo, published in Medicine in China: Historical Artifacts and Images by Paul Unschuld. The text on the painting suggests that this is a copy of an image that was constructed on the river Jialing during the Three Kingdoms period, a few years after Hua Tuo's death.

19th century Japanese painting showing Hua Tuo operating on the wounded arm of general Guan Yu, who is busy playing a board game.

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This site is devoted to Christian theology of the body for subjects other than those that were the focus of John Paul II's series of talks titled Theology of the Body that dealt with sexuality and marriage (see valuable links to that topic, lower left). There are other important subjects related to the body, including those listed to the left, which are presented in articles posted here and through links to other articles. At the heart of this site is the matter of health, sickness, and healing. Among the primary tenets to be described in relation to healing are: Prayer is a central focus of healing. Prayer, an expression of faith, is a means of healing presented in the Gospels. Prayer does not replace medical help, and there is no conflict between prayer and medical therapy. Turning to prayer as a last resort, when medical therapies have failed, misses the value of prayer in healing; it serves as an integral part of healing. We are commanded to help heal others. This does not mean that everyone needs to become a medical practitioner, though being a physician is a noble profession which may be likened to a religious vocation. There are many ways to help others in healing aside from technical medical interventions. Self-help, although of a distinct value, should not be the primary center of attention in the concept of healing. We are to maintain the health of our bodies in order to serve others. Living in a healthy way can be a model for all. Health is a goal, but is not the only satisfactory condition in life; suffering and debility can be seen as having their own value. Effective health maintenance is important for reducing waste of medical resources better reserved for treating unavoidable sickness and injury.

Vatican texts, especially the writings of John Paul II and Benedict XVI, will form a central reference point for several of the presentations. "Do you not know that your body is a temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore honor God with your body." -1 Corinthians 6:19-20 translation | exegesis | styles | author | contact *The icons at the top of this home page are available from Monastery Icons: http://www.monasteryicons.com/

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CHINESE MEDICINE IN ITALY Integrated into the Modern Medical System by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Background Italy has a long history of interaction with China. Two famous early Italian visitors to China were the Venetian Marco Polo (1254-1324) and the Jesuit priest from Macerata, Matteo Ricci (1552-1610). Chinese medicine made its way to Italy later, primarily via its development in France during the 20th Century (for the history of the first two centuries of European developments, from 1671-1871, see Appendix 1). Acupuncture, as a medical practice rather than a curiosity, was brought to France though the efforts of George Soulié de Morant, who was engaged in the French diplomatic service in China between 1901 and 1917. Soulié de Morant published articles and French translations of Chinese and Japanese medical texts, and on his return to France taught clinical applications of acupuncture to French physicians. He also systematically introduced acupuncture theory from the classical texts to them (see Appendix 2 for a more complete story of his contributions). A unique approach to acupuncture therapy was developed by the French proponents, which has come to be known as "French Energetic Acupuncture." Among its basic principles is the concept, common in the Chinese system, that diseases and symptoms (particularly pain) are related to blockages in the flow of qi. With this as a point of emphasis, there is a high reliance on acupuncture points that were designated as "barrier points" (see Appendix 3 for a brief review of the diagnostic approach and point selection). This system developed within the medical community, so it has primarily influenced medical doctors who practice Chinese medicine, including those in Italy and the U.S. A student of Soulié de Morant, Dr. Albert Chamfrault, helped establish the French Association of Acupuncture (Association Francaise d'Acupuncture; AFA) in 1945. By 1966 this association had set up six teaching centers in France (in Paris, Bordeaux, Limoges, Nice, Strasbourg, and Toulouse). With the establishment of formal teaching opportunities, a few doctors from Italy studied acupuncture in France during the latter 1960s, and then returned to found the Società Italiana Di Agopuntura (SIA; Italian Society for Acupuncture; www.sia-mtc.it) in 1968, one of numerous professional organizations that arose in Europe since that time (see Appendix 4 for a list of several of these). This Italian society has produced numerous workshops and congresses and a journal (now in its 25t h year, with quarterly publication; see article abstract and cover copy, Appendices 5, 6). Several schools of acupuncture were developed in Italy (there are at least 16 at present), one of the largest being So-Wen (Scuola di Medicina Naturale; School of Natural Medicine) in Milan, which opened its doors in 1973. The schools originally simply taught the French Energetic Method. During the 1980s, when China had become more open to foreign visitors, new contacts with mainland China were developed by several SIA members, revealing the more complete system of Chinese acupuncture, as well as the extensive system of herbal medicine, which had not been previously introduced in Italy (or France to any extent). While French Energetic Acupuncture relies mostly on the systematic study of the meridians, Chinese herb therapies rely more on zangfu theory. It took several years to introduce and develop the zangfu framework in the Italian schools. So-Wen and a few other advanced schools quickly turned to teaching this subject; Dr. Grazia Rotolo and Dr. Caterina Martucci (authors of Farmacoterapia Cinese), introduced the first herbal seminars as early as 1987. Still, up to late 1990s most students of Chinese medicine in Italy were not able to understand and apply herbal medicine. This has changed in the past five years. Presently, 80% of the schools have adopted a Chinese program that includes both acupuncture and herbs according to the full TCM system. Roberto Gatto (president of the SIA), Sonia Benassi (head of Lao Dan, an herb company), and a few other doctors who had visited China and attended many international seminars, continue to develop and promote the TCM system, including herbal prescribing. Aside from SIA, other organizations were established. For example, the Italian Association of Acupuncture-Moxibustion and Traditional Chinese Medicine (Associazione Italiana di Agopuntura-moxibustione e Medicina Tradizionale Cinese; AIAM) was established in 1987 with three central committees: scientific, educational, and legislative; it also incorporates the Inter-University Commission for Acupuncture Research. Additionally, there is an Italian Medical Association of Acupuncture (AMIA) in Rome and the Matteo Ricci Foundation (Fondazioni Matteo Ricci) that includes a school in Bologna, a journal, and several workshops. There are a sufficient number of acupuncture organizations in Italy that a coordinating organization was established: the Italian Federation of Acupuncture Societies (Federazione Italiana delle Società di Agopuntura; FISA) with 2,500 members. A plethora of schools and professional organizations have arisen in other European countries as well and a coordinating organization was established, called EuroTCM.

The Extent and Nature of Acupuncture in Italy According to the Italian law, acupuncture therapy must be performed only by medical doctors (this has also been the case in France, Belgium, Denmark, and the Scandinavian countries). The So-Wen data base of MD acupuncturists, the largest file available in Italy, counts more than 7,000 names. The total number of Italian MDs trained in acupuncture is likely to be about 10,000. As in France, this represents one of the highest densities of Chinese medical practitioners outside East Asia (Holland, which does not restrict acupuncture to medical doctors, has the highest density, with an estimated one practitioner for every 3,200 people). The population of Italy is about 56 million, or less than one-fifth that of the U.S., which has a more liberal legal status for acupuncture yet has only about 15,000 licensed acupuncturists and about 5,000 medical acupuncturists. It has been reported that about 16% of Italy's population uses various types of alternative medicine, including Chinese medicine; many would like to see these covered by national health insurance. The study of acupuncture in Italy involves 400-500 hours of training over a four year period. Since the students are medical doctors already in practice, they can only attend some weekend seminars, which accounts for the long total duration of the courses. The cost of the program is about 5,000 Euros ($6,000 U.S. at this time). The Italian programs provide about twice the training that medical acupuncturists receive in the U.S. at the main training center at UCLA School of Medicine (where French acupuncture has been a major theme). Chinese herbal medicine has been treated as an independent course in Italy (about 250-300 hours in 2 years) that is taken by

some doctors after their graduation from acupuncture studies. Since the duration of training is so long (six years with the added herb courses), most students do not pursue herbal training. Many of the acupuncturists are family doctors (general practitioners) who still rely on use of modern drug therapies. They have pursued acupuncture studies because of their concerns about drug side effects and the desire to find alternatives to the less than adequate drug therapies. A few of the doctors add Western herbs or homeopathic remedies to their prescription range; now several hundred have added Chinese herb prescribing. In Italy, there is a limited selection of herb products (and other natural supplements) sold in stores or via the internet as nonprescription items. These do not have a good reputation among the medical doctors. The doctors would prefer to prescribe specific remedies, including Chinese herbs, based on their diagnostic work. However, by Italian law, medical doctors are not allowed to sell or give any prescription (drugs or herbs) directly to the patient; thus, they must refer the patients to a pharmacy that will carry the appropriate herbal products. Unfortunately, among the Chinese herb products that were initially introduced to Italy the quality was often poor, and there have been concerns about contamination of those coming from China. Because the term "herbal therapy" in Italy (and throughout Europe) means use of only plants, some have argued against inclusion of any of the traditional minerals and animals as commonly found in many Chinese products. The concern for high quality products coupled with the small number of prescribers has resulted in expensive products. All these factors have restricted the use of Chinese herbs in Italy. As a result, many Italian acupuncturists just apply acupuncture to treat pain and some acute symptoms, but do not deal with internal medicine (herbal medicine). Research has focused on acupuncture therapy. Things are gradually changing in this regard; the introduction of Chinese herb courses (involving about 500 doctors) has stimulated greater interest in prescribing herbal remedies. A small herbal company in Milan, Lao Dan, began developing a product line in 1988 that has expanded to include over 30 traditional formulas relying solely on plant materials, with herb extraction carried out in Italy to assure quality (see Appendix 6 for sample label image). That company specifically aims its efforts toward assuring high quality of raw materials and manufacturing, correct formulation, and proper distribution. Due to low levels of demand at this time, it is difficult for the company to develop a full line of products, partly because all sales must go through pharmacies; it is estimated that only about 400 medical acupuncturists are routinely prescribing these items. Other small product lines have also appeared in Italy during the past few years, including a line of topical and internal remedies with a focus on orthopedics and traumatology (especially sports applications), developed by Dr. Karl Zippelius, who immigrated to Florence, Italy from Germany after studying acupuncture and herbs there. The products include pastes, salves, tinctures, and tablets. The new programs of herbal medicine education have the capability in the next three years to train about 500 new practitioners. In addition, through seminars, as many as 1,000 current practitioners could receive continuing education on the topics. However, it is unlikely that these participation levels will be met; the actual attendance may be only 20-30% of the potential audience due to scheduling conflicts and concerns about the ability to readily obtain and utilize the herbal remedies. Perhaps with positive response to the therapies the demand for training will increase in the coming decade.

APPENDIX 1: Early European Exposure to Acupuncture Prior to the work of George Soulié de Morant, a few Westerners had described acupuncture therapy and some had used it, but they failed to generate sufficient interest for the field to develop formally. The first records date back to 1671, when a French Jesuit priest named Harviell, who had served in China, published Les secrets de la Medicine des Chinois (Secrets of Chinese Medicine). There was brief mention of acupuncture from time to time after that, but then a number of articles and books appeared in the 19th century, outlined in the table below (adapted from Understanding Acupuncture by Birch and Felt, 1999 Churchill-Livingstone). Some 19th Century References to Acupuncture in the West Date

Country

Author(s)

Nature of publication

1802

England

W. Coley

Article about the uses of acupuncture

1816

France

L. Berlioz

Book on acupuncture for chronic disorders

1820

Italy

S. Bozetti

Book on acupuncture

1821

England

J.M. Churchill

Article on use of acupuncture in treating rheumatism

1822

USA

Anonymous

Medical journal commentary favorable to acupuncture

1825

France

J.B. Sarlandiere

Article on the use of electroacupuncture for gout

1825

Italy

A. Carraro

Article on uses of acupuncture

1826

USA

F. Bache

Article about uses of acupuncture

1826

England

D. Wandsworth

Article about using acupuncture for pain relief

1826

Germany

G.E. Woorst

Review article on status of acupuncture

1827

England

J. Elliotson

Article about acupuncture for rheumatism

1828

Germany

J. Bernstein

Article about acupuncture for rheumatism

1828

Germany

L.H.A. Lohmayer

Article about acupuncture for rheumatism

1828

France

J. Cloquet, T.M. Dantu Book on acupuncture

1833

USA

W.M. Lee

Article about acupuncture for rheumatism

1834

Italy

F.S. da Camin

Described Sarlandier's work on electroacupuncture

1871

England

T.P. Teale

Article about acupuncture for pain relief

APPENDIX 2: Soulié de Morant's Introduction of Chinese Medicine to Europe Peter Eckman, in his book In the Footsteps of the Yellow Emperor, presents the results of his intensive research into the development of acupuncture therapy in Europe. The main purpose of his effort was to discover the influences on J.R. Worsley, who became a significant figure in the development of acupuncture in England and America, two countries where Eckman has lived and worked. He was able to trace significant influence from both Japan (via visiting Japanese practitioners and teachers) and from China (mainly via George Soulié de Morant), as well as some influence from Vietnam and Korea, and then the interaction with German naturopathy and homeopathy. Regarding George Soulié de Morant, he wrote the following (slightly edited for presentation here): I think we can say that contemporary traditional acupuncture in the West started with George Soulié de Morant (18781955) in 1927 in France. Prior to that date, there had been scattered accounts and even some books about acupuncture in Western languages, but no attempt to formulate a systematic understanding of acupuncture based on points, meridians, the circulation of qi and its management and reflection in pulse diagnosis. Soulié de Morant grew up in an unusual family that encouraged him to learn Chinese from the age of eight. He was originally schooled by the Jesuits and intended to study medicine, but had to give up that ambition when his father died.

George Soulié de Morant Commemoration image for Soulié de Morant. At 21 (1899), based on his linguistic skills, he got a secretarial job in China, and happened to be in Beijing during a cholera epidemic. Soulié de Morant became acquainted with a Dr. Yang, who was considered extraordinarily successful in treating cholera victims with acupuncture (typical formula of points: ST-25, ST-36, LI-10, and points surrounding CV-8). Soulié de Morant's curiosity was piqued to the point that he began studying with Dr. Yang, who let him do some of the treatments under his guidance. Soulié de Morant was subsequently appointed to the French Consular Corps and sent to various cities in China, in each of which he sought out acupuncture teachers, including several in Yunnan, which is contiguous with Indochina. It is likely that the initial Vietnamese influence on French acupuncture was a consequence of his studies in Yunnan [though France ruled over Indochina since 1887, which may have allowed for other routes of influence, such as Vietnamese traditional doctors living in France]. Soulié de Morant adopted local custom as his own, and it was said that when he dressed up, his speech and manner were indistinguishable from a native Chinese, and so he earned the respect and trust of his teachers, who supplied him with the most precious texts and instruction. He became so proficient a practitioner that in 1908 the Viceroy of Yunnan certified him as a "Master Physician-Acupuncturist" [so, just four years after meeting Dr. Yang and beginning study of acupuncture]. One other Oriental influence on Soulié de Morant came from Japan, where he spent a month in 1906 because of his own poor state of health, and is reflected in Soulié de Morant's later citation of Japanese works in his publications. Thus, from its inception, the European acupuncture which Soulié de Morant inaugurated reflected aspects of Chinese, Japanese, and Vietnamese traditions. In fact, Soulié de Morant also cited several classical Korean texts, so that tradition was represented, too. Soulié de Morant returned to France in 1918, but it was not until 1927 that his career in acupuncture really began there. At that time, he brought his daughter for medical treatment to Dr. Paul Ferreyrolles (1880-1955), a member of a study group of physicians investigating alternative medicine. This study group prevailed upon Soulié de Morant to abandon all his other interests and translate the classical Chinese medical texts into French and train them in acupuncture treatment. This he did, while also developing his own clinical practice, first under medical supervision in several hospitals, and later in private practice. He also experimented on himself, needling different points to see their effects, and kept careful records which he used in his subsequent publications. Among Soulié de Morant's sources, aside from his extensive practical training, he used many classical Oriental texts, but the main ones were two Ming Dynasty Chinese tests: Zhenjiu Dacheng (Great Compendium of Acupuncture and Moxibustion; 1601) and Yixue Rumen (Basics of Medical Studies; 1575). He was also influenced by the Japanese work of Sawada as communicated by Nakayama, whose book Soulié de Morant translated into French with the assistance of the Japanese George Ohsawa (Japanese name: Sakurazawa Nyoitchi; 1893-1966, one of the originators of "macrobiotics"). His first writing about acupuncture was an article in the French Homeopathic Journal in 1929, in collaboration with Ferreyrolles, and his first serious book about acupuncture, Précis de la vrai acuponcture chinoice, was published in 1934.

All together, he wrote over 20 articles and books on acupuncture, his magnum opus being L'Acuponcture Chinoise, the first part of which appeared from 1939-1941, but was only published in its entirety posthumously in 1957, and later in English translation (title: Chinese Acupuncture) by Paradigm Press (1994). The students of Soulié de Morant, including Jean Niboyet (1913-1968, founder of the Mediteranian Acupuncture Association), Albert Chamfrault (ca. 1912-1971; French Association of Acupuncture), and Roger de la Fuÿe (?-1961), pushed forward the field of acupuncture with translations, associations, conferences, and developing clinical practices.

APPENDIX 3: French Acupuncture and the Barrier Points During the 19t h century, many of the European writings about acupuncture focused on its use for rheumatism, gout, and other pain disorders. This emphasis continues to this day; the dominant use of acupuncture in the West, especially amongst medical acupuncturists, is for the "musculoskeletal" problems. The unique approach taken in France, which has been formalized and promoted in the study groups and workshops of the French Acupuncture Association (AFA), led to description of two groups of points. According to the French medical acupuncturists Gérard Guillaume and Mach Chieu (as described in their book Rheumatology and Chinese Medicine), one type of points have either global effects or affect an entire channel (or axis, see below); these include most of the transport points, cleft points, source points, and connecting points. The others are specific for the area to be treated, and include mainly associated points, alarm points, and barrier points. Guillaume and Cheiu point out that "barrier points are extremely important in the treatment of pain." Dan Bensky has written about the French system (www.siom.com) and a portion of his presentation has been adopted for presentation here. Among the key concepts of the French system are use of the eight diagnostic parameters, grouping of acupuncture channels into axes, and the above-mentioned focus on barrier points. The eight diagnostic categories (deficiency/excess, cold/hot, interior/exterior, yin/yang) are applied, in the French system, to the diagnosis of local musculoskeletal pain, particularly joint pain, rather than just to the general syndromes as is commonly done in the TCM system. For example, pain that is lessened with pressure or support is classified as deficient while that which gets worse is considered to be of an excess nature. Pain that is lessened by heat and increased by cold is considered to be of a cold nature, and conversely for the heat type. The pain may come from invasion of external pathogenic factors and be lodged in the painful joint or muscle, or may come from interior disharmonies (of the internal organs) and migrate from there to the affected part. A yin-type pain is dull, throbbing, of moderate intensity, chronic, occurring or aggravated at night, and deep. A yang-type pain is sharp, violent, paroxysmal, stabbing, burning, intense, acute, diurnal, and superficial. The French place a strong emphasis on the channels, more so than on point sets as often done in modern TCM in China. The twelve channels are viewed as six pairs of channels: two greater yin channels, two lesser yang channels, etc. (taken from the six-fold system depicted in the Neijing Suwen for acupuncture and repeated in the Shanghan Lun for herbs). The functions of the two channels within each pair are understood to be related and so are the manifestations of their disharmonies. Each of these pairs is known as an axis (or great channel). The concept of barrier points originally came from the Chinese word guän, often translated as barrier or gate. Several French doctors were struck by the number of points that have this word in their name (either primary name or alternate) and they also noted the importance of the concept of barriers or gates in the discussion of joint problems in chapter 60 of the Neijing Suwen. Using this as a point of departure, they described each joint as a place through which physiologic energies (qi and blood in TCM terms) pass, as through an open gate; under certain pathological circumstances, the joint space can turn into a barrier (closed gate) that obstructs the circulation. The yin and yang qi enter and exit the joints. Utilizing the eight categories and properties of channel flow in the axes, the practitioner is to determine the fundamental nature of the disorder, specifically whether the blockage involves the yin or yang qi as it is either entering or exiting the joint. The barrier points (which are originally picked on the basis of traditional descriptions of their channels, specific point indications, the point names, and other factors) are then to be selected as the main part of treatment. These points are depicted in the following table. Barrier Points in the French Energetic Acupuncture System Yang Exiting

Yang Entering

Yin Exiting

Yin Entering

Shoulder

SI-11

LI-15

LU-2

PC-2

Elbow

TB-13

TB-7

HT-6

HT-6

Wrist

LI-9

SI-6

PC-4

LU-6

Hip

BL-29

ST-31

SP-12

LV-11

Knee

GB-33

GB-36

KI-5

KI-5

Ankle

ST-37

BL-63

LV-6

SP-8

APPENDIX 4: TCM in Europe: Member Organizations of EuroTCM EuroTCM is attempting to recruit participation of Chinese medicine organizations across Europe in a central information clearing house, along with work towards unifying education and laws. Following is a table of current member organizations, which represent only a fraction of those currently operating in Europe (listed here are the colleges and professional organizations involved with acupuncture and TCM generally): Country Austria

Abbreviation

Full name

Type

MED CHIN

Medizinische Gesellschaft für Chinesische Gesundheitspflege in Österreich

PROTCM

Austria Austrian Professional TCM Federation Professional org.

College

TCMA-W

TCM Academy - Campus Wien

College

TCM-U

TCM University

Private University

BAF

Belgian Acupunctors Federation

Professional org.

BATCM

Belgian Association of Traditional Chinese Medicine

Scientific org.

OTCG

Opleidingsinsituut Traditionele Chinese Geneeswijzen

College

Bulgaria

BAAPT

Bulgarian Acupuncture Association of Physical Professional org. Therapists

Czech Republic

CSBS

Ceskoslovenska Sinobiologicka Spolecnost

College

CSBSPTCM

Praktici TCM

Acupuncture org.

NBJ

Foundation of the white crane

Professional org.

TCMB

TCM Bohemia - Klinika Tradicni Cinske Mediciny

Clinic

England

BC

Bodyharmonics Centre

College

Germany

ABZ Süd

Ausbildungszentrum Süd

College

DBVTCM

Deutscher Berufsverband für TCM

Professional org.

MFTCM

Mercurius Chen Xing

College

TCMA-B

TCM Akademy Campus Berlin

College

TCMA-M

TCM Akademy Munchen

College

ESPKI

Elleniko Sillogos Paradosiakis Kinezikis latrikis Professional org.

HAOTCM

Hellenic Academy of TCM

College

Hungary

H.SH.T

Hungarian Shaolin Temple

College

Italy

SIA

Societa Italiana di Agopuntura

College

Ireland

ACMO

Acupuncture and Chinese Medicine Organisation

Professional org.

AFI

Acupuncture Foundation TCM Training Programme

College

AFPA

Acupuncture Foundation Professional Association

Professional org.

AIAc

Association of Irish Acupuncturists

Professional org.

DDF

Dutch Dao Foundation

Professional org.

HTUTCM

Hwa To University of Traditional Chinese Medicine

College

OC

Oriental College

College

ZHONG

Ned. Vereniging voor Traditionele Chinese Geneeskunde

Professional org.

RHCI

Railway Health Care Institute

Professional org.

SJC

Balkan Su Jok College

College

Slovac Republic

SINBIOS

Slovenska Sinobiologicka Spolecnost

College

Slovenia

SAATCM

Slovenian Association of Acupuncture and TCM

Professional org.

Sweden

CESAMQ

Cesamq international TCM organization

College

NJA

Nei Jing College

College

SAA-TCM

Swedisch Acupuncture Association

Professional org.

STCMS

Society of Traditional Chinese Medicine Sweden

Professional org.

YSTCM

Yangtorp School of TCM

College

Belgium

Greece

Netherlands

Serbia/Montenegro

APPENDIX 5: Sample Acupuncture Research in Italy In the Journal of Traditional Chinese Medicine (2000; volume 20, number 3, pages 231-240), a group of eight Italian medical acupuncturists reported on their comparison of drug therapy versus acupuncture for migraine. They evaluated 120 patients affected by migraine treated at four public health centers. Acupuncture therapy focused on use of 5 points: touwei (ST-8), xuanlu (GB-5), fengchi (GB-20), lieque (LU-7), and dazhui (GV-14), all but the last mentioned point were treated bilaterally. Patients were evaluated after 6 months and 12 months of therapy. The authors concluded that acupuncture was a cost-effective alternative to modern drug treatments.

Numerous clinical reports are published in Italian, mainly in the SIA Journal. Following is a sample abstract of a report on use of acupuncture for pain: Title: Acupuncture Therapy for Dysmenorrhea Authors: Stefania Bresciani, Raffaella Mezzopane, Roberto Malavasi, Alberto Lomuscio Institutions: Scuola di Medicina Naturale and Divisione di Ginecologia Ospedale San Paolo - Milano Published in: SIA Journal #108, December 2003 (pp: 36-40) Summary: Thirty women with primary dysmenorrhea have been treated with acupuncture, following a fixed protocol. The authors have evaluated the intensity and duration of pain, the number of work days lost every month, the amount of drugs used to control the pain of menstruation, and associated symptoms. The results show a very significant reduction of all these parameters. It is suggested to use acupuncture therapy in association with classical Western therapy in all the cases of primary dysmenorrhea.

APPENDIX 6: Sample of Developments in Italian TCM Following are images of the SIA journal cover and the Lao Dan product packaging to illustrate the work being done in Italy towards developing the field of TCM.

Label of Lao Dan Chinese Herb Products from Italy

SIA Journal Cover

September 2004

THE JIN-YUAN MEDICAL REFORMS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The history of traditional Chinese medicine is long and complex. The record of events is often broken down into a few major eras during which certain critical developments occurred that influenced practice for many centuries afterward. Thus, for example, considerable attention is given to the Han Dynasty period (220 B.C. to 220 A.D.) when the most famous texts of traditional Chinese medicine were written: Neijing (Suwen and Lingshu), Shanghan Lun (including Jingui Laoyue), and Shennong Bencao Jing. Any overview of traditional Chinese medicine includes a description of the medical developments of what has been called the Jin-Yuan period or Jin-Yuan medical reform. This reform era, which involved the development of four schools of thought about disease causation and treatment strategies, was the result of the efforts of medical activists during the 13th century and beginning of the 14th century. They were protesting common physicians' reliance on certain therapeutic approaches that had been recommended earlier, but were being used indiscriminately: not adjusted for changing circumstances or for differences in geographical location. The Jin-Yuan innovations and revisions have been considered one of the essential evolutionary changes in Chinese medicine, though some consider the four schools to have been only a diversion from the original form of Chinese medicine, at least in terms of theory.

HISTORICAL CONTEXT During the Northern Song Dynasty (960-1127 A.D.), the ancient texts of the Han period were revisited, with Zhang Zhongjing's Shanghan Lun and Jingui Laoyue recovered from near complete loss. Cheng Wuji (1062-1155) intensively studied these texts and wrote several books on the subject, his most famous being Zhujie Shanghan Lun (Commentary on the Shanghan Lun). At the same time, Xu Shuwei (1079-1154) also studied Zhang's works and produced an analysis of its content, especially with regard to pulse diagnosis and the theory of using drugs in relation to the intensity of the disease. It is also during this period that the famous prescription collection, the Taiping Huimin Hejiju Fang, was compiled. This formulary, produced in response to Imperial command, provided numerous formulas that were consistent with the Han Dynasty patterns of herb combining. It became the primary reference text for herb formulas. The relative political and social stability during the preceding Tang Dynasty (618-907 A.D.) and the appearance of stability during the Northern Song Dynasty (which replaced the Tang after a 53 year interim of disruption), also gave a degree of stability-a distinct conservatism-to the medical field. To a large extent, physicians during this time came to view the Han Dynasty as a golden age of Chinese medicine that was to be recaptured, and that this preservation and invigoration of Han medicine had been largely accomplished by the efforts of Tang and Song Dynasty medical experts. Further, the Imperial examination system was put in place during the Song Dynasty. Potential physicians studied the Confucian classics and the officially recognized medical works, particularly those of the Han, Tang, and current Song Dynasty, then took exams to gain official status. This procedure helped establish a national medical authority. Then, with the rise to power of the Jin tribes in northern China, the Song Dynasty retreated south. The Jin Dynasty (in the north; 1115-1234) coexisted with the Southern Song Dynasty (1127-1280). The Jin eventually gave way to their neighboring Mongolians, who established the Yuan Dynasty first in the north of China and then taking the rest of the country (eventually spreading west as far as Europe). Their capitol was established in what is today Beijing and they maintained control of China for less than a century, from 12801368, to be ousted by the Ming. The Jin-Yuan period is the time when the northern tribes had taken control of part or all of China, 11271368. During the Jin-Yuan period, there were many changes in Chinese culture influenced by the consolidation of power under the leadership of the Northerners. Among the most important changes was the development of neo-Confucianism by Zhu Xi (1120-1200). Neo-Confucianism adopted certain naturalistic tendencies that had been within the purview of Taoism. The sense of progressing from the conservative and rigid doctrines of the past to something more appropriate to the new conditions impacted thinking about medicine. In particular, much effort was expended in developing a new understanding of disease causation and corresponding treatment principles. Zhang Yuansu (aka Zhang Jiegu; ca. 1151-1234) was one of the most influential physicians who lived during the early part of this transitional period. Zhang's students became far more famous than he, so information on Zhang is often a footnote to that provided about his students. Thus, for example, in the book History and Development of Traditional Chinese Medicine (1), which serves as one of the primary references for this article, Zhang is not even described other than brief mention as a teacher of Li Gao (aka, Li Dongyuan). Some details about Zhang Yuansu were gathered together for the introduction to the ITM book, A Bag of Pearls , where the following depiction of Zhang Yuansu and his work are presented, edited here for clarity: The herbalist Zhang Yuansu produced a medical work called Zhenzhu Nang, literally, A Bag of Pearls (zhenzhu = pearl; nan = bag). The title has a double meaning. On the one hand, it indicates that the fundamental contents of the book are valuable (like a pearl), while the book itself is entirely expendable: it is a bag, not a permanent repository, such as a golden chamber (jingui, as in the title Jingui Yaolue ) . On the other hand, the title indicates that one must rely on oneself-the training, experience, self-cultivation, and intuition that goes into becoming a medical practitioner-rather than following some dogmatic system that is going to eventually change anyway [this orientation reflected neo-Confucianism]. Zhang's perspective on the practice of medicine is captured in this comment: 'In view of the different conditions between the ancient and modern times, it is impractical to treat new diseases with old methods; therefore, the obsolete traditional formulas are to be replaced by modern prescriptions.' Zhang provided an explanation of the new methodology for understanding and using herbs and for designing prescriptions in his book. What were the traditional prescriptions Zhang spoke of revising? They were mostly formulas devised many centuries before, such as those of the Shanghan Zabing Lun (Treatise on Shanghan and Miscellaneous Diseases) by Zhang Zhongjing (220 A.D.) and of the Qianjin Yaofang (Prescriptions Worth a Thousand Gold ) by Sun Simiao (650 A.D.)-collections of formulas compiled by two of the most famous physicians of early Chinese culture. Zhang Yuansu did not reject the earlier formulas or methods of formulation but merely wished to make the modifications required to update former approaches in light of recent medical conditions.

Zhenzhu Nang, aside from presenting ideas about disease causation, represents the culmination of Zhang's work in integrating two of the principal therapeutic methods of his time. He incorporated medicinal materials into the five element framework (wuxing), which formed the organizing principle of Chinese medicine at the time. Although there were earlier efforts to make such arrangements, such as Tao Hongjing's depiction of the five shen herbs (renshen, danshen, xuanshen, kushen, and shashen; ginseng, salvia, scrophularia, sophora, and adenophora, respectively), Zhang attempted to give a more uniform presentation of the principle. In particular, he helped to more clearly define the association of herb tastes and their effect on the different organs. Zhang also initiated the concept of herbs entering into and influencing the meridians, a description that is still relayed in modern Chinese herb books, though not much relied upon in modern practice. He remarked: "The method of appropriately using herbs in accordance with the symptom and sign presentation of the patient entails determining substances with the correct qi, taste, yin and yang, and thick and thin properties as well as the pathogenic factor involved and the channel it has entered." The meridian attributions for herbs were an effort to link the physiological effects of herbs with the concept-originally depicted in the Neijing Suwen-of pathogens influencing meridians. This interpretation also links the actions of herbs with the effects induced by acupuncture. He thereby unified the theories of disease causation and treatment and the practices of herbal medicine and acupuncture, two fields that had remained largely separate despite coexisting in the same medical culture. Li Shizhen, the famous herbalist of the 16th century (author of Bencao Gangmu; Compendium of Materia Medica), said that Zhang's book contributed much to the spread of medical principles. He went so far as to proclaim that not since the Suwen and Lingshu [two parts of the Neijing] had medical principles been explained so lucidly as by Zhang. Aside from the Zhenzhu Nang, Zhang also wrote the influential Yixue Qiyuan (Origins of Medicine), which affected the thinking of physicians for centuries afterward. Zhang's students, particularly Li Gao, became key participants in two of the four schools of the Jin-Yuan. Each of the schools depicted a certain principal cause of disease and a corresponding therapeutic approach. The four schools may be divided into two subcategories: one based on the idea that diseases are caused mainly by excess (of either fire or pathogens), for which the therapies were mainly those that were used for purging and repressing; the other based on the idea that diseases are caused by deficiency (of either stomach/spleen qi or kidney yin), for which the therapies were mainly those used for tonifying and supporting. Following is a brief overview of the four schools of the Jin-Yuan reform and their main protagonists, summarized from several medical histories (1-6).

Cold/Cooling School, Led by Liu Wansu (1120-1200) Liu Wansu was a contemporary of Zhang, 30 years his elder. These physicians were probably not influenced by each other's work, but both were influenced by similar conditions in what is now Hubei Province. It is said that Liu decided to take up the study of medicine when his mother fell ill and died for lack of treatment. His family was poor and despite three requests for a doctor's visit, no one came. When Liu was 25, he started to study the Neijing Suwen, and researched its implications, particularly in relation to the cause of disease, for the next 30 years. As a result of these efforts, he wrote the book Suwen Xuanji Yuanbing Shi (Exploration of the Mechanism of Illness Based on the Suwen). He also wrote about the Shanghan Lun in his book Shanghan Zhige (Discussion of Febrile Diseases), and provided details about the principles of designing herb formulas. His main proposition was that the Suwen indicated six pathogenic influences (wind, cold, summer heat, damp, dryness, and fire), but that all of these ultimately manifest as pathogenic fire. Even pathogenic cold could change into heat or undergo a process of mutual assimilation with fire and heat to yield the fire-type syndrome. He believed that the underlying force behind the six pathogenic influences was fire. Therefore, cool and cold natured herbs were important to most therapies. Liu did not advocate the position that cool drugs were always to be prescribed; rather, he noted that at this time in Hubei, febrile diseases dominated and, as a result, cooling herbs were frequently needed. In fact, he believed strongly that the kinds of external pathogenic influences vary in a cyclic manner related to the five elements, though this would not necessarily define which specific diseases would occur. Thus, Liu insisted that the treatment should be designed according to the time and place (that is, the environmental influences), the patient's health condition (e.g., constitutional factors), and the characteristics of the disease (e.g., symptoms), while recognizing that pathogenic fire was an underlying force that often had to be reckoned with. One of his main treatment principles was lowering heart fire and nourishing kidney water to alleviate the fire syndrome. A later commentator, Lu Yuanyin wrote: "Liu felt that the ice and snow of spring were beneficial to the pine and cedar but harmful to the willow." In other words, the cold therapy was suited to those with strong constitution, but not for those who are weak. Among Liu's famous formulas were Liu Yi San (Six to One Powder), made of just two herbs-talc and licorice-in a 6:1 ratio, and its variants. The main variants were Yi Yuan San (Powder to Benefit Vitality), made by adding cinnabar; Bi Yu San, made by adding indigo (qingdai); and Ji Su San, made by adding mentha to Liu Yi San. A more complex variant is Gui Ling Gan Lu Yin (Cinnamon, Hoelen, and Licorice Combination) also derived from Liu Yi San, by adding two other cold mineral agents-calcite and gypsum-plus the Shanghan Lun formula Wuling San (hoelen, atractylodes, alisma, polyporus, and cinnamon). All of these formulas, which are rich in talc, are classified as therapies for summer-heat syndrome complexed with dampness, usually involving limited production of dark urine. Today, one of Liu's complex formulas for clearing both internal and external heat is extensively used in China and Japan: Fangfeng Tongsheng San (Siler and Platycodon Formula). Like his other formulas, it contains cold mineral agents (talc, gypsum, and mirabilitum) and licorice. The situation where febrile diseases again dominated Chinese medical thinking was at the transition from the Ming to the Qing Dynasty (1644; another invasion of northern tribes), during which time the "Warm Disease" school evolved. While Liu's concept involved disease being caused primarily by the six environmental factors with fire as their basis, the Warm Disease school began to incorporate the concept of transmissible causative agents, liqi (pestilential factors) proposed by Wu Youxing (1582-1652). This idea was later formalized in the germ theory of disease that developed in Europe and was accepted in China at the end of the 19th Century after another series of epidemics was successfully controlled by Western medical methods. The term "warm diseases" often implied epidemic

febrile diseases.

Purgation School (or Attacking School), Led by Zhang Congzheng (1156-1228) Zhang Congzheng was a contemporary of Zhang Yuansu and was influenced by the teachings of Liu Wansu. He had great compassion for the poor and downtrodden, and though he had attained an Imperial medical position, he quit after four years to work in his hometown in Henan Province and to travel about as an itinerant doctor. He had found the Imperial social conditions oppressive, and he thought the official formulary (Hejiju Fang, which had just been adopted in 1110) had too much reliance on tonic herbs and drying aromatic agents. He believed that most diseases result from evils invading the body: the six exogenous pathogens of heaven (wind, cold, summerheat, dampness, dryness, and fire) and the six exogenous pathogens of earth (fog, dew, rain, hail, ice, and mud). Alternatively, disease could result from improper food intake, particularly from excessive amounts of one or more tastes (e.g., too much sour food, too much spicy food, etc.). He downplayed the role of internally generated disharmonies, such as those due to the emotions or inherent weaknesses, as did Liu Wansu. Removing evils (exogenous pathogens) and dispelling the food excesses would therefore be Zhang Congzheng's primary objective of treating diseases. Three approaches to removing evils with Chinese herbal medicine had already been adopted by the time of the Shanghan Lun: sweating, emesis, and purgation. He expanded the meaning of each therapeutic category. He advocated using all kinds of therapeutic measures to accomplish elimination by sweating; in addition to herbs, he recommended moxibustion, acupuncture, massage, steaming, washing, and exercising. The category of emesis (inducing vomiting) was expanded to include all upper body elimination other than sweating, with therapies that increased or induced salivation, lacrimation, or sneezing. Purgation (laxative effect) was expanded to include methods that eliminate retained fluids (diuretic method) and that expelled flatus. He believed that seasonal and social influences were very important, and that formulas had to be changed in accordance with the local conditions. When tonification therapy was deemed necessary, he preferred relying on food therapy rather than herbs such as astragalus and ginseng, which he deemed potentially harmful due to the potency of their tonifying effects. Some thought Zhang's methods were too risky. As aptly put by Lu Yuanyin: "Chang's treatment is something like an old general confronting the enemy: after crossing the river, he mobilizes the troops at the bank and burns the ships, leaving no escape route. Because the soldiers have to fight for their lives out of desperation, they eventually win the battle. The pity is that when the method fails, the results are ruinous." In other words, if the eliminative method is used but doesn't destroy the pathogen fully, the patient may be too weakened to survive; other methods can't be brought in to save the day. Zhang is not known for any specific herbal formulas, as he was mainly emphasizing the use of certain basic therapeutic principles, ones that had been addressed before. He was primarily rebelling against what he perceived as an overemphasis on tonifying and warming therapies and the tendency to provide valuable formulas that were not properly selected on the basis of local conditions. Zhang is also well-known for his interest in Confucian philosophy

Spleen/Stomach School, Led by Li Gao, (aka Li Dongyuan; 1180-1251) This is a derivative of the Yi Shui school attributed to Zhang Yuansu (1151-1234), then followed up by his students: Li Gao and Wang Haogu (1200-1264), as well as Li Gao's student, Luo Tianyi (1220-1290). The story is told that Li Gao came from a rich and powerful family in Hubei and was able to spend a great deal of money (a thousand pieces of gold, it is said) to study under one of the most famous physicians in the Province: Zhang Yuansu. Although he had a great interest in medicine, after his studies he became involved in managing the family property. Then, with the Mongolian army invasion, he left Hubei to escape the turmoil of war. During his travels, he ended up using his medical knowledge and abilities to treat the diseases that arose from war and famine. Li Gao is considered the primary contributor to the lasting impact of the Spleen/Stomach school. He relied on the syndrome discrimination patterns for the zangfu developed by Zhang Yuansu to put forth the doctrine that disorders mainly originate with damage to the spleen and stomach. As indicated in the Neijing, the basis of the body is the qi of the stomach, and this association led to the underlying concept. Li's main book on the subject was the Pi Wei Lun (Treatise of the Spleen and Stomach), which has been translated to English (8). Li believed that the cause of spleen and stomach damage was from three factors: improper food intake (especially consumption of excess amounts of cold, raw, fatty, or unclean foods), overstrain (causing one to feel exhausted and to lie down in the middle of the day), and mental irritation (excessive emotions that agitate the heart fire and thereby damage the spleen). He proposed that a critical problem was sinking of the middle qi, so he recommended treatments that included raising the qi. Two of his most important Spleen/Stomach formulas were Shengyang Yiwei Tang (Yang Ascending and Stomach Nourishing Decoction) and Buzhong Yiqi Tang (Tonify the Center and Regulate the Qi Decoction). Both formulas include ginseng, astragalus, and atractylodes to tonify the qi, and both utilized bupleurum to raise qi. He also formulated Shengmai San (Pulse Generating Powder), a formula that is widely used in modern Chinese hospitals, and Danggui Buxue Tang , a combination of astragalus and tang-kuei in a ratio of 5:1; used to nourish the qi and blood following extensive blood loss. Unlike the teachings of Liu and Zhang, for whom tonics and warming therapies were generally disliked, the Spleen/Stomach school relied on these types of remedies and became known as the School of Warm Tonification. Wang Haogu, who became famous for his book Tangye Bencao (Materia Medica of Decoction; 1298), particularly emphasized the use of tonics in the later stage of febrile diseases, when the person was weakened; he argued against using purgatives, as he believed they further weakened the patient. Zang Lu (1617-1672) was one of the chief protagonists of the Spleen/Stomach school; he was also a proponent of vaccination. During the Qing Dynasty, Ye Gui (1667-1746) pointed out that a missing element in the Spleen/Stomach school was the importance of nourishing stomach yin. Ye, a recognized leader in the Warm Disease school, added that component. Ye Gui also emphasized the value of aromatic orifice opening agents to treat certain febrile diseases. Xu Danchun (1693-1771) pointed out the circumstances of the Jin-Yuan period that he believed led Li Gao to recommend supplementation of the spleen and stomach, the "central palace" of the body, saying (11): "When in the final years of the Song Dynasty

the Chinese territory fell into the hands of the enemy [referring to the northerners], the head of state was weak and his ministers failed to show any strength. At the same time, Zhang Yuansu, Li Gao, and others, in establishing their prescriptions, emphasized supplementation of the central palace."

Nourishing Yin School, Led by Zhu Danxi (1281-1358) Zhu Danxi, and his students, Wang Lu (1332-1391) and Dai Sigong (1324-1405), developed this school as a response to the others; thus, it evolved as the last of the four. Zhu Danxi, from Zhejiang Province, was a descendent of Zhu Xi, and carried on the interest in Confucianism. It was said that he was such a diligent student that he would memorize a thousand lines of the Classics each day. He planned a government career and was ready to sit for the examinations at a young age, but he later decided to concentrate on medicine when his mother and teacher each became severely ill and could not be cured even after prolonged treatment. He sought out a good teacher, and decided on Luo Zhiti, a famous physician in Hangzhou. It took significant effort by Zhu to gain Luo's confidence and become his student. His studies went well, and he became a noted physician in a short time. His success was such that he became known as "one-dose Zhu" because he could often cure patients with a single dose of herbs. He was able to cure his mother's prolonged illness. Zhu studied the other three schools of thought that had developed during the preceding decades, but came to the conclusion that the origin of diseases was different. He believed that the "ministerial fire" tended to flare up and cause serious disorders; it had to be controlled primarily by nourishing kidney yin. Zhu understood that the teachings of the Neijing and subsequent authoritative texts pointed to a physiological role of the ministerial fire in activating the functions of all the zangfu. This fire was like a moving yang that gave rise to human desires. This same fire could become pathological-impairing the yin fluids (yin and blood) and causing fire symptoms-when those desires were excessive. He felt that the kidney yang was usually in plentiful supply, but that the yin was always tending towards deficiency with any adverse influence. He was particularly concerned that excessive sexual desires and activity would deplete the yin, as would fondness for flavorful foods and indulgence in them. He became alarmed at the use of warm, spicy herbs that some doctors relied upon, as these could harm the yin if improperly used. A representative formula of Zhu Danxi is Da Buyin Wan (Major Yin Nourishing Pill), which contains rehmannia, phellodendron, anemarrhena, and tortoise shell. The first three ingredients would later become the central ingredients of the most widely used formula for the yin-deficiency fire, Zhi Bai Dihuang Wan (Anemarrhena, Phellodendron, and Rehmannia Formula). Another formula for which Zhu Danxi is well-known is Huqian Wan (Tiger's Gate Pill), derived from Da Buyin Wan by adding peony, cynamorium, tiger's bone, and the warming pair of citrus and dry ginger to help protect the stomach and spleen. Although Zhu emphasized yin-nourishing therapies, he considered the role of the spleen and stomach important as a key source of yin-nourishing nutrients. Thus, he contributed some digestive formulas, such as Baohe Wan (Citrus and Crataegus Formula) and Gehua Jiecheng Tang (Pueraria Flower Combination), which treat food stagnation and heat from food excess and alcoholic beverages respectively. Having warned about the potential dangers of intemperance in eating and drinking, he also provided remedies for the problems they caused. Zhu Danxi wrote several books; some of his most important teachings were gathered and published as Danxi Xinfa (The Essential Methods of Danxi), which has been translated to English (9) along with his book Gezhi Yulun (Extra Treatises of Investigation) as a companion volume (10). The Nourishing Yin school gained more followers around the end of the Ming Dynasty as the result of work by Zhang Jingyue, a competent proponent of using rehmannia and other yin-nourishing herbs. During the Qing Dynasty, the famous Rehmannia Six Formula, originally a pediatric prescription, became the subject of much interest, including development of numerous modifications. Rehmannia Six Formula and its modifications are the basis for much of the modern application of the Nourishing Yin school's basic tenets.

AFTERWARD The Jin-Yuan medical reform had lasting impact on the further development of Chinese medicine, at least until Western medicine intervened during the Qing Dynasty period. There were some rebellions against the Jin-Yuan influence even before Western medicine had any impact, particularly during the 18th Century. The concern was that the "real" Chinese herbal medicine was that captured by Zhang Zhongjing in the Shanghan Lun and Jingui Yaolue , and that the reformers were not of the same caliber, producing a less valuable approach. For example, the commentator Xu Dachun opposed the reliance on the Jin-Yuan teachings. He recognized three of the four contributors of that time, discounting Zhang Congzheng, but he included the Han Dynasty authority Zhang Zhongjing in the discussion of the "four masters," and said of their contributions (11): For a long time already the path of medicine has been obscured by darkness. Among the people of the Ming Dynasty one spoke of "four great masters," referring to Zhang Zhongjing, Liu Wansu, Li Gao, and Zhu Danxi. They were said to have established "everlasting schools of medicine." This is truly nonsense based on ignorance. Zhang Zhongjing is, in fact, a sage who gathered observations and arrived at conclusions that will last forever. His position in medicine equals that of Confucius in Confucisim. Liu Wansu and Li Gao left only one-sided teachings and Zhu Danxi did nothing but consider the words of all the others. He modified here and there, discarded some statements and selected some others, and opened a convenient and simple gate for beginning students. Actually, these three authors, if compared with Zhang Zhongjing, were unable to recognize one principle out of ten thousand that he saw, and it is absolutely inappropriate to promote the former and name them together with the latter....Now, what are the achievements of these three men? Liu Wansu revered nothing but the Neijing; the fact is, he was unable to grasp its essential meaning. Zhu Danxi's ideas are flat and shallow; he never saw the sources. Li Gao stuck all his life to his doctrine on how to regulate spleen and stomach. He advocated nothing but the use of herbs with an aromatic and dry nature, only a rising effect in one's body. His views were unbalanced, and his patterns for designing prescriptions were chaotic. He misled posterity!.… It would be wrong to assume that I am stubbornly intending to despise these three authors. The fact is, though, that their doctrines have become popular, and the entire country knows only how to take hold of the remnants produced by these three authors, while no one searches in depth for the teachings of Zhang Zhongjing. As a result, the patterns of the earlier Sages, transmitted by Zhang Zhongjing, have lost strength day by day, and those who die young in the empire will fill the streets for all ages to come. Hence, the harm generated by these three scholars is severe, and an immediate correction of this situation is necessary.

In Japan, the practice of Chinese medicine was greatly influenced by the teachings of Li Gao and Zhu Danxi, and their work inspired the Goseiha School, which still has some followers today, led by the 20 th-Century physician Domei Yakazu. However, during the 18 th Century, the Goseiha School was all but abandoned, to give rise to the Kohoha School, which rejected the Jin-Yuan reformers as being too impractical and which largely returned to a study of the works of Zhang Zhongjing. The Kohoha School has remained the dominant school of thought in Japan to this day. The four schools of the Jin-Yuan medical reform era have been incorporated into a much more complex set of approaches to therapy, thus still playing a valuable role. Additions to these four schools include such innovations of the Qing Dynasty period as the Warm Disease school and the blood-vitalizing methods promoted by the medical reformer Wang Qingren. The introduction of Western medicine has led the development of Chinese medicine away from simplistic theories that attribute diseases primarily to one specific cause or pattern. Nonetheless, some concepts elaborated by the Jin-Yuan schools remain strong: that dietary problems, emotional disturbance, and qi deficiency are the causes of many chronic disease problems (an outgrowth of the Spleen/Stomach school); that many diseases of aging involve yin deficiency (an outgrowth of the Nourishing Yin school); and that external pathogens induce heat syndromes (an outgrowth of both the Fire school and Purgation school and the later Warm Disease school). Also, modern treatment strategies are frequently designed with reference to formulas of the Jin-Yuan period, notably Buzhong Yiqi Tang and Shengmai San from Li Gao and Huqian Wan and Baohe Wan from Zhu Danxi. One of Zhu Danxi's formulas, Danggui Longhui Wan (Tang-kuei and Aloe Pill), was developed into a treatment for leukemia during the 20 th Century, with isolation of the most active component, indirubin from indigo (qingdai). The importance of Li Gao and Zhu Danxi are reflected in continued production of their books for use by Chinese medical students, and translation of their key books into English. The Jin-Yuan reform period alerts modern students and practitioners of traditional Chinese medicine to the dynamic characteristic of this medical tradition. In all instances, the reformers carefully studied all the classic texts and their objections were not directed at the fundamental teachings, but only at what they perceived as improper application of those teachings. They saw that most practitioners simply dispensed formulas according to memorized doctrines, but didn't examine closely enough the factors that were causing disease and the steps involved in resolving the diseases. Yet, these scholars found that they could not find any single explanation of disease or any single treatment strategy that all could agree upon. No sooner would one school arise than another would contradict it. The particular circumstances in which the doctors lived influenced their thinking and they all concluded that it was necessary to take into account local circumstances and pay attention to the unique needs of the individual patient.

REFERENCES 1. Chen Ping (editor-in-chief), History and Development of Traditional Chinese Medicine, 1999 Science Press, Beijing. 2. Xie Zhufan, et al., Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong. 3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, volume 1, 1995 New World Press, Beijing. 4. Wong KC and Wu LT, History of Chinese Medicine, 1936 National Quarantine Service, Shanghai. 5. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. 6. Hsu HY and Peacher WG, Chen's History of Chinese Medical Science, 1978 Oriental Healing Arts Institute, Long Beach, CA. 7. Domei Yakazu, The descendent schools: the medical philosophy of Li and Zhu in the Jin and Yuan Dynasties, Bulletin of the Oriental Healing Arts Institute, 1985; 10(4): 141-148. 8. Yang Shouzhong and Li Jianyong (translators), Li Dongyuang's Treatise on the Spleen and Stomach, 1993 Blue Poppy Press, Boulder, CO. 9. Yang Shouzhong (translator), The Heart and Essence of Danxi's Methods of Treatment, 1993 Blue Poppy Press, Boulder, CO. 10. Yang Shouzhong and Duan Wujin (translators), Extra Treatises Based on Investigation and Inquiry, 1994 Blue Poppy Press, Boulder, CO. 11. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. November 2001

Jisheng Fang A Book of Formulas to Promote Well-Being by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The Jisheng Fang was written by Yan Yonghe, a little known but highly regarded physician of the Song Dynasty (see Appendix 1). Published in 1253, the text is in 10 volumes, each one made up of several subsections that are comprised of an essay followed by prescriptions. The Jisheng Fang had 79 essays on the subjects of internal medicine, external diseases, gynecology, pediatrics, and miscellaneous diseases, with 450 formulas (1, 2). In addition to providing new formulas, also includes formulas from other Song Dynasty works, such as Taiping Huimin Hejiju Fang and Sanyin Fang, and simple folk remedies. In the Ming edition that is still reprinted today, some of the original content has been lost: it consists of only 8 volumes that contain 56 of the essays and a total of 240 formulas. One of Yan's followers, Chong Dingyan, wrote a sequel to the text; it has been called Yanshi Jisheng Xufang (Master Yan's Continuation of the Jisheng Formulas) or Chong Dingyan Shi Jisheng Fang (Master Chong Dingyan's Jisheng Fang) containing 90 additional remedies. It is often considered a part of the original, together called Jisheng Fang. More than 20 of the formulas from these two works are retained in modern TCM literature (3). The Jisheng Fang was written during the middle of the Jin-Yuan medical reform period (1127-1368), when several competing ideas about the main causes of disease were presented (see: The Jin-Yuan medical reforms). Yan Yonghe was a younger contemporary of Li Dongyuan, also known as Li Gao (1180-1251), who was the recognized leader of one of four schools of medical thought that developed at this time. Li's school emphasized tonification of the spleen and stomach, because he believed that digestive weaknesscaused by poor diet, worrying, and overwork-led to many diseases. The main text of the school was Li's compendium Pi Wei Lun (Treatise on Spleen and Stomach ; published 1249). The most famous formula to come from his work is Buzhong Yiqi Tang , the formula for tonifying the center (with ginseng, astragalus, atractylodes, and baked licorice) and regulating the flow of qi (with bupleurum and cimicifuga used to raise the yang qi). Yan Yonghe, like Li Gao, emphasized the importance of the spleen and stomach-representing the digestive system-in the cause of and treatment of diseases. However, he supported the concept of the "pre-natal school," invoking the fundamental role of the kidney fire. The prenatal school had been the forerunner of Li's spleen/stomach school, which, instead, was based on the "post-natal" spleen/stomach. Xu Shuwei (1079-1155), a physician who represented the prenatal school and was author of Leizheng Puji Benshi Fang (Classified Effective Prescriptions for Universal Relief), stated (4): When the kidney qi is timid and weak, the genuine original qi is in a degenerated and exhausted condition; then there is inability to digest meals. As rice and grains in a cooking vessel which has no fire beneath it will not be ready to eat, when the genuine fire of the kidney is not sufficient, the food is not cooked-the stomach is unable to transform and digest it. The pre-natal school compared the stomach to a cooking vessel heated by a fire. Just as food is cooked in a wok to make it more tasty and digestible, when properly heated, the stomach is able to convert the food into usable qi. The spleen then transports the foods' basic flavors-its essential qi-to nourish the organs. The properly warmed stomach will break down the food materials so that the spleen can further transform and transport them, such as when it nourishes the lungs by raising the transformed food essence to them. The fire that warms the stomach is the mingmen fire (Life Gate; Kidney Qi; Genuine Fire). If this fire weakens, then the food is not properly digested, and one can suffer from food stagnation with transformation of the residual mass to pathologic dampness and phlegm. According to this school of thought, the mingmen fire is a key focus of attention for the physician, being even more important than the stomach and spleen organs that it supports. The "prenatal" school gets its name from the concept that the original kidney essence, determined while in the womb, gives rise to this mingmen fire, while the postnatal school gets its name from the idea that the spleen and stomach develop with maturation of the infant who, at first, is unable to consume food (5). The designation of prenatal and postnatal schools was explained later by Li Zhongzi (1588-1655), referring to the early days (prenatal) and later days (postnatal) (6): Why are the kidneys the roots of the early days? Even before the fetus assumes any form, the two kidneys are already in existence. They therefore constitute the roots of the zangfu, of the 12 blood channels, the roots of inhalation and exhalation, and the source of the triple burner. The very beginning of human existence depends on the kidneys. Therefore, it is said that the source of early days lies in the kidneys. Why is the spleen called the source of late days. When the infant assumes its bodily form and does not eat for a day, it becomes hungry. When it has received no nourishment for seven days, the intestines and stomach dry up and the baby dies. In the classic it is written: 'Whenever sufficient nourishment is present, life flourishes; where the supply of food is interrupted, life is doomed.' If the influences of the stomach have finally been destroyed, all medicines are of absolutely no use. As soon as the body assumes its physical form, it requires the influences contained in foods....For the entire course of his life, man depends on these influences, thus we speak of the roots of late days. In short, life cannot begin and the body cannot be formed without the essence stored in the kidneys, hence these are the root of the beginning of life. However, life cannot be sustained without the effective function of the stomach and spleen to take in and absorb nutrients, hence the continuation of life is rooted in these organs. The reason this distinction is deemed an important consideration in traditional Chinese medicine is that one of the primary issues debated over the centuries was: at which pivotal point should medical intervention be aimed? Is it warming the mingmen? Tonifying the spleen and stomach? Regulating the heart? Getting rid of pathological fire? Nourishing the yin? Of course, one can conclude-consistent with the doctrine of modern TCM-that for each individual one must analyze the constitution, disease influences, symptoms, and signs, and treat the individual accordingly. Yet, there had long been a hope entertained that one could identify a single primary basis for most disease. It is for this reason that there were the competing schools of the Jin-Yuan medical reform, each vying for the position of having identified the key to disease causation and, therefore, the associated prevention and treatment strategies that would work best. Yan Yonghe considered that indigestion, stuffiness of the chest and abdomen, and loose stools are examples of problems due to

"degeneration and deficiency of the genuine fire (mingmen)," with the resulting inability of the spleen and stomach to steam and cook the food, followed by symptoms of phlegm-fluid accumulation. Xu Shuwei, his predecessor in this school of thought, had advocated that when tonifying the spleen "the constant warming and tonifying of kidney qi is essential." But Yan went a step further and indicated that "tonifying the kidney qi is better than tonifying the spleen." The importance of mingmen fire persisted as a significant medical view for several centuries. For example, during the late Ming Dynasty, a "warm nourishment" school developed that was based on this concept. The therapeutic approach involved the use of warming tonics to invigorate the kidney qi and the spleen yang. Li Zhongzi, who was quoted above in relation to the distinction of pre- and postnatal schools, was a prominent member of the warm nourishment school, along with Xue Ji (1486-1558), Sun Yikui (1522-1619), Zhang Jingyue (1563-1640), and Zhao Xianke (1573-1644). Zhao specialized in the theory of the mingmen, and elaborated the functions of mingmen in relation to each of the viscera. In relation to the spleen and stomach, he said: "without it [mingmen fire], they are unable to steam and ferment the fluid and grains, and the production of the five tastes will be impaired." There had been an ongoing debate about the meaning of mingmen. In the Neijing ,the mingmen was directly associated with the eyes, but in the Nanjing (Difficult Questions, a series of inquiries into issues raised in the Neijing), the mingmen was associated with the kidneys. It was said, based on the Nanjing statements, that the left and right kidneys were different: the left is associated with kidney yin and the right with kidney yang and with the mingmen. Later, several authorities contested the idea that the two kidney lobes differed from one another, and, instead, placed the mingmen in the center of the kidneys and as the key element of the lower burner of the triple burner system (sanjiao). The mingmen contained, within this intermediate location, both a mingmen fire (yang aspect) and a mingmen water (yin aspect). From the discussion in the Nanjing and afterward, the mingmen was recognized as a key to life: without its warming influence, nothing in the body would function, nothing would move. Zhang Jingyue elaborated: The mingmen controls both kidneys and both kidneys belong to the mingmen. Mingmen is the mansion of both water and fire, the house of yin and yang, the sea of essence and blood, the nest of life and death. If the mingmen is depleted and damaged, the five zang and six f u lose their sustenance, and the yin and yang will become sick, causing all types of disorders. One of the main formulas for treating kidney qi deficiency had been presented in the ancient Jingui Yaolue (220 A.D.), which had become quite popular during the Song Dynasty and influenced the medical reforms that were soon to come. The formula, Bawei Dihuang Wan (Rehmannia Eight Formula), later became known as Jingui Shenqi Wan (the Kidney Qi Pill from the Jingui) . This formula, as understood in modern times, relies on cinnamon and aconite to invigorate the mingmen fire (or kidney yang) and rehmannia to nourish the mingmen water (or kidney yin). The role of rehmannia is dual and based on the fundamental yin/yang concept: on the one hand, it supplements the yin essence that nourishes the yang; on the other hand, it helps the yin essence control the yang and prevent it from flaring up. Zhang Jingyue always emphasized the first point-that the "deficiency of mingmen fire is due to depletion of genuine yin [mingmen water]-hence he frequently included rehmannia in formulas that he designed to treat the weakness of yang. Yan Yonghe demonstrated a particular interest in the problem of phlegm-fluid accumulation and adverse flow of qi that results from spleen and stomach disorders. Several of his formulas relied on spleen tonification with ginseng, which also supplements the yang qi. For dampness elimination, he relied upon citrus (zhupi), atractylodes (baizhu), hoelen (fuling), and, for severe cases with obvious edema, areca peel. For rectifying stomach qi he used fresh ginger and pinellia. To invigorate the kidney qi, aconite, cistanche, cuscuta, deer antler, cinnamon, and lindera were used. These herbs were recommended as therapies for enhancing mingmen fire by another contemporary of Yan, Wang Haogu (1210-1300) in his book Materia Medica of Decoction (Tangye Bencao). Over time, Yan Yonghe was nearly forgotten, and he has no biography listed in the major medical texts. But, his book became famous, particularly for its formulas that tonify the stomach and spleen, rectify qi circulation, dispel dampness, and transform phlegm. His best-known formula is Gui Pi Tang (Decoction for Returning the Spleen), which is understood as a prescription to warm up the spleen and stomach by nourishing the heart (within the Five Elements pattern, there is the concept that the fire element associated with the heart engenders the earth element associated with the spleen). The original formulas was: Gui Pi Tang astragalus ginseng atractylodes hoelen licorice (baked) zizyphus saussurea

30 g 15 g 30 g 30 g 10 g 30 g 15 g

The ingredients would be ground to powder, and then made into a tea by brief boiling along with fresh ginger and jujube. This formula has the same qi-supplementing basis as Buzhong Yiqi Tang , namely, the combination of ginseng, astragalus, atractylodes, and baked licorice. Astragalus and ginseng are thought to invigorate the heart qi, while zizyphus nourishes the heart blood (by analogy, these three herbs correspond to cinnamon, aconite, and rehmannia, respectively, in the Rehmannia Eight Formula). Gui Pi Tang was adjusted 300 years later (described in the book Jiaozhu Furen Liangfang) to include tang-kuei and polygala, which is the formulation that comes

down to us today. Other formulas described by Yan include several that are well-known, including Qipi Yin (Seven Peels Drink) for getting rid of damp and treating edema, Jiawei Shenqi Wan (modified Rehmannia Eight Formula) for treating dampness and numbness in the legs, and Ditan Tang (Phlegm-scouring Decoction) for resolving phlegm obstruction of the orifices (see the Appendix 2 for a listing of major formulas of the Jisheng Fang).

THE TITLE OF YAN YONGHE'S BOOK The translation of the title Jisheng Fang varies. Some translate it as Formulas to Aid the Living; others designate it Formulas to Save Lives. Fang simply means formulas or prescriptions; sheng refers to life, particularly in the sense of generation and growth, but the character is usually not used alone; rather it is combined with another character to produce a more specific meaning, though the second character can then be dropped in producing phrases like the book title. Ji means to help or aid or to provide relief. The title of Yan's book may be better translated as Formulas to Promote Well-Being, as sheng can be taken as short for shenghuo, referring to life and wellbeing, while j i can mean to alleviate suffering and bring relief. The title of another famous medical text, Puji Fang, is generally translated as Formulas for Universal Relief; which is also the translation for Puji in Xu Shuwei's book mentioned previously; so ji is used in this context to mean "bring relief." Only some of the formulas in Yan's extensive work might be characterized as life-saving, so the translation Formulas to Save Lives seems less suited. Most of the formulas are health-promoting in nature, and since one naturally uses formulas to aid the living, the other translations (commonly made and perhaps technically correct from the Chinese viewpoint) are probably not as valuable for our understanding of the text. So, Formulas to Promote Well-Being may be the translation closest to the original intent in naming the book Jisheng Fang.

REFERENCES 1. Xie Zhufan and Huang Xiokai (editors), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong. 2. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations , 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA. 3. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. 4. Jia Dedao, The historical development of the theories of the life gate and premier fire, Journal of the American College of Traditional Chinese Medicine 1982; (4): 3-7. 5. Zhang Haifeng, Spleen and stomach in traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1982; (2): 33-42. 6. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA.

December 2002

APPENDIX 1. Yan's Home Area: Lushan The Jin-Yuan medical reforms owed much of their impetus to physicians working in Hubei Province. Li Gao (1180-1251), head of the spleen/stomach school, was from that province and was influential in Yan's work. The dates of Yan's birth and death are not known but have been determined to be approximately 1206-1268, so he was able to learn from the elder Li Gao while Li was still vigorously working. Yan was born and lived near Lushan (Mount Lu). This famous mountain is situated at the outskirts of Jiujiang city at the northern tip of Jiangxi Province adjacent to Hubei (see map below). It's rugged beauty has influenced poets (it is said that over 1,500 of them climbed this mountain for inspiration), scholars, wise men, and religious seekers. On the mountain is the Donglin Monastery built in 384 A.D.; it is the birthplace of the Lian Sect (Pure Land) of Buddhism. Solitary and imposing, Lushan towers over the southern bank of the Yangtze River, leaving behind its shadows upon the huge Boyang Lake.

As a result of tremendous rubbing and grinding of glaciers, its sharp peaks and cragged cliffs look all the more precipitous. The enveloping clouds and mists make it very hard to define the true shapes of the peaks and ridges. The rapid streams cascade down and form numerous deep pools and hanging waterfalls. To describe the infinite variety of fantastic shapes of Lushan Mountain, Sudongpo (a famous Song Dynasty poet, 1037-1101) wrote in his poetic masterpiece: "I can't tell the true shape of Lushan, because I myself am in the mountain!"

Anhui Province, to the northeast of Lushan, is one of China's largest producers of medicinal herbs. Most of the herbs in Yan's formulas come from that province today. The region surrounding Jiujiang was famous for its production of magnolia bark, one of the important ingredients Yan used for the treatment of stagnated fluids. Unfortunately, most of the trees were felled in recent years.

APPENDIX 2. Formulas of the Jisheng Fang For ease of understanding Yan's approach to therapy, his formulas that come down to us today are here divided into three groups; tonic and warming formulas, surface relieving formulas, and formulas for accumulation, heat, and disordered stomach qi. The details of the formula ingredients and proportions are relayed from Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (3).

1. Tonics and Warming Formulas for the Spleen and Kidney Renshen Hutao Tang (Ginseng and Walnut Combination) Ginseng 6-9 grams Fresh ginger 5 pieces Walnut 5 nuts

This simple prescription warms the spleen, lungs, and kidneys to treat cough, asthma, and fullness in the chest. Jiawei Shenqi Wan or Jisheng Shenqi Wan (Rehmannia Eight Formula with achyranthes or cyathula and plantago seed added, sometimes called Achyranthes, Plantago, and Rehmannia Formula) Rehmannia Cornus Dioscorea Alisma Hoelen Moutan Cinnamon bark Aconite Cyathula Plantago seed

15 g 30 g 30 g 30 g 30 g 30 g 15 g 15 g 15 g 30 g

The ingredients are to be ground to powder, made into pills, and taken with rice water. It warms the yang, tonifies the kidneys, assists the qi in transforming water, and promotes urination to reduce edema. Jisheng Tusizi Wan (Dodder Seed Pill) (Equal parts all ingredients): Cuscuta Cistanche Aconite Antler Alpinia Lindera Dioscorea Oyster shell Schizandra Gallus Mantis The herbs are to be powdered and made into pills. The formula warms the kidney, invigorates yang, dispels abdominal chills, and astringes essence. Simo Tang (Four Milled Herbs Decoction) Ginseng Areca seed Aquilaria Lindera

3 g 9 g 3 g 9 g

The herbs are to be ground to powder and the briefly decocted. The formula regulates flow of qi, warms the kidney and spleen, alleviates fullness of chest and abdomen. It is used for constraint of liver qi due to injury from emotional upset, with uprising of stomach qi that adversely affects the appetite. Shi Ti Tang (Kaki Combination) Kaki Clove Fresh ginger

9 g 6 g 6 g

The herbs are decocted; the formula warms the middle burner and helps overcome upward flow of stomach qi. This prescription is used for hiccoughs due to cold stomach.

2. Surface Relieving Formulas Xiong Su San (Cnidium and Perilla Formula) Cnidium 10 g Atractylodes 10 g

Citrus

10 g

Pueraria Perilla Ophiopogon Peony Licorice

10 g 5 g 10 g 10 g 10 g

The ingredients are to be decocted with fresh ginger and green onion. The formula resolves the surface, dispels wind-cold, and reinforces the spleen. Ju Su San (Citrus and Perilla Formula) Citrus 3 g Apricot seed 3 g Perilla 3 g Atractylodes 3 g Pinellia 3 g Schizandra 3 g Licorice 1.5 g Fritillaria 3 g Morus bark 3 g The ingredients are to be ground to powder, then briefly decocted with fresh ginger. The formula is used to ventilate the lungs, resolve phlegm, alleviate cough, and resolve surface symptoms. It is deemed useful for common cold with cough. Canger San or Cangerzi San (Xanthium Formula) Angelica 30 g Magnolia flower 15 g Xanthium 7.5 g Mentha 1.5 g The herbs are ground to powder and taken in doses of 6 grams each time with green tea. It is used mainly for sinus congestion with sticky but profuse discharge accompanied by headache.

3. Formulas for Accumulation Disorders, Heat Disorders, and Uprising Qi Ditan Tang (Pinellia and Arisaema Combination; PhlegmScouring Decoction) Pinellia 8 g Arisaema-bile 8 g Citrus 6 g Chih-shih 6 g Hoelen 6 g Ginseng 3 g Acorus 3 g Licorice 2 g Bamboo 2 g The herbs are to be decocted. The formula is used for spleen/stomach weakness that leads to phlegm accumulation that pours over into the orifices, causing stroke with stiff tongue and difficult speech. Daotang Tang (Phlegm-expelling Decoction) Pinellia Arisaema (baked) Red citrus (juhong) Chih-shih Hoelen

6 g 3 g 3 g 3 g 3 g

Licorice

2 g

This is a modification of Ditan Tang. The ingredients are ground to powder and boiled with ten slices of fresh ginger. This formula is used for oppressive phlegm accumulation, causes fullness of the chest with expectoration of thick, sticky phlegm, or vomiting and loss of appetite due to phlegm stagnation of the stomach; other symptoms include headache, dizziness, vertigo, and stroke due to uprising phlegm blocking the orifices. Jupi Zhuru Tang (Citrus and Bamboo Combination) Red Hoelen 30 g Citrus 30 g Loquat 30 g Ophiopogon 30 g Bamboo 30 g Ginseng 15 g Baked Licorice 15 g The herbs are to be decocted with 5 pieces of fresh ginger. The formula is used to clear uprising stomach qi due to stomach heat, with vomiting and reduced appetite accompanied by thirst. This formula is modified to Jisheng Jupi Zhuru Tang by adding pinellia, with similar indications. Chixiaodou Tang (Phaeseolus Combination) Equal amounts of all ingredients (15 grams each) Phaeseolus Tang-kuei Poke Alisma Forsythia Red peony Stephania Polyporus Morus Euphorbia These herbs are to be decocted. The formula is used to clear heat, eliminate dampness, and dispel heat from the blood. Applications include treatment of sores and carbuncles, irritability, thirst, and reduced urination. Qipi Yin (Seven Peel Formula) Equal parts (15 grams each) Areca peel Citrus Hoelen peel Fresh ginger peel Blue citrus Lycium bark Licorice bark The herbs are to be powdered and then decocted briefly, with a dose of 9 grams each time. The formula regulates the qi, reinforces the spleen, and eliminates dampness accumulation. It is mainly used to treat edema. Shipi Yin (Spleen Bolstering Drink) Equal amounts of all ingredients (6 grams each, except licorice, 3 grams)

Magnolia bark White atractylodes Chaenomeles Saussurea Tsao-ko Areca seed Aconite Hoelen Dry ginger Licorice The herbs are to be powdered and then briefly decocted (the formula is also called Shipi San, referring to the powder). This formula is used for treating edema due to yang deficiency, with edema of the lower body, cold limbs, and not thirst; there is accompanying central stagnation of fluids, with distention of the chest and abdomen, loose stools, and thick greasy tongue coating. Juhe Wan or Jisheng Juhe Wan (Citrus Seed Pills) Citrus seed 30 g Sargassum 30 g Kelp 30 g Ecklonia 30 g Melia 30 g Persica 30 g Magnolia bark 15 g Akebia 15 g Chih-shih 15 g Corydalis 15 g Cinnamon bark 15 g Saussurea 15 g The herbs are to be ground to powder and made into pills with yellow wine and taken 9 grams each time with warm wine or salty water; alternatively, the powder can be briefly decocted. This formula resolves phlegm masses and disperses stagnant qi and blood. It is mainly used for the combination of qi stagnation, cold, and damp accumulation, leading to swelling and pain of the lower abdomen (including inguinal hernia or hydrocele). Shuzao Yinzi (Decoction for Diuresis) Alisma 12 g Phaseolus 15 g Poke 6 g Chiang-huo 9 g Areca peel 15 g Zanthoxylum 9 g Akebia 9 g Chin-chiu 9 g Areca seed 9 g Hoelen 30 g The herbs are to be decocted with 5 pieces of fresh ginger. The formula is used to alleviate edema with thirst and difficult urination. Qingpi Yin (Decoction for Clearing the Spleen) Equal amounts of the following (12 grams each) Blue citrus Magnolia bark Atractylodes Tsao-ko Bupleurum Hoelen Scute Pinellia Licorice

The herbs are to be decocted. This formula removes dampness and phlegm, and clears pathogenic heat of the liver that affects the spleen. It is a modification of Xiao Chaihu Tang (Minor Bupleurum Combination), with herbs added to disperse stagnant qi and dampness. Zhisou Baihua Wan (Lily and Trichosanthes Formula) Morus bark 100 g Aster 75 g Lily 75 g Asparagus 75 g Dioscorea 75 g Raw Rehmannia 75 g Fritillaria 75 g Ophiopogon 75 g Scrophularia 75 g Gelatin 50 g Anemarrhena 50 g Moutan 50 g Trichosanthes root 50 g Stemona 50 g Apricot seed 50 g Platycodon 50 g Scute 50 g Hoelen 50 g Licorice 25 g The herbs are to be powdered and made into pills. The formula is for cough and phlegm accumulation associated with lung heat, with spontaneous sweating due to yin deficiency heat. Xiaoji Yinzi (Thistle Drink) Raw rehmannia Breea Talc Akebia Typha Lotus node Lophatherum Tang-kuei Gardenia Baked licorice

30 g 15 g 15 g 9 g 9 g 9 g 9 g 9 g 9 g 6 g

The herbs are to be decocted; the formula is used for urination that is blood tinged due to excess of heat in the blood.

LI SHIZHEN Scholar Worthy of Emulation by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Li Shizhen was a highly influential figure in Chinese medicine and the author of the revered text Bencao Gangmu (Great Compendium of Herbs). The Bencao Gangmu is one of the most frequently mentioned books in the Chinese herbal tradition, rivaled only by the Shanghan Lun. Li Shizhen’s image (see Figures 1-7) is to be found at every traditional medical college in China and in any illustrated book about the history of Chinese medicine. Li Shizhen was the subject of a 1956 Chinese movie about his life and accomplishments. The modern kung-fu actor Jet Li described Li Shizhen as the person he most looks up to. There is a Li Shizhen award given to doctors and researchers who make valuable contributions to traditional Chinese Medicine. He is further given recognition in the labeling of herb products and there is even a Li Shizhen brand of herbs. One can say that in the pantheon of the greatest scholars of traditional China, Li Shizhen is the last towering figure to be recognized and, by virtue of that position, the main scholar who has been worthy of emulation ever since. The biographical information presented here about Li Shizhen and his main publication, the Bencao Gangmu, are derived primarily from three sources: the books History and Development of Traditional Chinese Medicine (1) and Medicine in China: History of Pharmaceutics (2), and the article China’s greatest naturalist (3). Li Shizhen was born in Waxiaopa, a small village just north of Qizhou on the Yellow River in what was northern Huguang and is today Hubei Province (see maps, Figure 8, 9). He was born in 1518 A.D., at the height of the Ming Dynasty (1368-1644 A.D.), which was a time when Neo-Confucianism gained many adherents. This doctrine emphasized the importance of personal behavior, morality, self-cultivation, study, meditation, and careful thought, while it downplayed the value of crafts and technology, including the practice of medicine. Neo-Confucianism was to have a significant influence on Li Shizhen’s life. Li Shizhen’s grandfather, who died when Shizhen was still an infant, had been an itinerant doctor; he would carry medicine pills and acupuncture needles as he journeyed from place to place, selling his services as a diagnostician and healer (see Figures 10 and 11, paintings depicting itinerant doctors). Such doctors were called lingyi, bell doctors, because they would announce their presence by ringing a bell; they were also called zoufang, wandering doctors, because they offered their services by visiting various places, especially the bazaars where many people gathered. Li Shizhen’s grandfather traveled across the rivers and lakes of the Qizhou region to visit towns at some distance from home. The itinerant doctors became known for an item they carried called a tiger’s sting, which could serve as the ringing bell (by tilting the ring, thus rotating the ball within it) to announce their presence. The story behind this icon was relayed by Mai Sun in 1890 in his description of itinerant doctors (4): They hold an iron implement in their hand which is shaped like a round hollow container. In this otherwise empty container, they swing an iron ball around in a circle. The implement has been called a tiger sting since the time of Li Cikou from the Song Period [around the 13th Century, when itinerant doctors are first mentioned in the medical literature]. Cikou was an itinerant doctor. He frequently traveled far into the mountains. Once, he encountered a tiger who had a thorn in his mouth and sought help from Li Cikou. Cikou placed the said implement into the tiger’s mouth in order to pull out the thorn. His art later gained fame everywhere. Those who carry on his art all carry this implement as their symbol and call it "tiger’s sting." The pills carried by these doctors were the early "patent medicines." The doctors required that the medicines, which were carried about in a bag slung over their shoulder or hung from their waist, had the qualities of being inexpensive, rapidly effective, and convenient. These qualities are today attributed to the Chinese patent medicines produced in large factories. In addition to carrying herbs and acupuncture needles, the doctors would perform moxibustion, pull rotted teeth, and apply salves to skin blemishes. Although these itinerant doctors were often popular among the masses, the scholarly doctors considered them mere quacks who would be involved in all sort of schemes to take money from the unsuspecting public. Thus, their position in Confucian society, where the scholars were at the highest levels, was rather low. Nonetheless, itinerant doctors remained a common part of China’s public life for eight centuries and a few such practitioners still exist today, most of them being herb salesmen who set up small stands and sell items collected from the local forests and mountains. Li Shizhen’s father, Li Yenwen, had decided to make a better life and became a traditional style (Confucian) physician and scholar. He was successful at this and attained the rank of a subordinate medical officer of the Imperial Medical Academy. He was widely respected by his peers. Li Yenwen is still known to this day for writing the first monograph on ginseng; he also wrote books on the four diagnostic techniques, on smallpox, on pulse diagnosis, and on the local artemisia (used for making moxa) of Hubei. Despite his accomplishments, those involved with practicing medicine were deemed to be residing low on the social scale even when among the scholarly class. Li Shizhen, who showed intelligence early on, was encouraged by his father to study the classics, take the imperial examinations, and aim for a government post as a non-medical scholar, the highest attainment possible for someone born outside Imperial circles. Little is known of Li Shizhen’s brother and sister, both of whom may have led ordinary lives. In his youth, Li Shizhen suffered from frequent illnesses and this generated in him a personal interest in becoming a doctor, despite his father’s intentions. He had available to him the medical books his father used, and he sometimes accompanied his father on medical calls, helping to write out the medical prescriptions as they were dictated to him. Meanwhile, his father continually encouraged Shizhen to study the literary classics, an effort which, no doubt, contributed to Li Shizhen’s far ranging accomplishments later in life. At age 14, Li Shizhen took the Imperial exams at the county level and passed. Unfortunately, when he went on to the national level examinations three years later, he repeatedly failed (three times) and eventually gave up that goal, but not for several more years. Under his father’s guidance, he continued to study the classics and plan for a governmental career. When Shizhen was 23, he decided that this scholarly path, based on philosophy, law, and bureaucratic procedures, was not suitable for him. Thus, he gave up on the pursuit, being determined, instead, to follow his father’s medical trade. At that time, his father relented and took him in as an apprentice, passed on all his clinical experience, and helped him become established as a doctor. Li Yenwen, having become a leading authority on pulse diagnosis, relayed to his son this valuable technique, for which Shizhen also became an acknowledged authority. Still, unlike some medical experts who thought that one could rely solely on the pulse, an idea which had

become the fashion at the time, Li Shizhen appreciated the fact that pulse diagnosis was just one of the four methods to be used. Li Shizhen found medical studies enthralling and he virtually shut himself away at his parent’s house for several years, carefully reading all the medical classics; he also studied relevant areas of philosophy and history and wrote poetry. In the field of herbal medicine, he became particularly interested in the method of writing prescriptions and was attracted to the idea of there being one dominant herb, the ruler of the prescription, that would contribute the main therapeutic effectiveness of the entire combination of ingredients. Such an approach requires intimate knowledge of the individual herbs that could serve as rulers in the formulas, leading to his extended study of the Materia Medica. By the time he was 27 years old, Li Shizhen had become recognized for his medical abilities; formal recognition came when he produced an accurate diagnosis and a cure for the son of Zhu Xian, prince of the Chu State. As a result, he was invited to be an official in the Chu Royal Court, in charge of the rituals and medical affairs. A few years later, he was recommended to the Imperial Medical Institute in Beijing as an assistant president. Thus, after some delays, he had succeeded in getting a governmental position. The bureaucratic surroundings did not suit him. Citing his delicate health as a reason, he left the governmental post after only one year of service, returning to his home where he worked as a medical practitioner. His short stays in the two royal courts provided a distinct advantage for his later work, as they gave him an opportunity to view rare books retained in the medical libraries, broadening his knowledge of medical history, theories, and practices. Desiring to help his patients by administering effective prescriptions, Shizhen diligently studied all the available books. It became readily apparent to him that there were serious problems with the herbal literature including considerable conflicting information, obvious mistakes, information that was simply being repeated in slightly different phrases, classification of unrelated items under a single heading or multiple listing of a single item under different headings, and omissions of important details. Seeing the disorder that permeated the field of herbal medicine, he decided to undertake a project of collecting the relevant information, sorting it out, correcting mistakes, and filling in missing items. Thus, at around the age 30, he began work on what was to become the Bencao Gangmu. In order to collect the necessary information, he traveled extensively and consulted experts in each area of interest, finding individuals who worked daily with field plants, water animals, snakes, birds, minerals, and so on. His travels took him to Hunan, Jiangsu, Jianshi, and Anhui (the latter still having one of the largest herb markets today). He collected and consulted 800 medical books, that is, virtually everything available in print at the time. His own book was loosely fashioned after the last Materia Medica guide that he considered reliable: the Jingshi Zhenglei Beiji Bencao (Classified Materia Medica for Emergencies, ca. 1090 A.D., during the Song Dynasty) by Tang Shenwei. Unlike earlier Materia Medicas, this book incorporated formulas, and attached a different recipe under each herb description to show how the herb was used. The resulting Bencao Gangmu was completed in 1578, when Li Shizhen was 60 years old, though he revised it in 1580, and again in 1587. As part of the 1580 revision, he approached a scholar, Wang Shizhen, to write the preface; Wang, who agreed to provide the preface, reported that Li was emaciated. His condition may have been due to his years of devoted deskwork finishing the book. The final illustrated text was completed with the help of Li Shizhen’s sons, particularly Li Qianyuan, and his grandsons; all together four of Li’s sons and four of his grandsons were mentioned as contributors in the acknowledgements section after the book’s preface. Li arranged to have the book printed in Nanjing, relying on the resources of the printer, Hu Chenglong. However, his main goal was to have it officially published: for that purpose it was turned over to the Imperial government of the Wanli Emperor, who ruled from 1573 to 1620. The book was delivered by Li Qianyuan, after his father’s death. Eventually, the Emperor added the notation: "Taken notice of; to be kept in the Ministry of Rites." In other words, the book was left to sit unappreciated until many years later when finally given formal recognition by the succeeding Emperor. The lack of interest in bringing the materia medica to official print was not due to any fault with the work itself, but disarray in the Imperial palace (5). The Ming Dynasty already had a poor track record for Imperial publication of medical texts: there was only one Materia Medica ordered during the Ming Dynasty (at the beginning of the 16th Century, just before Li Shizhen’s birth), and that one remained unpublished. In the past, the government sponsored production of Materia Medicas, usually by large committees of doctors; Li Shizhen undertook the task on his own and hoped for Imperial sanction after it was completed. The first edition of the Bencao Gangmu was eventually published in 1596 A.D., three years after Li Shizhen’s death. Hu Chenglong’s work on the project in Nanjing was done rather carelessly, and attained only limited distribution. Seven copies of the first edition made it to the modern era, but one was destroyed in Berlin during World War II. The next version, a 1603 edition, was published in Jiangxi, after the book was re-arranged. It incorporated three other works by Li Shizhen (about the meridians, not about herbs); like the Nanjing edition, it had limited distribution. Subsequent editions were in better form, though they mostly followed the arrangement of the 1603 edition. The original illustrations, which had not been of particularly good quality (see Figures 12-14, from the 1603 edition), were revised in 1640 A.D., just prior to the Manchu invasion that brought in the Qing Dynasty (1644-1911). With the reorganization and new illustrations, of which there were now 1,160 carefully executed drawings, the book quickly became recognized as a masterpiece. The book was then reproduced frequently, with subsequent editions in 1658, 1684, and 1717, with at least 15 editions during the Qing Dynasty. The book was disseminated around the world, with parts of it translated into Japanese (abridged version in 1637; more complete version in 1783), Latin (1656), French (1735), English (1736 and 1741 by different British translators), Russian (1868) and German (1895). Copies of the original Chinese version are found in rare book collections in many countries of the world (see Figure 15; a copy of the 1717 edition offered at a book shop in England). The most recent English translation is an abridgement that was published in England by B.E. Reid, in 1932. During the 20th Century, the Bencao Gangmu was finally replaced by modern Materia Medicas, the first official one sponsored by the Chinese communist government being Zhong Yao Zhi , published in 1959. The newer versions, produced since the 1980s, rely on full-color, realistic paintings of the herbs or photographs, and include the modern Latin binomials, information about chemical constituents, and other innovations. Thus, the Bencao Gangmu was the last major Materia Medica of the traditional era and is now a historical relic. The name Bencao Gangmu is derived from the title of the book by the Song Dynasty Neo-Confucian scholar Zhu Xi (1130-1200 A.D.), who wrote the Tongjian Gangmu. Bencao simply means Materia Medica (literally: ben = plant root; cao = plant top; hence: the various parts of plants); but gangmu has special meaning. Li Shizhen called each of his herb monographs "gang" (literally: key link,

essential points, subject), while the technical criteria for arranging the herb descriptions were called "mu" (literally: details, indexing, observing). The monographs contained up to 10 points of information about each medicinal material: · Information concerning a previously false classification; · Information on secondary names, including the sources of the names; · Collected explanations, commentaries and quotes in chronological order, including origin of the material, appearance, time of collection, medicinally useful parts, similarities with other medicinal materials; · Information concerning the preparation of the material; · Explanation of doubtful points; · Correction of mistakes; · Taste and nature; · Enumeration of main indications; · Explanation of the effects; and · Enumeration of prescriptions in which the material is used, including form and dosage of the prescriptions. The Bencao Gangmu is considered uniquely valuable for several reasons. First, it presented a huge number of diverse materials: 1,892 medicinal substances (1,094 from plants; 444 from animals, and 275 from mineral sources), including 374 new items. Many of the new items came from the far reaches of the Chinese Empire and from ships that sailed far from home to bring back foreign goods, among them, medicinal herbs. The new herbs generated considerable interest: some diseases are particularly difficult to cure or manage and doctors hope to find new therapies for such cases. Yet, in attaining this large total number of substances, Li had disposed of a number of items mentioned in Tang’s compendium, considering them to be of no value. He took care to correct errors in identification of materials presented in the earlier books and pointed out other medical errors. For example, he mentioned that the alchemical remedies made of heavy metals were quite toxic and did not prolong life, as had been recorded previously. Li particularly thought that the famous alchemist Ge Hong (281-341 A.D.) had led people astray by overly praising the value of these potentially toxic materials. So, the book both expanded and streamlined the prior medical works. Second, and as a reflection of his interest in formulation strategies, Li collected virtually all the prescriptions that had been handed down over the centuries and then presented over 11,000 formulas: about 2,000 of these were well known from other medical works, but over 8,000 were collected by Li from contemporary doctors and rare texts. With regard to ginseng (his father’s area of special interest), he recorded 77 prescriptions that included the herb, of which only 9 were ancient ones (including Si Junzi Tang, Four Major Herbs Combination); further, he explained the principles of the formulations (6). Five of the ginseng preparations relied on the single herb; most of the others had no more than 6 herbs. Third, as important as the breadth of the collection was its unique organization. Li was able to categorize the medicinal materials into more logical groupings than had been achieved ever before. The groupings came close to the binomial system introduced by Carl Linnaeus during the 18th Century (his main books being Genera plantarum, 1737, and Species plantarum, 1753). Charles Darwin (author of The Origin of Species, 1859), in working out his theory of evolution, is reported to have quoted from the Bencao Gangmu, which had such detailed information about the variations of plants and animals that it helped fill out the theory. Finally, the Bencao Gangmu is appreciated as a historical record because Li quoted from 952 previous authors. In fact, he also provided an extensive bibliography, listing 277 books on medical subjects and herbs and 591 other texts, such as literary classics and historical works. Joseph Needham, the famous British historian who spent most of his adult life on the multi-volume work, Science and Civilization in China, declared that the greatest scientific achievement in the Ming Dynasty was the Bencao Gangmu (8). The Bencao Gangmu was also criticized. As relayed by Paul Unschuld, this work was aimed at correcting errors, but ended up passing on and introducing several errors. More importantly, the book was so big that it was not practical for practitioners to use as a guide. Unschuld points out (5): Criticism of the Bencao Gangmu by subsequent Materia Medica authors was directed mainly against the size of the work. This criticism is justified when one judges the work according to its usefulness for the practicing physician. While Tao Hongjing [the last truly great materia medica author before Li Shizhen] in his work had restricted himself to the presentation of a purely medical-pharmaceutical subject, Li Shizhen created a comprehensive encyclopedia, in which he frequently went beyond the popular pharmaceutical scope. The size of the work made it expensive and unwieldy. The ballast of treatises digressing into marginal areas--of interest perhaps to Confucian medical scholars, but not to practicing physicians and pharmacists--therefore became the target of criticism. One of the famous herb authorities who came after Li Shizhen and who was overshadowed by him was Wang Ang (ca. 1615-1700 A.D.). He commented on Li Shizhen and the Bencao Gangmu: From antiquity to the present time [ca. 1700 A.D.], several hundred authors have written Materia Medicas. None of them, however, surpasses the Bencao Gangmu of Li Shizhen in either spirit or accuracy. The examinations and studies are both profound and extensive; information is comprehensive and clear. For this reason, I admire the attitude of this man and would like to speak in praise of his extreme perfection. However, the chapters and volumes were written in such numbers that it is difficult to study completely during the course of a lifetime. Furthermore, it is rather cumbersome to bring along when traveling by boat or carriage. It is indeed an all-embracing work, but that which is essential cannot be recognized immediately. In a review of the history of Chinese medicine, Wong and Wu (7) note that: In such an enormous work there are bound to be mistakes and defects. Some of the criticisms are that too many unrelated and useless articles are included which makes it very difficult for one to know what is good; the great number of recipes, some of them not well chosen, add to its cumbersomeness instead of enhancing its value, and the lack of a proper index in a work of this nature is a great drawback. It should be remembered that the tendency of the Ming writers was to produce voluminous works. It was therefore unavoidable that at times quality was sacrificed for quantity. Nonetheless, Wong and Wu, like other observers, mainly have good things to say about the work and its author, continuing: "Li Shizhen deserves all the praise accorded him in Ming history, for a work of this magnitude requires immense resources and the

undivided effort of a lifetime." Writing during the 1930’s, they noted: "Even today, it is considered one of the most popular books on medicine, being widely read both by the profession and the laity." Their overall assessment is that: "the Bencao Gangmu is undoubtedly the best work on Chinese materia medica. It is the most varied and comprehensive known." Starting in the 17th Century, in addition to several publishers reproducing the Bencao Gangmu, various explanatory texts and addenda to the work were written and published. The Wanfang Zhenxian (Needle and Thread for 10,000 Prescriptions ), which served as an indexing system for finding herb formulas in the Bencao Gangmu, was written by Cai Lixian and published around 1652. The Bencao Gangmu Shiyi (Addendum to Bencao Gangmu) was written by Zhao Xuemin around 1800 A.D. and published in 1871 A.D. It included several corrections of mistakes, reorganized and indexed the materials, and added 716 medicinal substances, many of them introduced from foreign countries during the decades since Li collected his original information. This work introduced tobacco and described the practice of smoking opium for the first time, clearly showing the foreign influences that would have a huge impact on the entire future of China. Li Shizhen also produced 11 other books on medical subjects, of which only 3 have survived to the present. Of those, his work on pulse diagnosis (Pinghu Maixue, 1564 A.D.) is most highly regarded and still referenced in discussions about the interpretation of the pulse categories. However, even if Li had done nothing else, he would have been recognized as a master scholar for the Bencao Gangmu. Li’s devotion to the subject--as revealed by the extent of his research and the decades of life dedicated to gathering, sorting through, and organizing the information--make him a scholar who is worthy of emulation even now, more than four hundred years after he completed his book. REFERENCES 1. Wang Zhenguo, Chen Ping, and Xie Peiping, History and Development of Traditional Chinese Medicine , 1999 Science Press, Beijing. 2. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 3. Lu Gwei-djen, China’s greatest naturalist: a brief biography of Li Shizhen , American Journal of Chinese Medicine 1976; 4(3): 209218. 4. Unschuld PU, Medicine in China: Historical Artifacts and Images, 2000 Prestel Verlag, Munich. 5. Huang R, 1587 A Year of No Significance: The Ming Dynasty in Decline, 1981 Yale University Press, New Haven, CT. 6. Hu Shiuying, Knowledge of ginseng from Chinese records, Journal of the Chinese University of Hong Kong 1977; 4(2): 281-305. 7. Wong Chimin and Wu Lien-Teh, History of Chinese Medicine, 1973 AMS Press, Inc., New York. 8. Sai HM, Medicine in China, 1965 Hamdard Academy, Karachi, Pakistan. 9. Hsu HY, et al., Oriental Materia Medica, 1980 Oriental Healing Arts Institute, Long Beach, CA.

Illustrations Figure 1. The most frequently reproduced drawing of Li Shizhen, seen in similar form in many books. The hat is typical of that worn by a Confucian scholar (1). Figure 2. Painting of Li Shizhen from a collection of 20th-Century paintings of famous medical scholars. The paintings, produced around 1959 to commemorate the achievements of traditional Chinese medicine, are displayed at the Academy of Traditional Chinese Medicine, Beijing (8). Figure 3: Li Shizhen on the dust jacket of the first English edition of Oriental Materia Medica published by Oriental Healing Arts Institute, Long Beach, California (9). Figure 4: Li Shizhen depicted learning about herbs from local specialists during his travels, printed on a postcard, Tianjin 1988 (4). Figure 5: Li Shizhen pointing to a passage in his work Bencao Gangmu describing a Chinese medicine product (Ejiao; gelatin from donkey skin, processed with several herbs) in this flier that accompanies the product, ca. 1985 (from actual package insert). Figure 6: Small statue of Li Shizhen, probably from Guangdong (4). Figure 7: Bust of Li Shizhen at his tomb in Hubei (1). Figure 8: Map of China at the time of Li Shizhen’s birth, during the height of the Ming Dynasty. Huguang Province was later divided into northern Hu (Hubei) and southern Hu (Hunan). The capital of Hubei is Wuhan and Li Shizhen’s home was on the Yangzi River (Yellow River), west of Wuhan. Figure 9: Local map of Hunan, showing Qizhou, closest city to Li Shizhen’s home on the Yellow River. Li Shizhen was also known as Pinghu Shanren, a recluse (literally: mountain man) at Pinghu Lake, where he resided while working on his books. Figure 10: Painting of itinerant doctor passing through a village; he carries in his right hand the tiger’s sting, in his left hand a staff with amulets (for protection from or exorcism of demons that cause disease), and at his waist a bag of medicines (4). Figure 11. Detail of itinerant doctor, holding his tiger’s sting and medicine bag; he also holds up a printed listing of his remedies and their indications and effects (4). Figures 12-14: Illustrations of birds, four legged animals, and plants from the 1603 edition of Bencao Gangmu with the original illustrations (2). Figure 15: Book pages from Sam Fogg Book Store (London) ad for a 1717 edition of Bencao Gangmu, showing the revised illustrations first provided in the 1640 edition.

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THE METHODS OF PREPARATION OF HERB FORMULAS: Decoctions, Dried Decoctions, Powders, Pills, Tablets, and Tinctures Essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Westerners learning about Chinese herbs are often exposed to unusual concepts regarding the form of herbal administration. I have heard some acupuncturists trained in the U.S. say that the Chinese believe that herbs should always be administered as decoctions, as this is the best. Unfortunately, they must never have heard of the numerous traditional herb formularies that described using herbs in the form of powders and pills, nor the 18th century essay by Xu Dachun titled "On the inadequacy of decoctions to completely cure illnesses." Also, they must not have read of successful clinical trials conducted in China using other forms of herbal preparation, nor the admonishment of pharmacists that using certain ingredients in decoction form can be a waste of raw materials. Others have told me that tinctures are clearly best, as the herbs are more assimilable in that form. Unfortunately, they must never have searched the literature for evidence supporting that claim, as they would not have found such evidence. Even if it were the case for a particular herb or a particular class of chemical compounds, one could hardly expect this to be an established fact for all herbs put in tincture form. They must also not have read the literature about the important category of polysaccharide ingredients in herbs. These components are condensed by alcohol and are generally absent from any alcohol-based preparation. Still others may purchase pills and tablets for their patients, feeling confident that compliance will be good, without stopping to consider whether this form is suitable for the condition being treated. They may never have heard the idea of using high dosage decoctions to initiate a therapy and then using the pills and tablets as a follow-up to consolidate the effects once a substantial improvement has been attained. Perhaps the practitioner may not have realized that typical dosages of pills or tablets given to patients in China are 10-15 at a time, often repeated three times daily, making this form seem less suitable for compliance and more expensive. In the introduction to Commonly Used Chinese Herbal Formulas with Illustrations (by Hsu and Hsu), examples of forms of administration are outlined. These include decoctions, powders, pills, unguents, pellets, elixirs, medicated essences, tablets/cakes, rods, threads, washes, fumigants, suppositories, and enemas. Clearly, the Chinese did not limit themselves in the methods of administration and did not focus solely on one type as the best. Today, Chinese herbs are also administered by injection (into acupuncture points or into veins), intravenous drip, nasal spray, and other means. In this article, I will explore some of the issues surrounding the selection of form of administration for herbs, relying on the methods most often used in the West (orally ingested materials). The subject matter is actually so broad that only a portion can be covered here, but it is hoped that readers will become more aware of the importance of considering the form of an herbal preparation.

DECOCTIONS We can only speculate on the origins of decoctions, but it is easy enough to imagine that if you wanted to try to consume a food or medicinal herbal material that was tough (perhaps very fibrous), there was little choice but to cook it up in water and drink the resulting liquid (and, possibly, eat the softened material that had been boiled for a long time). Converting the herb (or animal or mineral) to a powder was simply not an option for most individuals: that would require first taking the time to thoroughly dry the substance and then make the effort to reduce it to powder by some simple means (such as was used to make flour from grains; though grains are a lot easier to powder than many other natural materials). Perhaps at an Imperial herbal pharmacy, one would have enough impetus and enough labor to produce some powders and store them up for when they need to be used; making a powder is not a spur of the moment option (though administering the already produced powders is), making a decoction could be done relatively quickly and easily. Decoctions were the dominant form of therapy in the Shang Han Lun, though other forms were mentioned, including powders and pills. This seems appropriate given the situation and the methodology in the text. The situation was a rapidly progressing disease that could easily cause death if not properly treated and the methodology was to adjust the formulation, often by changing only an herb or two, as the symptoms changed. Often, time was of the essence and one might not wish to use a premade formula. Further, some of the important prescriptions were intended to induce perspiration, and the hot liquid form was helpful in bringing about that result. By contrast, in the Song Dynasty herb compendium known as the He Ji Ju Fang, many of the formulas were presented as powders or pills. In fact, this highly influential text might be regarded as the starting place of the patent medicine industry that we know of today. Visitors to modern Chinese hospitals will usually observe the strong reliance on decoctions there. In fact many hospitals, and several independent pharmacies, will cook up the herbs on the premises, so as to save the patient the effort. This situation reflects a number of factors: 1. When Chinese medicine was revived during the 1950's, there were not many patent medicine factories, not much herb manufacturing equipment, and transportation of premade formulas from one region of China to another was difficult. Therefore, the cruder method of boiling up large slices of herbs was relied upon, and this method has simply continued for some time afterward. 2. The recommended dosages of herbs has become quite high in recent years: higher than in the past. Some pharmacists claim that this is because of poor quality of herb materials and use of lots of substitute herbal materials. Whatever the cause, these high dosages can only be given at reasonable cost in the form of decoctions. 3. There is considerable emphasis on differential diagnosis in the hospitals. This means that premade formulations, such as powders and pills, are inappropriate. Yet, the situation is already changing as China's economy improves. There are now factories associated with many hospitals, turning out tablets that are used by patients (Western visitors may not see this aspect of medical practice unless they stay for some time). Decoctions were used by U.S. practitioners when Chinese herbal training was first available in the late 1970's and throughout the 1980's, but reliance on this method has declined somewhat for several reasons, including the widespread availability of other forms

deemed more convenient by practitioners and patients. Most often, herb decoctions are prescribed by Chinese immigrants who have prior training and experience in using this form and who are comfortable with designing herb formulas for each patient. Among the difficulties in using decoctions in the West today are the space requirements for storing herbs, the absence of pharmacists to take on the timely task of stocking the pharmacy and filling prescriptions, and the lack of adequate training at Western colleges of Oriental medicine (some of which do not emphasize herbal prescribing in any form). Further, there are techniques for making a highly effective decoction that have been ignored even in modern China, such as adjusting the cooking time for different ingredients. This issue will be explored here in some detail as a representative example of considerations that enter into making a good decoction.

COOKING TIMES FOR DIFFERENT HERBS The varying cooking times recommended for different Chinese herbs represent a balance between two major considerations: the time it takes for extraction of active components from the crude herbs and the rate of loss of active components by heat, oxidation, decomposition, and evaporation. When fresh vegetables are steamed or boiled, after just a few minutes the color of the vegetables becomes brighter, but a few moments later, they discolor and lose both taste and nutritional value. In the same way, herbs can be overcooked, with destruction of medicinal value. Minerals, and materials that have minerals as the main component, require the longest cooking time. They often have a low solubility and thus take longer to extract, but they are not damaged by prolonged cooking. In order to extract minerals, they must first be powdered, since the boiling water cannot penetrate to any significant depth; this is usually done by a device called a "cracker." Traditionally, it is recommended that minerals be cooked before other ingredients for about an hour. Dragon bone, oyster shell, haliotis, gypsum, talc, fluorite, and hematite are such examples. Prolonged cooking is also recommended when the destruction of active components is deemed desirable. For example, raw aconite is cooked for several hours to render it essentially non-toxic. Processed aconite need not be cooked as long since it has already been detoxified, but some herbalists still recommend extra cooking time compared to other herbs. An intermediate cooking time is recommended for herbs with non-volatile active components as their primary ingredients. For example, ginseng, astragalus, licorice, philodendron, coptis, and scute include components such as glycosides, flavonoids, and alkaloids that are not boiled away by prolonged cooking. Some components are not especially water soluble, that is, their chemical structure is such that it is "repelled" by water, but with long-term cooking, some of those components are forced out of the herb and into the water. These herbs are typically cooked for about 40-60 minutes (if these are added to a mineral brew after an hour of cooking, that means the minerals will have about two hours cooking time). In order for several herbs belonging to a complex formula to be effectively cooked in about the same amount of time, they must be cut to the appropriate thickness. The thickness of the herbs influences the time it takes for the active components to migrate from the middle of the herb material to the water medium. The slicing that is usually done before Chinese herbs are sold renders most herbs relatively thin, and thus able to be cooked for about the same amount of time (and a much shorter time than if they were uncut). Thick roots such as ginseng and tang-kuei are sometimes sold in whole form, but are best used after being sliced so that their thickness is comparable with other ingredients. Hard roots (e.g., tienchi) and barks (e.g., phellodendron) need to be thinner than soft fruits (e.g., lycium and chaenomeles). A significantly short cooking time is recommended for herbs that have volatile oils as major active components. As was recently demonstrated for cinnamon twigs, during the first ten minutes of cooking, the volatile oils appear in the liquid in increasing amounts as the water extracts them, but after ten minutes, the rate of loss into the air exceeds the rate of extraction, so the amount of active component decreases. Thus, a ten minute cooking time is about right. Herbs with volatile oils are especially found in the pharmacopoeia categories of Fragrant Herbs for Resolving Wetness, Spicy Herbs for Relieving the Surface, Herbs for Regulating Qi, Fragrant Herbs for Opening Orifices, and Herbs for Dispelling Chill (see: The use of aromatic agents for regulating qi, vitalizing blood, and relieving pain). To determine whether or not an herb has volatile oils, one can consider the fragrance of the herb when it is cooked (strong fragrance means more volatile oil) and one can also examine the list of ingredients in the herb, such as indicated in Oriental Materia Medica and in Chemical Constituents of Oriental Herbs by Hong-yen Hsu and his colleagues. The list of herbs relying on volatile components for their activity is very long; typical examples are cinnamon twig, cyperus, cardamon, clove, lindera, saussurea, and aquilaria. Some herbs are reputed to be damaged by prolonged cooking even though the volatile component is not the main ingredient. For example, uncaria and cnidium are recommended to be cooked for only ten minutes though the main ingredients recognized today are non-volatile. The problem that arises in relation to such herbs is that some chemical structures unfold under the influence of hot water, and become inactivated. Light flowery herbs usually require very little cooking because they are so thin. In some cases, it is recommended that the herb be wrapped in cloth (e.g., inula flower) so that it won't break up and float around in the tea, being difficult to strain out. Since flowers usually contain some volatile oil components, they can be cooked for a very short time with good effect, though it may not be required. Commonly used flowers include carthamus, chrysanthemum, buddleia, and lonicera. Gelatin is usually added to the hot tea after it has been strained because it will readily dissolve and by adding it last, it will not be lost to the pot (i.e., the sticky material will not attach to herb dregs and the cooking vessel). There are some items that ought not be cooked at all. For example, borneol is a highly volatile herb extract that is rapidly lost in decocting. It is intended to be used in the form of pills; one can obtain some borneol in a decoction by briefly cooking herbs such as cardamon. Many animal agents can be cooked but are not included in decoctions because they are very expensive. The extracted substances from animals tend to be a bit sticky and, as with gelatin, they can cling to the "dregs" that are tossed out. This may be acceptable for inexpensive items, such as earthworm, but is quite a problem when using products that cost several hundred dollars per pound. Musk is an example of a substance that is both extremely volatile and extremely expensive and thus would not be cooked (actually, today, musk is no longer available; muscone, a chemical component like borneol, is used, always in pill form). In modern Chinese practice, notoginseng (sanqi) and succinum are not included in decoctions, but given along with decoctions as a powder to be swallowed down with water or tea.

Despite the wide range of cooking times that can be recommended for optimal results, it is not at all uncommon for Chinese doctors to blend all items together to be cooked for the same period of time. The various losses that might occur from using a single cooking time (which may be too short for some items and too long for others) can be partly compensated for by using a larger dosage of those ingredients. This is not an exact compensation, since easily extractable and non-volatile ingredients will then be present in excessive amounts compared to other components, but it provides a reasonable approximation of the desired product. Fortunately for the herbalist, a majority of herbs are reasonably extracted by the intermediate cooking time. This includes virtually all components of the following Materia Medica categories (note exceptions for minerals): tonics, fire-purging, phlegm-resolving, blood-regulating, astringents, antirheumatics, and diuretics. There are certain rules to follow in making teas that can assist in getting the best quality product. Plant materials should be soaked in cold water for at least 20-30 minutes before cooking. This allows the plant cells to expand and thus to release their ingredients when boiled. If the herbs are boiled before they are fully moistened, the boiling water can seal in the active components by toughening the cell walls. To preserve volatile components, one can use a covered pot, but this will only help if the lid is several inches above the boiling surface (and thus at a lower temperature) and if the rate of boiling is low. Otherwise, the oils will just escape with steam around the edges of the lid (and the pot is likely to boil over). If this method is followed, a traditional technique of using a large volume of water and then boiling it down to a small volume of water cannot be followed. Since a reasonably large volume of water is needed to cover the herbs, this means that a larger volume of liquid must be consumed. To minimize leaving behind active components in the "dregs" (the strained out herb material), a second cooking can be done (with less water), and the two liquids (first cooking and second) can be combined. Some practitioners use the first cook as a one day supply and then have the dregs cooked again for a second day dosage. Unfortunately, this makes the two treatments markedly different. Dividing up materials according to cooking time is a major effort that helps explain why pre-made formulas that can just be swallowed down are so popular. However, one must be fully aware of all the major requirements for proper herb preparation to judge effectively when convenience may take precedence over other qualities.

DRIED DECOCTIONS Dried decoctions were developed in Japan in the 1950's and have become a major method of providing herbs in Japan, Taiwan, the U.S., and Europe. This new process appears to have been generated by the convergence of two virtually opposite trends. On the one hand, Japan began a major industrialization during this period, which led to the application of modern technologies to herbal medicine. On the other hand, there was a strong interest developed in relying on ancient Chinese herbal formulas, especially those from the Shang Han Lun and He Ji Ju Fang, with the belief that there was something inherently valuable in the ancient formulas that could not otherwise be matched by modern efforts. These two trends led to the production of convenient dried decoctions (a powder or, with additional processing, a granule) of the traditional formulas. In Japan forty years later, there are over 200 traditional combinations prepared by this method that are deemed standard pharmaceutical products covered by the national health insurance. In Taiwan, which adopted the technology and ideas from Japan, the dried decoctions are utilized in dozens of hospitals and clinics. The preparations were first imported into the U.S. around 1976 and into Europe around 1980, where they eventually superseded the use of home-prepared decoctions; due to various factors, the products imported from the Orient come from Taiwan rather than Japan. More recently, China has adopted this technology and now exports to the U.S. and at least one company in the U.S. manufactures the granules. The dried decoctions are produced by making very large batches of the herb formulas as decoctions (in large tanks), and then draining the liquid from the dregs. The liquid is then evaporated (using heat and vacuum) to form a syrup. The syrup is then put into a spray-drier along with a powder carrier (usually starch or the dried, powdered, herb dregs), and the remaining water is evaporated, leaving a dry powder. The amount of extractable materials varies considerably from one herb to another and from one formula to another. The finished product, on average, is about a 4.5:1 concentration of the ingredients of the crude herbs. Put another way, it takes about 450 grams (about one pound) of raw materials to yield about 100 grams of finished product (a typical amount dispensed at one time). Put another way, if you would prescribe to a patient a formula made with 90 grams of crude herbs (for a decoction), then you would prescribe about 20 grams per day of the dried extract. Actually, you may get by with a little less (say 12-18 grams/day) because some of the common errors of home preparation are eliminated by the factory processing. In the U.S. there are nearly 400 traditional formulas available in this form, and there are also about 400 single herbs made as dried extracts. One can prescribe the traditional formulas as is, or modify them by adding single herb extracts, or one can make up an entirely new formula using the single herb extracts. As with the decoctions there are a number of issues to be faced in using these materials. One has to rely on the factories to make decisions about the cooking time, and one is often unclear about the concentration factors of individual herbs and formulas, making dosing quite difficult to estimate. The cost of the materials is clearly higher than that for crude herbs used in making a decoction, but there are some cost-saving advantages in storage space, reduced losses (crude herbs are subject to damage by insects, for example), and better patient compliance (the patient need not spend time preparing the tea and need not consume the granules in tea form). In the U.S., the average cost per pound of crude herbs, from a Chinese shop, for making a decoction is about $10, while the average practitioner cost for 100 grams of granules is about $16. There are three ways to consume the materials. One is to put a measured quantity in the mouth and swallow down with a glass of water, just as one would do with a capsule or tablet. In fact, in Japan the granules are sometimes packaged in small foil tubes so that one simply tears the end off the tube and dumps the measured quantity of granules in the mouth, to be swallowed down with water. A second way is to encapsulate the granules and take them: some companies provide the traditional formulas already in capsules (or, in a few cases, in tablets). While this enhances compliance for some patients, it also tends to reduce the dosage consumed: a 15 gram daily dose generally requires 30 capsules (500 mg typical fill), which is both costly (compared to loose granules) and a lot of units to take. A third way is to put the dried decoction in a cup, add boiled water, and produce a tea. The products made in fine powder or tiny granule form can simply be stirred up and consumed immediately. Those made with larger granules (a specialty of Sun Ten Pharmaceuticals) are intended for the method of swallowing down rather than making a tea, but if left to soak in the boiled water for a few minutes, it can also be used as a tea. When a tea is made from the powders or granules, after sitting for a while there will be some powder at the bottom of

the cup. This is the carrier substance, and it need not be consumed. Increasingly in mainland China, herb formulas are prepared in factories by making a dried decoction and then pressing the material into a tablet (sometimes with small sugar coated tablets that are easy to swallow). These tablets are sometimes sold as patent medicines on the general market, but many are produced by factories associated with TCM colleges and hospitals and used locally only. Numerous Chinese medical journal reports mention this type of preparation in clinical trials.

POWDERS (other than dried decoctions), PILLS, CAPSULES, TABLETS Powdering of crude herbs to make medicines has a long history, having been mentioned in the Huangdi Neijing and even the pre-Neijing scroll "Wushier Bing Fang" (about 168 B.C.). The use of powdered herbs reached two peaks in Chinese medical history, the first marked by the publication of the He Ji Ju Fang (1080 A.D.) which mainly dealt with premade formulas in powder and pill form, and the other being the current era in which powdering machinery and the desire for convenient forms of herbs combined with ecological concerns to focus attention on this method. Powders may be ingested directly (swallowed with some water or tea) and are then called sanji ("powder form"), or made into a tea by boiling in hot water, and called zhusan ("pouring powders"). Powders that are rolled into sticky pills comprise a separate category because the binder used traditionally (e.g., honey or malt syrup) is believed to slow down absorption of the herb materials, and this is an intentional effect, or, at least, an effect that is taken into account in describing the action of the finished product. However, pills will be mentioned here because they are used, like powders, as substitutes for decoctions and other liquid preparations. Modern tableted or encapsulated powders correspond to the traditional powders that are ingested directly, since they are produced with the intention of promptly returning to powder form in the stomach, as the capsule or tablet quickly breaks down in the hot stomach juices. A Song Dynasty physician commented that the use of decoctions was declining in his time and that "When there is a situation where the use of decoctions is indicated, doctors usually prescribe boiling powders." Today, especially in the West, decoctions are largely being replaced by tableted powders instead. Producing powders is a difficult process: the herbs must be cut into very small pieces, dried sufficiently to make them brittle, and then crushed intensively enough to reduce them to a reasonably fine powder. This last step was accomplished, until this century, by grinding between stones by human or animal power (in some cases, small amounts were prepared in a mortar). In modern patent medicine factories in China, powders produced by machinery are expected to pass through very fine 80-100 mesh screens (such powders nearly dissolve in the stomach, not just break up into minute pieces). Many of the ancient powders could probably not pass through a 30 mesh screen. Powders sometimes have advantages over liquid preparations. To avoid wasting precious materials, it is usually recommended that items which yield poor extraction, which lose potency with heat and/or evaporation, or which are lost to the dregs and the pot, be powdered and ingested directly, even if other ingredients are to be taken in decoction form at the same time. In many modern Chinese herb factories, essential oils are sometimes separated from herbs and then added to the powders of the other formula ingredients. This is done, for example, to make Yin Qiao Jie Du Pian (Tablet of Forsythia and Lonicera Formula). Fragrant materials, such as borneol, aquilaria, dalbergia, and musk are often provided as powders or in pills. In modern times, many physicians are prescribing myrrh, frankincense, and other aromatics in powder form, though they had previously been used in decoctions. Toxic substances of medicinal value, such as realgar, centipede, scorpion, cinnabar, strychnos, and toad secretion are usually prescribed as powders or in pills in order to better control the dosage. When making an extract, the amount of toxic component available in the liquid can vary from a very large number of factors, while one can have much better control over the amount of a powder. Some ingredients, such as succinum, are poorly solubilized in hot water (or alcohol), while others are damaged by the extraction process, such as the heat denaturation of the anthelmintic proteins of omphalia: such materials are preferred in powder form. Even for some unexpected ingredients, such as alkaloids that are quite soluble and stable in water, there are instances where there are advantages to using powders. For example, in the 1988 Chinese Journal of Integrated Traditional and Western Medicine, a comparative study of Shedan Chuanbei (snake gallbladder and fritillaria) powder and liquid showed that the relative content of fritillaria alkaloids in the powder was much higher than in the liquid preparation (by more than 2:1). Further, the expectorant action, as measured in laboratory mice, was better with the powder than the liquid. In ancient times it was said that "The qi of raw materials is most poignant and works first." This suggests an appreciation for the properties of uncooked herbs. In the standard textbook Zhongyao Xue (1990), 80 medicinal materials are suggested to be prescribed in powder or pill form, either because they should never be boiled, are best if not boiled, or are more efficiently used if they are not extracted first. Among items commonly used in the West (and not already mentioned above) that are recommended in powder form are: the antiparasitic herbs torreya, quisqualis, and brucea (a tea of this herb is too bitter to consume); the purgatives mirabilitum and aloe; the animal substances gecko, wasp nest, arca shell, eupolyphaga, pangolin, leech, earthworm, tabanus, and clam shell; the minerals actinolite, magnetite, and lapis; the blood-vitalizing herbs cnidium, corydalis, and san-chi; the saps styrax, calamus gum, and bamboo sap; and miscellaneous items such as zizyphus, bletilla, indigo, cardamon, schizandra, and gleditsia. Convenience (of ingestion) is a major reason why powders are recommended by Chinese doctors. For example, if one has an acute symptom (e.g., an injury or influenza), it can defeat the value of an herbal remedy if one must first go to a doctor, get a script, go to the herb shop to fill the prescription, and then return home and spend an hour or more cooking the herbs prior to ingesting them. It is much more appropriate to have a prepared powder (at home or at a public pharmacy) which can be consumed by boiling in water for just a few minutes, or swallowing it down directly (even more convenient in pill, capsule, or tablet). These forms are also more convenient for those who are debilitated and don't have easy access to assistance in preparing decoctions, and for materials used repeatedly, for which the preparation and drinking of a decoction becomes tiresome. Prepared medicinal wines have similar advantages. As the population of China has soared, and the adoption of Chinese medicine by other cultures has grown, the demands on natural resources have dramatically increased while the land available for their cultivation has declined. One of the methods for dealing with this situation is to rely more heavily on powders, which are used at lower dosages, to replace the higher dosage decoctions. For "boiling

powders," the dosage of crude herbs is usually reduced by about two-thirds. As reported in the Handbook of Chinese Herb Preparation (1989), a comparison of making teas (by boiling) with licorice either from regular pharmacy pieces or from coarsely powdered licorice revealed that 28% more glycyrrhizin could be obtained from half as much licorice powder as cooked licorice slices. When ingesting powders directly, one-fifth to one-tenth the weight of herb materials utilized for decoction can sometimes be used in order to obtain similar effects. A 180 gram herb decoction might be replaced by two 9-gram boluses or by two dozen tablets. However, there are some limitations when the amount of crude materials is reduced in this way, such as getting reasonable amounts of trace minerals from the herbs. This must be taken into account when deciding which formulas to use in a lower dosage powder form and what disorders are to be treated by them. When herbs are powdered, their shelf-life is quite limited. The powdering process leaves much more surface area exposed to air, moisture, and light. Therefore, powdered herbs must be stored in tightly sealed, opaque containers, preferably in temperature-controlled environments if they are to be retained for an extended period. Making a tablet or pill alleviates this problem by again removing the exposed surface; encapsulation partly resolves the problem, depending on how tightly the powder has been packed into the capsules. Modern packaging (e.g., glass and plastic bottles) extends the shelf life of the materials. Directly swallowing loose powders has met with some resistance among Western patients (true also of the dried decoctions in powder or granule form). Making a tea from powdered herbs may be more acceptable for some, as long as the taste of the prescription is not too strong. Tableted powders have solved the majority of compliance problems encountered, but the number of tablets to be consumed still surprises many patients and there are some individuals with throat problems that have considerable difficulty swallowing tablets. Large tablets intended for treatment of adults may prove unacceptable to children who might otherwise benefit from the same formula. There are also some potential clinical disadvantages to prepared formulas presented as powders, capsules, pills, or tablets. One does not have control over the formulation (as would be the case with combining crude herbs for a decoction or combining dried decoctions of individual herbs), so one who relies solely on these forms is stuck trying to find a formulation that is compatible with the patient needs. Sometimes, it is necessary to combine two different formulas, with the result that a few herbs from each formula are included in the treatment even though they are unnecessary for the patient. Also, many Westerners are used to taking capsules or tablets made with Western drugs, at a dosage of one or two units at a time. With Chinese herbs, to get similar therapeutic activity, one may need to take 815 units at a time; this may deter patients and make them particularly concerned about any bodily changes that could be deemed an adverse effect of the herbs since they would certainly expect an adverse effect of that much of a drug product.

TINCTURES AND OTHER ALCOHOL EXTRACTS The term "alcohol" comes from the Arabic, meaning "finely divided spirit" and this makes reference to the idea that all substances have a spirit; the spirit of wine is so finely divided that it becomes invisible as it is driven from the liquid by heat, reappearing only upon condensation. The Chinese term for medicine, "yi", includes the pictogram for wine. It is meant to distinguish the "true" medical practitioners from the shamans, who were of questionable repute and relied on rituals, amulets, and things other than medicines. The best way to understand the uses of wine in medicine is to realize that, unlike water used to make tea or to swallow a pill, the wine or other alcohol preparation also serves a role as an herb. Alcohol contributes its own properties which are deemed rather potent and therefore must be taken into consideration. In the historical encyclopedia of the Han Dynasty, wine is classified as being hot, and is said to reach every part of the body, harmonize the blood and qi, open the meridians, foster yang, and expel cold. These properties are important to consider today because, in the West, a growing number of practitioners of Chinese medicine are using a wide variety of herb formulas in the form of tinctures (alcohol extracts). These same practitioners are often very cautious about using "hot" herbs, such as aconite, cinnamon bark, deer antler, and curculigo, or highly dispersive herbs, such as bupleurum, but may not give the same level of consideration to the role of the alcohol because it has not been discussed by most authors. If one were to visit China, Taiwan, or Japan, the use of herbal tinctures as substitutes for teas, powders, or pills would not be seen as common practice. There are medicinal wines, but these are to be consumed in substantial quantity and for specific ailments, not just any ailment. The utilization of all sorts of Chinese herbal formulas and single herbs in tincture form is a Western development, based on a practice of making tinctures of Western herbs, a practice that had rapidly expanded at about the same time that Chinese herbs were introduced to the West. The dosing of Chinese herbal formula tinctures was set at the same level as that for Western single-herb tinctures, resulting in consistent underdosing of the complex formulas. Henry C. Lu, a well-known Chinese doctor and teacher has said "Herbs may be taken with Chinese or Japanese wine or whisky or brandy in case of arthritis, rheumatism, and other symptoms of weakness, such as sexual impotence and recuperating from prolonged illness...when herbs are taken for hot diseases, liquor should not be taken at all." In the earliest known book about Chinese herbal therapies, the Wushier Bingfang, there are 30 alcohol prescriptions mentioned (about 11% of the total). Wine remedies mentioned in the Neijing are for treatment of meridian blockage, sudden fainting, and ear problems. Shang Han Lun formulas that are made with alcohol are exclusively for warming and blood-vitalizing effects; among them are two that are still widely used today: Carthamus Wine, for gynecological disorders, and Trichosanthes Fruit Wine, for cardiac disorders. Sun Simiao (6th century) described 80 formulas made with alcohol, also for warming and blood-vitalizing therapy. It is indicated in the Shengji Zonglu (1122 A.D.) that because of the penetrating action of alcohol, wine formulas are better than decoctions for treating meridian obstruction. The author also mentions the use of alcohol-based formulas for a syndrome of blood deficiency combined with qi stagnation, for cold syndrome, paralysis, cramping, and sudden fainting. Wine has been known in China for about 4,000 years. Originally, low-alcohol wines were produced from rice; specific herbs, such as curcuma (yujin), were included during the fermenting process to produce the finished product. Since about 500 A.D. it has become common to produce medicines by steeping the herbs in a distilled liquor. During the Qing Dynasty period, the practice of boiling herbs in wine instead of water was introduced as an alternative technique. Modern Chinese researchers have investigated the use of the "wine formulas." For example, two books have been published recently, A Great Compendium of Chinese Medicinal Wines (1991) and Treating 100 Diseases with Medicinal Wines (1990). The uses of the alcohol-based formulas are mainly in the following categories: Blood stasis, meridian obstruction, and/or cold syndrome: arthritis, paralysis, amenorrhea, dysmenorrhea, infertility, post-partum disorders, impotence, phlebitis, arteritis, chronic skin diseases (especially if associated with a cold syndrome), injuries, and fractures.

Miscellaneous disorders: cough/asthma, epilepsy in children, growth disorders due to malnutrition, tinnitus, and loss of voice. In Japan, a study of a medicinal wine, Youmeishu, first described in China during the Ming Dynasty, showed it to be an effective agent for post-surgical recovery for gynecological patients; consistent with use of wines in treating blood stasis. Because blood stasis and meridian obstruction are characteristic problems of aging, there is growing use of medicinal wines for that purpose. However, these materials can be problematic for some, since alcohol interacts with a wide range of modern drugs, and because of direct problems with alcohol ingestion for those with liver disease or alcohol hypersensitivity. The influence of alcohol on herb formulas is illustrated by the instructions for use of one of China's most famous remedies, Yunnan Pai Yao. When the product is to be used for stopping bleeding, it is to be taken with water. When, on the other hand, it is to be used to vitalize blood circulation, it is to be taken with wine for best effects. The amount of alcohol to be consumed with herbs was addressed by Sun Simiao. He indicated that to obtain the desired action, it was essential to consume a quantity which was sufficient to feel the effect of the alcohol (more than momentarily as a response to tasting it). He cautioned about the adverse effects of consuming too much. For the average American, the amount of alcohol in a single glass of wine is usually sufficient to meet Sun Simiao's criteria; this corresponds to about a "shot glass" of distilled alcohol (at 40% alcohol by volume); women have a lower tolerance in general. Recent Western findings that regular ingestion of wines made with red grapes may have health benefits, such as preventing heart disease, and that wines in general seem to promote longevity (perhaps by relaxation response) when consumed in the amount of about two to four glasses daily, tend to support the Chinese experience with wine ingredients that are even more medicinally potent than grapes. In many instances, Western manufacturers of Chinese herb tinctures do not select the tincturing process for any specific medicinal purpose, but rather to serve as a medium for extraction and preservation and to enhance compliance (especially among children). The dosage of herbs used in making the preparation is usually quite small, about 7-10 grams of dried crude herbs per one ounce of fluid extract. While alcohol/water mixtures (typically 20-40% alcohol) are generally superior to water in extracting active constituents of herbs, the effectiveness of boiling water is often comparable to cold alcohol used in tincturing. In some cases, such as the immuneenhancing polysaccharides of astragalus, lonicera, medicinal mushrooms, and other herbs, alcohol is actually a poor medium because it causes the components to condense out of the liquid (thus they stick to the herb dregs that are tossed out or to the surfaces of the processing equipment). The dosages usually recommended for tinctures, a few drops, may provide the extract of less than a gram of crude herbs and usually does not provide the "alcohol action" that Sun Simiao deemed important if the alcohol is indeed to count as part of the treatment (which may be of benefit in cases where alcohol provides a non-desired action, such as warming). Some practitioners advise adding the tincture to boiling hot water to drive off the alcohol, but this further condenses active components and drives off some of the important essential oils (for which alcohol/water is a good medium to aid evaporation). The thousands of years experience gained by Chinese herbalists and doctors in the use of alcohol in relation to herbal treatments should not be set aside lightly. Pretreatment of herbs with wine (e.g., the processing of rehmannia to produce shoudihuang), extraction of herbs with liquor (e.g., for Hu Gu Jiu for rheumatism), and consumption of alcohol along with an herbal pill (as is done with Yunnan Pai Yao), are part of the rich cultural heritage of China's medical tradition. In the West, tincturing was originally developed as a means of dealing with fresh plant materials; by soaking them in alcohol and straining out the plant mass, one could preserve herbs for future use. A large proportion of Western herbs are flowers and leaves, which have a very poor shelf-life if simply dried, as opposed to the Chinese tendency to rely on roots, rhizomes, and barks that have a longer shelf-life. The vast majority of early American patent medicines in liquid form relied on alcohol as the principal effective ingredient, containing very little of herb extracts. Most recently, tinctures have become common in part because of ready availability of alcohol for commercial use and the willingness of consumers and practitioners to accept the idea that minuscule amounts of such preparations have a substantial therapeutic potential. By pursuing a fuller understanding of the role of alcohol in the various stages of herb processing and in the general field of herbal therapeutics, the value of this method could be much better realized. May 1997

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MOXIBUSTION Practical Considerations for Modern Use of an Ancient Technique by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Practitioners of Chinese medicine usually receive limited training in moxibustion therapy. The training is mainly comprised of presentation of a few basic moxa techniques and a listing of some indications for use of moxibustion (e.g., to treat cold syndromes) and contraindications (e.g., in heat syndromes). The actual experience of utilizing moxibustion therapy is often confusing. Practitioners, patients, and others wonder about the smoke emanating from the moxa in terms of safety as well as other impacts. Practitioners are left without much instruction as to how intensively to apply moxa to get the desired results. Sometimes they are instructed to use moxa very mildly, with short duration, and infrequent administration in contrast to its actual use in China; and there remain questions about its mechanism of action and how effective it is. This article reports on an exploration of the literature on moxibustion to help clarify some of these matters. It is an expansion on a section of a previous START article from 1998, Borneol, Artemisia, and Moxa. That article makes reference to the herb material used for moxa (artemisia, also called mugwort) and one of its active components, borneol, which is isolated (provided in the form of crystals, called bingpian) and commonly used in topical therapies for its antiseptic and analgesic effects. A primary source used for this literature survey was the Journal of Traditional Chinese Medicine, published since 1982 in English and reviewed through 2003. This journal presents numerous articles on the various forms of traditional Chinese medicine practice, including a variety of techniques for acupuncture, moxibustion, cupping, blood-letting, therapeutic massage, as well as internal medicine (herb prescriptions) and topical applications of herbs. The journal includes articles that review techniques generally, as well as articles on treatment of specific diseases, or uses of specific acupuncture points or herbs. A limitation of this review is reliance on English language publications (translations from the Chinese), but an advantage is that readers will be able to examine most of the referenced texts and articles.

RELATIVE POSITION OF MOXIBUSTION IN ACU-MOXIBUSTION The original Chinese term for what we today routinely call acupuncture is zhenjiu, which refers to both needling (zhen) and moxibustion (jiu), two techniques understood to be essential parts of one fundamental approach to treating disease and maintaining health. Nonetheless, compared to acupuncture, moxibustion is usually deemed a secondary practice. In the Huangdi Niejing (comprised of the Suwen and the Lingshu), the textual basis of ancient and modern concepts about acupuncture and moxibustion treatments, only a few sentences are devoted to moxibustion. Paul Unschuld, in his detailed translation and analysis of the Neijing Suwen (1), devoted four pages to discussion of its application in a section on heat therapies. The origination and main application of moxibustion is described in the Suwen as follows: The North is the region where heaven and earth secure and store. Its land lies at a high altitude, its people live in earthen mounds. Wind and cold and icy chilliness dominate; its people find joy in living in the wilderness and in consuming milk. Their depots are cold and generate diseases of fullness. For their treatment, moxa burning is appropriate. Hence, moxa burning originated in the North. The reference here is to the north of China, specifically to the tribes of Mongolians, who drank mare's milk and lived at high altitude (the average altitude of Mongolia is 1,580 meters-about 5,000 feet-and its lowest point is 552 meters. Mud huts were the standard Mongolian housing in ancient times, and are still prevalent in smaller villages. The Mongolian winters are fiercely cold and windy and its climate is so difficult that only about 2.5 million Mongolians live in its vast territory today. It is clear that the purpose of moxa, a heating therapy, is to deal with the cold. Its role, as depicted in Unschuld's discussion, is to impart yang qi to the body. The typical diseases among these Mongolian people living in the cold north are categorized in this passage as involving fullness. This description is partly a reference to the concept that the north is devoted to securing and storing. Thus, for example, the Mongolians would gather plant and animal foods during the brief summer, and then store the materials for use throughout the year. The people, likewise, would store up foods within their body by eating heartily when food is abundant and relying, whenever possible, on rich, fatty foods, and on milk, which is to be used cautiously in those with spleen yang deficiency and fluid or phlegm retention (33). The cold could contribute to stagnation of the excess food essences, engendering a disease of fullness (e.g., excess yin). Often, such diseases would initially produce abdominal pain with gastric and intestinal spasms; if the disease advanced, it could cause swellings under the skin and formation of other masses. It is also mentioned in the Suwen that: In the case of harm caused by food, one should use moxa. If the disease does not come to an end, it is essential to watch for those conduits excessively filled with yang qi: pierce the respective transporters several times and give herbs. The situation where moxa fails, as described here, reveals some of the thinking about its effects. The harm caused by food is an accumulation, which should be dispersed by the warm moxa. The yang qi that the moxa treatment bestows is the basis of the dispersing effect. However, if the moxa fails to disperse the stagnation, then it has simply added a new excess, the yang qi, to the former excess of yin. Therefore, the response must be to drain the channels by blood-letting, so as to get rid of all the excesses. The case of treating accumulation associated with food stagnation and cold environment is one of the few instances in the ancient literature where moxa is recommended as the first therapy to try; in most instances, it is the resort should acupuncture fail. This fact is mentioned in the book Chinese Acupuncture and Moxibustion (2), with reference to the Neijing Lingshu as well as a later text: Chapter 73 of the Lingshu states: 'A disease that may not be treated [is not successfully treated] by acupuncture may be treated by moxibustion.' In Introduction to Medicine [1575 A.D.], it says: 'When a disease fails to respond to herbs and acupuncture, moxibustion is suggested.' A search for commentary on the history of moxibustion since the Neijing turns up little; apparently, the subject has not generated widespread interest, despite its continued use as a therapy. In the well-known text Huangdi Zhenjiu Jiayi Jing (Yellow Emperor's

Classic of Acupuncture) by Mi Huangfu (214-282 A.D.), moxibustion goes unmentioned, even in the chapters on diseases of cold (10). A monograph on the herb relied upon for moxibustion, artemisia (Aiye Chuan), published around 1500 A.D. by Li Yenwen, was lost. Its title is recorded, but nothing is quoted from it, not even in the Bencao Gangmu, published later that century by Li's son Li Shizhen, which carried quotations from his other monograph on ginseng (3). After the Chinese revolution in 1949, a great reorganization of traditional Chinese medicine was undertaken. One of the first steps was to investigate and evaluate the traditional methods of acupuncture and moxibustion therapy. The results of such studies were published in a series of reports in the English language Journal of Traditional Chinese Medicine in 1984. In the first article of the series (4), devoted to history of the practices, only the following was noted specifically about moxibustion: Some fifty kinds of moxibustion methods have been summarized through research into ancient literature on moxibustion. In these [documents] are discussed different materials for moxibustion, various shapes of mugwort cone or roll, materials to be placed between the point on the skin and the burning moxa, and different temperatures and manipulation of moxibustion. The second part of the series on acupuncture and moxibustion (5) is devoted to the variety of techniques employed currently (e.g., scalp acupuncture, wrist/ankle acupuncture, ear acupuncture, etc.). The article offers the following about moxibustion, with emphasis on the clinical efficacy of scarring moxibustion and attempts to introduce greater use of the other non-scarring methods: Some units have modified their moxibustion apparatus to facilitate the manipulation. Of the various methods of moxibustion, the ones in common use today are those using moxa cone, moxa stick for warm moxibustion, warm cylinder, and in certain cases, burning [the skin] with moxa. It has been pointed out that moxibustion therapy is especially effective for treating deficiency-cold disease, while it is contraindicated in excess disease and in fever due to yin deficiency. However, some workers have presented clinical cases of febrile disease successfully treated by moxibustion therapy. Ancient medical records support this claim. These workers have explored the problem and declare the banning of moxibustion therapy in febrile disease to be groundless. Still, the two opinions coexist and are debated. Moxibustion therapy is effective in simple and infantile diarrhea, chronic gastroenteritis, peptic ulcer, bronchial asthma, rheumatism of muscles and joints, neurasthenia, hypertension, menstrual disorders, chronic pelvic inflammation, and climacteric syndrome [menopause]. Definite effect was obtained in the treatment of pulmonary tuberculosis, and thromboangitis obliterans. A report of 182 cases of asthma treated with scarring moxibustion at acupoints selected on the basis of differential diagnosis resulted in a shot-term effective rate of 76.9%, with 70% long-term effective rate on followup examination for three years. Other reports claim that scarring moxibustion may markedly lower blood pressure, reduce blood viscosity, and dilate various vessels. These reports indicate that scarring moxibustion decreases the incidence of fulminant apoplexy by lowering blood pressure. Observation over 17 years of 54 cases of high blood pressure revealed that only 5 suffered from fulminant apoplexy after receiving scarring moxibustion, while 4 out of 12 in the control group did. These results of the therapy are obvious. Experimental and clinical studies have pointed to further health benefits of scarring moxibustion. An example is 299 cases of asthma treated by purulent moxibustion in which 70.6% were effective and 29.1% markedly effective. Abnormal WBC count in 20 cases before treatment were corrected in 19 cases….Animal experiments have showed moxibustion to markedly strengthen the immunity of the organism. Finally, it should be pointed out that although moxibustion has been extensively used clinically, it has received far less attention than acupuncture, a point deserving some thought. One can take note of the shift in therapeutic indications for moxibustion from accumulation (a type of excess) with cold to deficiency cold, where moxibustion is considered a means to tonify the deficiency. This shift may reflect a change from using moxibustion as a one-time treatment for dispersion to use of it in repeated daily treatments, since tonification of deficiency often requires prolonged therapy. Scarring moxa, also called purulent moxa, is where severe blistering and ulceration of the site occurs (sometimes with unintended infection of the sore), resulting in formation of a scar. This method reflects the dominant form of moxibustion until very recently; for this reason, many writers translate moxibustion as "cauterization." Instructions for moxa application in the Chinese literature would typically involve repeated burning of numerous small moxa cones on the skin directly, causing blistering or further damage. This type of moxa therapy is not discussed in any detail as part of Western acupuncture training because it is not allowable in Western practice. The production of useful moxa rolls for indirect heating is a modern technological development, compared to the simple practice of forming moxa wool into small cones by hand. Moxa rolls for indirect treatment were introduced at the end of the Ming Dynasty, but did not become common place until after 1950 when factories were established that could turn out thousands of them daily. Still, traditional doctors were used to employing the standard cones for direct moxa and many of them did not easily make the transition to this other method. In a report on scarring moxibustion presented at a conference in Beijing in 2000, Wang Kenliang (21) points out that: Moxibustion sore paste must be applied immediately after the moxibustion in order to protect the injured skin and promote non-bacterial suppuration. In one week after the moxibustion treatment, the exudate becomes more and the sore will suppurate gradually…after more than one month, the pus will disappear and the new flesh will grow, the injured skin will get recovered with only slight scar remaining. The patient must take good rest after suppurative moxibustion treatment and avoid heavy labor and abnormal emotions such as sadness and anger; the patient should also take proper food, limit sexual life, and prevent exposure to pathogenic cold or heat. More nutritious food should be taken such as fresh meat, beans, and fresh vegetables; all these foods help the recovery of the moxibustion sore and remove pathogenic factors….This therapy can treat tuberculosis, bronchial asthma, arthritis, hiccup, facial paralysis, and tuberculosis of the neck lymph. The author of the Journal of Traditional Chinese Medicine review article brings up point that moxa is used extensively in Chinese clinics but receives far less attention than acupuncture. This comment no doubt refers to limited reports of its use as a primary therapy and one can see from Wang's description that moxa treatment can sometimes be a rather serious ordeal, limiting its use in the large

hospitals from which most medical reports are generated. One can speculate about other reasons for its infrequent mention in the literature. Most articles on acupuncture therapy report on complex treatment patterns involving numerous acupuncture points. Needles can be inserted one by one and then the practitioner can perform manipulations on each, leaving them in place for 20-30 minutes. Moxibustion is usually done on only one or two of the points in a complex treatment pattern including acupuncture. As a result, the main part of therapy is the needling, with moxa as a small portion of the treatment. It is difficult for the authors of reports on these treatments to make the proclamation that the therapy is based on moxibustion or that the outcome was reliant on the moxibustion portion of treatment. Relatively few diseases are treated by moxa alone or with it as the primary therapy. Thus, little attention is given to this technique, in part, because it accompanies acupuncture where the latter is used with more points and with more specific manipulation. Articles on moxibustion as the primary technique tend to be short, and little is said about the point selection or method of applying the moxa. In an article purporting to describe diseases effectively treated by moxibustion (44), three cases are singled out and only one of them (treatment of pterygium) involved moxa alone, the others (carpal tunnel syndrome and throat neuralgia) involved moxa plus acupuncture. In fact, a search for clinical research on moxibustion in the Journal of Traditional Chinese Medicine (in publication for more than 20 years) revealed few articles on moxibustion, and the majority of the articles that mention this technique made use of it as a seemingly minor adjunct to acupuncture therapy. Articles that mention acupuncture and moxibustion in the title often are merely giving the translation of zhenjiu, while the treatments described involve needling only. In part 3 of the series reviewing acupuncture and moxibustion (6), with focus on the disorders the various techniques are considered useful in treating, moxibustion is specifically mentioned as successful for one application-correcting abnormal fetal position: The success rate of moxibustion on zhiyin (BL-67) in checking abnormal fetal position markedly exceeds the figure for manual restoration reported abroad. Two to 4 sessions sufficed, though cases with very loose or very tense abdominal wall, with fixing of the fetal head below the subcostal region, and with partial descent of the fetus into the pelvic cavity were less successful or even ineffective. The other reports summarized in that review involve either acupuncture alone or "acu-moxibustion," referring to use of acupuncture and possible inclusion of moxibustion in at least some of the treatments (with no mention of specific moxibustion techniques). A rare example of a report in which non-scarring moxibustion was used as a primary therapy for a chronic disease was published in 1992. It involved 183 patients with coronary heart disease. Here is the description of the technique, using moxa rolls: The acupoints selected included neiguan (PC-6, bilaterally), shenzhong (CV-17), and xinshu (BL-15 bilaterally). During treatment, the patient was in a lying position with full exposure of the acupoints. The ignited end of the moxa roll pointed directed toward neiguan (one side), with the burning end 0.5-1.0 cun away from the skin, for 5 minutes until the patient had a warm but not burning feeling and the skin color turned slightly red. Then, the same method was applied to neiguan of the other hand, shanzhong, and xinshu (both sides), each for 5 minutes. The treatment was given once a day, 6 times constituting one treatment course. There was one day of a rest before the second course of treatment started. The acupoints used for the control group were the same as for the moxibustion group, only acupuncture was used instead of moxibustion….Usually, the patients in both the moxibustion and control groups were given 5-10 courses of treatment, covering a period of 1-2 months. In their summary, the authors, echoing the comment that moxibustion does not receive much attention, noted that: "In recent years most clinical and experimental studies have proved that acupuncture with neiguan as the main point has good therapeutic effect in the treatment of coronary heart disease; however, few reports on moxibustion in the treatment of this disease have been seen." They also noted that: "There is no significant difference between the moxibustion and acupuncture groups in their effects." Unfortunately, in the absence of a placebo control, it is difficult to know how much of the effects were due to stimulation of the points and how much were due to other factors not specifically related to the treatment (such as responses usually attributed to "placebo effects"). The claimed benefits included relief of symptoms, improvement of ECG, and lowering of blood pressure and blood lipids. In this case, the authors suggested that the indirect moxibustion was preferred by patients over acupuncture because of lack of pain and discomfort (needling in Chinese clinics is far more vigorous than in Western clinics). This is in contrast to the situation with direct moxibustion, which can be more painful than acupuncture; the painful nature of the usual direct moxibustion being mentioned in several texts. The intensive moxibustion described in this clinical report where moxa rolls were used contrasts with common practice in Western clinics. Moxibustion was given for 5 minutes at each point, with five points treated, for a total of 25 minutes of moxibustion and the treatment was given daily for 30-60 days consecutively. Heating was done until there was an obvious reddening of the skin. In Acupuncture: A Comprehensive Text (27), the importance of adequate heating is mentioned: "A text of the Qing Dynasty, The Golden Mirror of Medicine, explains: 'When treating diseases with moxibustion, for there to be any effect, the heat must be sufficient to obtain the Qi.'" In another case of treating a chronic disease, herb-interposed moxibustion was administered in the treatment of Hashimoto's thyroiditis (28). Two groups of points were selected for treatment on alternate days: dazhui (GV-14), shenshu (BL-23), and mingmen (GV-4) made up one set; shanzhong (CV-17), zhongwan (CV-12), and guanyuan (CV-4) were in the second set. Each time, five cones of moxa, 2 grams each, were burned continuously on each point of the set. In patients were treated daily, out patients were treated every other day, with a total of 50 treatments for a course of therapy. Many of the patients were said to have benefited in terms of symptoms and findings in blood tests with regard to thyroid hormones and antithyroid antibodies. References to the use of moxibustion have declined in recent issues of the Journal. Two very brief articles in recent issues described use of moxibustion, both by the herb interposed method, one with ginger, the other with garlic: Gastroptosis (7): First, moxa was applied on a fresh ginger slice on baihui (GV-20) while the patient is sitting still and relaxing. When that part of the treatment is concluded, the patient lies down, and moxa is applied to zhongwan (CV-12) and qihai (CV-6). Treatment time was just 15 minutes (5 minutes per point), and the treatment was given once or twice a day. The patients were also given exercises to do daily to improve strength of the abdominal muscles. After a 15-day course of treatment, it was said that 30 of 50 cases were cured and that all other cases showed some degree of improvement. The

authors stated that: "baihui is a point of the governing channel, which dominates yang of the whole body. Moxibustion on it can tonify qi and promote qi ascending in the middle jiao. zhongwan and qihai of the conception vessel are selected as the essential local points. Moxibustion on these two points may warm up the middle-jiao, replenish qi, promote ascending of yang qi, so as to relieve the prolapse." Acute lymphagnitis (also called "red-thread furuncle;" 8): A three-edge needle is used to let out blood at both ends of the furuncle. Thin slices of garlic are placed on these two blood letting points, and then moxa is applied. The therapy involved 1 to 3 treatments, with claim of cure in all cases, most of them requiring 2 treatments. The second report involves moxibustion at a skin lesion. This method appears common in the practice of treating skin disorders, as relayed in the book Treatment of External Diseases with Acupuncture and Moxibustion (15), where this is the primary role of the moxibustion component presented by the authors.

IS THE MOXA-WOOL IMPORTANT? While it is evident from most presentations on moxibustion therapy that the heat administered during the treatment is a key element in dealing with cold and stagnation, the question arises as to what must be used to produce the heat. An explanation for use of moxa wool (shredded artemisia) is that it grows everywhere, so is cheap and easy to get, it readily holds its shape in cones, and its burning characteristics are ideal: it burns slowly, stays lit, produces an even heating, and has a pleasant fragrance (27). But entrance of moxa ingredients into the body doesn't seem to be essential. In Tibet, moxibustion was applied with a hot rod rather than burning moxa, and in China it is not uncommon to put something between the moxa and the skin (as in the cases above, with ginger or garlic) so that any elements of the moxa smoke are unlikely to get into the skin. In almost all Western practices and several of the modern Chinese practices, the elements of the burning moxa mainly go into the air, very little gets to the skin. Thus, one would expect that heat is the aspect of moxa being relied upon. Nonetheless, some authors describe the value of moxa in relation to its herbal nature. Here is what the authors of Chinese Acupuncture and Moxibustion (2) have to say: Artemisia vulgaris produced in Qizhou is known as the best kind for moxa, as the climate and soil is good for its growth. The leaves of Qizhou Artemisia are thick with much more wool [soft fibers]. Moxa cones and sticks made of this kind of artemisia are thought to be the top quality used in moxibustion. I n A New Edition of Materia Medica appears the following description: 'The moxa leaf is bitter and acrid, producing warmth when used in small amount and strong heat when used in large amount. It is of pure yang nature, having the ability to restore the primary yang from collapse. It can open the 12 regular meridians, traveling through the three yin meridians to regulate qi and blood, expel cold and dampness, warm the uterus, stop bleeding, warm the spleen and stomach to remove stagnation, regulate menstruation, and ease the fetus....When burned, it penetrates all the meridians eliminating hundreds of diseases.' Yang can be activated by the Artemisia leaf by virtue of its warm nature. The acrid odor [spicy fragrance, volatile oil] of the leaf can travel through the meridians, regulate qi and blood, and expel cold from the meridians, and its bitter nature resolves dampness. As a result, it is used as a necessary material in moxibustion treatment. It seems that the authors confuse the Materia Medica description of artemisia used as an internal remedy with its use in moxibustion. A contribution of the herb material is also mentioned by the authors of the recent text Manual of Dermatology in Chinese Medicine (9): Moxibustion is an important and perhaps underutilized therapeutic method in traditional Chinese medicine. It may be used alone or in combination with other modalities, such as acupuncture....This method involves the burning of moxa on or above the skin at the location of specific acupoints, or on or near the lesion [to be treated] itself. The heat of the cauterization, as well as the properties of the moxa itself, serve to warm the qi and blood in the channels, expel cold and dampness, restore yang, and, in general, help to regulate the organs and restore health. Unless the depiction of the herb penetrating through the meridians with application of moxa is understood to involve a spiritessence that travels from the mugwort into the body and has an effect as strong as the herb when used in decoction, it must be understood that a significant amount of the mugwort vapors and smoke enter the body, either through the skin where the moxa is burned or through breathing the fumes, or both. A question arises, though, as to whether or not it would be better to consume moxa orally (e.g., using artemesia in a decoction or an ingredient in a complex formula in the form of decoctions or pills) than to rely on tiny amounts penetrating the skin during the treatment or larger amounts inhaled as smoke. This issue is an important one if the practitioner is to select moxa materials and specific techniques. For example, when moxa cones are burned on the end of acupuncture needles (in China, this is typically done for 15 minutes after needling to get the deqi reaction), the constituents of the moxa do not interact with the skin and the local effect is limited to transferring heat through the needle to the acupoints (it is called "warm needling"). Smokeless moxa provides heat, but very little of the vapor; the way it is prepared eliminates those acrid components referred to above that are supposed to warm up the circulation by entering the meridians. Similarly, if one uses an interposing substance, the moxa ingredients are not going to penetrate the skin (though a very tiny amount of the substance from the interposing material might). Most modern clinics are designed to vent the moxa smoke or utilize air purifiers to eliminate as much of it as possible; this approach thus removes a large part of the inhaled smoke with moxa ingredients that might serve a therapeutic function. Further, herbal moxibustion is sometimes substituted by heat lamps or other techniques that eliminate the artemisia altogether; a lotion of herb extracts (that may or may not include artemisia) can be applied to the skin with heat delivered through such lamps in an effort to provide both warmth and some local penetration of herb constituents. In China, an additional impact of moxibustion was to help sterilize the atmosphere of the rooms in which it was being used; until recently, Chinese hospitals were not clean, and it was easy for patients to pass on infections. Visitors to China noted that acupuncture needles were not sterilized, but merely dipped in an alcohol solution, and the lack of hygienic rigor extended to other aspects of the hospitals. This role of moxa became recognized and some hospitals decided to use the approach routinely, even in rooms where moxa treatment wasn't being given. Hence, an incense made of artemisia and atractylodes (cangzhu) would be used to reduce the bacterial count in the air; it also apparently inhibited viruses (13). According to Chinese evaluations, it could be used in kindergartens and nurseries to reduce the transmission of diseases, including chicken pox, mumps, scarlet fever, common cold, and bronchitis. Thus, when

used in an acupuncture clinic, the smoke from moxibustion might help to prevent transmission of disease from one patient to another, which is especially important when dealing with immune-compromised patients. However, with modern Western clinics, the rooms tend to be clean and the smoke of moxa or incense in any large quantity goes unappreciated.

INDICATIONS AND APPLICATIONS FOR MOXIBUSTION Detailing the functions of moxibustion, the authors of Chinese Acupuncture and Moxibustion (2) say that it is used for the following purposes: 1. To warm meridians and expel cold. Abnormal flow of qi and blood usually results from cold and heat. Cold causes obstructed flow or even stagnation of qi, and heat results in rapid flow of qi. Normal heat activates blood circulation and cold impedes its smooth flow. Since stagnation of qi and blood is often relieved by warming up the qi, moxibustion is the right way to generate the smooth flow of qi with the help of the ignited moxa wool. In Chapter 75 of the Lingshu it says: 'If stagnation of blood in the vessels cannot be treated by warming up with moxibustion, it cannot be treated by acupuncture.' In Chapter 48 of the Lingshu it states, 'Depressed symptoms should be treated by moxibustion alone, because depression is due to blood stagnation caused by cold, which should be dispersed by moxibustion.' 2. To induce the smooth flow of qi and blood. Another function of moxibustion is to induce qi and blood to flow upward or downward. For example, moxibustion is given to yongquan (KI-1) to treat the disorders caused by excess in the upper part and deficiency in the lower part of the body and liver yang symptoms due to upward flowing yang qi so as to lead the qi and blood to go downward....If the disorder is due to deficiency in the upper portion and excess in the lower portion of the body and due to sinking of qi caused by deficiency, such as prolapse of the anus, prolapse of the uterus, prolonged diarrhea, etc., moxibustion to baihui (GV-20) may lead yang qi to flow upward. 3. To strengthen yang from collapse. Yang qi is the foundation of the human body. If it is in a sufficient condition, a man lives a long life; if it is lost, death occurs. Yang disorder is due to excess of yin, leading to cold, deficiency, and exhaustion of the primary qi, characterized by a fatal pulse. At this moment, moxibustion applied can reinforce yang qi and prevent collapse. In Chapter 73 of the Lingshu it says, 'Deficiency of both yin and yang should be treated by moxibustion.' 4. To prevent diseases and maintain health. In Thousand Pieces of Gold it states: "Anyone who travels in the southwest part of China, such as Yunnan and Sichuan Provinces, should have moxibustion at two or three points to prevent sores or boils and to avoid pernicious malaria, epidemic diseases, and pestilence." It is often said, "If one wants to be healthy, you should often have moxibustion over the point zusanli (ST-36)." In Notes on Bian Que's Moxibustion, it says, "When a healthy man often has moxibustion to the points guanyuan (CV-4), qihai (CV-6), mingmen (GV-4), and zhongwan (CV-12), he would live a very long life, at least one hundred years." These treatments might include scarring moxibustion depending on the particular case. The different styles of moxa application and the method of keeping-fit moxibustion (the fourth application listed above) were elaborated by Yuan Liren and Liu Xiaoming (11), though with reliance on different points, namely shenque (CV-8), zhongwan (CV-12), yongquan (KI-1), and zusanli (ST-36), the latter point was mentioned above and is a standard for many acupuncture and moxibustion treatments. According to the authors, these points are selected and treated as follows: zusanli (ST-36): Frequent moxibustion on zusanli can invigorate the spleen and stomach, assist in digestion, hence, strengthening the body and slowing down the process of aging. Some ancient experts advocated the use of scarring moxibustion, placing moxa wool directly on the skin over the point so that a scar is formed after the local skin has developed a boil with pus. Constant application of scarring moxibustion will maintain the moxibustion boil, and this will help to strengthen the body and prolong life. Another similar method, known as hanging moxibustion, is composed of hanging an ignited moxa stick 3-7 centimeters over the point without touching the skin for 5-10 minutes. Shenque (CV-8): Frequent moxibustion on this point can replenish qi and strengthen the body; it is especially suitable for the middle-aged and elderly. The particular procedure of this kind of moxibustion is as follows: put some salt on the navel, knead some moxa wool into the shape of a cone to be ignited and placed on the salt for moxibustion. The size of the moxa cone should vary with the individual conditions. For people of strong constitution, use big cones in the size of a broad bean and for those of weak constitution, use the middle-sized cones as big as a soybean or use small cones in the size of a wheat grain. The burning up of one moxa cone is referred to as one zhuang. Moxibustion on shenque point requires 7-15 zhuang. zhongwan (CV-12): This point is an important point for reinforcement, capable of strengthening the spleen and stomach. Both moxa stick and moxa cone are advisable for moxibustion on this point, the duration of which may last 5-10 minutes. yongquan (KI-1): Frequent moxibustion at this point can strengthen the body and contribute to longevity, for it replenishes the kidney and invigorates yang. When using moxa sticks for moxibustion, it should last 3-5 minutes, and in the case of using moxa cones, 3-7 cones are usually needed each time. The authors state that the duration of moxibustion should be at least 3-5 minutes, but not more than 10-15 minutes. A relatively longer duration of treatment is indicated for recovery from a serious disease or injury to recapture good health, in autumn and winter, on points of the abdomen (i.e., CV-8 and CV-12), and when treating young and middle-aged adults. Relatively shorter duration of treatment is indicated for simple health maintenance and longevity promotion, for spring and summer treatments, when applying moxibustion to the limbs (i.e., KI-1 and ST-36), for the aged and for children. They caution that: The aim of strengthening the body and achieving longevity cannot be attained by just applying moxibustion once or twice, it requires persistence for a long time. This does not mean that one should receive moxibustion every day. For the purpose of convalescence for the weak and sick, the moxibustion may be applied once every 2-3 days in the early stage; yet for reinforcement of the body or longevity, it should be once a week in the early stage. And when it has shown some effect, the frequency can be reduced to once a month, and later, once or twice every three months, or even once or twice a year. So long as the practice is persisted in, good effect is sure to ensue. Another description of life-prolonging moxibustion was offered by Liu Zhengcai (17), with primary focus on zusanli (ST-36), qihai (CV-6), guanyuan (CV-4), and zhongwan (CV-12). The technique was intensive moxibustion. For example, the experience of Wang

Chao is mentioned: he said that he never failed to burn 1,000 cones of moxa at guanyuan between summer and fall; or the experience of Liu Jiesheng, who used moxa once a day for five days at beginning of Spring and again at the beginning of Autumn, using large cones on sliced ginger, a total of 30 cones each day of treatment. Wang Leting, a famous physician in Beijing who practiced from 1929-1979, also commented on using moxa for prolonging life, as described by Dr. Wang's students (22): The Bian Que Xin Shu (Bian Que's Book of Heart Teachings) says: 'A person without disease should moxa himself for a long time [i.e., regularly]….Although one cannot obtain long life [is not destined to have a long life span], one can achieve longevity of more than 100 years.' Because moxibustion has a warming action and it supports yang, it can be used to course and free the flow of the channels and network vessels, move the qi and quicken the blood, dispel dampness and cold, disperse swelling, and scatter nodulation, secure yang and stem counterflow. For instance, constantly moxaing zusanli (ST36) is able to regulate and rectify the spleen and stomach function, increase and strengthen the bodily constitution. Constantly moxaing feishu (BL-13), it is not easy to catch an external affliction. Dr. Wang Leting was 88 years old, with the exception of being a little bit hard of hearing, he was still very healthy, his thinking was very keen, and he was still reading and writing books. His secret was mainly doing moxibustion on himself among other methods of protecting his health. He held that after age 40, one's kidney qi declines day by day. Hence, between Summer and Fall every year, when yang qi declines day by day, he began to do moxibustion at qihai (CV-6) and guanyuan (CV-4) with moxa cones. At first, he used 7 moxa cones per day. Then, he gradually used 10 per day and up to a total of 500 for the season. This method greatly strengthened his bodily constitution. He persisted in doing moxibustion for decades and obtained great benefit from it. The basis for using moxa in the late summer and early fall can be understood by comments in the classics, including the teaching of Li Dongyuan in his Pi Wei Lun (Treatise on Stomach and Spleen ). Although Li was an herb specialist and didn't describe use of moxa in this text, he noted that it was traditionally said that diseases of the spleen would heal in the Autumn and that "Blood must be nurtured by all means and the defensive must be warmed by all means. With blood warm and the defensive in harmony, one will live out one's heaven-decreed life span (36)." Moxa provides a warming therapy at this time of year to invigorate the circulation and activity of defensive qi (weiqi) and protect the spleen from the declining yang qi that is occurring as part of the annual cycle, and the blood can be nourished by eating healthy foods, which are digested, and the resulting essence is transported, by the strong spleen function. Failure to take care of this would lead to repeated illness during the cold months, and overall weakening of the body. The important role of the stomach and spleen in generating ying and wei qi helps explain the emphasis on moxibustion at ST-36. Aside from these uses of moxa for preventive health care, moxa is often applied for alleviating acute symptoms. In an attempt to relieve herpes zoster outbreaks, moxibustion was applied to dazhui (GV-14). According to the report of this application (23), the technique to be used would depend on the patient: for the elderly and weak, warming moxibustion (using a moxa roll) was administered, but for the strong and robust, direct moxa (9 cones, but non-blistering) was done. Treatment was given once per day, with pain alleviation and change of the zoster lesions to scabs occurring in 3-7 days of treatment. A report on moxibustion for gastric spasm by Song and Zhu (12) in the Journal of Traditional Chinese Medicine involved 97 patients with either gastric spasms or intestinal spasms who were treated primarily on the abdomen points CV-8 (along with ST-37 for intestinal spasm) and CV-12 (along with ST-34 for gastric spasm). The authors report that nearly all the patients had their abdominal pain alleviated with one moxa treatment. The technique used was: The moxa roll was ignited and placed over the selected points to produce a comfortable warm feeling. When the heat became excessive, the moxa roll was moved around the points or a little higher to avoid burns. A piece of gauze could be laid over the point to protect the skin from accidental injury. 30 minutes constituted one session of treatment. Unlike the concern expressed here to keep the patient comfortable and uninjured, many traditional moxa specialists (such as Wang Kenliang, quoted previously) believed that blistering of the skin was essential to the success of moxibustion when treating serious ailments, much the way that getting the qi reaction and propagated sensation in response to needling was deemed essential to successful acupuncture therapy. This blistering and scarring method is even mentioned in relation to Keeping-fit Moxibustion, which is for preventive health care. Such intensive moxibustion is avoided in the Western practice, which follows more closely the method used for the gastric and intestinal spasm treatments.

THE PRIMARY MOXIBUSTION POINTS There are certain points mentioned repeatedly in the literature on moxibustion; the accumulated experience with using these points suggests that they might be uniquely effective. Aside from zusanli (ST-36), which is also the most frequently mentioned of all the points used for needling, the primary moxibustion points are located on the governing and conception vessels. On the conception vessel, points 4, 6, 8, 12, and 17 are mainly utilized. On the governing vessel, points 4, 14, and 20 are mainly used. One of the important moxa points i s dazhui (GV-14), which is the meeting point of the governing vessel with the six yang channels of the hand and foot. An article reviewing the many uses of moxibustion at this point (31) listed the following examples of applications for moxa at this point: Expelling wind, clearing heat, and dispersing the lung to relieve the exterior (for acute feverish diseases); Dispersing the lung, eliminating cold, and activating yang to relieve asthma; Restoring consciousness, tranquilizing the mind, and calming internal wind to relieve epilepsy; Removing obstruction in the governing channel to relieve spasm and dispersing yang to eliminate pathogenic factors (for cervical spondylopathy and other disorders of the spinal column); Warming the channels, restoring yang, and replenishing qi to consolidate resistance (protecting from recurrent common cold and influenza). Dazhui was also described separately as the acupoint suitable for treating herpes zoster by moxibustion (23). Reflecting the common usage of the points, the students of Wang Leting noted that the points he used for moxibustion were relatively few. They included conception vessel points 4, 6, 8, and 12, and governing vessel points GV-4 and 20 (he also used the back shu points fenshu, BL13, and shenshu, BL-23). A harmonizing treatment for the yin and yang is moxibustion at guanyuan (CV-4) and dazhui (GV-14). Robert

Johns, in his book The Art of Acupuncture Techniques (32), mentions that this ancient formula is well suited to helping cancer patients recover from the adverse effects of modern cancer therapies. Other moxibustion therapies for helping patients with leucopenia mentioned in Chinese texts include dazhui with zusanli, usually along with one or two other points. One other point frequently mentioned is yongquan (KI-1), a point relied upon for treatment of collapse of yang, for which moxibustion seems appropriate. It might also be used, with slow heating, to help tonify yin.

POSSIBLE MECHANISMS OF ACTION OF MOXIBUSTION One theory of the effects of both moxibustion and acupuncture is that the local tissue damage (twisting of tissue fibers when stimulating acupuncture needles, extended cellular damage by the intense heat of moxibustion) initiates a non-specific healing reaction that can have effects throughout the body. This healing reaction is stimulated by production of immunological mediators and neurotransmitters. Modern techniques of acupuncture and moxibustion therapy used in the West may rely, instead, on lesser stimulation that does not produce significant tissue damage (e.g., using thin needles minimally manipulated, using moxa to gently warm the skin). However, it must also be recognized that some modern techniques may do little more than induce general relaxation, without some of the other effects that Chinese physicians have long depended on. The impact of the local heat stimulus was studied in the laboratory to follow-up on the suggestion that the production of inflammation mediators, mainly histamine, at the site of burning skin were important to the impact of moxibustion therapy (24). After burning a single cone of moxa, the authors found that: The maximum temperature of the treated spot was about 130° C at the outer skin, and about 56° C at the inner skin. Therefore, moxibustion treatments are naturally considered heat stimulation with inflammatory response. In general, inflammatory response induces vascular changes. Our results of moxibustion as a heat stimulation induced vasoconstriction at the site under the moxibustion spot and vasodilation around the moxibustion spot. The cause of cutaneous vasodilation was histamine and substance P….Our results indicate that moxibustion induces an increase in capillary permeability mediated by histamine; additionally, this enhancement of permeability can be correlated with the degree of mast cell degranulation [release of inflammation mediators by the cells], which relates to the weights of moxa cone used. The authors concluded from this study and from others (25) that a likely mechanism of moxa was the enhanced activity of the host defense mechanism in response to the local inflammation. They described the response to the localized heating of cone moxibustion as distinctly different from that of a widespread burn, which can impair immunity. Other researchers have also indicated that carefully controlled moxibustion as performed in the laboratory produced immunological responses, including increased lymphocyte numbers, and that it could aid the restoration of immune functions impaired by radiation (26). Moxibustion was suggested to have potential use in treating cancer by virtue of enhancing immune activity mediated by the red blood cells (30). In a laboratory animal study of moxibustion at the point equivalent to dazhui (GV-14) in mice, it was claimed that growth of implanted tumors could be inhibited by enhanced cellular immune functions, probably mediated by enhanced production of favorable cytokines (e.g., IL-2) and resulting increased natural killer cell activity (42). While moxa therapy appears to bolster immune responsiveness, it does not necessarily exacerbate autoimmunity. For example, moxa treatment was shown to reduce delayed type hypersensivity reaction in mice; this action may be accomplished by enhancing the function of suppressor T-cells (37). Substance P is a neurotransmitter, and one of several that are thought to be induced by acupuncture and moxibustion stimulation; for example, galanin is another neurotransmitter observed to be synthesized in response to moxibustion (38). These neurotransmitters are thought to be important in the regulation of pain, spasm, and neurological disorders, such as depression and anxiety; they are also invoked in response to exercise, and may be part of the explanation for several of the health benefits attributed to higher levels of physical activity (40). In a laboratory study on rabbits, the point equivalent to zusanli (ST-36) was treated by moxibustion and it was shown that intestinal smooth muscle spontaneous movements declined (39), suggesting a role of the neurotransmitters. This antispasmodic effect is consistent with what is seen during clinical treatment of gastric and intestinal spasms with alleviation of diarrhea. The neurotransmitters evoked by acupuncture (especially electro-acupuncture) and moxibustion may act in parallel with the modulation of immune responses and contribute to a broad systemic change.

MOXIBUSTION AND IMMUNE SYSTEM FUNCTION IN HUMAN CLINICAL WORK One of the frequently investigated functions of moxibustion mentioned in modern Chinese clinical literature is boosting the immune system. It remains unclear whether moxibustion differs in its effects from acupuncture in this regard. In elderly patients, both acupuncture and warm needle acupuncture (with moxa applied to the needles for 20 minutes, using daily treatment for 10 days) applied to zusanli (ST-36) enhanced production of IL-2 (45). In a review article on research examining immunological effects of acupuncture and moxibustion (18), no distinction was made regarding the two techniques, only the points treated and the outcomes were noted for each method interchangeably. The author of the review article concluded that the effect of the techniques on the immune system might be a secondary result of their effects on the whole body, rather than a specific action. This interpretation does not necessarily contradict the results of animal studies on mechanism of moxibustion: the technique might have an initial effect on the immune system that then produces, via the action of various mediators, a systemic effect that goes beyond the initial immune response, eventually causing a greater immunological improvement. In the report on moxibustion treatment of coronary heart disease, some immune parameters of the patients were measured (including lymphocyte conversion rates and levels of immunoglobulins), showing an enhanced immunological response. The authors had concluded that "moxibustion treats coronary heart disease through regulating the internal environment of the organism and reinforcing its ability to fight disease." This interpretation of results is consistent with the idea that the techniques produce non-specific improvements in the entire body that manifest in better immune function as well as better function of all the internal organs. In the TCM system, spleen deficiency (a subcategory of qi deficiency) syndrome is often associated with weak immune functions. Evaluation of immunological effects of moxibustion in spleen deficiency patients has been conducted (19, 20) with claimed benefits in immune function tests that accompany alleviation of symptoms. A clinical report on treatment of chronic diarrhea associated with ulcerative colitis or simple chronic colitis with moxibustion focused on immunologic mechanisms (29). Herb-interposed moxibustion

was used with two sets of points alternated daily: zhongwan (CV-12), qihai (CV-6), and zusanli (ST-36) made up one set; dachangshu (BL-25), tianshu (ST-25), and shangjuxu (ST-37) made up the second set. The number of moxa cones used would vary by site and syndrome, but ranged from 2 to 7 cones. Daily treatment was provided for 12 days, followed by an interval of 3 days, and then another course of 12 days, for a total of 60 treatments. It was claimed that along with resolution of the diarrhea there was a reduction in the excess IgM and complement that were present at the beginning of treatment for those with ulcerative colitis, and an improvement in the T-lymphocyte subgroup of suppressor cells that inhibit autoimmune reactions. An improvement in an autoimmune based disorder was also noted for Hoshimoto's thyroditis (28). Immune parameters that were normal at the beginning of the studies did not change. In an outline summary of laboratory and clinical studies of the immunological effects of moxibustion, it was reported that moxibustion could reduce the level of rheumatoid factor (considered a measure of the autoimmune aspect of the disease) in rheumatoid arthritis and improve symptoms of allergic rhinitis (41). Such findings suggest that the immunological and organ system changes may reinforce and contribute to one another, and that the immune functions are regularized by reinforcing the weak portion of the immune system rather than simply stimulating the immune system generally.

CONTRAINDICATIONS FOR MOXIBUSTION The primary contraindication for moxibustion has historically been the presence of a heat syndrome. This goes along with the idea that moxa introduces heat to the system and does so effectively, and thus the treatment method fails to meet the criteria of balancing a hot condition with a cooling therapy. Theoretically, it could cause the disease to worsen by increasing the imbalance. There are some who have argued against this, as noted above. In similar manner, there are cases where herbalists have argued against the view that in febrile diseases one must always avoid heating herbs and rely only on cooling herbs. However, this contraindication for moxibustion still remains listed in all standard texts. In particular, moxa is considered entirely inappropriate for a deficiency heat syndrome (one based on yin deficiency) and it must be used cautiously in cases where there is local dryness. In a report reviewing indications for acupuncture and moxibustion (43), the authors noted that "We found in our practice that most of the herpes zoster patients responded to moxibustion and round needling…although there were some cases with obvious local dryness due to skin injury where the patients experienced increased pain the more that moxibustion was applied." They suggested that since herpes zoster is a heat syndrome that responded well to the treatment in most of the cases, one should not automatically discount use of moxibustion for heat syndromes, especially those with localized heat as occurs with a zoster outbreak. Other contraindications for moxibustion involve the sensitive areas of the body, such as the face (where one especially avoids the scarring therapy, but also avoids getting smoke directly into the eyes or nose), the nipples, and the genitals. Ancient texts specify certain points on the head as being contraindicated for moxibustion (27), such as shangxing (GV-23), chengqi (ST-1), sibai (ST-2), touwei (ST8), jingming (BL-1), zanshu (BL-2), sizhukong (TB-23), heliao (LI-19), and yingxiang (LI-20). Concerns are raised about using moxa during pregnancy for the region of the abdomen and lower back (14, 27).

THE TECHNIQUES OF MOXIBUSTION As noted in the Journal of Traditional Medicine review article on acupuncture and moxibustion in China (4), there are about 50 techniques that have been elaborated. Many of these are minor variations: different substances used in interposed moxibustion (mainly fresh ginger slice, garlic slice, aconite cake, salt), different methods of applying heat to a broad area (moxa rolls, containers with large amounts of moxa), different size cones, applying moxa to the end of an acupuncture needle, and using materials other than artemisia to burn (such as juncus) or to cause hot sensation and blistering without using fire (e.g., with mustard seed or mylabris, an insect with irritant properties). For purposes of this article, the techniques most likely to be used in the modern clinic will be described, taken primarily from the recent compendium Acupuncture and Moxibustion (14), prepared by the Beijing University of Traditional Chinese Medicine.

1. Non-Scarring Moxibustion with Moxa Cones A moxa cone is placed on a point and ignited. When about 2/3 of it is burnt or the patient feels a burning discomfort, remove the cone and place another one. Three to seventeen cones are continuously burnt to cause flush in the local site, but no blister should be formed. This method is used widely, often for cold and deficiency disorders such as asthma, chronic diarrhea, and indigestion.

2. Indirect Moxibustion (Interposed Moxibustion) The ignited moxa cone does not contact the skin directly, but is insulated from the skin by a layer of ginseng, salt, garlic, or aconite cake. Depending on the technique used, this kind of moxa may induce blistering, but it is often used for non-scarring moxibustion. Ginger: cut a slice of ginger about 2-3 cm wide and 0.2-0.3 cm thick, punch numerous holes in it and place it on the point selected. On top of this, a moxa cone is placed and ignited. When the patient feels scorching, remove it and ignite another. Repeat this until all the cones burn and the skin becomes reddish. This method has the effects of warming the spleen and stomach and dispersing cold. It is therefore indicated for symptoms caused by weakness and cold of the spleen and stomach, such as abdominal pain, diarrhea, painful joints, and other symptoms due to yang deficiency. Garlic: cut a slice of garlic 0.2-0.3 cm thick (a large single clove of garlic is desirable), punch holes in it, put it on the point with the ignited moxa cone on top. Renew the cone when the patient feels scorching. This method has the effect of relieving swelling and pain, and is often used for the early stage of skin ulcer with boils or scrofula. Salt: this method is usually applied at the umbilicus. Fill the umbilicus with salt to the level of the skin, place a moxa cone on the top of the salt and then ignite it. When it burns out, renew another until all the cones have combusted. As this method has the action of restoring yang from collapse and warming the spleen and stomach, it is effective for the symptoms of sweating, cold limbs, and undetectable pulse resulting from acute vomiting and diarrhea, or flaccid-type of wind stroke and post-partum fainting. Aconite cake: punch holes in a cake made of aconite powder mixed with alcohol, 3 cm in diameter and about 0.3 cm in thickness. Place on the site for moxibustion with the moxa cone, which is ignited and burnt on top of it. This method is good for warming and strengthening kidney yang, and thus, is adopted to treat impotence, infertility, and ruptured abscess resistant to healing.

3. Moxibustion with Moxa Stick

Mild-warm moxa: Ignite a moxa stick and place it 2-3 centimeters away over the site to bring mild warmth to the local place, but not burning, for some 15 minutes until the skin becomes slightly red. It is suitable for all the syndromes indicated for moxibustion. Sparrow-pecking moxibustion: In this method, the ignited moxa stick is moved up and down over the point like a bird pecking, or moving left and right, or circularly. It is indicated for numbness and pain in the limbs.

4. Warming Needle Moxibustion Moxibustion with warming needle is an integration of acupuncture and moxibustion, and is used for conditions in which both retention of the needle and moxibustion are needed. It is applied as follows: after the arrival of qi and with the needle retained in the point, get a small section of a moxa stick (about 2 cm long) and put on the handle of the needle; ignite the moxa stick from its bottom and let it burn out. This method has the function of warming the meridians and promoting the flow of qi and blood so as to treat bi-syndrome caused by cold-damp and paralysis. Application to cold-damp syndrome was the subject of a clinical evaluation involving patients with rheumatoid arthritis (46). Acupuncture was performed by deep needling of the shu (stream) points, and then moxa was applied to the needles for 30 minutes, performed daily (with short breaks) during a two month course of therapy. The original technique described in the classics is different and was called the fire needle. This involved holding the needle in a lamp flame until very hot, and then inserting to the appropriate depth in the body quickly and removing it (34). Warming needle, as now used, allows longer retention and gentler heating.

TONIFICATION AND DRAINING STRATEGIES Just as there are needling techniques associated with tonification (reinforcement) and draining (reducing), moxibustion can be applied with these two different approaches. The basis for the different methods is the intensity and duration of heating during the moxa treatment. The distinction has been described by the followers of Wang Leting and relayed here with slight editing: As for the problem of supplementation and drainage by moxibustion, these are generally administered in the clinic based on the theory of the Lingshu chapter on back transporting points: 'To supplement by fire, do not blow on the fire, but let it burn out. To drain by fire, quickly blow on the fire and let it burn out spontaneously.' The former method involves letting a slow burning cone burn out by itself: although the heat power is weak, it is persistent and substantial. The latter is quickened by blowing on it. Although the heat power is violent, it is temporary and short. If the supplementing technique is to be used, do not blow on the moxa cone after igniting it. Just allow it to burn gradually and burn itself out. Then, press the point with the hand to concentrate the qi and make the warming persistent. If the drainage technique is to be used, blow on the ignited moxa to increase its speed of burning, then let it burn out or remove it when too hot; do not press the point, but let the pathogenic qi be scattered externally. When using moxa rolls or other techniques, the basic approach to tonification or draining can still be applied. Tonification utilizes a more steady and prolonged heating, while drainage involves a more rapid and more intense but shorter duration heating of the point (bird pecking moxa is often used, with the end of the moxa roll being brought quite close to the skin with repeated thrusts to get more intense heating of the skin). A description of reinforcing and reducing techniques of moxibustion was included in a broader report on these techniques for needling (35). The commentators noted: In ancient times, reinforcement and reduction techniques were attributed to moxibustion, while in modern textbooks they are seldom mentioned. We treated a patient suffering from impotence due to deficiency of the kidneys with moxibustion using reinforcing manipulations; the patient was cured after 5 sessions of treatment. In herpes zoster, moxa cones were ignited and the fire blown with mouth to increase the temperature and thus produce a reducing effect. We have treated dozens of patients in this way with an alleviation rate of 95% immediately after the first session. All the patients were cured after 2 to 3 sessions of treatment. In a case of chronic cold syndrome of the insufficiency type, mild moxibustion (a moxa roll is held approximately 3.5 cm above the skin to produce a sensation of warmth until the skin becomes slightly flushed) and revolving moxibustion (circling the lighted end of a moxa roll around the acupuncture point until the skin becomes flushed) are most often used. In case of acute heat of the excess type, direct moxibustion and bird-pecking moxibustion are most often used….When mild moxibustion is applied to stimulate baihu (GV-20), an action of invigorating yang and arresting prostration is produced, curing organ prolapse. When garlic paste moxibustion or bird-pecking moxibustion is applied to stimulate yongquan (KI-1), an obvious effect of nourishing yin to purge pathogenic fire results, providing a cure for hemoptysis and epistaxis (i.e., bleeding due to heat).

SMOKELESS MOXA Though not widely used in China, an increasingly popular method in the West is the use of smokeless moxa. The following is the description for use in the modern clinic.

Smokeless moxa is a rod of charcoal impregnated with moxa. It burns hot, but slowly, at an average rate of just 2.7 inches per hour; the rods are about 4.5 inches long, so the total burning time is about 90 minutes before the rod becomes too short to use. The moxa is not easily lit, so it is common to use a torch rather than a simple lighter. Once lit, it burns consistently.

The smokeless moxa pole produces ash at the burning end which tends to stick to the rod. When trying to safely remove the ash from smokeless moxa, the stick should not be tapped against something (e.g., against an ashtray). The tapping, aside from making undesired noise, can crack the charcoal, generating a risk for a piece to fall off and burn the carpet, treatment table, or patient. Instead, the burning end of the moxa stick should be gently rubbed against the top edge and inside of a moxa extinguisher, which will be a quiet operation that dislodges the ash and does not crack the moxa rod. The moxa extinguisher can be carried in an ashtray, so that the ash is contained. At the end of the moxa session, the moxa stick may be carefully retained while still burning for use with another patient (if it is to be used within minutes) or put out. It is important to check from time to time that all moxa rods are in their proper place so that none are left burning where they can cause damage.

Moxa can be carried out using a single pole to provide intense heat to a specific point, or with two poles held side by side to heat a larger area. Moxa may be applied to acupuncture needles, but take care not to hold the lit end near the plastic holders, as this can cause melting or evaporation of the plastic (or rely on metal handle needles). While a brief moxa treatment can feel good to the patients, all Chinese texts refer to prolonged heating, usually by repeated application of heat to the same site over a period of several minutes. Be careful not to lose most of the potential benefits by applying moxa for a very brief period or by trying to apply moxa to too many sites, so that each site is only briefly treated.

MOXA PADS, HEAT LAMPS In contrast to the intense direct heating of points for treating diseases, heat therapy may also be employed to relax tense muscles and gently relieve aching and mild pain. Self-heating moxa pads for these purposes have been available from Korea for more than 20 years. This technology involves having a bag of mugwort and charcoal with an oxygen-sensitive system (iron that reacts strongly with oxygen), so that when the sealed package containing the bag is opened and the bag of material is vigorously shaken for a moment, it heats up. Within five minutes, the pack is heated and it maintains a temperature of 6075°C (140-165°F) for hours. This is the same technology used for the popular new drugstore products, such as ThermaCare, which are self-heating pads applied to the body (but without the artemisia).

Typical applications of the moxa pads include treatment of injuries, back pain, knee pain, and menstrual pain. In addition, these pads are applied for chilliness and discomfort following exposure to excessive air conditioning, frigid outdoor winter conditions, or damp windy weather. A belt to hold the pad over the abdomen is also available. The pads can be used following a treatment with acupuncture and moxibustion to extend the effects of the initial therapy, or as an alternative to those treatments when professional help is not convenient. Moxa pads should not be applied to skin that is broken or to areas that display red inflammation or that develop greater discomfort with application of heat.

Another method of applying heat is the infra-red heat lamp; a useful variant of this was developed in China, called the "TDP-lamp." It was invented in 1980 by a group of scientists and physicians headed by Dr. Gou Wenbin at the Chinese Medicine Institute in Chongqing. Unlike conventional infrared therapeutic devices, the TDP device features a plate coated with a mineral formation (a low conductance metal with diverse composition). When heated by an electric heating element, the mineral plate emits waves in the infrared range. It produces a uniform heating that makes it more useful than ordinary glass bulb lamps. To increase the heating of a region by the lamp, a medicated oil can be rubbed on the skin; the oil helps retain the heat and its herbal constituents may contribute to the improvement of local blood circulation. Although the makers of the TDP lamp make claims about the special value of its frequency of infrared emissions, there is no evidence that it performs a unique function on this basis.

INTERPRETATION

The report presented here may offer the practitioner some insights into practical aspects of moxa applications. There are a number of unanswered questions about moxa, and this section contains some conclusions of the current author derived from this literature survey. A certain part of the theory of applying moxibustion is simply based on the traditional Chinese medicine dogma and may not have important implications for practice. For example, the role of the moxa wool appears to be primarily for introducing heat rather than for pharmacological effects of artemisia promoting circulation, warming the meridians, and so on. Similarly, the special applications depicted for moxa with interposing herb materials (ginger, aconite, garlic, or complex herb formulations) appear to be based on the traditional roles of the herbs when taken internally, but these actions are probably not conferred by this method and would certainly be better accomplished by providing such herbs orally. The interposing substances serve primarily as suitable media for conveniently providing moxibustion without direct contact to the skin. Salt interposed moxa works well for treating the umbilicus because of its form; direct moxa would be inappropriate for this sensitive spot, especially in children who are likely to receive this particular therapy. There has been a heavy reliance on scarring moxibustion in the Chinese tradition. This method is listed first in most of the modern texts that describe moxa, and is featured prominently in the review article about moxa in clinical applications. There is a theory of acupuncture whereby the main function is to induce tissue damage at the acupoints. The twirling, lifting, and thrusting is shown to grab and pull fibers in the subcutaneous level, forcing the body to respond. Another aspect is stimulation of nerves leading to effects in the brain as well as effects of locally-produced neurotransmitters; such stimulation is especially noted with the "deqi" reaction, including tugging of the tissues at the needle and sensations of distention, numbness, and radiating tingling. Scarring moxa also damages the tissues and produces a strong nerve stimulus. Such severe treatment may not be essential, but Chinese specialists repeatedly emphasize the benefits of strong stimulus to the points and laboratory studies suggest that the inflammatory response to local damage by moxibustion is important. At the least, the skin must become sufficiently reddened that there is a healing response to limited damage. Some of the reliance on scarring moxibustion may be based in archaic ideas that would no longer be widely accepted. In Treatment of External Diseases with Acupuncture and Moxibustion (15), it is pointed out that sometimes the sores induced by direct moxa not be allowed to heal: The Thousand Pieces of Gold says: 'People who tour Wu and Shu should moxa some points regularly and leave the sores unhealed for some time. This will keep the toxic qi of miasma, leprosy, and warm malaria away from them.' The Great Compendium also says, 'If one intends to be safe and sound, one should keep zusanli (ST-36) wet' [that is, from the drainage of a moxibustion sore]….The blister and its sore are called a moxibustion flower. In former times and still by some practitioners, the production of such a moxa flower has been considered crucial for successful treatment. The Taiping Shenghui Fang (992 A.D.) says: 'Suppose a sufficient number of cones are burned up. Only when a sore develops and weeps pus may the disease be cured. If no sore is produced or no pus engendered, the disease will not be relieved.' In modern times, some Chinese practitioners continue with this practice, and their clinical experience confirms that intentionally produced moxa sores do have something to do with the curative effect. In spite of the effectiveness, only a few patients are undaunted enough to receive this therapy because of the pain it inflicts. Clearly, the thinking about moxibustion by most modern clinicians is moving away from the concept that scarring (with or without maintaining the drainage) must be used. The claims for superior effectiveness of scarring moxibustion have to be questioned since there are no studies comparing scarring versus non-scarring moxibustion. These claims are only impressions of the practitioners who obviously believe enough in the therapy to put the patients through the ordeal. On the other hand, it might be reasonable to assume that intense heating of the skin by direct moxibustion is likely to produce more of a response than mild heating as sometimes administered with use of moxa rolls held at a distance from the skin. When non-scarring moxibustion is used, the duration of treatment in reported clinical trials is usually long and probably much longer than administered by most Western practitioners. Numerous moxa cones and moxa sticks are applied typically for 15 minutes or more in total, with 5-15 minutes per point (longer for warm needle technique). Thus, the treatment is still strong in nature even if there is no blister formed. Practitioners in the West might consider the following: 1. If one wishes to avoid the smoke of regular moxibustion, it seems acceptable to use other methods of heating, so long as they can provide similar levels of heat and as long as one can maintain adequate control over the heating (e.g., to prevent burning and also to prevent the heating from becoming too light). As such, smokeless moxa may be satisfactory. In fact, moxibustion may be replaced by acupuncture in most applications, providing that the acupuncture stimulus is sufficiently strong to generate an immunological and neurological response. 2. When using herb-slice or cake interposed moxibustion, do not forget to punch holes in the material; this allows the heat to penetrate. The thickness of the slice should be just 0.2-0.3 cm; thicker slices may prevent adequate heating. For practical purposes, ginger slices may be most convenient and it is not evident that one must choose the interposing substance based on its pharmacological properties in relation to the condition to be treated. 3. For moxibustion to be effective, it needs to cause significant local heating and inflammatory response and should be done for a prolonged period, not just a minute or two. Therefore, specific points for moxa heating should be chosen and treated effectively, rather than trying to warm numerous points with only a little stimulus. Warming a broader region is an acceptable treatment for relaxing tension and moderating pain at the site; this is a different application than trying to stimulate the immune system, alter internal organ functions, or otherwise rapidly heal a disease. For chronic ailments, Chinese physicians typically administer moxa daily for several treatments, up to 50-60 sessions. Moxa treatments might be alternated with acupuncture and patients may appreciate the variation in treatment methods. 4. The most frequently mentioned applications of moxa are gastro-intestinal disorders, asthma, organ prolapse, bi-syndromes, and herpes zoster. These are reasonable targets for modern clinicians to consider for this type of therapy, which may otherwise be too inconvenient as a method (at least, when done properly). In particular, herpes zoster is emphasized as a case where moxibustion is effective. For asthma, both acupuncture and cupping have also been claimed to be highly effective, and these might be more appropriate for those who are sensitive to inhaling smoke from moxibustion. 5. The risks of exposure to moxa smoke are probably similar to that for any other smoke, and total exposure time, particularly

when it involves prolonged exposure, is the key concern. Occasional use of ordinary moxa would be associated with low risk, while routine exposure to moxa smoke during much of the day would be a moderate risk. Therefore, venting or filtering is an appropriate step when moxa is done regularly. There is no evidence that moxa smoke contains any unusually harmful substances. Standard commercial moxa materials do not contain realgar (an arsenic compound), though this substance has been rarely included in blends made by individual doctors in China for their own use. 6. There are certain points that are most frequently mentioned in the moxibustion literature which may be a good basis for consideration by modern practitioners. These points may be relatively convenient to treat from a physical perspective, may be well accepted by most patients, and may have a higher response rate than others. Most of the points are on the conception and governing vessels, plus zusanli and yongquan, and shu points on the back. It is difficult to know, based on the literature review, whether moxibustion is more effective than acupuncture or other stimulus methods administered for the same condition. In the absence of more detailed studies, moxa is applied primarily on the basis of the Chinese traditional medical descriptions, such as treating syndromes associated with cold, retention of food, spasms, immune deficiency, and local stagnation of fluids with formation masses. Moxa may be utilized in some cases of heat syndromes.

REFERENCES 1. Unschuld PU, Huang Di Nei Jing Su Wen: Nature, Knowledge, Imagery in an Ancient Chinese Medical Text, 2003 University of California Press, Berkeley, CA. 2. Cheng Xinnong (chief editor), Chinese Acupuncture and Moxibustion, 1987 Foreign Languages Press, Beijing. 3. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 4. Wang Xuetai, An introduction to the study of acupuncture and moxibustion in China, Part 1, Journal of Traditional Chinese Medicine, 1984; 4(2): 85-90. 5. Jiao Guorui, An introduction to the study of acupuncture and moxibustion in China, Part 2, Journal of Traditional Chinese Medicine, 1984; 4(3): 169-176. 6. Kuang Yihuang and Wei Jia, An introduction to the study of acupuncture and moxibustion in China, Part 3, Journal of Traditional Chinese Medicine, 1985; 5(1): 67-76. 7. Wu Chunguang, et al., Fifty cases of gastroptosis treated by moxibustion therapy, Journal of Traditional Chinese Medicine, 2000; 20 (1): 42-43. 8. Zhou Wei, Acute lymphangitis treated by moxibustion with garlic in 118 cases. Journal of Traditional Chinese Medicine, 2003; 23(3): 198. 9. Shen Dehui, Wu Xiufen, and Nissi Wang, Manual of Dermatology in Chinese Medicine, 1995 Eastland Press, Seattle, WA. 10. Yang Shouzhong and Chace C, The Systematic Classic of Acupuncture and Moxibustion, 1994 Blue Poppy Press, Boulder, CO. 11. Yuan Liren and Liu Xiaoming, Keeping-fit moxibustion, Journal of Traditional Chinese Medicine 1993; 13(3): 227-229. 12. Song Zhenzhi and Zhu Deyou, 97 cases of gastrointestinal spasm treated with moxibustion, Journal of Traditional Chinese Medicine 1991; 11(2): 110-111. 13. Chang HM and But PPH (editors), Pharmacology and Applications of Chinese Materia Medica, 1986 World Scientific, Singapore. 14. Long Zhixian (chief editor), Acupuncture and Moxibustion, 1999 Academy Press, Beijing. 15. Yan Cuilan and Zhu Yunlong, The Treatment of External Diseases with Acupuncture and Moxibustion, 1997 Blue Poppy Press, Boulder, CO. 16. Zheang Dengbu, et al., Suspended moxibustion of ignited moxa roll in treating coronary heart disease: a clinical observation of 138 cases, Journal of Traditional Chinese Medicine 1992; 12 (2): 95-99. 17. Liu Zhangcai, Health-preserving, life-prolonging moxibustion, Acupuncture Today, December 2003; page 26. 18. Cui Meng, Present status of research abroad concerning the effect of acupuncture and moxibustion on immunological functions, Journal of Traditional Chinese Medicine 1992; 12 (3): 211-219. 19. Shi Huaisheng, et al., Ginger-partitioned moxibustion on sifeng point (extra-29) in treating children's asthenia and its effects on cellular immune functions, Chinese Acupuncture and Moxibustion 1995; (6): 9-10. 20. Xhou Jianwei, et al., Impact of medicated mugwort moxibustion on serum gastrin, d-xylose excretion rate, and T-cell subgroup in patients with spleen deficiency syndrome, Chinese Acupuncture and Moxibustion 1998; (1): 15-16. 21. Wang Kenliang, Several diseases treated by suppurative moxibustion therapy, 2000 International Congress on Traditional Medicine, April 22-24, Beijing. 22. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1996 Blue Poppy Press, Boulder, CO. 23. Li Huailin, 34 cases of herpes zoster treated by moxibustion at dazhui (GV-14), Journal of Traditional Chinese Medicine 1992; 12 (1): 71. 24. Okazaki M, et al., Effects of a single moxibustion on cutaneous blood vessel and microvascular permeability in mice, American Journal of Chinese Medicine 1990; 18(3-4): 121-130. 25. Okazaki M, et al., Effects of single and multiple moxibustions on activity of platelet function, blood coagulation, and fibrinolysis in mice, American Journal of Chinese Medicine 1990; 18(1-2): 77-85. 26. Hau DM, et al., Effects of moxibustion on cellular immunocompetence of γ-irradiated mice, American Journal of Chinese

Medicine 1989; 17(3-4): 157-163. 27. O'Connor J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981, Eastland Press, Seattle, WA. 28. Hu Guosheng, et al., Clinical observations on Hashimoto's thyroiditis treated by indirect moxibustion with various Chinese medicines, Journal of Traditional Chinese Medicine 1996; 16(1): 27-32. 29. Wu Huangan, et al., Clinical therapeutic effect of drug-separated moxibustion on chronic diarrhea and its immunological mechanisms, Journal of Traditional Chinese Medicine 1997; 17(4): 253-258. 30. Wu Ping, Cao Yong, and Wu Junmei, Effects of moxa-cone moxibustion at guanyuan on erythrocytic immunity in tumor bearing mice, Journal of Traditional Chinese Medicine 2000; 20(1): 68-71. 31. Liu Anran, Clinical application of moxibustion over point dazhui, Journal of Traditional Chinese Medicine 1999; 19(4): 283-286. 32. Johns R, The Art of Acupuncture Techniques, 1996 North Atlantic Books, Berkeley, CA. 33. Zhang Enquin (ed. in chief), Chinese Medicated Diet, 1988 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai. 34. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988, Kluwer Academic Publishers, Dordrecht, Holland. 35. Tiao Yuansheng, et al., (contributors), Discussion on reinforcement and reduction manipulations in acupuncture and moxibustion, Journal of Traditional Chinese Medicine 1992; 12(1): 3-9. 36. Yang Shouzhong and Li Jianyong (translators), Li Dongyuan's Treatise on the Spleen and Stomach, 1993 Blue Poppy Press, Boulder, CO. 37. Tohya K, et al., Suppression of the DTH reaction in mice by means of moxibustion at electro-permeable points, American Journal of Chinese Medicine 1989; 17(3-4): 139-144. 38. Kashiba H, Nishigori A, and Useda Y, Expression of galanin in rat primary sensory afferents after moxibustion to the skin, American Journal of Chinese Medicine 1992; 20(2): 103-114. 39. Ma Jiqing, Wang Deshan, and Qin Yanbin, Effects on the interdigestive myoelectric complex of small intestine by zusanli moxibustion, Journal of Traditional Chinese Medicine 1986; 16(3): 213-215. 40. Bucinskaite V, et al., Effects of electro-acupuncture and physical exercise (running) on neuropeptides in the hippocampus in rats, European Journal of Neurosciences 1996; 8(2): 382-387. 41. Tang Youwei and Chen Shuhong, Acupuncture, moxibustion, and the immune system, International Journal of Oriental Medicine, 1999; 24(4): 192-198. 42. Pei Jian, et al., Effect of moxibustion of dazhui (GV-14) on cellular immune function in tumor-bearing mice, International Journal of Oriental Medicine 1995; 20(2): 72-76. 43. Chen Gongsun, Zhong Yuanming, and Xing Jianqiu, On the indications of acupuncture and moxibustion, Journal of Traditional Chinese Medicine 1998; 18(3): 225-229. 44. Ma Yuan, Reports on illustrative cases of various diseases effectively treated with moxibustion, Journal of Traditional Chinese Medicine 1996; 16(2): 121-124. 45. Li Su, et al., Effects of warm needling at zusanli (ST-36) on nitrous oxide and IL-2 levels in middle-aged and old people, Journal of Traditional Chinese Medicine 2003; 23(2): 127-128. 46. Li Changdu, Jiang Zhenya and Li Yingkun, Therapeutic effect of needle warming through moxibustion at twelve shu points on rheumatoid arthritis, Journal of Traditional Chinese Medicine 1999; 19(1): 22-26.

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INTRODUCTION TO “MYTH AND MEANING” Understanding of Acupuncture through Ancient Chinese Myths by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

In 1992, Lonnie Jarrett’s article Myth and meaning in Chinese medicine, was published in the Traditional Acupuncture Society Journal (No. 11, p.45–48). Here I provide an introduction to the article, followed by a slightly edited version of it. Daoism (Taoism) is an important aspect of Chinese medicine. A commonly mentioned depiction of the dao is that it flows like a stream. In this article, a different aspect of the dao is depicted: its flood-like nature. Jarret has selected a famous Chinese myth, about a great flood and the efforts to control it, and illustrated how this myth can help one understand the basis of acupuncture therapy. As the story unfolds, the meaning of one of the key acupuncture points, GV-20, is elucidated. The myth is based, largely, on the reputation of Emperor Yü, who is one of five legendary founders of Chinese civilization (one for each of the Five Elements; Huangdi, the Yellow Emperor, was associated with the earth element; Yü, with the wood element). Historically, Yü is known for his work in “draining and ditching” to control the flow of water, especially to control floods (it was reported that, in the time of Yü, there were 9 floods in a period of 10 years), and he is thus ascribed the position of founder of Chinese agriculture (his predecessor, by about six centuries, Shennong, taught the basics of agriculture, but Yü made its development possible). Chinese agriculture evolved, as it did in all countries, along large rivers. The southern Chinese staple grain, rice, requires intensive water regulation. The farmers’ ability to produce plants, that ultimately resulted from Yü’s effective flood control, are, perhaps, the reason he is affiliated with the wood element (associated with growth) rather than with the earth element (manipulating the soil). Acupuncture meridians were originally thought to correspond to the great rivers (see Jingluo: Drawing a concept). Acupuncture therapy—regulating the flow of qi through the meridians—corresponds, to a certain extent, to the draining and ditching. As the rest of the myth about Yü illustrates, there are other aspects of the medical system that can be revealed through the Chinese mythology. I believe this article is important for several reasons, aside from providing the specific insights just stated: 1. It reveals how the study of Chinese culture, through its ancient literature, can enhance one’s understanding of medical practice. That is, one does not need to simply read modern medical texts to gain a better understanding of the traditional medical practice. Among the books revealing images of value are: Taoist Ritual in Chinese Society and History, Myth and Meaning in Early Daoism, and Chinese Mythology. 2. It gives the reader an insight into acupuncture point functions (based on one specific example) that differs from the formulaic version, that “this point is useful for treating that disorder.” 3. Readers are alerted to specific traditional Chinese texts, namely the I-Ching (Yijing), Tao Te Ching (Dao De Jing), the writings of Chuang-tzu (Zhuangzi), the Tao Chang (Dao Zang), Tso Chuan (Zuo Chuan), and the Scripture of the Mountains and Seas (Shan Hai Jing). The article contains a caution about suppressing symptoms. I have heard many people involved with Chinese medicine make the statement that Western techniques that alleviate symptoms necessarily suppress them. This is not necessarily so; it is better to consider each treatment according to its specific effects. Chinese medical philosophy emphasizes free movement as a fundamental remedy. By contrast, suppressing the function of the immune system or the nervous system to get rid of a symptom of a disease—otherwise left unresolved by the suppressive therapy—may be exactly what is cautioned about in the flood control myth. April 1998



MYTH AND MEANING IN CHINESE MEDICINE by Lonny Jarrett, L.Ac.

All medical systems reflect the underlying beliefs and assumptions about life inherent in the culture in which they are formulated. The ways of knowing in ancient China focused on understanding the movements of dao as represented externally in the universe and internally in human beings. Chinese medicine, likewise, focuses on movements that reflect internally that which is observed externally. Specifically, acupuncture meridians and points reflect the way in which the Chinese saw, in ancient times, the macrocosm of the universe mapped onto the microcosm of the body. This map illustrates the functional relationships which maintain the integrity of the human being. Just as the Yijing (I-Ching) is a tool to guide our intuition to an understanding of the dao’s implicit movement in the world, knowledge of the imagery of the acupuncture points gives us access to the ways in which the dao is striving to express itself through each individual, and the ways in which that effort is blocked, resulting in imbalance and ill health. In order to truly appreciate the function of the acupuncture points, it is helpful to understand how the Chinese thought about their world at the time when the collection of acupuncture therapeutics was codified as standard medical practice. Since the early Chinese conception of the universe is well reflected in their mythology, by understanding this mythology (shenhua, spirit talk) the spirits of the points come alive and talk to us. This article explores one of the fundamental myths of Chinese culture, and relates it to the spirit of the acupuncture point Governor Vessel-20. In so doing, it also reveals the inner tradition of healing in Chinese medicine. DAO AS CHAOS: THE GREAT FLOOD

The Dao De Jing characterizes the dao as a vast whirlpool constantly moving away from and returning to its source in the process of its own self-becoming (1). Chapter 25 of the Dao De Jing calls the fundamental nature of dao chaotic. The sage, in aligning himself with the dao, steers by the torch of chaos and doubt (2). In his book Taoist Ritual in Chinese Society and History, Lagerwey says (3): “If chaos is eternal, the order introduced into chaos of the universe has an end, as it has a beginning. This is because, slowly, names given cease to fit; political systems invented in simpler times cease to function; old irrigation ditches get choked up with new vegetation; the waters of chaos begin to mount.” As the Dao De Jing says (4), “the great dao floods over.” The dao is likened to a river whose waters are constantly rising and the Dao De Jing is a survival manual informing us that, through the cultivation of virtue [the de in the title] (5), we may channel the flood and avoid being inundated by it. Hence, Zhuangzi (Chuang-tzu) states: “Though flood waters pile up high to the sky, he [the sage] will not drown (6).” Controlling the floods was a continual problem for the early Chinese (as it remains so today). The imagery and theme of a brother and sister surviving a great flood to land on Kunlun mountain, there giving birth incestuously to the human race, is pervasive in early Chinese mythology. The flood itself represents the dao’s efforts to assert its original, spontaneous nature. The flood does so in human society, where it (spontaneity) has been civilized, thus to wipe the slate clean for a new beginning. This drama of building and civilizing, followed by destruction, is played out eternally as humans lose their original natures of self-becoming (see: The Spirit of Chinese medicine: the return to original nature ), and seek to control the ensuing chaos. THE MYTH OF GUN AND YÜ

The theme of the epic flood is well represented in the myth of Gun and Yü which, I believe, lays the foundation for understanding the inner tradition of healing in Chinese medicine. As the story goes, during the time of Emperor Yao (during the legendary period), the overflowing waters reached up to the sky. Yao enlisted Gun, the great grandson of Huangdi (the Yellow Emperor), to control the flooding (7). Gun set about building dams—to hold back the waters—out of rich earth which he stole from Huangdi. The dams, however, continually collapsed under the weight of the flood waters. For his neglect of orders in failing to control the floods, Gun was executed by Huangdi’s heavenly executioner, Zhurong, the spirit of fire, on Feather Mountain (8). Finally, Gun fell into feather abyss, becoming its spirit in the form of a tortoise. Gun’s son, Yü, was then appointed the task of controlling the floods in Gun’s place. Yü worked devotedly for thirteen years cutting ditches and tunneling through mountains to provide a way (dao, as in the title of Dao De Jing) for the water from the rivers to be channeled to the sea. Here, the sea is that great abyss (taiyuan), which, like the dao, can receive all things without being filled, yet is never depleted though its waters are used constantly. The acupuncture point Lung-9 is named taiyuan because it is the meeting point of the vessels, where the qi is plentiful and deep like an abyss (9). Gun, in trying to directly suppress the flooding by blocking its expression, was unsuccessful. Likewise, by suppressing any symptom of the body, it, like the dao, will eventually express itself, breaking any barriers placed in its path. Only by opening the channels—and thereby assisting the patient in bringing life’s energy through them—can treatment be successful. Zhaungzi informs (10): In all things, the way does not want to be obstructed, for if there is obstruction, there is choking; if the choking does not cease, there is disorder; and disorder harms the life of all creatures....All things that have consciousness depend on breath. But if they do not get their fill of breath, it is not the fault of

heaven. Heaven opens up the passages and supplies them day and night without stop. But man on the contrary blocks up the holes. The myth of Gun and Yü thus serves as metaphor for several fundamental principles of Chinese medicine. In describing the way of heaven, the Dao De Jing states: “What has surplus is reduced, what is deficient is supplemented” (11). It is the same message that is given repeatedly in the Neijing Lingshu (Spiritual Pivot of the Inner Classic; ca. 100 B.C.). This notion is expressed nicely by Zhang Congzheng (12) in the Rumen Shihqin (ca. 1228): [Physicians who] consider a supplementing for persons who have been affected by evil accumulations are followers of Gun, who drowned in the great flood [because he applied the wrong method]. DESTINY

The importance of channeling rather than suppressing is well-expressed in the Chinese word ming (destiny). According to Wieger (13), this character is a picture of a written order, with a seal of authority fixed upon it, and the mouth of heaven dictating to man his destiny between heaven and earth. Destiny is to be met, not overcome. Scholar Tang Qunyi defines ming as existing: “in the mutuality of heaven and man, i.e., in their mutual influence and response, their mutual giving and receiving.” Mencius states: “What I command to myself is what heaven intended to command to me; thus, the heavenly ming is established through me. (14)” For Mencius “The way to understand heaven is through understanding one’s own [original] nature, which, in turn, is known through the exhaustion or utmost devotion of one’s heart; on the other hand, the way to serve heaven is to preserve one’s heart within and nourish one’s own [original] nature” (15). It is through acting as a vessel for the dao, and bringing the heart of heaven into the world, that one fulfills one’s destiny. The Zuo Chuan warns that he who ignores his own destiny “probably will not return home again” (16). Gun, who ignored his destiny, died in Feather Abyss never to return home. Yü, the heart of commitment, returned to his home only after fulfilling his destiny and controlling the floods. During the time Yü was busy channeling the waters: Whenever he came to a famous mountain or a big swamp, he would summon its spirit and ask it concerning the deep structure of the mountains and rivers, about the kinds of precious stones, of birds, beasts, and reptiles found there, as well as concerning the customs of the people on all eight sides and the boundaries, soil quality, and size of the various states. He and Yi and Gui wrote all this down and called it The Classic of the Mountains and Seas (Shan Hai Jing). In his journeys, Yü becomes familiar with the “hundred demons,” or spirits of the deep structures of the earth. Similarly, the acupuncturist must know intimately the nature of the spirit present in each acupuncture point. The meridians [mai] are the internal rivers of the microcosm, each acupuncture point representing a specific aspect of being in the individual’s inner kingdom. THE GREAT MEETING

According to the myth, after taming the floods Yü became emperor and founded the Xia Dynasty (2205–1766 B.C.), during which time he dealt successfully with numerous floods. Yet, his greatest accomplishment was unification of a divided China (17): After three years he examined the merit [of his ministers]; within five years his government was securely established. He went on tour of all under heaven, and when he came back to Great Yueh, he ascended Mount Mao in order to receive in audience his subjects from the four directions and to inspect the feudal lords of the Central Province. When Oppose-the-Wind arrived late, Yü beheaded him and displayed [his head] to the multitude in order to make clear that all under heaven belonged to him. Then he had a great assembly to decide how to rule the state. Inside, he praised the merit of [the text found on] Mount Cauldron [by means of which he had] stabilized the land; outside, he displayed the saintly virtue which made him a man after Heaven’s heart. Then he changed the name of Mount Mao to the Mountain of the Assembly of Accounts. Among his subjects, convened on top of Mount Mao, are the “hundred demons,” pulling China in different directions. By bringing them together, Yü is able to bring spiritual unity to ancient China. Oppose-the-Wind is “not a loyal subject but a rebellious energy,” one who will, like the stellar winds, “prevent the communication that is to occur during the ritual.” In the microcosm of the body, the acupuncture point Governor Vessel-20 (GV-20), located on the vertex of the head, is named the hundred meetings (baihui). The Dao Zang (Hidden Dao) states that the head is the meeting point of the hundred spirits (18). Governor-20, then, can be understood to be the place on top of the head (the head corresponding to Mount Mao) that the 100 spirits meet. The traditional function of GV-20 in draining wind from the head is reflected in the “beheading” of Oppose-the-Wind, the influence that threatens the integrity of the kingdom by opposing Yü’s rule. For, it is Yü who establishes harmony by controlling the rising waters of chaos. Wind in Chinese medicine is revealed by signs and/or symptoms that change location and severity quickly. Its general presentation is that of chaos and is exemplified by muscle spasms, seizures, fainting, violent outbursts of anger, or headaches. The point GV-20 can help restore control and marshal the patient’s resources to quell the chaos. Governor-20 is the point that aligns us with the polestar (19), to which “all the lesser stars do homage” (20) and it is Yü’s virtue in being a man after heaven’s heart that allows him to gain control of the kingdom. It is his power of intention in visualizing the spirits that allows him to summon and transform them into one body, an assembly (hui) of all under heaven. Yü’s intimate knowledge of the spirits of the rivers and mountains ( maili: veins of the earth) enabled him to draw the waters off (out of the southeastern “door of the earth”) and out to the abyss of the sea (21). The medical implications of the myth are captured in Chinese characters and speech. The character zhi, meaning “to

set in order,” is used in medical literature with the meaning “to heal” or “to treat.” The name of emperor Yü is a homophone for the modern character yu, which is a picture of a boat over that for heart meaning “to heal.” Another homophone is found in the character yu meaning “to meet.” Lagerwey points out the similarity between the function of the priest in Daoist ritual and that of Yü in taming the floods and uniting the empire. What Yü did for ancient China in controlling the floods and uniting the kingdom, the traditional acupuncturist, in much the same role as the Daoist priest, does for each patient. By learning intimately the nature of the spirits living in the internal structures of the patient’s being, and channeling off the excess and supplementing the deficiencies, traditional acupuncture is able to maintain and restore harmony in the kingdom of the Body/Mind/Spirit. ENDNOTES AND REFERENCES

1. Chen EM, The Dao De Ching, 1989 Paragon House, NY, p. 60, 117 2. Watson B, Chuang Tzu, Basic Writings , 1964 Columbia University Press, p.38. 3. Lagerway J, Taoist Ritual in Chinese Society and History, 1987 Macmillan, NY, p.11. 4. Chen EM, The Dao De Ching, 1989 Paragon House, NY, p.137. 5. The character de is translated as virtue and has three key components. The first is a picture of a man walking and implies movement or action. The second means “perfectly right” and suggests that a thing scrutinized by the eye from all directions, has shown no deviation. The last component denotes the heart. It may be interpreted to mean that the virtuous man’s behavior perfectly reflects his heart which, under scrutiny, shows no deviation. Chen (ibid, p.184) defines de as: “The original endowment of nature prior to moral distinctions and conscious effort.” 6. Watson B, Chuang Tzu, Basic Writings , 1964 Columbia University Press, p.27. 7. Girardot NJ, Myth and Meaning in Early Daoism, 1988 University of California Press, Berkeley, CA. 8. Christie A, Chinese Mythology, 1968 Hamlyn Publishing Group Ltd., London, p.87. 9. Ellis A, Wiseman N, and Boss K, Grasping the Wind, 1989 Paradigm Publications, MA, p 33. 10. Watson B, Chuang Tzu, Basic Writings , Columbia University Press, 1964, p.138. 11. Chen EM, The Dao De Ching, 1989 Paragon House, NY, Ch. 77, p.223. 12. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988 Kluwer Academic Publishers, Boston, MA, p.216. 13. Weiger L, Chinese Characters, 1965 Paragon Books, NY, p 47. 14. T’ang Chun-I, The T’ien Ming [Heavenly Ordinance] in Pre-Ch’in China , Philosophy and Culture: East and West 1962; 12, p.34. 15. Ibid. p.33. 16. T’ang, Chun-I, (1962), The T’ien Ming [Heavenly Ordinance] in Pre-Ch’in China , Philosophy and Culture: East and West 1962; 11, p 208. 17. Lagerway J, Taoist Ritual in Chinese Society and History, 1987 Macmillan, NY, p.160. 18. Ibid. p.151 19. Ellis A, Wiseman N, and Boss K, Grasping the Wind, 1989 Paradigm Publications, MA, p.344. 20. The pole star, di, is the heart of heaven as the emperor, di, is the heart of the nation. The pole star is the center of the universe and the governor vessel is the meridian which centers the functions of the body/mind/spirit to the axis of heaven. Chan, Wing-Tsit, p.22.—Most notable of these stars is the great dipper which is the giant spoon circling around the polestar churning us along through the whirlpool of life. The big dipper is the central administration of heaven in which live the primordial gods of fundamental destiny (See Anderson, P., The Method of Holding the Three Ones, 1989 Curzon Press, Great Britain, p.61). The alchemical texts refer to the process of being distanced from one’s original nature [de], which leads to illness, as “going along”. Restoration of original nature is referred to as “reversing the course of the dipper’s handle.” 21. Lagerway J, Taoist Ritual in Chinese Society and History, 1987 Macmillan, NY, p.11.



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Towards a Spirit at Peace Understanding the Treatment of Shen Disorders with Chinese Medicine by Subhuti Dharmananda, Ph.D. About the Title Illustration Postscript Chapter One What Is Shen (Spirit)? Chapter Two A Mind that Is Free Chapter Three Emotional Equilibrium Chapter Four Acupuncture Points Chapter Five Acupuncture Treatment Protocols Chapter Six Xuedao Zheng, Bahie Bing, Meihi Ming Chapter Seven Herbs Chapter Eight Traditional Herb Formulas Chapter Nine Sample Herbal Treatment Strategies Chapter Ten Summary, Speculation, Suggestions Appendix Quick Reference to Herb Names

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THE MOVEMENT TOWARD ORGANIC HERB CULTIVATION IN CHINA by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND Following its vast political revolution of 1949, China closed itself off from most contact with Western countries, primarily maintaining ties with the Soviet Union, as a benefactor and political ally, plus limited interactions with a few other communist countries. China and all its allies during this time period faced enormous struggles in food production and supply of other basic needs for their citizens. China first opened itself to interchange and trade with the West in the 1970s, when its self-destructive cultural revolution was coming to an end. This opening was manifest in the development of a biannual international trade fair in Guangzhou (Canton) beginning in 1976. Western countries could then begin importing from China certain foods, tea, and medicinal herbs, as well as a variety of manufactured goods. The issue of organically grown materials did not arise immediately. At that time, there was little attention given to organic foods even in the West. For example, in the U.S., there were only a few thousand acres of land with organic cultivation, very few outlets for organically grown food, and the foods were much more expensive than those produced by standard agricultural methods. In China, the concept of specifically seeking organically grown foods would not even make sense following the years of severe famine that from 1959 to 1976 probably killed about 30 million people. Simply getting enough food was an issue, and getting adequate variety of foods was still quite difficult, especially with the planned agricultural production determined by the central government that was often way off the mark of what was actually needed. In the 1970s and the 1980s, the issue for Chinese farmers with regard to pesticides, fungicides, antibiotics, and other agricultural aids, such as prepared fertilizers, was not how to avoid them: it was whether or not the farmers could afford them. If they could be obtained, they would be used. There was too little animal manure to go around, so human waste was used as fertilizer. Production had to be increased to meet the needs of a billion people who were living on lands that had been depleted by long-term agriculture. With larger plots of individual crops, especially those that are repeatedly planted on the same land, it is almost inevitable that plant pathogens will become a problem. People who established large plots would have to face the disastrous loss of entire crops if an insect infestation or root rot occurred. Sometimes the government would send millions of peasants to collect birds that were eating seeds or insects that were eating leaves. Under such circumstances, the population did not have a chance to think about dangers of pesticides. The organic foods movement in the West did not make great progress until the 1990s. According to USDA estimates, the certified organic cropland doubled from 1992 to 1997 to reach 1.3 million acres (out of just over 430 million acres total cropland). Even today, organic farmland remains a small portion of American agriculture, currently well under 1% of the total farm acreage. The rapid growth of this agricultural industry led to some problems with labeling of products as organic, so new standards have been imposed, and people interested in organic products have increased their demands for purity and certification of purity as well. The situation has developed favorably to the point where organic foods are now sold in larger quantities in standard grocery outlets than in specialty "health food" or "whole food" stores. Major areas for organic foods are beverages and snack items more so than bulk fresh produce. Selling processed and packaged foods provides a more stable base for the producers, distributors, and retailers. Consumers who are interested in seeking out organic foods tend to reject chemicals in a broader context than just those applied in agricultural practices. Thus, this group includes many people who seek herbal alternatives to drugs (as well as other therapies perceived as natural). Western herbs, by virtue of being grown in Europe and America where the organic foods movements began, and being most often sold as single herb remedies, are sometimes available as organically grown products. During the late 1990s, an increasing number of patients of practitioners prescribing Chinese herbs have inquired about organic production of the herbs. For them, the situation is complex, both because the herbs come from China and because the usual products are large mixtures of herbs from numerous sources within China, making it difficult to maintain any control over the growing conditions of each ingredient. The situation in China with regard to herbs is somewhat different than that for foods, but there are many parallels. Within China, the demand for organic foods has only recently begun, with a lag of 10-15 years after the West developed a large scale interest. However, the issue is only gradually spreading to the herb market. The level of demand for special growing conditions for the herbs remains low, and comes mainly from the relatively small foreign markets (China only exports about 5% of its medicinal herb supply). The majority of herbs are still collected from the wild, so that cultivation conditions are not a matter of concern. For herbs that are cultivated, the materials are usually in short supply, so that efforts have been primarily focused on increasing production rather than on developing organic production methods. However, the attention of the Chinese government and of producers is changing due to problems that have been encountered with non-organic production methods. Thus, for example, the market for Asian ginseng was greatly impaired when U.S. officials noted the presence of quintozene residue (a commonly used fungicide that prevents root rot) in some imported roots (mainly from Korea). The problem encountered initially was that this fungicide is not approved for use on ginseng by the U.S. Department of Agriculture (not because it is inherently problematic, as it is used for numerous crops in the U.S., but only because the approval hadn't been established). For herb users who are seeking chemical-free foods and herbs, this news also indicated that ginseng could not be trusted to be organically grown or, at the least, free from chemical residues. Indeed, it is almost impossible to grow ginseng on a commercial scale without using fungicides of some type; it is possible to minimize the presence of residues, frequently reaching the non-detectable level. An even greater impact was felt in China after Western countries banned imports of its bee products. This came about when chloramphenicol (an antibiotic) was detected in several samples of pollen (it was also found in royal jelly). At that moment, China was the largest supplier of bee products in the world; a situation that changed immediately and put the bee industry in China into turmoil. A positive development for China has been the recent publicity for the health benefits of green tea, for which China is the main

source. Tea producers had to scramble to produce organically grown green tea for export, since those seeking its health benefits included many who were following the organic foods movement. Tea is usually produced with a small amount of fungicides to protect the plants from blister blight and root rot, so organic tea is a specialty item. China has now gotten on board with Western countries that desire to develop organically grown crops, teas, and medicinal herbs. These were initially called "Green Foods," referring to the environmental political parties that were known as Green parties in Germany and other European countries. The progress that China is making in this area should reassure manufacturers, practitioners, patients, and consumers who rely on Chinese medicinal herbs and teas. For example, a problem of lead contamination of herbs (not just from China) was discovered in the 1990s, and this has largely been resolved by the elimination of lead from gasoline supplies (lead in car exhaust was settling on soil and plants). China was late in eliminating this contaminant-the U.S. banned leaded gasoline in 1970, Europe followed suit in the 1980s and early 1990s; China did so in 2000). An international symposium on organic farming was held in Korea in 2002 (1st Gangjin International Symposium on Organic Agriculture), and a report on organic foods production in China was presented by Lu Zhenhui, of the Organic Tea Research and Development Center (a department of the Tea Research Institute of the Chinese Academy of Agricultural Sciences in Hangzhou). Following is a slightly edited version of his report, followed by a report of the current author regarding information personally collected on this subject.

Production and Market of Organic Foods in China by Lu Zhenhui, of the Organic Tea Research and Development Center. Edited and updated by ITM

Introduction Organic farming aims at maintaining the long-term fertility of the soil through application of various sustainable cultivation techniques (e.g., crop rotation, manure rather than chemical fertilizer), building-up diversified production systems, and reducing the dependence on unnatural additives. With their sustainable production systems, organic farmers contribute to the protection of natural resources. Organic growing practices follow written standards which exclude the use of synthetic fertilizers and chemical pesticides. Organic food is free of chemical residues, healthy, and of high quality. Therefore, consumers are willing to pay premium prices for organic products. Today, organic agriculture is growing rapidly in China. Organic farming is promoted mainly for two reasons: 1. To meet requirements of both international and domestic consumers, which are in line with international rules or guidelines. In the future, WTO (World Trade Organization) rules and notably the TBT Agreement (Technical Barriers to Trade) as well as the international standards for organic farming will play an even more important role than today. Organic food produced in China is mainly exported to Japan, the United States, Canada, and some European countries such as Holland, Germany, and France. It is estimated that the total value of organic food exported in 1999 was about $15 million (U.S.), and the annual growth rate at that time was 50% (based on trends since 1995). The majority of exported products were organic tea, soybeans, green beans, and other vegetables. Recently, organically produced foods such as tea, honey, vegetables, grains, and milk powder sold in the domestic market had a very fast rate of growth. In 2001, the sale value of foods sold on the domestic market with the Green Food designation (see below) reached around $3.5 billion (U.S.). 2. To generate innovations which replace the use of agro-chemicals and allow for environmentally friendly agricultural practices. Increasing problems of contaminated food and deteriorating water quality have brought environmentally-friendly agricultural production to the top of the agenda for the central government. Organic farming is part of this strategy. The Ministry of Agriculture has planned a number of projects which monitor water and food quality in intensive farming systems. Shanghai Municipality has designed a package of supportive policies which promote environmentally-friendly agriculture, including organic farming. Food safety is a major issue which determines the behavior of urban consumers; it will also be an important quality of agro-products on the national market.

Main Organizations in Organic Food There are now several major Chinese certifying agencies-China Green Food Development Center, Organic Food Development Center, Organic Tea Research and Development Center-plus other agencies investigating and promoting organic production techniques, such as the Intercontinental Center for Agro-ecological Industry Research, and the organic production site Jiangsu Ruikang Organic Food Trade. These organizations are briefly outlined below. China Green Food Development Center (CGFDC) , in Beijing, was the first organization in organic/green food development in China. It is a national level institution with the authority to certify agricultural products as being free of chemical contamination. Preparatory work began in earnest in 1990 and the center was officially established in November 1992 under the jurisdiction of the Ministry of Agriculture. The Green Food certified food products cover 7 major categories and 29 subcategories of China's agricultural products, including grains, oils, fruits, vegetables, animal products (meat and diary), aquatic products, liquors, and non-alcoholic beverages. By the end of 2000, green food certification was granted to 1,831 kinds of food products with the total output of 15 million tons and cultivated area of 3.33 million hectares (1.35 million acres). There are two levels of certification; both for freedom from detectable chemical residues: Grade A: allows the grower to use a very limited amount of synthetic substance during the production process, emphasizing the reduction of chemical use compared to routine practices rather than enforcing complete elimination of chemical use, but requiring the absence of detectable chemical residues rather than the adoption of full organic farming practices. Grade AA: in 1995, Green Food established the "AA Grade" Green Food label to certify products produced without any chemical pesticides or fertilizers throughout. The AA Grade label aims at increasing Green Food's competitiveness in the

international organic market. CGFDC has three goals: To protect the agro-ecological environment and to search for and extend sustainable food production methods to enhance the sustainable agriculture; To satisfy the growing demand for better food by both urban and rural people; and To bring closer the relationship between agriculture and the food industry and between producers and consumers in order to create new opportunities and ways to increase farmers' income and profits from the food industry with a focus on contaminant free foods. Major activities are inspection of food products, certification of accepted products, teaching about environmental protection and sustainable food production, and training of personnel at all levels of production and testing. CGFDC formulates programs, policies, and plans for developing Green Foods, administers the use of the Green Food label, and organizes the formulation and improvement of the various standards for Green Food. It also makes arrangements for carrying out key scientific and technological work, conducts promotional activities and advertising for the Green Food Project, organizes and participates in related domestic and foreign economic and technological exchanges and cooperative efforts, and directs the work of Green Food administration bodies in the provinces, autonomous regions, and cities. It sets up Green Food demonstration bases as well. CGFDC is a member of the International Federation of Organic Agricultural Movements (IFOAM). Organic Food Development Center (OFDC) is an organization within the Nanjing Institute of Environmental Science (NIES) under the State Environmental Protection Agency (SEPA) of China; it has been involved in organic inspection and certification since 1994. OFDC is a specialized institution following international certification standards and requirements. It has received official accreditation by the International Federation of Organic Agricultural Movements (IFOAM). OFDC certified products are mainly exported to Japan, the United States, Canada, and European countries. The main tasks of OFDC are to control agro-environmental pollution caused by heavy application of synthetic pesticides and fertilizers, to promote the development of organic agriculture, and to provide certified quality organic food for consumers. OFDC now has set up branches in 11 provinces and regions. Some organic food development offices were set up at the county levels; there are 35 qualified inspectors approved by OFDC. OFDC has developed rigorous standards for organic food production and processing, and for regulating the use of the OFDC organic logo (registered and protected by law in China). The standards have been approved by SEPA, a governmental institution. The Organic Tea Research and Development Center (OTRDC), under the Tea Research Institute of the CAAS (China Academy of Agricultural Sciences), is a domestic certification body specializing in organic teas, beverages, and herb products. Since its establishment in March 1999, it has issued certificates to a total of 110 organic tea gardens and three organic fertilizer plants. OTRDC certified products are widely accepted by Chinese consumers and spread quickly in domestic market. It has begun promoting its certification to the world market. Intercontinental Center for Agroecological Industry Research (ICAIR) was established in Nanjing in 1998 by professors, experts, and technicians in the fields of plant ecology, agro-ecology, and organic food development. It is a non-profit research organization with the aim of increasing the productivity and improving the stability and sustainability of agricultural production systems by promoting the development of the agro-ecological industry, organic agriculture, and sustainable agriculture in China. The goal of ICAIR is to protect rural environments from pollution while promoting sustainable development of rural economies through agro-ecological industries, including organic industry and rational utilization of natural resources. This is accomplished, in part, through international and national collaborative study and information exchange of agro-ecological knowledge, technology, and science. Thus, the researchers and developers at ICAIR have extensive contacts and relationships with research institutions, universities, governmental organizations and NGOs. Professor Li Zhengfang, the President of ICAIR, is a well-known ecologist, developer of organic food in China, and one of the founders of the Chinese organic agriculture movement. He was also the founding director of the Organic Food Development Center (OFDC). Jiangsu Ruikang Organic Food Trade (JROFT) was established in 1995 and is one of the pioneers of the organic agricultural movement in China. JROFT has cultivated organic tea, organic licorice, and organic star anise. All products are organically grown in the natural and wild environment and conform to the EEC (European Economic Community) regulations and the standards of OFDC (Organic Food Development Center) for organic agriculture. JROFT aims to arouse interest in organic farming by Chinese farmers, help improve the farming environment, exchange experiences in organic farming and organic food trade with devotees of the organic movement throughout the whole world, and open up a bigger market for organic agriculture by its own efforts and those of friends and colleagues.

International Certifiers Presently, many export-oriented products are certified directly by some external certifiers, such as ECOCERT International and Bio Control Systems (BCS) in Germany; Institute for Marketecology in Switzerland and Germany; the Soil Association in England; and the Organic Crop Improvement Association (OCIA) in the U.S. ECOCERT and BCS have established local branches as joint ventures with Chinese partners. In this case, local inspectors and certifiers do inspection jointly. All together, the many certifiers are competing for a rather limited area of production at this time. In most cases the foreign importers of Chinese goods decide on which certification label should be used on its products.

Development of Green Food and Organic Foods: A Brief Historical Overview In 1990, China officially announced its plans to commence the development of Green Food, in what was called the Green Food Project. The project was depicted as being large in scale-involving many government departments and enterprises as well as branches of scientific organizations. Green Food included organically grown foods and foods that were free of chemical contamination. The development of Green Food can be described in 3 stages:

Initiation stage (1990-1993): During first three years, many fundamental policies and institutional bodies were established and organized. The China Green Food Development Center (CGFDC) was established to organize and carry out the Green Food Project throughout the country. Besides that, the quality testing and control agencies were established, as were the quality criteria and standards. The CGFDC have made and promulgated a document describing the management of the symbol for Green Food. During this period, Green Food production grew up quickly in some areas, but lagged in others. Rapid development stage (1994-1996): The developments of Green Food in the second stage were characterized as follows: Numbers of products increased rapidly. The number of new certified products added in 1995 and 1996 were 263 and 289 kinds, respectively. The varieties of these goods then stabilized and covered most essential areas. By the end of 2000, there were a total of more than 1,000 kinds of certified products. Acreage for Green Food production enlarged quickly. Planting area for Green Food production in 1995 was 1.2 million hectares (0.5 million acres) that was 3.6 times of that in 1994; in 1996 it was 2.2 million hectares, an increase of 88.2%. The amount stabilized thereafter, by the end of the year 2000, the total planting area for Green Food was about 3.3 million hectares, with increased productivity. Production of Green Food increased greatly. In 1995, the total production of Green Food was 2.1 million tons with an increasing rate of over 200% per year. After 1996, the rate of increase slowed somewhat; by the end of 2000, the total production was about 8.4 million tons. Green Food development became very important in local economic development. Wide popularizing, marketing and internationalizing stage (1997-current): The socialization of Green Food has evolved as follows: More local governments and government bodies have given attention to Green Food development; More consumers have been acknowledging the value of Green Food; Public media has become focused on Green Food; More technologies have been developed for Green Food production; More large enterprises have become involved in Green Food; and World markets for Green Food are being expanded. Marketing of Green Food has developed very quickly. At present, market systems for Green Food have been established in many large and medium size cities. Consumers are getting more and more familiar with the Green Food. The total production output at the end of 2000 was $5 billion (U.S.).

Organic Foods Versus Green Foods While the original Green Foods movement was aimed at having food free of detectable contaminants, the organic foods movement focuses on the method by which the food ends up free of contaminants, namely, by being farmed in a unique chemical-free way, and linking this to sustainable agricultural practices. As an example of the establishment of organic farming, the oldest site is the Liu Min Ying Ecological Farm, outside of Beijing. It was founded in 1982, and became the first "ecological village" in China. By 1987, it was selected as one of the United Nations' 500 environmental models for the world. Now, it is a diversified farming enterprise with grain production, greenhouses for vegetables, an orchard, nursery, and facilities for animal husbandry. The farm makes use of organic wastes, solar energy, and other ecological approaches. Development of organic foods in China can be described in 3 stages: Research phase (1982-1994): Since 1982, when China began to develop ecological agriculture, some research institutes started to do research on organic foods, determining the methods by which chemical agriculture could be avoided. In 1990, organic green tea produced in Zhejiang Province was certificated by the SKAL (the Dutch certifying agency) and exported to Holland, which represented the initiation of organic food production in China with internationally recognized certification. Development of organic production fields (1994-2000): By the year 2000, more than 100 kinds of products were grown organically and certificated. The value of trade in this organic produce reached more than $20 million (US). The products include tea, honey, soybean, buckwheat, wheat, sunflower seeds, pine nuts, pumpkin seeds, walnuts, condiments, milk powder, and some traditional Chinese medicines. These products were mainly exported to Great Britain, Japan, America, Holland, Canada, Germany, France, and Australia. By 2000, there were 9 research groups that carried out research on organic food; nearly 30 companies undertook trade in organic foods; more than 50 bases of organic food production; 5 organic fertilizer factories; and more than 30 processing factories that handled organic foods and herbs. Chinese regulation systems and expansion of domestic sales (developments after 2000): The number of units involved in the organic industry is rapidly increasing. Authorities such as the Ministry of Agriculture and the Environment Protection Agency are formulating new regulations for the management of organic food. The disordered state of competition in this industry is changing and the primary focus is towards standardization of procedures and goals. Improvements in the quality-control systems will prevent imitations and fake products from spoiling the programs. The development of a domestic organic food industry will draw people's attention and promotion of organic foods will be strengthened. There will be more special shops that sell organic food, as well as organic foods sold in retail chains and in supermarkets.

Recent Problems The following are the key problems persisting in organic farming in China: The quantity of organic production and trading is still rather small at present. Organic operations are scattered throughout China and their production scales are limited. Most companies are not able to invest adequately in further developing their organic production base nor in the intensive and fine processing and packaging required to make the products ready for

market. The domestic market for organic food is still underdeveloped. Thus, most producers and trading companies currently depend on overseas importers and markets; they are producing organic food on request, a practice which carries high economic risks. Organic products from China are mostly raw materials; processing and packaging are of low quality. Therefore, producers earn comparatively low prices. This creates no incentives for establishment of sustainable production systems. The legal framework for organic farming remains undeveloped and a decision has not yet been made by the government as to which of the organic certifying bodies should have the mandate for the elaboration of regulations and laws and for setting up a central certification authority to meet international requirements. Without such a regulatory framework, foreign traders and certifiers are operating according to the importing countries requirements only; this leads to contradicting and arbitrary decisions on what should be "organic." Most producers and processors lack the special knowledge of organic production technologies. Qualified advisors are few, and the lack of professional know-how in China probably forms the biggest constraint for the extension of the area under organic cultivation.

Policy Needs for Action The expansion of the organic movement in China will require the following: 1. Establish a Legal Framework for Organic Standards: An even and high quality of organic products can only be achieved if China has its own legal standards which are in line with international requirements. These standards would provide a binding base for the certification systems working at the farming level. The legal framework can only be established after the political responsibilities in organic farming have been clarified. 2. Coordinate and Standardize Organic Certification: An Organic Food Authority would have to be authorized by the State which would be responsible for implementing the legal guidelines, accreditation of certification bodies and supervision of certification systems. The establishing of such an authority would be a precondition for organic products from China to be recognized by the importing countries of the EU (European Union). 3. Develop Policy Incentives: Cheap chemical fertilizer and pesticides are the most important incentives in intensive farming which lead to the poisoning of food and water. Incentives for environmental-friendly agriculture must be decided on the policy level, like for purchase of essential substances (such as natural fertilizer) and provision of extension services (such as professional advisors) for assisting the farmers. 4. Network Information Flow Among Producers and Traders: Fair-trade is based on a transparent system for production and marketing in which intermediary traders play a minor role. Producer's direct access to traders is encouraged and market information such as commodity prices, profit margins of traders, etc., is available. The local governments should support farmers in gaining their own marketing channel or cooperating with trading companies on fair marketing of organic products. 5. Develop Professional Support Services: For achieving a high standard of organic production, farmers and processors would need qualified advisors whose work is guided by professional norms and standards. Most likely, theses advisors would be organized in professional associations. 6. Develop Vocational Training: Specialized technical knowledge would have to be developed and disseminated both in agricultural universities and among the practitioners within the extension system. Building up the know-how in organic farming would require a strong link between theory and practice.

PERSONAL OBSERVATIONS-BY SUBHUTI DHARMANANDA During a visit to a ginseng farm in northeast China in 1979, we asked the farm manager about use of chemicals in growing ginseng. He acknowledged that some "soil amendments" were used (these prevent root rot), but he was concerned about minimizing their use and avoiding residues. As one of the measures taken, during the weeks prior to harvest of the plants, use of such chemicals would cease, and the rains during that time of year were expected to wash away the chemicals, thereby leaving the roots free of residues. This approach may have worked well, but some farms in Korea apparently did not follow this approach and, about 20 years later, the detection of fungicides (quintozene) on ginseng was publicized in the West, adversely affecting the ginseng trade. In fact, Dr. Fu Kezhi at the ITM China office in Harbin pointed out that this negative publicity caused several ginseng farms in Heilongjiang Province to close down due to loss of markets. In a visit to some Chinese herb cultivation fields and botanical research centers in China in 1983, I was told that several of the Chinese herbs did not require use of pesticides or other chemicals, but a few of them did. Cultivators generally agreed that they wanted to minimize use of such chemicals, both because of their high cost and because of their artificial nature compared to the intended quality of the crop (as a natural product), so they were usually minimized. This comment appears to be confirmed by testing that was done by companies importing Chinese herbs, with most herbs testing free of any detectable amounts of pesticides. Although organic farming efforts were begun in China during the 1980s, the awareness level remained low until quite recently. For example, Dr. Li Zhengfang, one of the early promoters of this approach (founder of OFDC and president of ICAIR, described above), sent out a letter in 1995 to American specialists trying to get some handle on the definitions of organic versus sustainable farming and about the developments of organic farming here, saying:

Please allow me to raise some questions of you, and ask for your help. The following are my questions: 1. What is the relationship between organic and sustainable agriculture? Are they the same thing or something different? 2. What's the definition of sustainable agriculture? Is the definition accepted by most of academic people? 3. What is the trend of organic agriculture development in your country? And around the world? 4. Are the demands for organic foods in US growing or not? I'm very interested in sustainable and organic agriculture and now am engaging in organic food development in China. Because of some vagueness and confusion in the concepts, I put to you the above questions.

This inquiry shows that even by 1995, Chinese specialists were not clear on what the agricultural movements in the West were about. Still, tremendous progress has been made since then, particularly in the field of organic tea production. In 2000, ITM began supporting a licorice cultivation project in Heilongjiang (partly managed by Fu Kezhi of the ITM China office). This project will help the transition from threatened wild supplies to a cultivated supply and will help local peasants earn a living. It has been necessary to relay important concepts about pest control and avoidance of pesticide use from here to assure a good outcome. Dr Fu reported: Based upon your advice to us making a warning about the problems of plant diseases and insect pests for licorice plantations, we plan to give a lecture about the importance of a rational crop-rotation cultivation method for the licorice crop (leguminous plant) with crops of grass family plant (Gramineae), as well as undertaking better measures to treat plant diseases and prevent insect pests without residual contaminations. The major insect pests of licorice cultivation at Heilongjiang area are the flea beetle and the leaf beetle (Phyllotreta spp.) and aphids (Aphis eracivora usuana). I will be bringing attention to this issue to our scientific exemplary group at the Anmin Base [site of licorice cultivation] by inviting an expert about these problems from the agriculture or forest college next year, before the beginning of spring plowing. We have especially checked on the qualities of growth for the one-year-seedling rootlets and the transplanting status of the rootlets in the fields. On the whole, the one-year-young plants in the licorice field (each peasant household grew 5 Chinese mu; about 3 acres) are growing very well, without plant diseases and insect pests, but in the transplanting fields the twoyear-plants are growing very badly at the present time, almost all the leaves fall off from the standing plant stems. This is exactly what can happened with a "repeat crop" [that is, growing the same item in a field two years simultaneously, rather than rotating crops, often resulting in problems of fungal infection of the roots]. And a few of two-year and three-year plant growing fields have been partially invaded by insect pests, but not seriously. In attempting to more quickly expand the cultivation of licorice at the Anmin base to meet the demands of our main customer, you had advised us that when only a single plant is cultivated over a vast land area that would cause an occurrence of plant diseases and insect pests. The plant diseases and pest control will become a serious problem at the Anmin base. We have requested the first and the second exemplary groups to employ small farm units in a three-year-cycle of production for a reasonable rotation of cultivation. We hope the exemplary group's households will practice the cultivation technique as requested. One can see that the attempt to cultivate herbs without using pesticides is a significant challenge. These farmers are basing a large part of their livelihood on success of these crops. They have relatively little guidance, with support for proper organic and sustainable cultivation coming primarily from U.S. interests and from a few specialists who have to be brought to the area from distant colleges and Universities. A project aimed at training farmers of tea and gastrodia ( tianma) to develop sustainable crops and use less pesticides was reported by Wang Huiyang recently (at a 2002 conference in Indonesia). This project was undertaken in Huoshan County of Anhui Province, an area famous for its tea fields and medicinal herbs, including dendrobium, fritillaria, and mulberry, as well as gastrodia. It is also a major rice producing area. Wang described "farmer field schools" established to educate farmers about pests and their control with minimal use of chemicals, while looking out for their primary need of successfully making a living from producing crops. During a five year program (starting in 1998), 549 farmers obtained training in techniques associated with cultivation of gastrodia. It was recognized that gastrodia cultivation had the potential to yield a good income because of the high demand, but that few farmers knew how to cultivate it effectively. The project resulted in farmers using less toxic chemicals and fewer chemicals while increasing their yields. Recently, I have helped bring into the U.S. some organically grown tea from Tibet. The tea plantation was set up with the aid of a Chinese company in Sichuan Province directed by He Xingyou, who has a personal interest in Tibet (for example, he has produced a magnificent book of artistic photos of Tibetan landscape and culture called Voice from the Heavens ). The plantation is located in what has been called "the last pollution free land on earth," and features organic gardening (which is made possible, in part, by the relative isolation and high altitude, producing fewer problems with pathogens that is found in much of China). Because this plantation was established many years ago, the only certification available at the time was the Green Foods certification. That certification assures that the finished product is free from pesticides and certain other contaminants and is internationally recognized, but some of the newer certifications (such as by OFDC) are more desirable because of their affiliation with major international organic certifiers. In the attempt to ship the tea to the U.S., the company found that Chinese authorities were very strict and would not allow the tea to be exported until it had been thoroughly tested by government laboratories, not only to assure that it was free of contaminants, but also to assure that all the ingredients (including some herb flavors, like saffron, rhodiola, or snow lotus) were truly from Tibet. Although disruptive, this rigorous checking demonstrates that the Chinese government is committed to having its exports meet very high standards.

Even to get the Green Food certification at its lowest level is expensive and time consuming. A black tea product from Tibet produced by the same method as the green tea has not yet been certified. . Even though it is organically grown, it was decided to forego certification because the market for the black tea is substantially less than for the green tea, and the certification value doesn't yet justify the expense. Certification for the organic cultivation is not an easy task due to the remote location of the fields. To make the inspections and certification affordable overall, there has to be a larger scale of operations, which will come about once demand for organically grown products increases substantially. As more Western firms enter into joint ventures with Chinese groups to support sustainable agriculture and to make products for export, the use of organic farming methods is sure to increase. Similarly, as the Chinese economy improves, the domestic demand for specialty foods, such as those grown organically, will also increase. One can reasonably expect a dramatic improvement in the situation within the next 10 years.

Inspectors from the United Nations at an organic tea plantation in China

REFERENCES 1. Lu Zhenhui, Production and market of organic foods in China, 1st Gangjin International Symposium on Organic Agriculture, 2002 (November 15), Gangjin, Korea. 2. Wang Haiyang, Farmer field schools (FFS) in China: experience in Huoshan County, International FFS Workshop, 2002 (October 21-25), Yogiyakarta, Indonesia.

January 2004

ON THE IMPORTANCE OF PERSPIRATION IN CHINESE MEDICAL DIAGNOSIS AND THERAPY by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

There are numerous cases in which traditional Chinese medical texts describe what has been deemed by the authors to be a critical method of applying therapeutic techniques, but such methods are no longer utilized in modern practice. In many cases, there is no explanation for this deletion. Diaphoretic therapy is a good example. This article explores some of the changes that have occurred. In ancient texts of Chinese medicine, perspiration (diaphoresis) is frequently mentioned as an important sign in the diagnosis of a disease pattern and as a measure of the successful application of a treatment. For example, in scroll 23 of the Ling Shu (1) it is said that in treating hot diseases one should "disperse the hot so that the patient sweats." Also: "When a hot disease has lasted seven or eight days and the Pulse Mouths [site of pulse taking] are agitated and the breaths are short, quickly needle so that sweating will occur in the patient....When a hot disease is complete, and sweating has been achieved but the pulses are still rough and the panting and the fever has returned, do not needle the skin....If there is no perspiration, one cannot needle between the flesh and the skin....When there is a hot disease and sweat has come out, then the pulses are smooth because of the sweating....In a hot disease, the pulses are full and rough but there is no sweating, this means the yang channels are in extremis, then death; yet, if the channels are full and rough and a tranquil sweating can be obtained, then life." In these passages, perspiration is seen as an indicator of the disease status that dictates what types of therapy one might use or avoid, sweating is an intended result of certain treatments, and it is associated with a favorable or unfavorable prognosis. In the Shang Han Lun (2), a large part of the scroll devoted to Tai Yang disease includes descriptions of the disease state in terms of absence, or presence, of perspiration, as well as inducing perspiration as a therapeutic method. For example: "If treatment of the primary stage of Tai Yang disease with the sweating method does not result in thorough perspiring as desired, the condition shifts to the sunlight yang category....If spontaneous perspiration continues without severe chills, a mild sweating method may be used. In the case the patient has an intensely ruddy complexion, rapid respiration, and cannot lie down, he can be cured by an additional sweating treatment." Inducing diaphoresis was one of the original three methods of therapy (with emesis and purgation) and later one of the eight methods of therapy (see: Enumerating the methods of therapy) that is still described in textbooks and taught in modern colleges of Chinese medicine. Despite its importance over many centuries, modern literature about treatment strategies, whether describing acupuncture or herbal medicine, rarely mentions induction of perspiration. Further, the diagnostic patterns used to describe various diseases often mention perspiration or its absence only in passing among a long list of possible symptoms, rarely including any discussion of different treatment strategies based on the status of this particular sign. Is this change in emphasis the result of a finding that perspiration is not as important as originally believed, or has something been overlooked simply because of shifts in modern focus to other therapeutic concerns, such as vitalizing blood circulation and regulating the immune system?

THE ROLE OF PERSPIRATION IN HEALTH AND ILLNESS As to the role of perspiration as seen by traditional practitioners, consider the following commentary (3) from the Rumen Shiqin (ca. 1228 A.D.): An illness is something that the human body originally does not have. An illness may enter the body from outside of it, or it may emerge from inside of it....The six influences sent out by heaven are wind, heat, fire, dampness, dryness, and cold. The six influences sent out by earth are fog, dew, rain, hail, ice, and mud...illness resulting from evil influences sent out by heaven affect mostly the upper sections of the body; illnesses resulting from evil influences sent out by the earth affect mostly the lower sections of the body, and illness resulting from evil influences invited by man through his living habits mostly affect the central section of the body. These then are the three possibilities as to how an illness may emerge. Since they may be localized in the three sections they can be driven out by the three methods. All evil influences resulting from an impact of wind or cold assemble in the skin; they are stored inside the main conduits [jing] and network conduits [luo], they remain where they are and do not leave the body by themselves. In some cases they cause pain that moves through the body, or numbness and loss of sensitivity, and also swellings, itching, and cramps in one's four limbs. In all of these cases, the evil influences responsible can be eliminated through therapies causing perspiration.... This passage describes the basis for what we today often call "surface-relieving" or "surface-releasing" therapies-those that help remove evil influences from the skin (and from the jingluo). But what does the induced perspiration do? From the traditional viewpoint, it literally carries the disease out of the body with it. According to Xu Dachun (4): "If no perspiration develops, there is nothing to which the evil influences can attach to leave the body...." As is understood from reading the Neijing (5), the sweat pores are both the entry and exit point for external evil influences coming from above (heaven). Wind, cold, and heat were the main pathologic influences of concern in relation to perspiration. To treat such ailments, perspiration was induced (if not already profuse), and it was believed that the induced perspiration would carry the pathologic influence out of the body. This was the appropriate therapy only while the pathological influence was still residing in the surface and not mixed in with the "constructive influences," that is, the ying qi. From these basic ideas of eliminating disease arose the formal category of surface-relieving therapies: their action would be to overcome a contraction of the skin, allowing the pores to open, the perspiration to flow, and the evil influences to be released. As we know today, the blood vessels at the body surface, when affected by diaphoretic herbs or drugs, dilate and permit fluid to exit as perspiration. Surface-relieving formulas not only treat diseases that are confined to the surface, but also diseases for which regulation of perspiration is deemed important. Although not all surface-relieving formulas are intended to induce perspiration (some may simply regulate the circulation in the skin and muscles), many of them were designed to do so.

MAKING SURFACE-REGULATING TREATMENTS WORK

In the Shang Han Lun, the main formula described for surface ailments, Cinnamon Combination, makes use of the surface-releasing agent cinnamon twig. According to the instructions in the text, the treatment is to be modulated in order to induce a mild perspiration, but it is also used to treat profuse perspiration (it contains the perspiration-controlling ingredient peony). Failure to induce perspiration was thought to condemn the treatment to failure, and excessive perspiration, either as a result of the disease process or the excessive use of sweating therapies, was thought to damage the patient (by removing too much essential fluid). To induce the therapeutic perspiration in someone with only mild spontaneous perspiration (as a sign of disease), the herb decoction would be taken warm, the dosage would be repeated if necessary, and the individual would consume warm rice gruel and bundle-up in blankets. Once some perspiration is induced, efforts to induce it could be stopped (see: Exploring Yin/Yang #5). The ingestion of rice gruel was deemed an important means of assuring adequate fluid for producing perspiration. Rice (or grains in general) generates stomach qi, replenishing the essential bodily fluids. According to Xu: "Later generations [after the Song Dynasty revival of the Shang Han Lun] were no longer aware of the necessity to support any induced sweating by means of enriching the patient's liquids." The failure to employ this step, especially in the case of a feverish disease which is consuming the normal fluids, can lead to failure to induce perspiration and even to weakening the patient. Excessive perspiration was considered a problem because the perspiration carried out not only the external pathogen, but some of the essence (jing) of the body. When too much flowed out, the central viscera (zang) became depleted, especially the heart, which has traditionally been considered the source of perspiration (though the Ling Shu describes perspiration from different organs arising under different circumstances). Eventually, the kidney system could be endangered by this depletion of the body's essential fluids. According to Xu: "If one causes the patient to perspire even further, the yang fire reaches its utmost strength and the patients true yin influences are set in motion. The water of the kidneys comes to offer assistance, and it is followed by the original yang influences. The patient perspires profusely in the upper parts of the body, and signs indicating the danger of complete loss of yang emerge." Much concern was raised in the post-Song Dynasty era about the harm that could be done by applying too many warm spicy herbs, as had become a common practice by following the Shang Han Lun treatment of initial disease stage. Of course, the main complaint was against using these herbs thoughtlessly, without properly diagnosing the patient and figuring out the appropriate treatment, instead simply using formulas that had a reputation for great effectiveness. The Advanced Textbook on Traditional Chinese Medicine and Pharmacology (6) summarizes the traditional view as it comes down to us today: "The proper dosage of drugs for relieving exterior syndrome causes slight perspiration; overdose can cause excessive perspiration, damage yang qi and consume body fluid. In summer or hot days when people perspire easily, the dosage should be decreased. For patients with spontaneous sweating, night sweating, or blood loss, these drugs should be applied with great care even though the patients suffer from exterior syndrome due to an attack of exogenous pathogenic factors. Most drugs for relieving exterior syndrome are aromatics and contain volatile oils, and so should not be decocted for a long time, otherwise, their therapeutic effects will be reduced." Under the section on surface relieving therapy (as one of the eight methods of therapy), it cautions further: "It is contraindicated in cases of severe vomiting, severe diarrhea, stranguria [inhibited urination], skin infections, and hemorrhaging; it should be discontinued as soon as the pathogenic factors are dispelled, since excessive sweating may consume yin and yang; the diaphoretic method differs in different seasons, geographic areas, and the conditions of the individual patients. For instance, mild diaphoretics are prescribed in summer, but potent diaphoretics in winter. A large dose of diaphoretic is prescribed for the cold climates, and a smaller dose for the warm climates. Slow-acting diaphoretics are advisable for patients with weak constitutions, and potent ones for patients with strong constitutions...." As the textbook indicates, it is quite important to use diaphoresis properly, especially to avoid harm and to coincide with the conditions of the patient and the environment.

LOSS OF THE TRADITIONAL PRACTICE In modern practice, induction of perspiration is frequently overlooked. Acupuncture texts no longer mention it and herb books make only passing reference as necessary to report on traditional categories. Treatment is usually based instead on the practice of treating the symptom complex with matching herbs, but not with matching therapy. Thus, the therapeutic regimen recommended to patients might include herbs for relieving the surface, but sweating is not induced or even monitored. In some cases, this new approach may still successful; then it would be understandable that further attention to the traditional ideas might not be given. However, if the therapy fails to promptly produce the desired results, one should not necessarily assume first that the wrong herbs were selected. The diaphoretic therapy, not just the surface-relieving herb formulation, might be tried before simply changing to a different set of herbs. Similarly, for those disorders that involve excessive perspiration, specific attempts to inhibit perspiration may be important, beyond simply including a small amount of astringent herbs in the prescription. Why has diaphoresis been de-emphasized? First, there may have been some failures of diaphoretic therapy due to incorrect application, eventually leading doctors away from the method. During the 18th century Xu Dachun said "Whenever today's physicians apply prescriptions to induce perspiration, they use warm and parching drugs such as magnolia bark, pueraria, chiang-huo, angelica, atractylodes (cangzhu), and tou-kou [a type of cardamon]. If the patient's internal liquids had not yet wasted away, but are heated by the fire of the wind, and if they are then, in addition, parched by the parching herbs, from whence could perspiration develop?" The reference to "fire of the wind" here is to the fact that dryness (as in yin and blood deficiency) leads to internal wind, which stirs up fire that damages the fluids to yield more wind, further vitalizing the fire. Acrid herbs, because of their dispersing nature, also whip up the internal wind (if the essential fluids are insufficient), and they cause further drying, thus stimulating the fire. This is a case of using warming, drying, diaphoretic herbs because the basic therapy is thought to be appropriate for the disease, but making an error in applying it because there are insufficient fluids to support the therapy. If practitioners apply the general rules but fail to make the specific adjustments, they may fail to gain success or, even worse, make their patients suffer additional symptoms. Using a milder treatment as the general approach (leaving out actual diaphoresis) reduces the chance of adverse effects, but might also reduce success in some situations. Second, the modernization of traditional medicine brings less attention to immediate patient responses (e.g., effects of the first or second herb doses on perspiration) and more to long-term effects (e.g., effects of several days or weeks of treatment on the overall condition of the patient). This is partly because of the high volume of patients who must be seen for a brief time and then seen again some time later, usually when the prescription is deemed, in advance, to need to be checked (e.g., in several days). Also, modern

preparation methods steer people away from the high dosage warming decoctions commonly used for diaphoretic therapies, to the lower dosage pills, dried decoctions, and other forms that are less likely to induce perspiration. Third, the ancient concept that a disease entity could be carried out with the sweat does not match up with modern understanding of disease. Rather, the conception that the person's internal mechanisms (i.e., the immune functions) meet the pathological agent and destroy it, are more prevalent. Even when it is thought that some kind of toxins or other pathological agents need to be expelled from the body, carrying them out via sweat does not play a prominent role in modern thinking about how this could be accomplished. Therefore, it is difficult for practitioners, especially in the West, to request that patients pursue a carefully managed perspiration induction and then give them an acceptable explanation as to why this should be done.

CONCLUSION At this time, we do not know the full significance of perspiration in relation to disease state nor the potential benefits (or harm) from inducing perspiration as a therapeutic method. According to traditional doctors, perspiration is quite important. It may not make sense to give out traditional prescriptions (or ones based on them) that were designed for altering perspiration as the means to heal the patient without considering this aspect of the complete treatment. Therefore, one may be cautious about adopting ancient formulas based on ancient indications unless clinical evidence has accumulated to suggest that they still function without what was long considered the correct method of applying them. This same caution would apply not only to diaphoretics, but also to other traditional therapeutic approaches.

REFERENCES 1. Wu Jingnuan (translator), Ling Shu, 1993 University of Hawaii Press, Honolulu, HI. 2. Hsu HY and Peacher WG, Shang Han Lun: The Great Classic of Chinese Medicine, 1981 Oriental Healing Arts Institute, Long Beach, CA. 3. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988 Kluwer Academic, Dordrecht, Holland. 4. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. 5. Ni Maoshing, The Yellow Emperor's Classic of Medicine, 1995 Shambala, Boston, MA. 6. State Administration of Traditional Chinese Medicine and Pharmacy, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, 1996 New World Press, Beijing. May 1997

A STUDY GUIDE TO PHLEGM-RESOLVING HERBS by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Phlegm is a product of the body's activities acting upon qi and moisture taken in with food and beverages; it is "congealed moisture." Unlike qi, phlegm is always viewed by Chinese physicians as substantive and stagnating rather than light and flowing, though there are two kinds of phlegm: the visible, which has greater accumulation of matter, and the invisible, which is finely divided, though not as fine as qi. Phlegm is, in some ways, comparable to another body humor, blood, which is also produced by the body's activities acting upon qi, and is a sticky substance that shares some of the same potential pathologies with phlegm: deficiency, inadequate circulation, firm coagulation, and complexing with heat or cold factors. Phlegm is a normal and required substance in terms of the mucous membrane lining and other lubricating functions, but it becomes a pathological substance when: 1. it is derived from stagnated food in the stomach; 2. when normal phlegm (mucoid substance) is produced in excess; or 3. when it is complexed with internal or external pathological factors, such as cold, heat, wind, or toxin. Phlegm accumulates when the lungs are irritated, when the moisture of the body is overheated by pathological qi (causing it to dry and transform into thick phlegm), when the qi is stagnant and the normal phlegm is not circulated (or when pathological phlegm is not eliminated quickly due to poor circulation of the fluid), and when the kidneys are too cold and the moisture condenses and transforms into phlegm. Phlegm may become insufficient when there is an inadequate source of the necessary nutrients in the diet; when the spleen is weak and cannot raise the qi derived from food upward to moisturize the upper body; when the lungs suffer from deficient qi and cannot transform moisture to phlegm; or when the environmental conditions or the consumption of drying foods (such as spices) disperse too much of the existing phlegm Phlegm is thought to have a similarity to grease or fat, and therefore, fatty foods are deemed one potential source of phlegm. In general, any food that is not completely digested is said to give rise only to a pathological type of phlegm: normal phlegm is produced when pure substances are obtained from digested foods and then processed into a useful body lubricant. Obese persons are said to be displaying an excess of phlegm in their extra body weight (see: Obesity and hyperlipidemia: Bojenmi tea and other Chinese herb formulas): the equivalence of phlegm, fatty foods, and body fat is most clearly demonstrated by this connection. According to Chinese thinking, the spleen and lungs have the primary responsibility for generating and circulating the mucoid substances necessary for normal body functions, and dysfunctions of these organs are often responsible for the accumulation of fats. While most Westerners think of phlegm as referring only to the excess mucus produced in the lungs and sinuses, from the Oriental view, phlegm can exist in many places in the body; it may form lumps, it may block the meridians, obstruct the heart orifices, or simply accumulate throughout the tissues, preventing the normal in and out flow of qi. Soft or fluid-filled swellings in the body are generally regarded as phlegm masses. This would include lymphatic swellings, ovarian cysts, thyroid nodules, lipomas, and breast lumps that are not hardened; some of these are malignant masses. The thickened fluid obstructing the bursa of the joints in patients with bursitis is considered a phlegm disorder. Symptoms of phlegm accumulation associated with the digestive system include nausea, vomiting, and greasy stool. Here is a description of the problem of phlegm fluid accumulation (retention) described in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology: Phlegm and retained fluids are pathological products of impaired local or general water metabolism. The concept of phlegm (tan) and phlegm-fluid retention (tanyin) in Chinese medicine embraces a wide range of manifestations....Phlegm and phlegm fluids are either substantial or non-substantial. Substantial phlegm and retained fluids are visible....Nonsubstantial phlegm and retained fluids refer to pathological manifestations such as dizziness, nausea, vomiting, shortness of breath, palpitations, or mania and semi-consciousness, all of which are linked to invisible phlegm or fluid discharge from the body. Nonetheless, these conditions respond well when treated as substantial phlegm and retained fluids....Phlegm and retained fluids are caused by the influence of the six exogenous pathogenic factors, irregular diet, or abnormal emotional activities; all impair the water metabolism of the lung, spleen, kidney, and triple burner qi. The lung dominates the dispersion and descent of qi and the distribution of body fluids. The water retention resulting from a failure of these functions produces phlegm and retained fluids. The spleen controls the transportation and transformation of water, the failure of which causes an accumulation of water which then turns into phlegm and other retained fluids. The kidney is responsible for the gassification of water [steaming the water; converting water to qi]. When kidney yang is insufficient, water cannot be transformed into qi. It accumulates and, again, turns into phlegm and other retained fluids. Retained fluids and phlegm may also appear when the triple burner passages are blocked, for the normal transportation, distribution, and excretion of body fluids are interfered with. Furthermore, since the triple burner houses all the zangfu organs, failure of the qi activity of the triple burner may result in the formation of pathogenic phlegm and retained fluids and make them accumulate in the zangfu organs and, more superficially, in the tendons, bones, skin, and muscles, causing various pathological changes. The diagnosis of phlegm or fluid retention syndrome often revolves around three factors: a moist, and, especially, a thick tongue coating; a smooth, and, especially, a full, slippery pulse; and obvious signs of phlegm accumulation, such as discharge of excess sputum (lung/sinus problems), obesity, palpable soft accumulations (lumps and swellings), and adverse reactions to intake of greasy foods. However, because phlegm retention can occur in persons with a wide range of accompanying conditions, and because phlegm retention can be of the "non-substantial" type, one may need to look further. Some examples of manifestation of phlegm disorder are mentioned in the Advanced Textbook... , as follows:

Phlegm that blocks the lungs results in coughing, asthmatic breathing, and expectoration of sputum. Phlegm in the heart causes suffocating feeling in the chest and palpitations. If the Heart Meridian [heart orifices] is obstructed by phlegm, dementia and loss of consciousness may occur. If the heart is disturbed by phlegm-fire, mania may occur. Phlegm stagnating in the stomach causes nausea, vomiting, and fullness in the stomach. An accumulation of phlegm in the meridians, tendons, and bones may cause scrofula, subcutaneous nodules, a numbness of the limbs, hemiplegia, or fistulous infection of the tissues. Phlegm attacking the head produces dizziness. Phlegm and qi in the throat may produce the sensation of a foreign body in the throat. Retention of fluids also has different syndromes. Morbid fluid in the intestine produces a gurgling sound. In the costal region, it produces a full sensation in the chest and pain on coughing. If it accumulates in the diaphragm, it causes stuffiness in the chest, coughing, dyspnea, difficulty in lying flat, and puffiness. Morbid fluid in the tissues and skin causes edema, absence of sweat, and heavy feeling of the body.

PHLEGM-RESOLVING HERBS Herbs that help resolve phlegm problems are divided, in the Materia Medica, into those which resolve cold phlegm (which is moist, thin, and clear), and those which resolve hot phlegm (which is drier, thick, and sometimes discolored). In most cases, herbs from both categories are combined together in varying proportions to get the best influences of the important phlegm-resolving herbs; several herbs from other Materia Medica categories have phlegm-resolving properties, and may be included in developing an optimal prescription. In the following presentation, the two main groups (herbs for resolving hot phlegm and herbs for resolving cold-phlegm) are listed in accordance with Oriental Materia Medica (Hsu) with some adjustments from Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (Huang and Wang). Along with the description of each herb, an example of a formula in which it is utilized is offered to help illustrate the principles of combining that have been relied upon in China. It will be noted that many of the formulas contain citrus materials: citrus (chenpi), aurantium (jupi), chih-shih (zhishi), or blue citrus (qingpi). These herbs are found in the qi-regulating section of the Materia Medica, but they are important herbs for resolving phlegm accumulations, both because of inherent phlegm-resolving activity of the herbs and because of the principle: "if the qi circulates well, phlegm also circulates." Ginger (fresh ginger, shengjiang) also appears in many of the formulas because it helps to resolve phlegm and to promote the stomach function so that food stagnation does not arise. In addition, several of the formulas contain herbs for clearing heat (e.g., scute, gardenia, anemarrhena); their use is indicated in cases where heat pathogens combine with or cause phlegm accumulation and it also is important when prolonged phlegm accumulation turns to heat. Several of the formulas contain herbs for dispelling wind (notably siler, angelica, chiang-huo, asarum, and schizonepeta) to help treat acute ailments or the surface manifestation of a chronic ailment, and some formulas contain tonic herbs (e.g., ginseng, jujube, licorice, atractylodes, and hoelen) to aid the spleen in transforming and transporting functions so that phlegm does not continue to accumulate. When the phlegm is in the lungs, herbs that reduce coughing may also be included (e.g., apricot seed, perilla seed). For phlegm masses, oyster shell may be added; for wind-phlegm-fire disorder (which tends to cause spasms or paralysis), silkworm is often added; for thickened phlegm associated with yin deficiency, ophiopogon is often added; when food accumulation leads to phlegm production, shenchu, malt, and crataegus may be included; schizandra is included in some formulas to astringe excess fluid production, but is in other formulas to help generate fluid when there is yin deficiency yielding insufficient mucus production.

RESOLVING HOT PHLEGM. The herbs that resolve hot phlegm generally have a cold property; those with a salty or bitter taste are often used for resolving swellings, including tumors, while those with a sweet taste moisten dryness. Bamboo refers to the shavings of the stem of several species of bamboos, most commonly Phyllostachys nigra. The Chinese name, zhuru, means the edible part of the well-known plant called zhu. It has a sweet taste and a mild cold nature, entering the lung and stomach meridians to resolve thick phlegm and to control vomiting due to heat and accumulation in the stomach. It is an important ingredient of Aurantium and Bamboo Combination (Jupi Zhuru Tang) used for nausea, hiccoughing, and vomiting. The active components, including triterpenes, resolve thickened phlegm and reduce inflammation of the stomach. Aurantium and Bamboo Combination Jupi Zhuru Tang Aurantium

jupi; or use chenpi

12 g

Bamboo

zhuru

12 g

Ginger

shengjiang

9 g

Jujube

dazao

5 pieces

Licorice

zhi gancao

6 g

Bamboo sap, in liquid form is called zhuli, and dried bamboo sap is often called tianzhuhuang (heavenly bamboo yellow); these materials have similar applications to bamboo shavings (zhuru), but are more cooling in nature (perhaps due to the higher content of minerals). These sap materials enter the heart meridian and treat phlegm mist obstructing the heart orifices, to relieve convulsions, paralysis, and high fever. Bamboo sap is included in patent medicines for phlegm-fire disorder, such as Baoying Dan, used for fever and difficult respiration due to acute ailment in infants.

Snake gallbladder Scorpion

Zhu Po Baoying Dan patent remedy from Guangzhou sanshedan 12.9% quanxie 9.7%

Gastrodia Silkworm Siler Uncaria Succinum

tianma jiangcan fangfeng gouteng hupo

8.0% 8.0% 8.0% 8.0% 7.2%

Bamboo sap

tianzhuhuang

Calomel

qingfen

5.7% 5.7% [note: contains mercury]

Borneol Cicada Pearl Musk

bingpian chantui zhenzhu shexiang

5.7% 5.7% 5.4% 4.3%

Clam shells are obtained from many species of bivalves, but especially Cyclina sinensis. The Chinese name, haigeke, simply refers to the ocean, hai, the clam, ge, and its shell, ke. Like other sea shells, it has a salty taste, a cold nature, and it influences the liver and lungs. It resolves phlegm masses, which include tenacious sputum in the lungs, and swellings. Clam shell is a major component of Isatis and Hai-ko Formula (Dai Ge San), comprised of those two herbs alone, for stubborn phlegm in the lungs that is discolored (due to toxic heat; an infection); it is also a major component of Atractylodes and Haiko Formula (Kaiyu Zhengyuan San) that is used for abdominal masses, such as uterine fibroids (this formula is a modification of Kaiyu Erchen Tang), which develop secondary to qi stagnation and food stagnation with phlegm accumulation. The active components of the clam shell are calcium salts and proteins. Atractylodes and Hai-ko Formula Kaiyu Zhengyuan San Atractylodes baizhu 3 g Citrus chenpi 3 g Blue citrus qingpi 2 g Cyperus Crataegus Hai-ko Platycodon Hoelen

xiangfuzi shanzha haige jiegeng fuling

3 g 3 g 3 g 3 g 3 g

Cardamon Corydalis Malt Licorice

sharen yansuhuo guya gancao

1.5 g 3 g 3 g 1.5 g

Shen-chu Ginger

shenqu shengjiang

3 g 2 slices

Bulbifera refers to the rhizome of Dioscorea bulbifera, one of several Dioscorea species used in Chinese medicine. The Chinese name huangyaozi refers to its yellow color and to the bulbous underground stem, with zi indicating offspring, as it does for aconite branch roots, fuzi. Its influence is cooling, affecting the liver and heart to reduce swellings associated with interior heat, such as carbuncles, lung abscess, breast lumps, goiter, and tumors. Bulbifera is a component of Jia Kang Wan for treating hyperthyroidism: it is one of several phlegm-resolving herbs used to remove the thyroid mass, which is interpreted as a phlegm mass. Researchers caution, however, that high dosage or prolonged use of bulbifera can cause liver damage. This herb is usually not used in by Western practitioners due to the safety concerns, though the amount in this formula is small and, thus, it is considered by Chinese physicians to be a safe level for use in China. Li Shizhen had written that bulbifera is "bitter in taste, mild in nature, and nonpoisonous, reducing heat by cooling the blood and curing goiter through removing toxins." Jia Kang Wan (main ingredients of pill used in clinical trial for hyperthyroid disease) Prunella

xiakucao

16%

Oyster shell

muli

12%

Sargassum

haizao

12%

Laminaria

kunbu

12%

Pinellia

banxia

12%

Fritillaria

zhebaimu

12%

Hoelen

fuling

12%

Aurantium

juhong

8%

Bulbifera

huangyaozi

4%

Cynanchum refers to the rhizome of Cynanchum stauntoni and related species. The Chinese name, baiqian, means white front, referring to the appearance of the leaves. The taste is acrid and sweet, and the influence is mildly cold. It enters the lung meridian to help moisten the lungs, aid the descent of qi, and expel profuse sputum. Cynanchum is a major ingredient of the Platycodon and Schizonepeta Formula (Zhi Sou San) used for the treatment of cough with excessive sputum. The active components are saponins that thin the sputum and relieve inflammation. Platycodon and Schizonepeta Formula Zhi Sou San Cynanchum

baiqian

17%

Platycodon

jiegeng

17%

Schizonepeta

jingjie

17%

Aster

ziyuan

17%

Stemona

baibu

17%

Citrus

chenpi

9%

Licorice

gancao

6%

Fritillaria refers to two major species of fritillaria, F. cirrosa and F. thunbergii, members of the Lily family. Both varieties are bitter, mildly cold, and affect the lung and heart. The two species have similar actions and uses, but the cirrhosa species is deemed more suitable for moistening the lungs when there is a heat syndrome, and thunbergii is more suited for removing phlegm masses, including tumors. The Chinese name, beimu, makes reference to the appearance of the white bulbs like cowry shells (the cirrosa species is known as chuanbeimu because it comes from Sichuan Province; the thunbergii species is known as zhebeimu, produced in Zhejiang Province). In most formulas, the variety of fritillaria is not specified and, because it is more readily available and less expensive, zhebeimu is usually selected. Fritillaria is an important ingredient of Platycodon and Fritillaria Combination (Qingfei Tang), a traditional prescription for bronchitis that is mostly used in Japan. The formula nourishes yin and clears heat, two properties common to the lily bulbs, and the complex formulation is aimed at treating sputum that is sticky but profuse. The active components of fritillaria are steroidal alkaloids which have sedative, anti-inflammatory, and phlegm resolving actions. Platycodon and Fritillaria Combination Qingfei Tang Platycodon

jiegeng

6 g

Fritillaria

beimu

6 g

Scute

huangqin

6 g

Apricot seed

xingren

6 g

Bamboo

zhuru

6 g

Ophiopogon maimendong

9 g

Gardenia

zhizi

6 g

Citrus

chenpi

6 g

Hoelen

fuling

9 g

Morus

sangbaipi

6 g

Asparagus

tianmendong

6 g

Tang-kuei

danggui

9 g

Jujube

dazao

6 pieces

Fresh ginger

shengjiang

1 slice

Licorice

gancao

3 g

Schizandra

wuweizi

1.5 g

Lapis is a mineral which is well-known as a semi-precious stone laced with mica schist; in fact, today, Chinese doctors use the less expensive mica (which has a golden color) alone. The Chinese name, jinmengshi, refers to the inconsistent color meng, of the stone, shi, for which the golden variety, jin, has been selected. The taste is acrid and salty, and it has a cold nature. Lapis affects the lung and liver, resolving phlegm and calming agitation. Lapis is an ingredient in the Lapis and Scute Formula (Mengshi Guntan Wan) used for phlegm fire syndrome, as applied in the treatment of mental disorders, convulsions and tenacious sputum associated with an inflammatory disease, such as gastritis, bronchitis, pharyngitis, and tuberculosis. Lapis and Scute Formula Mengshi Guntan Wan Lapis

mengshi

35%

Rhubarb

dahuang

26%

Scute

huangqin

26%

Aquilaria

chenxiang

13%

Peucedanum refers to the roots of Peucedanum praeruptorum, a close relative of the more commonly used herb bupleurum. Its Chinese name, qianhu, reflects its comparison to bupleurum, called chaihu. The taste is bitter and acrid, it has a mild, cold nature and affects the lungs to resolve phlegm and to relieve coughing. It is especially used in cases of acute bronchitis, and because of its mild nature, it is used for both hot and cold syndromes. It is an important ingredient in the Perilla Fruit Combination (Suzi Jiangqi Tang), used for treatment of asthma, bronchitis, emphysema, and other lung disorders, given when there is copious sputum. The active components include flavonoids, such as peupraerin, which dilate the blood vessels and aid expectoration. Perilla Fruit Combination Suzi Jiangqi Tang Perilla seed

suzi

9 g

Pinellia

banxia

9 g

Tang-kuei

danggui

9 g

Peucedanum

qianhu

6 g

Magnolia bark

houpo

6 g

Cinnamon bark

rougui

6 g

Licorice

zhi gancao

6 g

Ginger

shengjiang

3 slices

Pumice refers to volcanic lava that has entered the ocean, becoming light due to the influence of steaming water, making it porous as it cools. The pores become filled with tiny marine life. The resulting material is salty, mildly cold, and influences the lungs to remove phlegm masses; its mild nature makes it suitable for treatment of children's coughs. It is also used for resolving swellings, such as goiter, tumors, and scrofula. Pumice is not included as an ingredient among traditional formulas. It is included in the modern formula Laminaria 4 (Hai Lin Pian), used for phlegm masses and tenacious sputum in the lungs. The active components of pumice are silicon dioxide, a component also found in bamboo sap, plus the minerals common to sea materials such as clam shells, mainly calcium salts. Laminaria 4 Hai Lin Pian Laminaria

kunbu

40%

Sargassum

haizao

39%

Oyster shell

muli

10%

Pumice

haifushi

10%

Sinapis

baijiezi

1%

Sterculia refers to the seed of Sterculia scahigera. Its Chinese name pangdahai, refers to the fact that the herb swells up when dipped in water and floats like a sponge. Although listed in the phlegm-resolving section of most Chinese herb texts, it has minimal direct action on phlegm, mainly having an "opening" action that aids the normal flow of mucus. It has a sweet taste and cold property, affecting the lungs and large intestine-moistening dryness, opening the lungs and throat, and promoting bowel movements. The herb is rarely included in traditional formulas, but it is sometimes used in modern clinical practice. For example is an ingredient of Yanhou Tang, used for the treatment of chronic pharyngitis. The active components of this herb have not yet been ascertained.

Yanhou Tang (used in clinical research, proportions not available) Lonicera

jinyinhua

Ophiopogon

maimendong

Chyrsanthemum

juhua

Platycodon

jiegeng

Sterculia

pangdahai

Oroxylum

muhudie

Licorice

gancao

Trichosanthes refers to a starchy root obtained from the Chinese gourd plant Trichosanthes kirilowii. The Chinese name, gualougen, simply refers to the root, gen, of the gourd; it is also called tianhuafen, indicating the white powder obtained from the root. The taste is sweet and sour and it has a cold property. It influences the lung and stomach, moistening dryness and clearing heat and swelling. It is most commonly used for diseases with thirst as a symptom, including diabetes. It is an important ingredient of Ophiopogon and Trichosanthes Combination (Maimendong Yin Zi), a formula used for diabetes and chronic bronchitis with dry cough. The active components of trichosanthes include sterols and saponins. The root is also the source of a protein drug, trichosanthin, commonly called Compound Q, which has been used as an abortifacient, a treatment for cancer, and a trial drug in the treatment of AIDS. Ophiopogon and Trichosanthes Combination Maimendong Yin Zi Ophiopogon

maimendong

21 g

Hoelen

fuling

18 g

Rehmannia

shengdi

12 g

Anemarrhena

zhimu

9 g

Pueraria

gegen

9 g

Trichosanthes root

gualougen

6 g

Ginseng

renshen

6 g

Bamboo

zhuru

3 g

Schizandra

wuweizi

3 g

Licorice

gancao

3 g

Trichosanthes seed is derived from the same plant as the root. The Chinese name, gualouren simply indicates that it is the seed of the gourd. The taste is bitter and it affects the lung and stomach as well as the large intestine to resolve phlegm and treat dryness. Trichosanthes seed is an ingredient of Anemarrhena and Fritillaria Formula (Ermu Ningsou Wan), a pill used for severe coughing with dryness. The active components include fatty acids and saponins. The whole trichosanthes gourd or just the outer portion are also used in Chinese medicine, with similar applications, especially used for treating persistent discharge of colored phlegm; the seed is selected in cases of congestion accompanied by constipation, while the outer portion is selected when there is sticky phlegm in the chest. Anemarrhena and Fritillaria Formula Ermu Ningsou Wan Anemarrhena

zhimu

10%

Fritillaria

chuanbeimu

8%

Trichosanthes seed

gualouren

10%

Morus bark

sangbaipi

10%

Citrus

chenpi

10%

Hoelen

fuling

10%

Gardenia

zhizi

10%

Scute

huangqin

10%

Chih-shih

zhishi

8%

Schizandra

wuweizi

8%

Licorice

gancao

6%

Trichosanthes fruit is derived from the same plant as the root. The Chinese name, gualou simply indicates that it is this particular gourd. Sometimes, only the peel of the fruit is used; it is known as gualoupi. The taste is sweet and it affects the lung and stomach as well as the large intestine to resolve thick phlegm and treat dryness. Trichosanthes fruit is a major component of Trichosanthes, Bakeri, and Pinellia Combination (Gualou Xiebai Banxia Tang) which is used for phlegm accumulation in the chest area, affecting the heart and lungs, as occurs with some heart disease. Trichosanthes, Bakeri, and Pinellia Combination Gualou Xiebai Banxia Tang Trichosanthes fruit

gualou

3 g

Bakeri

Xiebai

4.5 g

Pinellia

Banxia

6 g

Usnea refers to the parasitic plant Usnea longissima and related species, found growing from the branches of pine trees. The Chinese name, songluo, refers to its beard-like appearance on the pine tree. It has a bitter and sweet taste, cleanses the lungs, controls bleeding, and reduces inflammation and infection. It is an ingredient of Pinellia and Usnea Formula (Ying Jie San), used in the treatment of tumors that are comprised of a phlegm mass, such as melanomas and lymphatic tumors. The active components of usnea include usnic acid. Pinellia and Usnea Formula Ying Jie San Fried wheat

zhi xiaomai

12 g

Usnea

songluo

9 g

Pinellia

banxia

9 g

Fritillaria

zhebeimu

9 g

Sargassum

haizao

9 g

Laminaria

kunbu

9 g

Gentiana

longdancao

9 g

Arca shells

walengzi

9 g

Tetrapanax

tongcao

9 g

Alum

mingfan

9 g

Laminaria refers to at least two seaweeds, Laminaria japonica or Ecklonia kurome, the latter being the most common source in modern times. The Chinese name kunbu refers to the appearance of its many broad leaves. The seaweed, like others, is salty in taste and has a cold property. It influences the liver, kidney, and stomach, reducing swellings and eliminating excess moisture. Since laminaria is almost always combined with another seaweed, sargassum, a representative formula using laminaria is presented with the sargassum entry. The salts in seaweed may be responsible for both diuretic and phlegm-resolving activities. There are also polysaccharides that reduce lung irritation. Laminaria is mainly used in formulas that "soften" masses, being used for ovarian cysts, thyroid swellings, and tumors. Sargassum is a seaweed obtained from Sargassum fusiforme and some related species. The Chinese name, haizao simply means sea hair. Its taste is salty and bitter, and it has a cold nature. It influences the liver, kidney, and stomach to treat swelling, edema, and phlegm accumulation. Its properties are like those of laminaria, with which it is usually combined. Sargassum and laminaria are ingredients of the Sargassum and Laminaria Combination, sometimes called the Seaweed Combination (Haizao Yuhu Tang). It is used in the treatment of thyroid swellings and tumors. Sargassum and Tu-huo Combination Haizao Yuhu Tang Sargassum

haizao

3 g

Laminaria

kunbu

3 g

Pinellia

banxia

3 g

Citrus

chenpi

3 g

Blue citrus

qingpi

3 g

Forsythia

lianqiao

3 g

Fritillaria

zhebeimu

3 g

Tang-kuei

danggui

3 g

Cnidium

chuanxiong

3 g

Tu-huo

duhuo

3 g

Licorice

gancao

3 g

Kelp

haidai

1.5 g

Chu-dan is the bile obtained from pigs; the Chinese name zhudan simply refers to the pig's (zhu) gallbladder or bile (dan). It has a bitter taste and affects the lung, liver, and gallbladder. Chu-dan is used to treat cough with profuse phlegm or difficult expectoration due to a lung heat syndrome; it is also utilized for a wide range of heat syndromes, including swollen and painful eyes, sore throat, dysentery, boils, inflammation of the liver, and congestion of the bile duct or gallbladder. It is an ingredient of cough syrups, such as Chuan Ke Ling, and is often used as an inexpensive substitute for snake bile (shedan). The active constituents are bile acids. Chuan Ke Ling (patent cough syrup) Platycodon

jiegeng

35%

Licorice

gancao

30%

Apricot seed

xingren

25%

Chu-dan

zhudan

10%

HERBS FOR COLD PHLEGM Arisaema refers to the processed tuber of Arisaema consanguineum. The Chinese name tiannanxing means heaven's southern star. It is acrid and bitter, and somewhat toxic before processing, usually with pig's bile (it is then often called dannanxing; dan means gallbladder or bile). Its influence is mainly on the lung, liver, and spleen, resolving phlegm, calming wind, and drying dampness; it is also used to resolve resulting heart phlegm congestion, for stroke, paralysis, and convulsion. Arisaema is a major ingredient of the Pinellia and Arisaema Combination (Qingshi Huatan Tang), used for pain and numbness due to phlegm obstruction of the nerves, muscles, and joints. The main active components are saponins that thin the phlegm and reduce inflammation. Pinellia and Arisaema Combination Qingshi Huatan Tang Pinellia

banxia

12 g

Hoelen

fuling

12 g

Atractylodes

baizhu

12 g

Arisaema

tiannanxing

9 g

Scute

huangqin

9 g

Fresh ginger

shengjiang

3 slices

Citrus

chenpi

7.5 g

Sinapis

baijiezi

4.5 g

Bamboo sap

tianjuhuang

4.5 g

Chiang-huo

qianghuo

4.5 g

Angelica

baizhi

4.5 g

Licorice

gancao

4.5 g

Centipeda refers to the whole plant of Centipeda minima, a member of the Dandelion Family; it should not be confused with the insect centipede, which is also used in Chinese medicine. One of the Chinese names, shihusui, makes reference to similarities in its appearance to husui, coriander; it is more commonly know as ebushicao ("herb that even a goose won't eat;" because of its strong taste). It has an acrid taste and is said to enter the lung meridian because of its strong effects on the lungs and sinuses, alleviating stuffiness. In addition, it clarifies obstructed vision and can be used in treating infections of the respiratory system or intestines. It is not commonly included in traditional Chinese formulas, but is used in some modern

clinical applications. It is an ingredient of the formula Xanthium 12, devised in the U.S. to treat allergy reactions, especially sinus allergies. The active components of centipeda include taraxesterols found also in dandelion, and flavonoids that reduce allergy reaction. Xanthium 12 Kang Xieqi Pian Xanthium

cangerzi

13%

Sophora

kushen

12%

Bupleurum

chaihu

9%

Centipeda

ebushicao

9%

Scute

huangqin

9%

Cynanchum

baiqian

9%

Siler

fangfeng

8%

Mume

wumei

8%

Ginseng

renshen

6%

Licorice

gancao

6%

Asarum

xixin

6%

Schizandra

wuweizi

5%

Gleditsia refers to the sharp spines of Gleditsia officinalis and related species of the member of the Legume family. The Chinese name, zaoci, simply refers to the spike, ci, of the plant commonly called zao, meaning black, because black soap was made from the saponins of the fruits. It has an acrid taste and a mild warm quality. It enters the lung meridian and aids in dispersing phlegm masses. Gleditsia is an ingredient in many antitumor formulas, such as Angelica and Mastic Combination (Xianfang Huoming Yin), used for carbuncles, abscess, swelling ulcers, and tumors. The main active components are saponins. Gleditsia fruits (zaojia) have similar properties, but are mainly used for cases of phlegm obstruction of the orifices, thus treating stroke, convulsion, and paralysis. Angelica and Mastic Combination Xianfang Huoming Yin Lonicera

jinyinhua

9 g

Citrus

chenpi

9 g

Anteater scales

chuanshanjia

3 g

Angelica

baizhi

3 g

Gleditsia spine

zaoci

3 g

Trichosanthes root

gualuogen

3 g

Peony

baishao

3 g

Myrrh

moyao

3 g

Frankincense

ruxiang

3 g

Fritillaria

zhebeimu

3 g

Tang-kuei

danggui

3 g

Siler

fangfeng

3 g

Licorice

gancao

3 g

Inula refers to the flowers of Inula britannica, an internationally used herb of the Dandelion family. Its name xuanfuhua, refers to the dense curled shape of the flower head. The taste is acrid and bitter, and its property is mildly warm. It affects the lung and large intestine, and the spleen and stomach, resolving phlegm, causing qi to descend, and softening hardness. Inula is an ingredient of the Schizonepeta and Pinellia Formula (Qingfei Cao San) used for the treatment of bronchitis with productive cough and sinus congestion. The active components are mainly taraxasterol and related compounds that reduce inflammation and disperse phlegm. Schizonepeta and Pinellia Formula Qingfei Cao San

Schizonepeta

jingjie

17.5 g

Peucedanum

qianhu

13.5 g

Inula

xuanfuhua

9 g

Asarum

xixin

9 g

Hoelen

fuling

5.4 g

Pinellia

banxia

4.5 g

Licorice

gancao

3 g

Ginger

shengjiang

2 slices

Jujube

dazao

3 pieces

Pinellia refers to the processed tuber of Pinellia ternata, the most frequently used of all the phlegm-resolving herbs. The Chinese name, banxia, means half summer, and refers to the fact that it is collected in mid-summer. It has an acrid taste and is toxic until processed, usually cooked with ginger juice. It enters the spleen and stomach meridians, harmonizing the stomach and reducing the production of phlegm due to undigested food and excessive upward movement of qi and moisture. It is the key herb of Pinellia Combination (Banxia Xiexin Tang), a formula that is widely used and often modified slightly for specific applications; it is mostly used for indigestion, nausea, vomiting, gastritis, and ulcer. The active components are many, including alkaloids, phenols, and sterols, producing a sedative, antiemetic, and phlegm-resolving action. Pinellia Combination Banxia Xiexin Tang Pinellia

banxia

18 g

Ginseng

renshen

9 g

Jujube

dazao

6 pieces

Fresh ginger

shengjiang

3 slices

Coptis

huanglian

3 g

Scute

huangqin

9 g

Licorice

zhi gancao

9 g

Platycodon refers to the roots of Platycodon graniflorum; it is a relative of the tonic herbs codonopsis and adenophora. The Chinese name, jiegeng, makes reference to the quality of the plant's stalk. Its taste is acrid and bitter, and its property is neutral. It enters the lung meridian to ventilate the lungs, resolve phlegm and disperse cold; because of its neutral quality, however, it is frequently used in treatment of lung heat and sore throat. It is an ingredient of the Fritillaria and Platycodon Formula (Ning Sou Wan), a pill that is used for acute and chronic bronchitis with persisting cough and excessive sputum. The active components of platycodon are saponins, sterols, and triterpenoids, that reduce inflammation and thin the sputum. Fritillaria and Platycodon Formula Ning Sou Wan Platycodon

jiegeng

10%

Perilla fruit

zisuzi

10%

Dendrobium

shihu

10%

Fritillaria

beimu

10%

Hoelen

fuling

10%

Pinellia

banxia

10%

Mentha

bohe

8%

Morus

sangbaipi

8%

Apricot seed

xingren

8%

Red citrus

juhong

6%

Wheat sprout

xiaomai

6%

Licorice

gancao

4%

Sinapis, sometimes called brassica, refers to the seed of Brassica alba, also called Sinapis alba, and related species of mustard. The Chinese name, baijiezi, refers to the white seed that confers strength. It has an acrid taste and enters the lung meridian to promote the flow of qi in the chest, expel phlegm, and disperse swellings. Sinapis is an ingredient in Lige

Huotan Tang, used for the treatment of phlegm accumulation that leads to hiccups, choking sensation, and difficulty consuming food. Even though sinapis is warming, it is included in this formula for phlegm stagnation that has turned hot, because of its powerful dispersing qualities, counterbalanced by inclusion of coptis, gardenia, and gypsum. The active components of sinapis include the glycoside sinalbin, which has expectorant properties. Lige Huotan Tang Pinellia

banxia

9 g

Red citrus

juhong

9 g

Chih-shih

zhishi

9 g

Areca seed

binglang

9 g

Aquilaria

chenxiang

9 g

Platycodon

jiegeng

9 g

Trichosanthes root

gualougen

9 g

Coptis

haunglian

9 g

Gardenia

zhizi

9 g

Cyperus

xiangfuzi

9 g

Sinapis

baijiezi

6 g

Gypsum

shigao

12 g

Tea

xicha

3 g

Typhonium, often called "white aconite," is obtained either from the tuber of Typhonium giganteum or Aconitum koreanum. The Chinese name, baifuzi, means white aconite. The taste is acrid and sweet, and it affects mainly the stomach, to get rid of phlegm that rises due to adverse movement of qi. The herb is used for phlegm obstruction causing paralysis, pain, or convulsion. Typhonium is an important ingredient of the formula True Jade Powder (Yu Zhen San) used for tonic muscular paralysis. The active components of the Typhonium species are sterols while the Aconitum species yield alkaloids, the latter having a stronger pain-relieving action. True Jade Powder Yu Zhen San Typhonium

baifuzi

3 g

Arisaema

tiannanxing

3 g

Siler

fangfeng

3 g

Angelica

baizhi

3 g

Gastrodia

tianma

3 g

Chiang-huo

qianghuo

3 g

June 1998

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What is Phlegm-Mist Affecting the Orifices of the Heart? An Examination of a TCM Perspective on Causes of Stroke essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

There is a concept in Chinese medicine depicting a phlegm disorder primarily affecting brain functions. The terminology of "phlegm misting the orifices of the heart" (tanmi xinqiao) is frequently used for this concept. Most Chinese texts simply list the symptoms and signs pointing to this diagnosis, rather than elucidating what the condition is. An exposition of this diagnostic category may benefit the development of Chinese medical practice. The condition is sometimes described as phlegm entering the heart, or as phlegm entering the heart meridian (or "channel"). In another article (Drawing a Concept: Jingluo), the original description of meridians in the Chinese medical system is shown to be related to blood vessels. We know this, in part, because virtually all mentions of the flow of qi in the ancient texts are actually about the combined flow of "qi and blood." It is easy to become confused about the Chinese view of human physiology when modern writers describe meridians as pathways existing solely for the flow of qi, to be distinguished from blood vessels for the flow of blood, which is not consistent with the prior 2,000 years of Chinese literature. The fact that the meridian maps do not correspond with blood vessels merely indicates that what was eventually mapped for purposes of describing acupuncture therapies failed to follow precisely the underlying traditional conceptual framework.

Two representations of the heart: the classical Chinese representation (left) and the modern medical representation (right). Early Chinese doctors had the opportunity to see the internal organs, particularly as a result of war injuries. The heart is a distinctive organ that has several large vessels protruding (e.g., aorta and pulmonary artery), and these could easily be understood as "orifices of the heart." Further, the flow of blood upward to the brain was readily displayed when injuries to the neck (including decapitation) occurred. So, it was clear that there was a strong blood flow from the heart to the brain. Again, this would be interpreted as flow of qi and blood through the large vessels linking the heart and brain. Since the heart, as a yin organ (zang), was deemed to be "solid" (one of the yin organs, the zang) rather than "hollow" (as with the yang organs, the fu), it would be a natural assumption that the phlegm accumulated in the heart channels. Such accumulation was not restricted to the heart meridian as described today (traversing the arm) but, rather, to the actual arteries of the heart. Phlegm mist is a concept that can be traced back at least to the Song Dynasty. By that time, Chinese doctors were distinguishing "substantial" phlegm (such as sputum, which is described as "condensed pathological fluid") and "insubstantial phlegm" or "hidden phlegm" (such as the mist of the heart orifices; a "thin pathological fluid"). The substantial phlegm would mainly accumulate in the lungs and stomach, while the insubstantial phlegm would accumulate in the meridians, distributing to various parts of the body, such as the heart orifices and the brain (e.g., causing dizziness or loss of consciousness), the lymph nodes (causing nodules and swellings), and the limbs (e.g., causing numbness). The two types of phlegm were thought to have the same origin and the same fundamental nature, but would permeate different parts of the body (the thick sputum could not penetrate the meridians, but the insubstantial phlegm could). Further, insubstantial phlegm could combine with other pathological influences to yield phlegm-fire, wind-phlegm, and phlegm-turbidity. According to the doctrine that evolved, the phlegm mist could cause the other pathological factors-such as fire, wind, or damp-to produce more severe symptoms. Further, its material nature would capture the more ethereal forces of fire or wind to make the disease persist; similarly, the phlegm-mist could blend with damp to yield turbidity that obscures the clear flow of qi and yang to the brain, interfering with normal mental and sensory functions though not completely blocking the circulation to the brain. Diseases and symptoms attributed to phlegm mist affecting the heart orifices include dizziness, loss of consciousness (coma), hemiplegia (stroke), mania (emotional outbursts, disturbed speech), convulsions (especially epilepsy), sudden sensory loss (deafness, blurred vision, loss of taste and smell, inability to speak), lockjaw, and stiff tongue. Diseases currently treated in China by herbs that resolve phlegm-mist affecting the heart orifices (see Table), also include manic-depressive disorder and senile dementia (Alzheimer's disease). Table 1: Herbs that are commonly used in formulas to clear phlegm mist and open the orifices Herb

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Acorus changpu

This is the most commonly-used Chinese herb (of opens orifices, expels phlegm and turbidity, plant origin) for treatment of mental disorders. It was listed in the Shennong Bencao Jing as a replenishes intelligence superior herb.

Arisaema tiannanxing, dannanxing

Arisaema is described as having the power to vaporize phlegm accumulations; it is mainly used relieves convulsions, resolves phlegm mist, when treating phlegm obstruction of the orifices. disperses accumulations Bile processed arisaema is used for phlegm-mist associated with a fire syndrome.

Bamboo zhuru, zhuli, tianzhuhuang

removes heat, transforms phlegm, calms fright

Bamboo shaving, leaves, juice, or dried secretion are all used to treat irritability, fidgets, and convulsions. They are particularly favored in treatment of children's disorders.

Borneol longnao

opens orifices, moves qi, clears vision

Borneol is usually used as an adjunct ingredient in formulas for resolving phlegm that causes brain disorders; it is often combined with musk and/or acorus to open orifices.

Curcuma yujin

Curcuma is best known for its ability to vitalize circulation of qi and blood, but it enters into regulates flow of qi, dissolves qi stagnation, several formulas for brain disorders because it is disperses stagnant blood useful in treating phlegm accumulation disorders, especially when there is a heat syndrome.

Musk shexiang

opens orifices

Musk, with its penetrating aroma and stimulating quality, is mostly used for severe cases of brain disorder, especially when the person is losing consciousness or suffering from delirium.

opens orifices, transforms phlegm, clears heat, removes toxin, calms fright

Ox gallstone is utilized to correct gallbladder disorders that result in hot phlegm moving upward to cloud the consciousness. A mixture of bile acids and minerals is used today to make synthetic oxstone.

harmonizes stomach, dries dampness, removes phlegm, disperses accumulation

Pinellia is the most commonly-used phlegmresolving herb in Chinese medicine and it enters into formulas for treating brain and mind disorders that involve phlegm accumulation due to stomach/spleen weakness.

resolves phlegm

Platycodon is thought to direct the action of other herbs to the upper body, making it useful in treating brain disorders; in addition, it helps to resolve phlegm accumulation

Polygala yuanzhi

stabilizes the heart and calm the mind

Polygala is often used as an adjunct to acorus for resolving phlegm that obstructs the orifices of the heart. In addition, it is used as a sedative, often along with zizyphus.

Silkworm baijiangcan

calms wind, resolves phlegm, disperses accumulation

A fungus infecting the silkworm is the active component, as with cordyceps. It is especially used for wind-phlegm disorder, with tonic paralysis or convulsion.

Ox gallstone niuhuang

Pinellia banxia

Platycodon jiegeng

It is tempting to try and correlate the traditional Chinese concept of phlegm-mist with a substance or condition defined by modern medicine so that the Chinese diagnostic category could be explained in terms of our current knowledge of physiology. Attempts to find correlations between modern medical knowledge and other traditional Chinese concepts, such as qi, blood, and even the organ functions, are often unsatisfactory. However, we may be able to link some of the TCM concepts to modern interpretations. Thus, for example, the condition of atherosclerosis, where plaques that include fatty materials (e.g., cholesterol and lipoproteins) coat the arteries, might be one case of phlegm-mist affecting the orifices; certainly, stroke is frequently associated with this type of blockage of the carotid arteries. The accumulation of amyloid plaques in the brain of persons with Alzheimer's disease might also correspond, to some extent, to phlegm mist. Disorders of the thick fluid in the ear drum, which might be depicted as a phlegm-type disorder (e.g., phlegm-turbidity), can yield dizziness. The formation of blood clots in the arteries or veins, while seeming to fit the category of blood stasis, may be an example of phlegm accumulation, in the sense that phlegm is a sticky substance and the clot forms by the coagulation of various blood components (such as fibrin and platelets) into a spongy mass. By contrast, extensive bruising, where clotted blood resides outside the vessels and forms a firm mass, more clearly fits the blood stasis description. The ancient doctors saw phlegm-mist primarily involved with sudden and dramatic change: the person would faint, go into a convulsion, or suddenly erupt with crazy behavior. For example, as described in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology: "voracious eating, overdrinking alcohol, and emotional irritation combine to cause food retention in the stomach, which causes stomach qi to disturb upward, blocking the clear cavity and thus resulting in loss of consciousness." The idea was that a substantial amount of phlegm would suddenly rush to the heart. Then, when the phlegm blockage cleared, the person would return

to normal, though in some cases, there could be persisting symptoms (e.g., hemiplegia). The condition being described parallels what happens when a blood clot forms in the arteries supplying the heart or brain, causing the person to collapse. If the clot clears out quickly enough (spontaneously or with medical intervention), the person recovers; if not, there may be persisting symptoms or the person may die. This connection between the traditional concept of phlegm blockage and the modern understanding of formation of obstructive blood clots in the vessels is well illustrated in the presentation by Wang Yongyan and his colleagues describing their work with stroke patients, presented at a 1987 TCM conference in Shanghai. They differentiated the disease conditions of 158 patients who suffered from "upward disturbances of wind-phlegm and accumulation of phlegm-heat." Using the TCM criteria, they divided these cases into: 120 of "channel stroke" (phlegm blocking the heart orifices); 32 cases of fu-organ stroke (e.g., phlegm originating from the stomach or gallbladder); and 6 cases of zang-organ stroke (e.g., phlegm blocking the heart). Turning to Western medical diagnosis for these same patients yielded: 145 cases of thrombosis of the carotid artery system; 8 cases of thrombosis of the vertebro-basilar system; and 5 cases of embolism. The treatment administered to the patients was based on expelling phlegm and purging the intestines, using a formula that included bile-treated arisaema, rhubarb, and trichosanthes seed (which has a laxative effect due to the thick seed oils; this herb also phlegm-resolving). After a few days of this purging therapy (generally less than two weeks), the focus of treatment shifted to "clearing heat, expelling phlegm, vitalizing blood, and invigorating the channels." Liquid bamboo sap (zhuli) was used as an essential ingredient in most of the cases.

TRADITIONAL HERB THERAPIES FOR PHLEGM MISTING THE HEART To treat patients who remained unconscious for a long time (more than a few minutes), Chinese physicians would administer aromatic formulas in an attempt to get the vapors to break up the blockage. These are usually rich in borneol and musk (see appendix for further descriptions of the ingredients). The formula might be forced into the stomach, so that it could potentially have a greater effect, compared to merely placing some of the fragrant substance in the nostrils (some coma patients retain a swallowing reflex making oral administration easier). In modern China, the formulations are given by intravenous drip (e.g., Qingkailing injection or Xingnaojing injection). The same highly aromatic agents are also given to those who are not in a coma, such as persons suffering from frequent convulsions or other phlegm-mist disorders. Pills made with ingredients listed in Table 1 were among the important formulas of the Hejiju Fang (ca. 1110) of the Song Dynasty. A typical example, a pill still used in recent times (though finally taken off the international market due to concerns about toxic substances and endangered species among its 30 ingredients), is Niuhuang Qingxin Wan (Ox Gallstone Cleanse the Heart Pill). Key ingredients for eliminating phlegm obstruction in this formula are ox gallstone, borneol, musk, platycodon, and curcuma. According to Commonly Used Chinese Herbal Formulas with Illustrations, the formula is said to calm a person who is suffering from fright, and is prescribed for mental-distress conditions including panic, amnesia, absent-mindedness, mental uneasiness, horror, sorrow, irritability, perversities, anger, hysteria, madness, mental disorders, and spiritual miasma, especially in those who also experience physical manifestations such as loss of ability to control the limbs, difficulty in speech, distorted mouth and stiff tongue, heart palpitations, visual disturbances, or rigidity of neck and back. During the Jin-Yuan reform period (1127-1368), Zhu Danxi wrote about the phlegm-mist disorder. He gave an example, recorded in Danxi Zhifa Xinyao, where fright is the initiating cause: "Because of fright, the spirit leaves its abode, and, when its abode is left vacant, phlegm may enter. Occupying this abode, phlegm repulses the spirit. Thus, it is impossible for the spirit to return." The abode spoken of here is the heart orifices, the resting place of shen, the spirit. This description follows an ancient concept that the spirit takes its rest in the heart, but is not confined there: it may wander, and then return. This wandering gives us the experiences of imagination and brilliant ideas, dreams, spiritual experiences, and visions. The spirit returns to the heart for its rest. However, if the orifices are filled with phlegm mist, the spirit cannot return (also, if the heart yin and blood is deficient, the heart is not providing a comfortable resting place, and the spirit becomes disturbed). Excessive wandering of the spirit, especially without rest, leads to bizarre and unrealistic thoughts and speech, nightmares, emotional disturbance, and other undesirable conditions. Another reason that the phlegm can fill this abode (aside from the spirit being absent) is because the abode is not already rich in qi and blood. Hence, an underlying deficiency syndrome greatly increases the chance of having a phlegm obstruction. Still, the accumulation of phlegm is a type of excess. Describing the problem of coma, Clinical Manual of Chinese Herbal Medicine and Acupuncture says that this condition "often presents with an excess syndrome marked by obstruction of phlegm and heat, the principle is to clear heat, resolve phlegm, and promote mental resuscitation." According to this text, commonly used herbs in the treatment of obstruction syndromes include: acorus, curcuma, polygala, and bamboo silica (tianzhuhuang); to further resolve excessive phlegm, bile processed arisaema, pinellia, and bamboo sap (liquid; zhuli) are added. As to the origins of the phlegm mist, the starting point is understood to be the generation of pathological phlegm (excess phlegmfluid) which can be the result of external influences (six exogenous pathogenic factors), internal influences (abnormal emotional activities), and/or behavior (especially irregular diet, but also overeating rich foods and/or drinking excess alcohol). For phlegm mist to affect the heart orifices, which are at the top of the internal organs, it must rise upward, and that occurs through certain mechanisms such as uprising qi from the stomach; uprising damp-heat from the gallbladder (often due to persistent qi stagnation of the liver and rising liver yang); excessive "steaming" of water by kidney yang (due to kidney yin deficiency); and heart fire. Perhaps the most serious of the phlegm-mist syndromes is from a fire disorder (tanhuo raoxin). It is described in Chinese Herbal Therapies Formulas and Strategies this way: "The vigorous blazing heat scorches the fluids and causes them to congeal into phlegm. Heat and phlegm accentuate each other and completely veil the orifices of the heart, further disturbing the spirit and impairing the consciousness." Persons with phlegm-mist syndrome need not have obvious phlegm excess, such as coughing up sputum, runny nose, obesity, or phlegm-nodules, but the problems of substantial phlegm and insubstantial phlegm may go together. Usually, the patient suffering from phlegm-mist will display some signs of phlegm, such as slippery and smooth tongue coating or slippery pulse. In the ancient Chinese texts, there are stories about treating patients with phlegm-mist disorder using herbs that induce vomiting: discharge of copious amounts of mucous fluid from the stomach occurs, followed by alleviation of the symptoms. Several ingredients used in the traditional formulas for phlegm-mist disorders are problematic for Western practitioners, aside from the banned ingredients cinnabar (a mercury compound) and realgar (an arsenic compound) that are used as sedatives and detoxicants. For

example, neither ox gallstone nor musk are readily available, and sometimes the dosage of borneol used in Chinese formulas can be risky (it acts as a heart stimulant in high doses). But, other ingredients are considered acceptable and the most commonly used ones are the pair of acorus and polygala, usually combined with herbs that are considered heart sedatives, and the pair of bamboo with arisaema, often with herbs that resolve phlegm-damp. A good example of the former is Anshen Dingzhi Wan, which is comprised of acorus, polygala, dragon teeth, fu-shen, ginseng, hoelen; an example of the latter is Ditan Tang, which is comprised of bamboo, arisaema, pinellia, citrus, chih-shih, hoelen, ginseng, acorus, and licorice. Note that both formulas include ginseng, hoelen, and acorus, where ginseng and hoelen tonify the spleen (to help prevent phlegm-fluid accumulation) and calm the heart (fu-shen is a type of hoelen with greater calming qualities), and acorus is used to clear phlegm mist from the orifices. The role of the stronger medicinal agents (musk, ox gallstone, borneol) for opening the orifices is described in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology: Herbs that open the obstructed heart orifice and restore consciousness are known as herbs for promoting resuscitation, or analeptics [agents that strongly stimulate the central nervous system]. These herbs are acrid, aromatic, and dispersive. They mainly enter the heart meridian and restore consciousness in comatose patients. They are applied for loss of consciousness in febrile diseases, apoplexy, epilepsy, and syncope due to heat attacking the pericardium or phlegm and turbidity obstructing the heart orifice. The heart orifice obstruction syndrome can be of either the hot or cold type. Those cases of the heat type are due to obstruction by pathogenic heat, exhibiting fever, flushed face, convulsion, deep red tongue with yellow coating and rapid pulse. Here analeptic herbs are combined with those that purge heat and toxins, cool the blood and eliminate wind, thus resuscitating with cool herbs [e.g., rhino horn, raw rehmannia, moutan, coptis, gardenia]. Cases of the cold type are usually due to obstruction by pathogenic cold or phlegm-turbidity, manifested as bodily coldness, cyanosis, or rattling in the throat due to phlegm, pale tongue with white coating and slow pulse. For such cases, analeptic drugs are used together with drugs that eliminate cold and activate qi, thus resuscitating with warm herbs [e.g., aconite, cinnamon bark, dry ginger]. Analeptics are mostly used for emergency cases. As they have a powerful dispersive action and likely cause damage to the primordial qi, they should not be taken for a long time. The text then notes that the action of acorus is not as strong as that of musk and borneol, but it resolves phlegm and damp and is indicated for phlegm-damp obstructing the heart and for those cases due to dampness retained in the center (i.e., stomach/spleen). In traditional texts, the phlegm-mist herbs, such as acorus, are specifically indicated for loss of consciousness (e.g., having a stroke) with stiff tongue (a frequent result of brain damage due to stroke). The idea of phlegm-mist has evolved over time, and this entity is now included as a diagnostic category for certain chronic ailments that do not necessarily have sudden onset, as occurs with some cases of depression, deterioration of memory, or gradual onset of a seizure disorder, as well as for the prolonged period of post-stroke syndrome. In such cases, milder agents (other than the highly aromatic musk and borneol) are relied upon. As an example, Clinic of Traditional Chinese Medicine recommends a formula for treating a syndrome of "depressive psychosis" marked by conditions such as emotional depression, apathy, dementia, muttering to oneself, frequent outbursts of crying or laughing for no apparent reason, and low desire for food; the formula is comprised of acorus, polygala, arisaema, curcuma, pinellia, citrus, chih-shih, cyperus, hoelen, licorice. In the book Traditional Chinese Treatment for Senile Diseases , a similar formula is suggested for cases of senile dementia with depression and other symptoms such as those just mentioned, with the herbs chih-shih and licorice removed and replaced by gardenia. These formulas are modifications of the traditional Shunqi Daotan Tang (Smooth the Qi and Purge the Phlegm Decoction). For the long-term therapy of patients suffering from phlegm-mist disorder, dietary adjustments are considered very important. Fried foods, heavily salted foods, and foods that are difficult to digest are eliminated to avoid the problem of producing pathological phlegm. Herbs that promote digestion are also potentially of value, including shen-chu, raphanus, and crataegus. If constipation is present, this disorder is to be addressed because it contributes to abdominal stagnation and the increased possibility of upward flow of qi and fluid to affect the heart and its orifices. Rhubarb is the primary ingredient in formulas for alleviating constipation, and it is typically combined with chih-shih to aid the downward flow.

APPENDIX: Herbs in the Materia Medica Section Devoted to Opening the Orifices In the book Ten Lectures on the Use of Medicinals from the Personal Experience of Jao Shude , three key herbs from the Materia Medica section devoted to opening the heart orifices are described in detail. The book's presentation of these herbs for phlegm-mist obstructing the orifices is relayed here: Musk: acrid in flavor and warm in nature, musk opens the orifices of the heart, frees the channels and network vessels [jingluo, may correspond to arteries and veins], frees the twelve channels above and below, and penetrates inward to the bone and marrow and outward to the skin and hair. As an aromatic, mobile, and penetrating substance, it opens the gates (i.e., frees the jaws) and disinhibits orifices. For coma and clenched jaw that result from wind strike, heat entering the pericardium, or phlegm confounding the orifices of the heart, this medicinal opens the orifices of the heart and arouses the heart spirit. Borneol: acrid and bitter in flavor and slightly cold in nature, borneol is aromatic, penetrating, and mobile; there is nowhere it does not reach. It dissipates depressed fire and frees all the orifices, clears the heart and arouses the brain, and dispels eye redness and nebulous eye screens. For all symptoms such as coma, hoisted eyes [eyes open and turned upward], convulsions, and loss of speech that results from wind-phlegm harassing the upper body or phlegm-heat confounding the heart, acute childhood fright wind due to febrile disease, epilepsy, or sudden collapse from wind stroke, use borneol to open the orifices of the heart and clear heart heat and to arouse the brain and quiet the spirit. Acorus: acrid in flavor and warm in nature, opens and frees the orifices of the heart, diffuses qi, and eliminates phlegm, sharpens hearing and vision, and enhances the voice. For heat entering the pericardium or phlegm confounding the orifices of the heart that result in coma, clouding, inability to speak, and in severe cases, convulsions, acorus is frequently used to open and free the orifices of the heart, diffuse qi, and eliminate phlegm, thereby arousing the brain and clearing the spirit. When phlegm turbidity and qi depression affect the heart spirit and result in palpitations, forgetfulness, fright and fear, and disquieted essence-spirit, which in severe cases can manifest as epilepsy or mania and withdrawal, acorus is used to diffuse qi and eliminate phlegm and to open the orifices of the heart in order to quiet the heart spirit.

Musk, which is obtained from the musk deer, a rare and endangered species, is now replaced in China by synthetic muscone, the primary active component. Borneol is considered potentially unsafe, particularly by the California Bureau of Foods and Drugs; the amount should be limited to about 2% of a prescription to maintain its concentration consistent with that in simple extracts of borneolcontaining herbs (such as cardamom). Acorus is commonly derived from two species: Acorus gramineus, which is considered a safe herb, and the stronger Acorus calamus, for which some health warnings have been issued (mainly due to a single laboratory study conducted over 30 years ago, indicating a carcinogenic potential). Ox gallstone (not mentioned in the Jao Shude book) is a rare and expensive agent that is sometimes replaced by manufactured compounds using bile salts; due to inconsistencies in production of this artificial form, it is not used outside of China.

December 2004

APPENDIX: Cause of Stroke As Understood by Modern TCM In their article Progress of Research on Ischemic Stroke Treated with Chinese Medicine (Journal of Traditional Chinese Medicine, 1992), Chen Keji and Song Jun present a diagram (reproduced below) summarizing the primary causes of stroke (apoplexy) as understood in the TCM view. Chen Keji is a professor at Beijing's Xiyuan Hospital. He is also an academician of the Chinese Academy of Sciences, World Health Organization consultant on traditional medicine, and President of the Chinese Association of Integrative Medicine. He was one of the chief researchers involved in the studies of the widely-used formula Coronary Heart No. II, and the first clinician to apply ligustrazine (the main active ingredient of the herb chuanxiong) in treating acute ischemic stroke, having studied its pharmacology in relation to anti-platelet activity and thromboxane inhibition. He directed the project of sorting out original medical archives preserved in the imperial palace of the Qing Dynasty and published the findings in the book Medical Prescriptions Written for Cixi and Guangxu with Commentary. He is editor in Chief of the Chinese Journal of Integrated Traditional and Western Medicine ; Song Jun is a member of the China Academy of Traditional Chinese Medicine and an editorial board member for this journal.

Diagram of the factors causing ischemic stroke In this diagram, the causative factors are first subdivided into three categories: those that cause accumulation and blockage in the channels; genetic influences; and factors that lead to deficient nourishment, referring mainly to qi, yin, and blood deficiency. The first category is further subdivided into fatigue and worry and dietary imbalance; the third category is also further subdivided into decrepitude, dissatisfaction, and deficiency of qi. Genetics (inherent defect), which is under-represented in standard TCM, is not expanded upon in this TCM-based diagram, but will be elaborated below, along with discussion of the other factors. The uppermost entry in the diagram is the influence of fatigue and worry. Here, fatigue refers not to the symptom but to the actions that lead to fatigue, such as overwork, insufficient sleep, and sweating too much (such as from working in hot conditions). These actions, as well as worrying a lot, are said to consume the heart yin, causing imbalances that ultimately affect the circulation (including damage to the fluids that yield a phlegm-mist). The next entry involves improper diet, focusing on its contribution to phlegm accumulation. Overeating or eating difficult to digest foods (including foods that are too fatty, too cold, or too high in sugar) can cause one to feel tired after a meal, a sign that the food is improper and that the digestive process ultimately will be incomplete, leading to production of pathogenic phlegm (with repeated improper eating, the stomach and spleen are weakened, thus leading to further problems with digestion of foods). The combination of overeating and overdrinking, referring to drinking too much alcohol, contributes to "phlegm misting the heart orifices," which is considered a major contributor to blockage of the vessels to the brain. In addition, inherent defect is mentioned, but the diagram provided by Chen is incomplete. Inherent defects may be of several types and are understood now to be based on genetics or traced to injuries that might occur during early development (or from diseases during

childhood). For example, there can be a defect in the blood vessels themselves, leading to easy blockage or to an aneurism; there can be defects in the digestive system or the metabolism of food components, leading to production of the phlegm mist even in the absence of overeating or excess alcohol consumption; or, there may be defects in the heart or in the blood constituents that lead to easy clotting of the blood. These defects are difficult to eliminate; their impact may be exacerbated by the other factors depicted in the diagram or minimized by healthful practices. "Decrepitude" refers to the deterioration that is seen with aging. This is expressed as decline of kidney essence; it is a natural process, but it can be accelerated by a variety of factors, especially emotional distress ("psychic trauma"), which causes imbalances leading to circulatory disturbance. Decrepitude also involves a decline in the overall activity of the body, so that it suffers from sluggish circulation that results from lack of exercise; this problem especially occurs when the joints become stiff, the legs become weak, or the heart muscle loses its strength. Dissatisfaction is a gnawing, ongoing psychological state that may be based partly on one's circumstances and partly on one's approach to dealing with difficult circumstances. This irritating condition involves stagnation of the liver qi circulation, which generates heat in the liver and damages the liver yin (over time, this will contribute to the decline of heart yin, a disorder that was mentioned in relation to worry and overwork). Liver qi stagnation can be exacerbated by highly distressing events, leading to a severe disturbance in the circulation of qi and blood. Thus, one may suffer a stroke following an outburst of anger or other emotion, because of the underlying disturbance that already exists due to persistent dissatisfaction. Finally, a deficiency of qi is an important contributor to susceptibility to disease and damage to the organs and other body parts. As implied in the chart, external pathogenic factors, such as wind, heat, and damp, are able to penetrate the channels and cause pathological conditions if the channels are relatively empty of their vital qi and blood (by contrast, when the vessels are full of healthy qi and blood, external environmental changes are unlikely to "enter" and cause disturbances). Similarly, viruses and other pathogens can affect the person who has qi deficiency because of the lack of sufficient defensive qi. Ultimately, the environmental influences and/or pathogens will result in circulatory changes, including sudden blockage. This variety of potential adverse influences comes together in two calamitous outcomes: the channels become blocked by phlegm mist and blood stasis, while the lack of adequate circulation of qi allows these blocking accumulations to impede the circulation and cause a stroke. While any one of the listed factors alone may not cause a catastrophic event, the combination of two or more, particularly the combination of a deficiency (e.g., qi or heart yin) and an accumulation-blockage (e.g., phlegm mist or blood stasis) will likely result in a stroke or heart attack .

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THE SIGNIFICANCE OF TRADITIONAL PULSE DIAGNOSIS IN THE MODERN PRACTICE OF CHINESE MEDICINE essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

INTRODUCTION The changing setting in which Chinese medicine is practiced in modern versus ancient times, especially with the advent of advanced technological medical diagnostics, has raised questions as to the value of pulse diagnosis. Should its use be limited to confirming a diagnosis reached by other means? Or, does the pulse information add critical information that can greatly alter the treatment strategy? Training in pulse diagnosis is often quite limited; further, the requisites for carrying out a traditional style diagnosis are sometimes absent from the clinical setting, making the results of the pulse taking less certain. How does one get the desired information under such circumstances? Several years ago, an acupuncturist in the U.S. wrote to me saying: I've been practicing for over five years now and have a busy practice; but, I'm totally disheartened about my abilities. The biggest difficulties are diagnostic. I graduated school as one of the best students in my class, yet neither I nor any of my classmates had any clear sense of tongue or pulse diagnosis. I've gone to endless seminars, but theory isn't doing it for me. All the theory is useless if you're unsure of your diagnosis. What I need is an experienced practitioner to work with who can and will tell me if what I'm seeing on the tongue and feeling in the pulse is correct. Otherwise, I feel as if I'm fantasizing all the time. Is that what Chinese medicine is all about? This practitioner has recognized something that many others, who feel more confident despite limited training, may ignore: there is a great potential to simply "fantasize" the diagnostic signs, that is, to read into it something that is not really present. But, this is not what Chinese medicine is about; rather, there is a clearly defined method of pulse taking (and tongue examination, as well as other important diagnostic techniques) that can lead to reasonably well-defined syndrome determination. The information presented below is aimed at examining the traditional and modern roles of pulse diagnosis, the techniques for taking the pulse, the interpretation of various pulse forms, and some of the controversies that exist regarding the use of pulse diagnosis.

THE ORIGINAL PLACE OF PULSE DIAGNOSIS IN THE CHINESE TRADITION Pulse diagnosis is one of the original set of four diagnostic methods that are described as an essential part of traditional Chinese medical practice (1). The other three diagnostic methods are: inspection: general observations of the patient, including facial expression; skin color and texture; general appearance, and the shape, color, and distinctive markings of the tongue and the nature of its coating; and smelling (noting any unusual smell of the body, mouth, or urine); listening: to the quality of speech (including responsiveness to questions, rapidity of talking, volume of the voice); to the respiration; and to sounds of illness, such as coughing, gurgling from the intestines; and inquiring: obtaining information about the patient's medical history and their symptoms and signs, such as chills/fever, perspiration, appetite and dietary habits, elimination, sleep, and any pains; also, for women inquiring about menstruation, pregnancy, leukorrhea and other gyno-obstetric concerns. All of these diagnostic methods yield information that helps to determine the syndrome and constitution to be treated. While the Chinese pulse and tongue diagnosis methods, because of their frequent mention and somewhat unique quality among traditional medical systems, receive much attention, the other aspects of diagnosis cannot be ignored or downplayed. The Chinese term indicating a blood vessel or a meridian (which are two interlinked concepts; see Drawing a concept: jingluo) is mai, and the same term is used to describe the pulse. Pulse feeling is called qiemai, which is part of the general diagnostic method of palpating or feeling the body: qiezhen [feeling method]. Pulse diagnosis is mentioned in ancient texts, such as the Huangdi Neijing and the Huangdi Neijing of the Han Dynasty period, but with only sporadic mention of various pulse forms and their meaning. In the Huangdi Neijing, pulse is depicted primarily as a means of prognosis for impending death. As an example, in the section of the book on yin and yang it is said that (2): A yin pulse that shows no stomach qi is called the pulse of zhenzang [decaying pulse] and the prognosis is usually death. Why? Because a yin pulse reflects absence of yang and thus absence of life activity. If you can distinguish the presence or absence of the stomach pulse, you can know where the disease is located and give the prognosis for life or death, and even know when death might occur....When yang pulses are absent in a patient, the yin or the decaying pulse of the liver is like a thin thread on the verge of breaking, or like a tightly wound wire about to snap. The patient will die within eighteen days. If the decaying pulse of the heart is like a thin fragile thread, the patient will surely die within nine days. If this pulse is found in the lung pulse, the patient will not survive longer than twelve days. If it is found in the kidney pulse, the patient will die in seven days. If it is found in the spleen pulse, the patient will die in four days. A more complete prognosis involves coupling the information about the pulse with the examination of the facial color and the "spirit" expressed by the facial expressions (especially the eyes). In the Neijing, it is said that: "In diagnosis, observation of the spirit and facial color, and palpation of the pulses, are the two methods that were emphasized by the ancient emperors and revered teachers...." As a text expounding on the virtues of the ancient teachers, there were complaints about failings of the modern practitioners in their diagnostic work, which echoes forward to the modern era. The practitioners of the time were encouraged not to forget the other necessary diagnostic methods, especially inquiry: Today, doctors deviate from [the treatment methods of ancient times]. They cannot even follow the changes in the four seasons [that influence the pulse and other body conditions]. They do not know the importance and principles of the

complexion and pulses....Doctors today should eliminate their bad habits and ignorance, open their minds, and learn the essence of pulse and color diagnosis [i.e., analysis of facial colors]. Only by doing so will they ever succeed in reaching the level of the ancient sages....There is one other important thing. That is the interrogation of the patient, the inquiry....Select a quiet environment; close all doors and windows; gain the trust of your patient so that the patient can completely convey everything that is pertinent to the condition. Be thorough and differentiate the truth. In the Huangdi Neijing (3), the pulse is mentioned briefly and simply among a list of symptoms that would indicate a particular disease stage or category; thus, for the taiyang disease, the pulse is floating, for a yangming disease, the pulse is large, and for the jueyin disease, the pulse is feeble. In the companion volume Jingui Yaolue , there is more description of the pulses and some explanation of their meaning. For example, it is said that: A pulse too strong or too weak denotes illness. A minute pulse on the cun site and a chordal pulse on the chi site portends thoracic debility and aching because it reflects an extremely weak condition of yang in the upper warmer. Heart pain follows the thriving yin evil as characterized by the deep chordal pulse. The presentation of diagnostic information in these works of Zhang Zhongjing confirms the importance of inquiry, since it is by this means that one learns the essential features described throughout most of the text, such as location of pain, duration of disease, and other factors that determine the selection of herbs (thirst, mental conditions, urination, etc.). In his preface to the Huangdi Neijing, Zhang continues the complaint expressed in the Neijing about practitioners in his time, a century or more after the Neijing was produced in the form we have currently: Physicians today do not thoroughly study the medical classics before they begin to practice, but merely follow their predecessors with no attempt to improve age-old forms....They take the front pulse, but not the rear; check the hands, but not the feet; and do not make a diagnosis of the complete upper, middle, and lower parts of the body. How can a pulse alone and careless observation tell about all the syndromes and diseases? The concern is about incomplete and careless diagnosis, particularly where the pulse is the primary diagnostic method (omitting or minimizing the others), and failure to carry out the full pulse taking (front and rear pulses). This is a theme that persists throughout Chinese medical history, and applies to modern medical diagnostics as well (where medical doctors are chided for having missed a diagnosis by not performing all necessary tests or by carelessly interpreting the test results). The proclaimed failings in the Han Dynasty times, an era regarded by subsequent authors as one of the high points of Chinese medicine, illustrate that the reverence for the past is aimed at the wise instructions of the small number of highly accomplished scholar physicians (who left behind the classic texts), rather than the state of medical practice as a whole. The desire, which can only be professed and never fully accomplished, is that all physicians should attain the highest possible standard and should master the diagnostic methods through diligent study of the classics and continual attention to detail.

THE PULSE CLASSIC The subject of pulse diagnosis was first tackled in an organized manner by Wang Shuhe, who lived during the 3rd century A.D. (just after the fall of the Han Dynasty). Wang was responsible for recovering and organizing the Huangdi Neijing (see: A modern view of the Huangdi Neijing); he may have fully rewritten the first three critical chapters. His text on pulse diagnosis became known as the Mai Jing (Pulse Classic) . Although the text had been regarded as quite difficult to understand, and was therefore often replaced by simpler, derivative tracts, it has, in modern times, been deemed a classic worthy of preservation. A translation of the Mai Jing, based on a modern Chinese edited version, has been published by Blue Poppy Press (4). In the Mai Jing, a broad spectrum of applications for pulse diagnosis is delineated, including etiology of disease, nature of the disease, and prognosis. As an example of etiology and disease development, it is said that: "If the pulse is bowstring, tight, choppy, slippery, floating, or deep, these six point to murderous evils which are capable of causing disease in various channels." As an example of disease analysis, the following pulse characteristics and implications are given: If its emerging and submerging are equal, this is a normal state; if its submerging is twice as long as its emerging, this is shaoyin. If its submerging is three time as long as its emerging, this is taiyin. If its submerging is four times as long as its emerging, this is jueyin. If its emerging is twice as long as its submerging, this is shaoyang. If its emerging is three times as long as submerging, this is yangming. If its emerging is four times as long as its submerging, this is taiyang. As to prognosis, an example with great specificity is: "If, on the seventh or eighth day, a febrile disease exhibits a pulse which is not grasping-like but beating rapidly at a constant pace, there ought to arise a disease of loss of voice. Perspiration is expected to come in three days. If it fails to come then, death will occur on the fourth day." As before, the main prognostic value of the pulse was in relation to impending death (or, if the pulse is favorable, recovery from the disease). After the production of the Mai Jing, many different conceptions of pulse diagnosis arose and led to a great deal of confusion about interpreting what was being felt by the physician. Xu Dachun (1693-1771) produced a chapter on the Mai Jing in his book Yixue Yuanliu Lun (12), commenting that: Those experts who discussed the pulse through the ages have all contradicted one another, and they all differed in what they considered right and wrong. They all cling to their specific doctrine, and their advantages and errors balance each other....Students reading the Mai Jing must consult the Nei Jing, the Nan Jing, and the doctrines of Zhang Zhongjing [Huangdi Neijing, Jingui Yaolue]. In other words, the classic texts of the Han Dynasty have the basic doctrines of importance, and they must all be studied in order for the Mai Jing to be fully meaningful. The digressions in the theory and practice of pulse diagnosis that were made later should, according to Xu, be ignored, because they introduce confusion rather than clarification. All the books mentioned by Xu in the above quote are now available in English translation (see: Some selected Chinese medical texts in translation), reflecting the common view that they are essential to the study of Chinese medical doctrines.

AIM AND METHOD OF PULSE DIAGNOSIS

The aim of pulse diagnosis, like the other methods of diagnosis, has always been to obtain useful information about what goes on inside the body, what has caused disease, what might be done to rectify the problem, and what are the chances of success. According to the Chinese understanding, the pulse can reveal whether a syndrome is of hot or cold nature, whether it is of excess or deficiency type, which of the humors (qi, moisture, blood) are affected, and which organ systems suffer from dysfunction. In order to make these determinations, the physician must feel the pulse under the proper conditions-following the established procedures-and must then translate the unique pulse that is felt into one or more of the categories of pulse form. In his book reviewing pulse diagnosis (5), Bob Flaws emphasizes the importance of learning the basic pulse categories in order for pulse diagnosis to be conducted effectively. He says: In my experience, the secret of Chinese pulse examination is exactly this: One cannot feel a pulse image unless one can consciously and accurately state the standard, textbook definition of that pulse image. In support of this contention, he also quotes Manfred Porkert (6): This, precisely, is the critical issue: there is no point in attempting practical training in pulse diagnosis unless all pertinent theory and, more important, the complete iconography [set of image categories] of the pulse has previously been absorbed intellectually. Chinese medical texts do not describe what the practitioner experience is (or should be) during pulse diagnosis; this is left to be passed on from accomplished practitioner to student. In contrast, these Western scholars are trying to relate to their Western readers, in written form, the steps by which one can master the diagnostic method. The basic premise outlined by Flaws and Porkert-that one must master the categories first-appears to be supported in the Chinese literature by the almost universal practice of introducing pulse diagnosis by listing and describing the basic set of pulse categories. The most standard inconography involves from 24-28 different pulse forms, depending on the recitation (sometimes a pulse type is subdivided into two; sometimes a complex pulse type is not included), though simplified sets are often given in less formal presentations. Despite the numerous descriptions of pulse forms in the lengthy Mai Jing, the practitioner is really being asked to become familiar with this modest sized and basic set of pulse categories, which were first outlined in the opening chapter of the Mai Jing. In the English language translation of the book, the description of these fundamental pulse categories take up just 3 pages out of 360.

PULSE CATEGORIES In a recent article describing the standard pulse categories by terminology expert Xie Zhufan (7), 26 basic pulse types were outlined and given updated English language interpretations (two of the types have the same Chinese name but different descriptions). Table 1 presents these pulse categories. In the table, the English translation term is given first; in a few cases, alternative English names are given for the same traditional category indicated by a single Chinese term (given in pinyin). The naming and interpretation of the pulse is taken directly from the article Selected terms in traditional Chinese medicine and their interpretations (7). The comments are added here by the current author, with reference also to information from the Dictionary of Traditional Chinese Medicine (8). The 7 pulses presented first (scattered, intermittent, swift, hollow, faint, surging, and hidden) are ones that may have little relevance to practice of traditional medicine in the modern setting. The other 19 pulses appear more likely to help the practitioner determine imbalances that relate to the selection of traditional style therapeutics (i.e., acupuncture points and individual herbs). Several of the pulses listed in the table represent pairs depicting yin/yang opposites, such as: floating vs. sinking (surface/interior); slow vs. rapid (cold/hot); weak vs. replete (deficiency/excess); and short vs. long (also indicating deficiency/excess). There are three additional pulse types reported in the Dictionary (8): gemai (hard and hollow pulse), is large and taut yet feels hollow like touching the surface of a drum, indicating loss of blood and essence; it may also occur with hypertension; laomai (a forceful and taut pulse) is felt only by hard pressure, usually seen in cases with accumulation of cold pathogenic factors yielding formation of a firm mass; and damai (large pulse), is a high pulse wave that lifts the finger to a greater height then normal. Damai is either forceful (has a large mass behind it, indicating excess heat with damaged internal organ function) or weak (indicating little force, seen in cases of general debility, with "floating yang"). Many authors regard these pulses as composites of two or more basic pulses rather than unique pulse types. Table 1: Pulse Categories in Translation. Pulse Type

Interpretation

Comments

Scattered pulse [sanmai]

An irregular pulse, hardly perceptible, occurring in critical cases showing exhaustion of qi.

These are cases where the patient is critically ill, perhaps near death; such patients are normally hospitalized (or sent home to die) and their diagnosis is usually well-established. The pulse only tells that the patient is severely debilitated; it diffuses on light touch and is faint with heavy pressure.

Intermittent pulse [daimai]

A slow pulse pausing at regular intervals, often As with the scattered pulse, this pulse type is occurring in exhaustion of zangfu organs, usually only seen in cases where the person is severe trauma, or being seized by terror. hospitalized or otherwise in an advanced disease stage. It is expected to occur, for example, with those having serious heart disease.

Swift pulse [jimai]

A pulse feeling hasty and swift, 120-140 beats per minute, often occurring in severe acute febrile disease or consumptive conditions.

This pulse is so rapid (twice the normal speed) that it is easily detected; the acute febrile disease involves an easily measured high temperature and is usually subject of pathogen testing. Consumptive conditions with such high pulse rates are generally under emergency medical care.

Hollow pulse [koumai]

A pulse that feels floating, large, soft, and hollow, like a scallion stalk, occurring in massive loss of blood.

Massive blood loss can easily be reported. This pulse is felt lightly at the superficial level and lightly at the deep level, but barely felt at the intermediate level. The light pulse is like the flexible scallion material, with a hollow center. It means that there is still some flow of qi at the vessel surface, but not much blood.

Faint pulse [weimai]

A pulse feeling thready and soft, scarcely perceptible, showing extreme exhaustion.

Extreme exhaustion is obvious to both the patient and the practitioner. The pulse, lacking substance, volume, and strength, simply reveals the exhaustion of the body essences. It is weaker than the thready (faint) pulse.

Surging pulse [hongmai]

A pulse beating like dashing waves with forceful rising and gradual decline, indicating excessive heat.

Excess heat syndromes are rarely difficult to detect, so this pulse type adds little information. The force of the pulse indicates that the condition is pathologically excessive, the gradual decline shows that the syndrome is primarily one of heat (qi excess) rather than fluid excess. The pulse is sometimes described as a "full pulse" indicating the excess condition.

Hidden pulse [fumai]

A pulse that can only be felt by pressing to the bone, located even deeper than the sinking pulse, often appearing in syncope or severe pain.

This pulse is quite extreme, in that one can barely detect it except by applying deep pressure; it gives the sense that the pulse is hidden in the muscles. If there is little musculature, it is as if it is resting on the surface of the bone. The conditions for which it is typical, syncome (fainting) and severe pain, can easily be determined without taking the pulse.

Knotted pulse [jiemai]

A slow pulse pausing at irregular intervals, often occurring in stagnation of qi and blood.

Qi and blood stasis represents a traditional diagnostic category that does not have a direct correlation with modern diagnostics. In this pulse, the irregularity and slowness is due to obstruction.

Hurried pulse [cumai]

A rapid pulse with irregular intermittence, often due to excessive heat with stagnation of qi and blood, or retention of phlegm or undigested food.

This is the excess version of the knotted pulse. It is sometimes called the "running" or "abrupt" pulse. The rapidity indicates heat and the irregularity indicates the blockage caused by stagnation and/or accumulation.

Long pulse [changmai]

A pulse with lengthy extent and prolonged stroke. A long pulse with moderate tension may be found in normal persons, but a long and stringy pulse indicates excess of yang, especially liver yang.

Particularly in young people, the pulse is felt rather easily across all three finger positions, as is characteristic of the long pulse. The prolonged stroke shows that the vessels are both strong and flexible. A stringy quality indicates a certain level of tension, that corresponds with a liver syndrome. In cases of acute disease, a long pulse will occur when there is a strong confrontation between the body's resistance and the pathogenic factor.

Short pulse [duanmai]

A pulse with short extent. A short and forceful The short pulse seems to deteriorate from the pulse is often found in qi stagnation and a short central pulse position towards the two adjacent and weak pulse implies consumption of qi. pulse positions. It strikes the middle finger sharply and leaves quickly. On the one hand, this can represent contraction of the qi, as in liver qi stagnation, or it can represent deficiency of the qi.

Fine pulse [ximai] or Thready pulse [ximai]

A pulse felt like a fine thread, but always distinctly perceptible, indicating deficiency of qi and blood or other deficiency states.

Although the deficiency can be easily detected by other means, some patients can show an artificially robust exterior appearance, while having notable deficiency. Essence deficiency, the result of chronic illness, can give rise to this pulse type.

Hesitant pulse [semai] or Uneven pulse [semai] or Choppy pulse [semai]

A pulse coming and going choppily with small, fine, slow, joggling tempo like scraping bamboo with a knife, indicating sluggish blood circulation due to deficiency of blood or stagnation of qi and blood.

This has a more irregular pattern than the knotted pulse that also shows stagnation of qi and blood. The severity of the blood disorder is greater. As the knife scrapes across the bamboo, it vibrates and irregularly moves forward, yielding a choppy sensation with brief hesitations or interruptions in movement.

Slippery pulse [huamai]

A pulse like beads rolling on a plate, found in patients with phlegm-damp or food stagnation, and also in normal persons. A slippery and rapid pulse may indicate pregnancy.

While use of the pulse to indicate pregnancy is no longer of value (as more reliable tests are readily available), and while this pulse, like the long pulse is often normal (occurring especially in persons who are somewhat heavy), it is a good confirmation of a diagnosis of phlegm-damp accumulation. It is sometimes referred to as a "smooth pulse."

Relaxed pulse [huanmai] or Loose pulse [huanmai]

A pulse with diminished tension, occurring in dampness or insufficiency of the spleen.

The pulse has a softness or looseness that is due to the weakness of the qi and the obstructing effect of dampness. The dampness differs from phlegm-damp in having no solidity.

Moderate pulse [huanmai]

A pulse with even rhythm and moderate tension, indicating a normal condition.

This is similar to the loose pulse, above (and the Chinese name is the same), except that it has a better tension, showing that the qi is adequate. As a normal pulse, it indicates that the disease condition being treated is localized and has not disturbed or been caused by disturbance of the viscera.

Tense pulse [jinmai] or Tight pulse [jinmai]

A pulse felt like a tightly stretched cord, indicating cold or pain.

This is similar to the wiry pulse, but not as long. While pain can be easily reported, a cold syndrome is sometimes disguised by localized heat symptoms; this pulse can indicate either exterior or interior chill.

Stringy pulse [xianmai] or Wiry pulse [xianmai]

A pulse that feels straight and long, like a musical instrument string, usually occurring in liver and gallbladder disorders or severe pain.

This is similar to the tense pulse, but longer and more tremulous. While severe pain can be easily reported, the wiry pulse confirms the liver and/or gallbladder as the focal point of the internal disharmony.

Replete pulse [shimai] or Forceful pulse [shimai]

A pulse felt vigorously and forcefully on both light and heavy pressure, implying excessiveness.

This pulse gives relatively little information other than that the condition is one of excess; one must further determine the nature of the excess in order to select a therapeutic strategy. This pulse, however, generally rejects the use of tonification strategies, as it indicates that the body resistance is undamaged.

Weak pulse [ruomai]

A pulse feeling deep and soft, usually due to deficiency of qi and blood.

This pulse is similar to the fine pulse, but has a softer quality. Usually, this indicates a weakness of the spleen qi, leading to deficiency of both qi and blood. In the system of pulse taking, it serves as the opposite of the replete pulse.

Soggy pulse [rumai]

A superficial, thin, and soft pulse which can be felt on light touch like a thread floating on water, but grows faint on hard pressuring, indicating deficiency conditions or damp retention.

This pulse is similar to the fine and weak pulses. The thready pulse sensation felt on light touch gives the impression of being easily moved, as if floating on water; hence, it tends to indicate spleen-qi deficiency with accumulation of dampness. It is sometimes referred to as the "soft pulse."

Feeble pulse [xumai]

A pulse feeling feeble and void, indicating deficiency of qi and blood or impairment of body fluid.

This pulse is similar to the weak, fine, and faint pulses. It occurs when the deficiency of blood is more severe than in the case of weak and fine pulses, but not so deficient as with the faint pulse.

Rapid pulse [shoumai]

A pulse with increased frequency (more than 90 beats per minute), usually indicating the presence of heat.

The rapid pulse is quite a bit more rapid than a normal pulse, and usually occurs only when there is a serious illness and mainly when there is a fever. The pulse can become rapid from activity prior to pulse taking.

Slow pulse [chimai]

A pulse with reduced frequency (less than 60 beats per minute), usually indicating endogenous cold.

A slow pulse may also indicate a person at rest who normally has a high level of physical activity, so must be interpreted in light of other diagnostic information.

Sinking pulse [chenmai]

A pulse that can only be felt by pressing hard, usually indicating that the illness is located deep in the interior of the body.

The circulation of qi and blood from the internal viscera to the surface is weak; it is usually confined to the interior as part of the body's attempt to deal with a serious disorder threatening the viscera. Sometimes referred to as the deep pulse.

Floating pulse [fumai]

A pulse that is palpable by light touch and grows faint on hard pressure, usually indicating that the illness is in the exterior portion of the body.

The circulation of qi and blood is focused in the body's surface to deal with an external pathogenic agent. The internal circulation is temporarily sacrificed to assure that the pathogen is eliminated before it can enter more deeply and cause serious problems at the visceral level. Debilitated patients may show a floating pulse that is feeble, indicating the inability to retain the qi and yang in the interior due to the deficiency of the vital organs.

Gao De, a diagnosis specialist at the Academy of Traditional Chinese Medicine, cautioned that pulse taking has become obscured by a multiplication of pulse categories (13). He wrote: The types of pulses that have been listed are too numerous and great disparity exists in the ways in which they have been recorded. Beginners often find them confusing. There are two major reasons for such confusion: 1. The difference between some categories is not so sharp, such as that between overflowing and large, thready and small, rapid and fast (hurried), and deep and hidden. 2. Additional nomenclature is given to the multi-feature pulse conditions. For example, the leathery pulse is the combination of hollow and wiry; weak-superficial is another name for both weak and superficial; firm (or hard) means the combination of deep, full, wiry, and long; etc. Single-feature pulse conditions are already numerous enough and the additional nomenclature adds even more names which have little clinical significance but add to the difficulties for beginners. Therefore, it is advisable to simplify the categories of pulse conditions by omitting the names of those confusing multi-feature pulse conditions. If more than one feature has to be described, the doctor can simply put those single features together. With this in mind, I would recommend the following list of simplified pulse conditions: superficial vs. deep; slow vs. rapid; empty vs. full; overflowing vs. thready; and minute, rolling, choppy, wiry, scattered, hasty, knotted, and intermittent. Mastery of these 16 basic single-feature pulse conditions, together with their possible combinations and their indications, is sufficient to meet the needs in clinical differentiation of syndromes. In the text Chinese Acupuncture and Moxibustion (15), there is a listing of 17 pulses to know, all of which are said to represent the abnormal conditions. The same paired pulses as listed above by Gao De are included, but the list of additional pulses varies slightly. Compared to the list of 28 pulses in Table 1, the categories that have been disregarded in order to yield the shorter list of abnormal pulses include several of those that are indicating severe deficiency diseases (scattered, hollow, faint) and those that indicate a relatively normal condition (long, relaxed, moderate). In Essentials of Chinese Acupuncture (20), 12 basic pulses are listed, with the same paired pulses given above, plus the wiry pulse and three of the irregular pulses. Similarly, in the book Chinese Herbal Science (17) by Hong-yen Hsu, the pulses of importance are limited in number. The author states: "In traditional Chinese pulse diagnosis, there are 28 qualities, but they are grouping into eight types according to the nature and associated symptoms. The most important qualities for the physician to be able to differentiation are floating, sinking, slow, and fast." The other four pulse qualities listed in this text are: weak, solid, slippery, and full. The same author gave a more detailed listing of pulses

in a presentation on Chinese diagnostics (18), with 7 types of floating pulses, 3 types of sinking pulses, 5 types of late pulses, 5 types of fast pulses, 6 types of weak pulses, 3 types of solid pulses, and 11 types of dying pulses. Thus, 40 pulse types were depicted, but they fell into just a few basic categories. The general implication of the literature on pulse is that there are about two dozen pulse types to be learned in detail, but that there are only a few of them (sometimes grouping similar pulses together) that are critical for the everyday utilization of this diagnostic technique used in combination with other methods of diagnosis. Therefore, pulse diagnosis should be within the grasp of all practitioners of traditional Chinese medicine. Those who have limited training and abilities must learn about 8-17 fundamental pulse types; those who wish to make greater use of this technique must be able to distinguish more subtle variations, but the number of different pulses to learn is still limited.

TRADITIONAL PULSE TAKING METHODS A variety of sites for pulse taking have been mentioned in the traditional literature. For example, in the Neijing Suwen, it is mentioned that the yang pulses can be felt at the carotid artery (next to the Adam's apple on the neck), while the yin pulses can be felt at the radial artery (above the wrist). Under healthy circumstances these pulses should be the same, but they differ with disease. Feeling the pulse at more than one site is said to improve the diagnosis. Other pulse taking methods include using the head and upper and lower limbs, and use of different pulse locations at arteries under certain acupuncture points to assess individual organs (e.g, at taiyang, ermen, dicang, daying, shenmen, hegu, wuli, taichong, qimen, chongyang, and taixi). Despite the availability of more than one site for pulse taking, standard Chinese medical diagnosis almost always is limited to the wrist pulse. It is felt by placing three fingers at the radial artery (see Figures 1 & 2), testing each arm one at a time. The classic Chinese pattern of pulse taking is based on touching the wrist with three levels of pressure: superficial palpation (almost no pressure, to feel the bounding of the pulse up to the skin surface); intermediate palpation (light pressure, to feel the basic pulse form); and deep palpation (somewhat heavy pressure, to feel how the pulse is able to emerge from the physical constraint). In addition, the changes in pulse feeling as one moves from less to more pressure, and again from more to less pressure, can also give some information about the resilience of the pulse. In essence, there are nine pulse takings on each wrist: one for each of the three pulse taking fingers at each of the three levels of pressure. However, the system of pulse taking can be divided into two parts: The general sensation of the pulse at the two wrists overall: instead of distinguishing each pulse position ( cun, guan, chi), the quality of the pulse is categorized generally, as felt under the three fingers. In this case, there are just three pulse readings at each wrist, with superficial, intermediate, and deep pressure. The results of this type of pulse reading are then categorized as in Table 1, with combinations of two (or infrequently more than two) pulse categories being possible. Feeling the pulse at each of the individual positions on the wrists, to assess the condition of each of the internal organs. The association of individual pulse positions with internal organs has changed over time and varies from one traditional system to another (illustrating a lack of consistency in interpretation). The current understanding is that the left wrist presents information for the heart, liver, and kidney yin, while the right wrist presents information for the lung, spleen, and kidney yang. This classification is consistent with the five element system that depicts five basic viscera; the kidney is subdivided to make the sixth. However, one can alternatively incorporate the pericardium/triple burner system in place of the kidney yang pulse. The interpretation of which pulse position corresponds to which organ has changed over time; the assignments commonly relied upon today are attributed to Li Shizhen (1518-1593), who is most famous as the author of the Bencao Gangmu. He wrote Binhu Maixue (The Pulse Studies of Binhu), in which the pulse taking method was elaborated, for which 27 categories of pulse were listed. The various outcomes of the pulse diagnostics are outlined succinctly and in table form in Ted Kaptchuk's book The Web that Has No Weaver (14). Here is an example for one pulse type, the choppy pulse: Combination pulses: choppy and wiry indicates constraining liver qi, congealed blood; choppy and frail indicates qi exhausted; choppy and minute indicates deficient blood and deficient yang; choppy and thin indicates dried fluids. Pulses by position: first position pulse being choppy indicates deficient heart qi and chest pain; if only on the left side, heart pain and heart palpitations; if on the right side, deficient lung qi, cough with foamy sputum; second position pulse being choppy indicates deficient spleen qi and deficient stomach qi, painful, distended flanks; if just the left side, it means deficient liver blood; on the right side it means weak spleen and inability to eat; third position pulse being choppy indicates essence and blood are injured; constipation or dribbling urine, or bleeding from the anus; if just on the left side, it means lower back is weak and sore; if just on the right side, it means a weak mingmen fire and/or essence injury.

FACTORS TO CONSIDER BEFORE AND DURING PULSE EXAMINATION In the well-known study guide, Acupuncture: A Comprehensive Text (15), it is said that: "Diagnosis by pulse is a subtle art and, even more than other diagnostic procedures, requires a tremendous amount of attentiveness and experience in order to acquire the sensitivity necessary to do it well." Proper pulse taking involves accounting for a number of factors that can affect the ability to feel the pulse and interpret it properly. These factors include several that affect the traditional practitioner in China, but some that present new problems for the modern practitioner: 1. The patient must be relaxed and have not undertaken any vigorous activity for some time prior to the pulse taking. It is generally thought that the pulse should be felt in the morning to get the best reading. Unfortunately, most modern patients rush through traffic to arrive at an appointment that takes place later in the day, after many activities have influenced the quality of the pulse. 2. The patient's arm, wrist, and hand must be relaxed, with the hand supported on a small pillow or other object; the hand is below the heart, at about the location of the navel as the person sits. The physician is calm and able to concentrate; the physician's hand that is performing the diagnosis is also in a relaxed position. As described in Chinese Acupuncture and Moxibustion: "The three fingers are slightly flexed, presenting the shape of an arch. The finger tips are kept on the same horizontal level." In many rushed modern practices, the pulse is taken whenever it seems convenient, with the position of patient and practitioner often being less than ideal, thus distorting the pulse reading.

3. The placement of the physician's fingers are at the cun ("inch"), guan ("bar"), and chi ("cubit") positions. The middle finger is placed over the eminent head of the radius and the other two fingers are placed adjacent to that one, but usually not touching one another or just barely touching (the separation of fingers depends on the size of the patient, being greater in those who are tall and have long arms, and less in patients who are relatively smaller), along the artery. The wide range of body types that are encountered in the modern practice make it more difficult to place the fingers properly to feel the pulse. 4. The physician, through training and experience, applies the appropriate amount of pressure. Gao De, in his review of pulse diagnosis, commented: "Doctors exerting different forces in pulse-taking get different conclusions regarding both the depth at which the pulse beating is felt and the strength of the pulse; hence, also different conclusions of the overall pulse condition arise." Having applied pressure properly, the doctor must be familiar with the different categories of pulse conditions so as to be able to classify that which is detected into the category that most closely describes what is felt. As described above, this is the essential feature of pulse taking, one that Western writers must emphasize because it is not necessarily taught that way in the standard training programs. 5. Adequate duration of pulse diagnosis is allowed to assure that the pulse description holds true over many pulsations, and that both arms are checked in order to give a full evaluation. Often, there is not enough time available to perform a complete pulse diagnosis. As stated in Acupuncture: A Comprehensive Text: "The doctor must refrain from quick pulse-taking in a hurried frame of mind. If this precaution is not observed, the resulting pulse readings will be misleading." 6. One must take into account the season. Although there is great detail in describing seasonal influences on the pulse in traditional texts, a most general depiction is: the spring pulse is slightly taut (bowstring); the summer pulse is slightly full and surging; the autumn pulse somewhat floating and fine or soft; and the winter pulse somewhat sinking and slippery or hard. If the pulse type is consistent with the season, that indicates a normal condition, while if it differs markedly, it suggests a pathological condition. There is some question, however, as to how this seasonal influence might be modified by modern living habits, including rising and going to bed out of synch with the sunrise and sunset, use of central heating and air conditioning, and eating foods out of season. 7. One must take into account patient characteristics that influence the pulse. According to Acupuncture: A Comprehensive Text: In a healthy person, the front position tends to be floating, while the rear position is usually submerged....Athletes often have a slow pulse, young children have quick pulses. Fat people have deep pulses, while thin people have pulses with a tendency to be bigger than normal. Woman's pulses are usually softer and slightly quicker than men's. Also, women's right pulses are usually stronger than their left, while the opposite is true of men. Gao De commented: A doctor must be aware of the fact that as numerous changes can take place within a man's body under natural physical condition, so can variations of normal pulse condition. Such variations will be within certain limits and still bear the basic features of the normal pulse condition. Theoretically speaking, the demarcation line between variation of normal pulse condition and diseased pulse condition is not clear cut....Diseases pulse conditions: 1) are attended with symptoms and signs corresponding to the pulse conditions; 2. cannot be explained by the external factors that may affect pulse condition [e.g., age, sex, physical constitution, season, etc.]; and 3) remain abnormal after the external factors seemingly affecting the pulse are removed unless effective treatment is applied. In addition to these factors based on traditional and natural considerations, one must take into account new factors that may influence the pulse, such as use of drugs, including nicotine products, pharmaceutical drugs, and illegal drugs. The numerous factors to be taken into consideration and the associated difficulties in interpretation mean that pulse taking in the modern setting is rarely as informative as it is depicted in the historical texts. Nonetheless, despite the problems that can arise, modern pulse taking can usually reveal most of the 24-28 basic categories. The pulse taking may not as easily reveal the more numerous indications depicted in the Mai Jing or in some other texts. Of course, a practitioner who specializes in pulse diagnosis and spends years studying the theory and categories and carefully takes the pulse of many hundreds of patients could still master the system, but the impetus to do so seems muted: there are too many interferences of modern society that make the pulse less informative and there is plenty of other diagnostic information available. Yet, those involved with modern Chinese medicine should not dismiss the pulse simply because a variety of factors need to be taken into account; it becomes necessary to become aware of these factors and give adequate time and attention so as to limit their potential for confusing the interpretation.

PULSE AS AN AID TO OTHER DIAGNOSTICS During the development of Chinese medicine, there appears to have arisen, from time to time, an understanding that a well-trained physician was able to make a diagnosis almost entirely by pulse taking, while asking virtually no questions of the patient. As a result, pulse analysis sometimes took on a certain mystical aura and was a major focus of doctor-patient interaction. Aside from the complaints about this in the historical literature as already cited, Gao De mentions it as a continuing problem in the practice of Chinese medicine up to the modern era: "Some even applied pulse diagnosis in clinical practice in a completely isolated way, disregarding the other three, namely inspection, smelling, and asking, thus having led the development of pulse diagnosis astray." I n Acupuncture: A Comprehensive Text, the authors still allude to the possibility of using the pulse as a sole method of diagnosis by saying: "While most Chinese doctors would agree that the pulse is best used in conjunction with the other diagnostic methods, doctors well-skilled in pulse diagnosis can discover an enormous amount of information about their patients by this method alone." The utility of pulse diagnosis may be more properly viewed as belonging to the realm of confirming a diagnosis attained by other means, including modern medical testing, or implying that something is missing from the diagnosis when the pulse does not agree, setting off a series of questions or investigations for additional information. This application of pulse as confirmation is one that Bob Flaws has argued against having modern practitioners rely on, even though he observed it as a common situation in China. He wrote in the introduction to his book on pulse:

This Western ambivalence toward and pervasive lack of mastery of the pulse examination is, I believe, exacerbated by a somewhat similar attitude towards pulse examination current in the People's Republic of China at least in the 1980's. When I was a student in China during that time, the importance of pulse examination was deliberately played down by many of my teachers and clinical preceptors....I never had a teacher tell me a pulse was anything other than wiry, slippery, fast, slow, floating, deep, or fine...it seems that many modern Chinese TCM practitioners relegate pulse examination to a minor, confirmatory role....I believe that mastery of pulse examination is vitally important to making a correct TCM pattern discrimination. And, I believe the pulse examination is, perhaps, even more important to Western practitioners than for our Chinese counterparts. Indeed, the set of pulses that Flaws mentioned hearing repeatedly in China is the most basic set that must be learned and is similar to what was described above by several authors as the key categories. He has relayed a group of opposing pairs that help assure that the treatment is consistent with the underlying pattern and unlikely to cause adverse effects by reinforcing an imbalance. In the opening chapter of The Heart Transmission of Medicine (9), by the famous 19th Century physician Liu Yiren, he states: "Four kinds of pulse are the key criteria in examination: the floating, deep, slow, and rapid. The floating and deep can be discerned by light and heavy pressure of the fingers. The slow and rapid may become the moderate and the racing. This can be identified by respirations [i.e., counting the number of pulses per respiration]." While Liu then goes on to give a somewhat more complex system of diagnosis, with attention focused on the three pulse positions of each radial artery to discover ailments of the major internal organs, even that is greatly simplified compared to what is found in the Mai Jing. Overall, Liu aims his comments on pulse at helping the practitioner to integrate pulse information with other diagnostic methods, mainly rational inquiry. In his book, Flaws goes on to argue that the importance of the pulse in modern practice lies with the complexity of chronic conditions suffered by many patients who turn to acupuncture in the West. The idea is that these patients typically present a picture that is difficult to sort out, and that the pulse can provide information that resolves the dilemma. I would argue, contrarily, that this complexity of the patients makes pulse diagnosis more difficult to rely on, rather than more valuable. One can come to this view by reading the indications of the pulses in the Mai Jing, in which the interpretations are very succinct and focused: this pulse is common in the spring, this pulse means taiyin disease, this pulse means a fever, etc. By contrast, the complexity of modern patients, especially those who are older and suffer from numerous diseases, means that within one individual there is a complex of deficiencies and excesses, of internal and surface disorders, of stagnation and looseness, and influences of drugs, surgery, and daily habits that don't fit any traditional pattern. The resulting pulse is more difficult to analyze and less informative. According to Chinese Acupuncture and Moxibustion: "As the process of disease is complex, the abnormal pulses do not often appear in their pure form, the combination of two pulses or more is often present. The condition of a number of pulses present at the same time is called complicated pulse. The indication of a complicated pulse is the combination of indications of each single pulse." The complexity depicted in this textbook statement is applied to ordinary cases that have occurred throughout medical history in China. Today, the influence of surgery, powerful modern drugs that are taken chronically, and extreme variability in life style means that the complexity can be even greater. Thus, the physician who wishes to rely on the pulse under such circumstances must become familiar not only with several basic pulse types, but must develop the ability to detect and interpret very complex pulse forms, teasing out multiple pulse types within the sensation under the fingers. Some physicians have argued, instead, that the pulse diagnosis should have a relatively limited role. Xu Dachun commented: "In my own view, the doctrine of the pulse only includes examining whether a patient's qi and blood are present abundantly or insufficiently, and through which meridian or through which organ cold, heat, or other evil influences flow. This has to be compared to the patient's symptoms...." Clearly, the role of pulse within the full framework of diagnosis will remain an area of some contention. Advocates of pulse diagnosis having a central role can point to the large amount of information contained in the pulse that can lead one to an improved understanding of the disease process affecting the patient; critics will point to the wide variation in results of pulse taking, being dependent on so many factors, and will emphasize, instead, the essential role of examining the medical history and current symptoms as revealed by inquiry. However, few proponents of pulse diagnosis today would suggest downgrading the other diagnostic techniques and few critics of pulse diagnosis propose eliminating it. So, a certain level of consensus arises.

THE POTENTIAL ROLE OF PULSE DIAGNOSIS IN MODERN PRACTICE OF TCM In modern medicine, the traditional style of pulse diagnosis, which was also practiced in a slightly different form in Western medicine until the 19th century, is replaced by a number of other tests. Tests by stethoscope and blood pressure cuff are routinely performed as pulse diagnostic techniques. The stethoscope reveals pulse rate and, at a low level of inference, irregularities in the structure and function of the heart, which must be evaluated further. When deemed necessary, additional testing is performed via various heart monitors, such as an electrocardiogram. The non-invasive sonograms as well as the more invasive testing (e.g., insertion of monitors into the body) allow modern physicians to examine the interior of the arteries and the heart. The information from these tests is generally understood to reflect only the conditions of the heart and major vessels (the cardiovascular system); it is not thought of as a means of examining other aspects of health. Unlike the traditional concept, the pulse form or information obtained by examining the vessels is not thought to provide useful information about, for example, the liver, kidney, lung, or spleen conditions. Modern medicine has numerous other kinds of tests, including blood tests, urine tests, and a variety of scans and biopsies, that reveal a tremendous amount of information about what goes on inside the body, so as to produce a diagnosis. Such tests reveal much about the functions of the internal organs; for example, inflammation of the liver or malfunction of the kidney filtration system is readily detected with a simple blood test. Most of these testing methods have been utilized only in recent decades and add a new dimension to the practice of Chinese medicine. While patients in China have come to rely on the traditional medical practitioners to simply carry out their diagnosis in silence and prescribe a therapy to be taken without question, modern patients in the West prefer to talk about their diseases. They usually demand to have explanations given for every step of diagnosis and for every factor that goes into a determination of a therapy. In fact, one of the main complaints raised by Westerners who visit Chinese immigrant doctors is that there is no significant discussion of their case, even when language is not a major barrier. For the Western patient, the focus is shifted towards the concerns that can be verbally expressed and away from the more mysterious diagnosis attained by pulse taking.

The complex condition of many modern patients may require one to rely heavily on modern medical diagnostics as a primary resource, making it the essential fifth diagnostic method for the practitioner of Chinese medicine. This is not a matter of the traditional practitioner deciding that this is the desired route, but a reflection of the extent to which modern lifestyle and modern medicine imposes itself on people who might have an interest in a traditional and natural approach. It is not uncommon for a patient to come to a traditional practitioner with Western medical test results and diagnosis and to want to know what is going to be done specifically about this situation as defined by those tests. A response that the therapy will rectify qi and blood and resolve the dysfunction of an organ system not mentioned in the modern test results may prove unsatisfying to the patient. Yet, it is precisely in this area-of measuring traditional-style indicators-that pulse diagnosis is employed in order to make corrections. The question arises: does the old system of pulse diagnosis still have a value to practitioners of traditional medicine given the wealth of information derived from modern tests? In particular, in Western countries where extensive testing is readily available, can the traditional practitioner either ignore the information from those tests in favor of traditional style diagnostic methods or even gain any additional information from traditional pulse diagnosis once the modern tests have been conducted? This is answered in favor of retaining pulse diagnosis because of the nature of the therapeutics to be employed by the traditional practitioner. For the most part, the indications and applications of acupuncture and herbal therapies are not described in terms that correlate with the results of modern medical tests. They are described in terms of effects on qi and blood, hot and cold, and the zangfu organs. Even with the more limited use of pulse diagnosis that has been advocated by many authorities-relying on only about half of the basic pulse categories to get the fundamental differentiation-the results of the pulse taking can be applied to determining the therapeutic strategy. Regardless of whether one considers pulse taking a central and key part of a traditional style diagnosis or relegates it to a more minor confirmatory role, it still belongs to the modern practice of traditional medicine and requires the practitioner to be familiar with the major pulse categories.

ALTERED USE OF PULSE DIAGNOSIS Many acupuncturists trained in the West have pursued a type of pulse diagnosis that is not described in the traditional Chinese literature. While the original Chinese pulse taking is utilized to arrive at both a diagnosis and at prognosis, many Western acupuncturists utilize a pulse analysis to determine whether or not they have properly inserted the needles. This is done by feeling the pulse after the needles have been inserted, either immediately or after they have been in place for several minutes. It is claimed that a properly conducted treatment yields correction of the pulse to a normal, or more normal, condition which is detected at the time of the treatment. Presumably, what is being detected is the improvement in the flow of qi and blood under the influence of the acupuncture needles. The source of this method and application of pulse diagnosis remains unclear, but it was described by He Honlao, a Chinese acupuncturist working in the U.S., in an article published in 1987 (10). He stated: "By clinical practice, I noticed the fact: There are changes in the pulse condition after acupuncture." In explaining the observation, he conjectured that this use of the pulse analysis was a means of detecting the "arrival of qi" with acupuncture (see: Getting qi). From the modern perspective, he referred to research carried out in China during the 1950's that indicated a short term contraction followed by a longer-term expansion (dilation) of the blood vessels as a response to acupuncture therapy. In his article, he evaluated the pulse changes in 400 patients who had a string-like pulse (in which he included wiry, tense, solid, and firm pulse types), which indicated a tension syndrome. Accordingly, if acupuncture successfully dilates and relaxes the vessels, the pulse will change so that it is not as string-like (or taut). He claimed that in those patients whose pulse changed (softened immediately, as well as eventually, after several treatments) with acupuncture, nearly all had their symptoms relieved; of those whose pulse did not change with acupuncture, or those that showed immediate changes that promptly reverted after treatment, the symptoms were usually not relieved (in 3 out of 4 cases). Dr. He indicated that, ideally, the pulse would return to normal or markedly calm down after the needle insertion and this improved pulse condition would continue until the needle was withdrawn; the pulse would stay calm at least for a time afterward. In some cases, the pulse returned to its former condition immediately after needle removal; and in other cases, the pulse was not altered by acupuncture at all. In rare cases, the pulse would actually become stronger, or more tense. He also noted that over several treatments the majority of patients had their pulse gradually becoming more normal, while others took several treatments before this response developed at all; some patients continually returned to pretreatment pulse conditions after every acupuncture session. In the introduction to the article, Dr. He describes his observation as a "discovery," therefore not something belonging to the Chinese tradition and not something that he was aware was being relied upon by other acupuncturists at the time. In his discussion, he cites one statement from the Jingui Yaolue that he believes supports his contention and method. The quotation, taken here from a published translation (11), states: "If the pulse is minute and harsh on the cun site and thin and tense on the guan site, it is appropriate to activate yang qi by acupuncture in order to soften the harshness and to relax the tenseness, thus bringing about recovery." Dr. He has assumed, perhaps correctly, that the softening and relaxing effect described in this text applies to the immediate change in the described pulse, as opposed to merely suggesting a change in the patient's overall tense condition. It is difficult to know what was meant in the ancient text, but the lack of further reference to the spontaneous pulse changes in the traditional Chinese medical literature suggests that this was not a major means of utilizing pulse evaluation. It would not be surprising that acupuncture would alter the pulse sensation detected in some or even most individuals (see: An introduction to acupuncture and how it works). More research would be needed to determine how widespread this phenomena is, since Dr. He described only one very broad type of pulse and did not indicate anything about the nature of the treatments given (for example, whether needles were inserted proximate to the artery on which the pulse was measured). Such research might help to confirm or deny whether such pulse changes were truly valuable indicators of the success of a long-term treatment. Certainly, this method has a potential for good use in the modern setting where some people are asked to pursue acupuncture for many sessions over several weeks in order to determine if it is ultimately going to alleviate their condition. The immediate pulse response or lack thereof, if truly informative as Dr. He suggests, might help the practitioner and patient determine the likelihood of success after only a couple of sessions. While this type of diagnosis may be valuable for its primary purpose as a means of confirming the desired reaction from acupuncture therapy, it is not the same as the pulse taking method that is used for basic diagnosis and should not be assumed to replace the traditional style and application of pulse diagnosis. Rather, it can be regarded as an added technique which may be of value for the modern practitioner.

ATTEMPTS TO MAKE PULSE DIAGNOSIS OBJECTIVE

One of the serious objections to reliance on pulse diagnosis is that the pulse form determined by a practitioner is very subjective. It relies on how the physician places fingers on the wrist, what pressure is applied, and how the physician's mind interprets the sensations. Several physicians feeling the pulse of the same patient consecutively may report differing pulses. In China, researchers hoped to illustrate the value of the wrist pulses as a diagnostic method and also to aid in standardizing their measurement by devising modern devices for getting an objective pulse form. The result of such a measurement, using devices to detect the pulse, is a printed version, called a sphygmogram. In his article on pulse diagnosis, Gao De said that: "The most pressing need in our study on pulse taking diagnosis is to devise an instrument to assist doctors when they take pulse with their fingers so as to get an objective judgment of the patient's pulse condition." Such instruments were soon developed. At a 1987 traditional medicine conference in Shanghai (19), several doctors reported on methods of measuring the pulse by pulse detecting devices. They further proposed that such measuring devices could assist students of Chinese medicine in learning pulse diagnosis, since the accuracy of the students' pulse determinations could be verified by the sphygmogram. Indeed, one author described the use of a device to reproduce the measured pulse which could then transmit the pulse to the student. By this means, the different kinds of pulses, having been prerecorded and stored in a computer, could be imitated for the student to experience so that each of the pulse categories could be learned. Just as simulators are used today to train pilots learning to fly, these pulse simulations are deemed a means of training practitioners to perform the diagnosis, which is to be mastered with actual pulse feeling after learning the basics. Fei Zhaofu and his colleagues at the Shanghai College of Traditional Chinese Medicine commented about the pulse-imitating devices used for this purpose: Imitating the pulse actually means that the abstract descriptions and images [of the traditional system] are changed to specific figures signifying digital senses directly felt and stored. During the process of investigation, the device has been affirmed by many veteran practitioners of TCM, with repeated correction for improvement leading to its final approval by TCM circles. The device is therefore considered to have effectively inherited TCM sphygmology theory and preserved the pulse feeling experience of TCM. Medical personnel may use it to gradually promote the standardization of pulse diagnosis....

RECENT INVESTIGATIONS OF PULSE Chinese researchers have pursued the question of how often certain pulse types are found, particularly with frequently occurring serious diseases, such as cancer and hepatitis. For example, it was reported by researchers working at several institutions in mainland China that (21): Studies indicate that wiry, slippery, and rapid pulse, or simply wiry and rapid pulse, often denotes exacerbation of the illness [cancer]. When slippery and rapid pulse, wiry and rapid pulse, or weak and rapid pulse appears post-operatively in patients with carcinoma, one should seriously consider the possibility of an incomplete operation. Owing to difficulty in inspection of tongue features of patients with oral or facial neoplasms, physicians often resort to pulse-taking to follow-up the patient, and it is found that the chi pulse is weakened in 50%, and absent in 25% of the patients, which is statistically significant in comparison with the pulse of normal subjects. In a study of advanced hepatitis patients with cirrhosis or liver cancer carried out in Taiwan, it was reported that most of the patients had a weak pulse on the left wrist at the cun and chi positions, compared to normal subjects (22). In a broad evaluation conducted in Hong Kong, it was reported that specific pulse categories are more commonly found with the initial stage of illness, versus more developed and advanced stages of an illness (23). The common pulses were: Original pulses (initial stage of illness): floating, deep, slippery, uneven, long, short, taut, soft, large, small; Changing pulses (serious disease develops): rapid, tense, slow, moderate, full, hollow, indistinct, thready, firm, weak; and Very abnormal pulses (critical illness): tremulous, running, knotted, intermittent, tympanic, scattered, deep-sited, replete, feeble, no pulse.

CONCLUSION Pulse diagnosis is one method of determining the internal conditions of patients with the aim of deciding upon a therapeutic regimen. In order to make use of this diagnostic, the practitioner must learn the proper method of taking the pulse, the factors that influence the pulse, and the categories into which each patient's unique pulse form can be fit. Practitioners must remain especially alert to new factors that influence the pulse readings so as to assure that the results of pulse taking are meaningful. Most authorities agree that in the modern era one must be able to detect a relatively limited basic group of pulse forms in order to utilize the information for devising a therapy (i.e., acupuncture, herbs). These requisite forms determine whether the focus of the pathological process is at the body's surface or interior, is of a hot or cold nature, or is of an excess or deficiency type. The fundamental pulse categories that practitioners are to learn correlate directly with the well-known "eight methods of therapy" (see: Enumerating the methods of therapy). There have been recent attempts to broaden the scope of pulse diagnosis; for example, feeling the pulses immediately after insertion of acupuncture needles has been suggested recently as a means of determining whether the "qi has arrived" as a result of correct point selection and needle manipulation. There have also been attempts to more clearly define the pulse forms; for example, by developing medical equipment that can detect and record the pulse forms, and to develop statistical analysis of pulse types by disease. Pulse diagnosis remains an important part of the practice of traditional Chinese medicine that is still being explored and developed.

REFERENCES 1. Academy of Traditional Chinese Medicine, Lectures on essentials of traditional Chinese medicine VI: Methods of diagnosis, Journal of Traditional Chinese Medicine 1982; 2(4) 321-328. 2. Maoshing Ni, The Yellow Emperor's Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA. 3. Hong-Yen Hsu and Peacher WG (eds.), Shang Han Lun: The Great Classic of Chinese Medicine, 1981 Oriental Healing Arts Institute, Long Beach, CA.

4. Yang Shou-zhong, The Pulse Classic, 1997 Blue Poppy Press, Boulder, CO. 5. Flaws B, The Secret of Chinese Pulse Diagnosis, 1995 Blue Poppy Press, Boulder, CO. 6. Porkert, M, The Essentials of Chinese Diagnostics, 1983 Chinese Medicine Publications, Zurich. 7. Xie Zhufan, Selected terms in traditional Chinese medicine and their interpretations (VIII), Chinese Journal of Integrated Traditional and Western Medicine, 1999; 5(3): 227-229. 8. Xie Zhufan and Huang Xiaokai (editors), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong. 9. Yang Shouzhong, The Heart Transmission of Medicine, 1997 Blue Poppy Press, Boulder, CO. 10. He Honlao, Exploration of the effect of acupuncture on string-like pulse, Journal of the American College of Traditional Chinese Medicine 1987; (1): 51-55. 11. Hsu HY and Wang SY (translators), Chin Kuei Yao Lueh, 1983 Oriental Healing Arts Institute, Long Beach, CA. 12. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. 13. Gao De, A discussion on selected topics relating to pulse-taking diagnostics, Journal of the American College of Traditional Chinese Medicine 1987; (1); 57-61. 14. Kaptchuk T, The Web that Has No Weaver, 1983 Congdon and Weed, New York. 15. O'Connor J and Bensky D (translators and editors), Acupuncture: A Comprehensive Text, 1981 Eastland Press, Seattle, WA. 16. Cheng Xinnong, Chinese Acupuncture and Moxibustion, 1993 Foreign Languages Press, Beijing. 17. Hsu HY, Chinese Herbal Science, 1982 Oriental Healing Arts Institute, Long Beach, CA. 18. Hsu HY, A description of the four diagnoses and the eight principles, Bulletin of the Oriental Healing Arts Institute of U.S.A., 1978;3 (2): 17-22. 19. Editorial Committee, International Conference on Traditional Chinese Medicine and Pharmacology Proceedings, 1987 China Academic Publishers, Beijing; 1087-1099. 20. Anonymous, Essentials of Chinese Acupuncture, 1980 Beijing Foreign Languages Press, Beijing. 21. Yu Guiqing, et al., New progress in the four diagnostic methods of cancer, Journal of Traditional Chinese Medicine 1990; 10(2): 152-155. 22. Chan Yensong, et al., The pulse phenomenon of liver cirrhosis and hepatoma, Journal of Chinese Medicine 1992; 3(2): 1321. 23. Huang Huibo, New theory on pulse study, in International Congress on Traditional Medicine Abstracts, 2000 Academic Bureau of the Congress, Beijing.

Figure 1. Pulse positions on each wrist and their associated organs.

Figure 2. TCM practitioner performing pulse diagnosis. August 2000

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FOUR BASIC QI GONG FOR HEALTH MAINTENANCE Clicking Teeth, Breathing Deep, Rubbing Belly, Combing Head by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Qi gong is an ancient art of China that has tremendous impact on health and has thus become famous worldwide. While it is probably best known for its dynamic exercises that involve moving the limbs or the whole body, there are several quiet exercises that are typically done morning and evening and easily undertaken by all, whether healthy or ill. Ultimately, the aim of qi gong is to focus the mind. In the ancient book Su Wen (Simple Questions), it is said that “Some great masters in ancient times could marshal heaven and earth, controlling yin and yang; they breathed the essential qi, stood quietly, and concentrated their minds on what they wanted. The spirit and body joined in flawless unity.” There are numerous qi gong practices based on rhythmic movement that stabilize the body in order to make such mental focus possible. As the Han Dynasty physician Hua Tuo has said: “A door hinge will never become insect-riddled [because it is always being moved]. Rhythmic movement regulates qi, promotes digestion and blood flow, and guards against disease.” Four simple qi gong exercises can be practiced by anyone, almost anytime, and with great benefit. The first of these is clicking the teeth. It will induce the flow of saliva and stimulate the meridians that pass along the mouth. Saliva neutralizes oral acids and helps prevent tooth decay; thus, if done after eating, this practice can maintain oral hygiene. Saliva promotes the digestion of starches, and thus if done just before a meal, it can make the food break down more completely. Saliva also inhibits the growth of oral pathogens that can cause inflammation and discomfort of the mouth and esophagus. Clicking the teeth stimulates the energy meridians that enter the base of the teeth: the practice will prevent infection and deterioration of the tooth nerves, and will improve the energy circulation through the meridians to benefit the internal organs. A folk saying in China is “Tap the teeth together 36 times in early morning and your teeth will not fall out when you are old.” The practice is done by closing the mouth lightly and gently tapping the teeth together. Generally, the molars are tapped together in one round of exercise, the front teeth in another round, and the canines in another: 36 times each round. Before swallowing the induced saliva, it can be moved around the teeth and gums and inside of the mouth with the tongue. This one exercise, which only takes a minute, is typical of several qi gong practices that focus on making the most of the body’s secretion systems. The second exercise is deep breathing. Breathing is the natural cycle that is easiest to control, and the control is directly related to mental and emotional focus and restraint. A person who is mentally and emotionally agitated will breathe rapidly and shallowly. In order to breathe slowly and deeply, it is necessary to calm the mind and emotions, and the deep breathing will then reinforce the calmness. A simple breathing exercise is to take a moment and give attention to the breaths, feeling each deep breath go down to the lower abdomen (dan tian). What is actually felt, obviously, is the movement of the muscles and internal organs as one allows the diaphragm to descend to its most relaxed and lowest position; however, the sensation is as if the air moves down to the lower abdomen. As each breath enters and exits, it can be counted; to count even twenty-four deep breaths, without being distracted by thinking, is a beneficial practice. The beginner may find that after counting just a few breaths the whole exercise has been momentarily forgotten as some train of thought comes through and takes over the awareness. As this happens, one should start over again, counting from the first new breath. Another practice which is sometimes undertaken is to repeat certain words (usually those having a calming or spiritually uplifting meaning) along with each breath. However, the initial practice of simple counting reinforces the awareness of the invasion of thoughts and their ability to disrupt the practice. Deep breathing gets rid of the stale air at the base of the lungs, it increases the oxygen to all the body (and particularly to the brain), and it massages the internal organs. In particular, it helps to open up the stomach, circulates the energy of the liver, and vitalizes the kidneys and endocrine glands. The calmness attained during the practice of following the breaths can carry over to other times, and frequent practice makes it very easy to recover equilibrium when agitation is caused by some event. In fact, with steady practice, one can maintain a calm attitude through most situations. The regulated breathing is done either while sitting, standing, or lying down (an upright posture is generally preferred because it is easier to maintain mental alertness); the spine must be extended—not bent—to allow full breathing capacity. The preferred mental focus for qi gong is to imagine the movement of energy to the middle or lower dan tian which is an area of the lower abdomen from the navel to about two inches below the navel. There are many patterns of breathing and visualization of movement of the breath and energy that can be adopted to gain the most from the breathing exercises, and these are described in the numerous books about qi gong. The breathing practice is one of several rhythmic exercises that yields greater integration of mind and body. Physical exercises, rotating the joints, stretching the muscles, and moving in certain patterns (much as is done in tai chi exercise), also aids this integration. These exercises massage the internal organs, the skeletal and internal muscles, and the connective tissues. The third practice is a type of self-massage, using the hands to rub the body and stimulate local circulation. The upper abdomen is massaged by placing the palm on the abdomen and circling it with light pressure in a clockwise

direction several times (e.g. about 30), covering the area of the stomach, upper intestines, and liver. This exercise will enhance the digestive functions and can be undertaken before and/or after meals. Before meals, it can enhance the appetite if it is weak, or calm the appetite if it is excessive. After meals it will speed up digestion and will alleviate gas and bloating. If a deeper massage is desired, the base of the palm can be rotated over a local area, and then moved to the next spot, a little at a time in a clockwise direction. As described by the 16 th century medical specialist Gao Ling: “Selecting a place to do so that is free of draft, comb your head daily 100–200 times during the summer months, taking care not to injure the scalp. This is a natural method to expel wind and brighten the eyes.” This combing is done with the fingers; the hand is curved and fingers separated to make a comb-like action, moving from the front hairline back (for those who are bald, the same basic pattern of combing the head is used). The breathing is kept steady and attention drawn to the sensation in the palms. All the meridians of the head are thus stimulated, and this especially affects the circulation of the yang qi. The number of strokes is typically about 50 at one time, and that can done two or more times per day. The four exercises selected here, taken together will help correct many disorders of the gastro-intestinal system, will cam the mind, and brighten the senses. Regular practice (which takes up only about five to ten minutes per day) over a period of several weeks may produce remarkable improvements. Continued practice will help prevent future dysfunctions of the internal organs. October 2010

RESOURCES FOR THE STUDY OF CHINESE MEDICINE I. Books and Journals ITM's Library of East Asian Medical Sciences The Institute for Traditional Medicine has established a library of medical texts collected over the past twenty-five years. The library project was inspired by the extensive holdings gathered by Joseph Needham and his colleagues at Cambridge University in England and the collection started by Hong-yen Hsu and his associates at the Oriental Healing Arts Institute in California, each of which is comprised of thousands of titles. ITM's more modest project includes 400 English language books, of which about 160 focus on Chinese herbal medicine and related medical information and theories, which has been the primary focus of ITM's work. There are also a few Chinese language books that are not mentioned in this document, including several large illustrated guides to medicinal materials. ITM has part or all of a collection of certain journals related to Chinese herbs and acupuncture, of which only three have current subscriptions, plus other journals that contain relevant information. The following pages detail the English language books in the collection, providing for each the name of the book and its author(s), the publication date, publisher, and principal city for the publisher's distribution. The information is presented in the format that ITM has adopted for referencing books. Oriental names of authors have the family name first, but sometimes they are Westernized, placing the family name last (in such case, it is common, though not always the practice, to hyphenate the two personal names). To make searching for titles easier, the books have been classified as follows: 1. Materia Medicas and other books that provide information about the traditional uses of individual medicinal materials. 2. Formularies that provide information about the content and applications of numerous traditional formulas, sometimes with modern formulas included. 3. Historical records, including translations of traditional texts, analysis of archeological and historical records, and discussions of the development of traditional Chinese medicine and its cultural context. 4. Clinical experience reports (herbal medicine), which represent suggestions for treatments of a large number of different diseases based on the experience of an individual practitioner or a group of practitioners who collaborated in writing about clinical efforts. 5. Acupuncture and moxibustion texts. There are dozens of books available on this subject, but many present essentially the same information; ITM's efforts have focused on herbal medicine rather than acupuncture, so this collection is somewhat limited. 6. Food as medicine books, depicting Oriental efforts to understand the health impact of foods. Some of these books review the historical developments of food use in China, with only passing reference to medicine. 7. General subjects, including overviews of Asian medicine, special topics within the field of Chinese medicine (including physiology and diagnosis), and general analysis of the application of herbs based on the theoretical framework applied mainly to traditional prescriptions, rather than direct clinical experience of the author(s). 8. Modern research on herbs, including analysis of chemical constituents, pharmacology experiments, and clinical trials. 9. Medical specialties that are the focus of the books in the library, including cancer, ophthalmology, pediatric disorders, gynecology, and dermatology. 10. Translation guides, dictionaries and books about Chinese characters-their origins, meaning, and uses-that can be used to investigate the implications of Chinese medical and philosophical terms. 11. Tibetan medicine books; Tibetan medicine incorporates both Ayurvedic and Chinese medical practices. Tibet has been incorporated into China during this century. 12. Ayurvedic medicine; Chinese medicine was partly influenced by the traditional medicine of India, with some of the herbs used by the Chinese coming from India. Like Chinese traditional medicine, Ayurvedic medicine has had a continuous history of theoretical developments, recorded experience, and professional training. 13. Western medicine; these are books that are used primarily for the purpose of brief description of disease characteristics and associated therapeutics, or studies of nutrients and herbal active ingredients that do not focus on Chinese herbs. 14. Journals of Chinese medicine; these are the journals that present information about Chinese herbs; many of them also contain articles about general Chinese medical subjects and acupuncture. 15. Other journals; these are journals that contain relevant information but are not specific to Chinese medicine. The library is not a comprehensive collection of works on these subjects, partly because there are numerous books and journals that may be popular but do not have any scholarly or scientific orientation, and because others have a very limited scope. This listing includes the primary reference texts and journals used in producing the articles generated at ITM. To assist practitioners of Chinese medicine in collecting their own library, the books have been given a rating in relation to their value for the study of Chinese medicine. This rating is placed either as a heading or as a code following the book information. Essential Reading/Reference [ER]: Most practitioners of traditional Chinese medicine will find the information in the book of value in improving their background knowledge and capabilities. Only books that have general applications related to the traditional practices are listed as essential; if the book's contents are highly focused on a special subject, the book will usually be classified as advanced reading. Out of Print books are removed from the essential reading section, even if deemed quite valuable. Recommended Reading/Reference [RR]: The books may cover much the same ground as others that are rated essential reading, but

are less comprehensive or not as detailed. Still, these books may provide some additional insights, perspectives, specialty information, or expanded information that make them quite useful. Or, it may cover a subject of peripheral or more limited interest, but do so in an interesting way. Advanced Reading/Reference [AR]: The book contains information that may be of value for the scholarly pursuit of the field, or for the pursuit of a specialty area within the field. Books that may have been designed for general use by practitioners but which fail to attain their goal and those that may require the judgment of well-educated readers to weed through the interpretations (some of which may be incorrect) or through difficult language may be classified as Advanced Reading. Not Recommended [NR]: By comparison with other available books, the book does not provide much useful information for the practice of Chinese medicine (or other fields that shed light on that practice), and/or may be poorly written, and/or is too limited in scope or too out of date to be of value to the majority of practitioners. Books that are of particularly poor quality are not included in this reference list. Out of Print [OP]: The book might only be found in a library, used book store, or by a book search service. The publisher no longer has copies available. Clearly, there will be substantial differences in opinion about how these books ought to be rated; in fact, it was not always easy to place the books within one of the categories based on the criteria established here. These ratings are largely determined by the perceived ability to obtain information useful for producing the ITM articles about various Chinese medical subjects. Emphasis is placed on such features as: inclusion of quality translation work; comprehensiveness in dealing with the subject at hand; apparent reliability of the information presented; and readability. Sometimes, books containing valuable information may be recommended despite poor readability, and others that have reliable information may be deemed valuable despite lack of comprehensive approach or lack of complete faithfulness of translation. It is possible that a rating will be changed over time; for example, a book that is deemed essential may become out of date (and/or out of print) and may be superseded by another book on the same or similar subject that is better or, at the least, still available. Generally, books that are well-translated Chinese medical classics and books that are written by Chinese experts with extensive experience will be rated as essential or recommended reading. Books by secondary authors, that is, those who have learned the subject relatively recently and have rushed ahead to write what they know, are generally not recommended. Health care providers that prescribe Chinese herbs should develop a library that includes most of the essential reading books plus at least one or two of the "recommended reading" books from each category (at least from those that correspond to their scope of practice). A minimum library of about 35-40 such books in these categories would likely provide the resource information that is essential to conduct a successful practice. The books listed in the following pages that are not out of print may be obtained either directly from the publisher or from one of the many distributors of Oriental medical books, including: Redwing Book Company: 44 Linden St., Brookline, MA 02146 (general supplier of natural healing books). Eastwind Books and Arts: 633 Vallejo St., San Francisco, CA 94133 (selected Chinese medical books). Oriental Healing Arts Institute: 1945 Palo Verde Ave., Long Beach, CA 90815. Blue Poppy Press: 1775 Linden Ave. Boulder, CO 80304 (mainly their own publications). Institute for Traditional Medicine: 2017 SE Hawthorne, Portland, OR 97214 (ITM publications plus several books rated here as Essential, Recommended, or Advanced).

1. MATERIA MEDICAS AND GUIDES TO INDIVIDUAL HERBS The most comprehensive guides to individual herbs with traditional indications and uses described are Thousand Formulas and Thousand Herbs, volume 1(listing 1,000 items); Oriental Materia Medica(765 items); Chinese Herbal Medicine Materia Medica (470 items); and Chinese-English Manual of Common-Used Herbs in Traditional Chinese Medicine (350 items). All of these present accurate and useful information though only one, Chinese Herbal Medicine Materia Medica, was written by Westerners and is accepted as a teaching text at American colleges of Oriental medicine. All of these guides will prove useful to practitioners, as they have notably differing presentation styles and some differences in content even for individual herbs. Oriental Materia Medicais relied upon extensively for the ITM literature and contains most of the herbs that are important to know, so is listed as an essential reference. Most of the other items in this section of the library present only a relatively small selection of herbs and present more limited information (and are therefore not recommended) or specialized information (and are deemed advanced reading) about the herbs.

Essential Reading/Reference Hsu HY, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA.

Recommended Reading/Reference Bensky D and Gamble A, Chinese Herbal Medicine: Materia Medica, 1993, Eastland Press, Seattle, WA. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 1, 1993 Heilongjiang Education Press, Harbin. [OP] Ou Ming (chief editor), Chinese-English Manual of Common-Used Herbs in Traditional Chinese Medicine, 1989 Joint Publishing Co., Hong Kong.

Advanced Reading/Reference Ling Yeouruenn, A New Compendium of Materia Medica, 1995 Science Press, Beijing. Perry LM, Medicinal Plants of East and Southeast Asia, 1980 MIT Press, Cambridge, MA. [OP] Pharmacopoeia Commission of PRC, Pharmacopoeia of the PRC, (English edition) 1988 People's Medical Publishing House, Beijing.

[OP; 1995 edition is available] Sionneau P, Pao Zhi: An Introduction to the Use of Processed Chinese Medicinals, 1995 Blue Poppy Press, Boulder, CO. Smith FP and Stuart GA, Chinese Medicinal Herbs, 1973 Georgetown Press, San Francisco, CA. Yen Kunying, Illustrated Chinese Materia Medica, (2 vol.), 1986 Southern Materials Center, Inc., Taipei. Zhang Enquin (ed. in chief), English-Chinese Rare Chinese Materia Medica, 1990 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai.

Not Recommended Cheung CS and Kaw UA, Synopsis of the Pharmacopeia, 1984 American College of Traditional Chinese Medicine, San Francisco. [OP] Chin WY and Keng H, Illustrated Dictionary of Chinese Medicinal Herbs, 1992 CRCS Publications, Sebastopol, CA. Geng Junying, et al., Practical Traditional Chinese Medicine and Pharmacology: Medicinal Herbs, 1991 New World Press, Beijing. Himche Yeung, Handbook of Chinese Herbs and Formulas, vol. 1: Herbs, 1985 Institute of Chinese Medicine, Los Angeles, CA. Hu, SY, An Enumeration of Chinese Materia Medica, 1980 The Chinese University Press, Hong Kong. [OP] Li Ninghon, et al., Chinese Medicinal Herbs of Hong Kong (5 vol.), 1986 Chinese Medical Research Institute, Hong Kong. [OP] Liu Changxiao and Xiao Peigen, An Introduction to Chinese Materia Medica, 1993 Beijing Medical University Press, Beijing. [OP] Pang TY, Chinese Herbal: An Introduction, 1982 Tai Chi School of Philosophy and Art, Honolulu, HI.

2. FORMULARIES AND GUIDES TO FORMULATION Books of formulas can be divided into three broad categories: those with the traditional formulas that are studied in China; the formulas that are used by Kanpo doctors in Japan (and similarly in Taiwan), which are mainly a subset of the former with a few items rarely discussed in China; and the patent formulas which include traditional and modern prescriptions that are manufactured by a large number of commercial enterprises. The principal books of Chinese herbal formulas and Kanpo formulas that are relied on at ITM are from the same publishers and are companion volumes to the Materia Medica guides mentioned above. In order from largest number of traditional formulas down, Thousand Formulas and Thousand Herbs, volume 2, Chinese Herbal Medicine: Formulas and Strategies, and Chinese-English Manual of Common-Used Prescriptions in Traditional Chinese Medicine . Commonly Used Chinese Herbal Formulas with Illustrations Companion Guide offers over 400 formulas that are mainly those used by Japanese Kanpo and Taiwanese practitioners. The older patent medicine guides are not very useful, due to the rapidly changing availability of the patents, changing and inaccurate labeling (relied upon by Western authors of the guides), and limited information about the formulation and uses. The new book by Fratkin resolves some of these problems, at least for now. Of the formula guides, only Chinese Herbal Medicine: Formulas and Strategies is listed as essential reading because of the presentation of a large number of formulas along with extensive descriptions for many of them.

Essential Reading/Reference Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA.

Recommended Reading/Reference Dong Zhilin and Jiang Jingxian, 100 Famous and Effective Prescriptions of Ancient and Modern Times , 1990 China Ocean Press, Beijing. [OP] Fratkin J, Chinese Herbal Patent Medicines: The Clinical Desk Reference, 2001 Shya Publications, Boulder, CO. Geng Junying, et al., Practical Traditional Chinese Medicine and Pharmacology: Herbal Formulas 1991 New World Press, Beijing. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas Companion Handbook, 1997 Oriental Healing Arts Institute, Long Beach, CA. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations , 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA. [OP; replaced by above title] Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. [OP] Ou Ming, Chinese-English Manual of Common-Used Prescriptions in Traditional Chinese Medicine , 1989 Joint Publishing Co., Hong Kong. Naeser M, Outline Guide to Chinese Herbal Patent Medicines in Pill Form, 1990 Boston Chinese Medicine, Boston, MA. Songnong (chief editor), Chinese Medicated Liquor Therapy, 1996 Beijing Science and Technology Press, Beijing. Zhu CH, Clinical Handbook of Chinese Prepared Medicines, 1989 Paradigm Publications, Brookline, MA.

Not Recommended Chen Keji (editor), Chinese Patent Medicines, 1997 Hunan Science and Technology Press, Hunan, China. Him-che Yeung, Handbook of Chinese Herbs and Formulas, vol. 2: Formulas, 1985 Institute of Chinese Medicine, Los Angeles, CA.

3. HISTORICAL RECORDS Practitioners of Chinese herbal medicine are expected to be familiar with the Nei Jing (which has two component parts, Su Wen and Ling Shu) and with the Shang Han Lun (also having two parts, Shang Han Lun and Jin Gui Yao Lue ); additionally, it is helpful to be aware of one or more works of famous physicians, such as Li Dongyuan (a.k.a. Li Gao). Translation of these ancient texts is no easy matter. Chinese writing tends to be quite succinct and readers (especially translators) often read into the text things that may or may not

have been intended by the original author(s). Often, the book that is being translated has already been modified from the original by Chinese authors who not only copied the text, but made corrections, re-arrangements, and interpretations. Despite some concerns about the translations, one volume each of the Nei Jing components have been rated as essential reading, and one volume each of the Shang Han Lun have been rated as recommended reading. Most others are either not recommended or are suggested only for those undertaking advanced studies; the exception is the unique work by Zhang Xuchun translated by Paul Unschuld under the title Forgotten Traditions of Ancient Chinese Medicine, which, I believe, provides valuable insights into the thinking about traditional Chinese medicine and the forces that shape it, and has been rated as essential reading (made easier by having available an inexpensive paperback version).

Essential Reading/Reference Maoshing Ni, The Yellow Emperor's Classic of Medicine: A New Translation of the Neijing Suwen with Commentary , 1995 Shambhala, Boston, MA. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. Wu Jingnuan (translator), Ling Shu, or The Spiritual Pivot, 1993 Taoist Center, Washington, D.C.

Recommended Reading/Reference Chen Ping (editor in chief), History and Development of Traditional Chinese Medicine, 1999 Science Press, Beijing. Hsu HY and Peacher WG (editors), Shang Han Lun: The Great Classic of Chinese Medicine, 1981 Oriental Healing Arts Institute, Long Beach, CA. Hsu HY and Wang SY (translators), Chin Kuei You Lueh, 1983 Oriental Healing Arts Institute, Long Beach, CA. Hsu HY and Wang SY, The Theory of Feverish Diseases and Its Clinical Applications , 1985 Oriental Healing Arts Institute, Long Beach, CA. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. Yang Shouzhong and Li Jianyong (translators), Li Dongyuan's Treatise on the Spleen and Stomach , 1993 Blue Poppy Press, Boulder, CO. Zhu Ming, The Medical Classic of the Yellow Emperor, 2001 Foreign Languages Press, Beijing.

Advanced Reading/Reference Chace C and Zhang Tingliang, A Qin Bowei Anthology, 1997 Paradigm Publications, Brookline, MA Nakayama S and Sivin N, (editors), Chinese Science: Explorations of an Ancient Tradition, 1973 MIT Press, Cambridge, MA. [OP] Needham J, Science and Civilisation in China, vol. 2, 1974 Cambridge University Press, London. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988, Kluwer Academic Publishers, Dordrecht, Holland. Unschuld PU, Medicine in China: Nan-Ching, 1986 University of California Press, Berkeley, CA. Unschuld PU, Medicine in China: Historical Artifacts and Images, 2000 Prestel Verlag, Munich. Wong KC and Wu LT, History of Chinese Medicine, 1973 AMS Press, Inc., New York. [OP] Yang Shouzhong (translator), Extra Treatises based on Investigation and Inquiry (Gezhi Yulun ), 1994 Blue Poppy Press, Boulder, CO. Yang Shouzhong (translator), The Heart Transmission of Medicine, 1997 Blue Poppy Press, Boulder, CO. Yang Shouzhong, Master Hua's Classic of the Central Viscera, 1993 Blue Poppy Press, Boulder, CO. Yang Shouzhong (translator), The Divine Farmer's Materia Medica, 1997 Blue Poppy Press, Boulder, CO. Yang Shouzhong and Chace C, The Systematic Classic of Acupuncture and Moxibustion, 1994 Blue Poppy Press, Boulder, CO. Zhang Zhongjing, Synopsis of Prescriptions of the Golden Chamber, 1987 New World Press, Beijing. Zhang Zhongjing, Treatise on Febrile Diseases Caused by Cold with 500 Cases, 1993 New World Press, Beijing.

Not Recommended Sivin N, Chinese Alchemy: Preliminary Studies, 1968 Harvard University Press, Cambridge, MA. [OP] Unschuld PU, Medical Ethics in Imperial China, 1979 University of California Press, Berkeley, CA. [OP] Veith I, The Yellow Emperor's Classic of Internal Medicine, 1966 University of California Press, Berkeley, CA. Ware JR, Alchemy, Medicine, and Religion in the China of A.D. 320, 1966 Dover Publications, Inc., New York. Yang Shouzhong, The Pulse Classic, 1997 Blue Poppy Press, Boulder, CO.

4. CLINICAL EXPERIENCE WITH HERBS AND TREATMENT RECOMMENDATIONS It has become common practice in China for physicians to compile suggestions of treatments-herbal formulas-based on what is done in their own practice or what is generally done at a hospital facility. These books may be compiled by experienced physicians or by young practitioners who report on what they have learned from their teachers. Frequently, these books are laid out according to disorder (a favored pattern is to deal with disorders of the body from top down, then general metabolic disorders, and then deal with specialty areas, such as gynecology, pediatrics, and "surgical problems"). There is a brief description of the etiology and manifestation of the disease, traditional sub-categories (e.g., liver fire, spleen weakness, liver/kidney deficiency), and one or more recommended formulas. In some books, a case study is presented, and this case usually shows that the prescription given to the patient is not the same as the one that has just been recommended in the book, but, rather, a derivative or modification. Unfortunately, it is difficult to rate any of these as essential

reading, as they rarely provide sufficient insight, but some are recommended because the information presented appears to be a reliable reflection of modern Chinese practice.

Recommended Reading/Reference Shang Xianmin, et al., Practical Traditional Chinese Medicine and Pharmacology: Clinical Experiences, 1990 New World Press, Beijing. Yan Wu and Warren Fischer, Practical Therapeutics of Traditional Chinese Medicine, 1997 Paradigm Publications, Brookline, MA. Zhang Enquin, Clinic of Traditional Chinese Medicine, 1990 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai.

Advanced Reading/Reference Fruehauf H and Dharmananda S, Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 ITM, Portland, OR. Maciocia G, The Practice of Chinese Medicine, 1994 Churchill Livingstone, London. Shao Nianfang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine , 1990 Shandong Science and Technology Press, Jinan. Wang Qi and Dong Zhilin, Modern Clinical Necessities for Traditional Chinese Medicine, 1990 China Ocean Press, Beijing.

Not Recommended Chen Songyu and Li Fei, A Clinical Guide to Chinese Herbs and Formulae, 1993 Churchill Livingstone, London. He Shaoqi (editor), Handbook of Modern TCM Internal Medicine, 1991 Zhongyiyao Keji, Beijing. Otsuka K, et al., Natural Healing with Chinese Herbs, 1982 Oriental Healing Arts Institute, Long Beach, CA. Otsuka K, 30 Years of Kanpo, 1984 Oriental Healing Arts Institute, Long Beach, CA. Takahide Kuwaki, Chinese Herbal Therapy, 1990 Oriental Healing Arts Institute, Long Beach, CA. Zhang Junwen, et al., Integrating Chinese and Western Medicine: A Handbook for Practitioners , 1993 Foreign Languages Press, Beijing. Zhou Zhongying and Jin Huide, Clinical Manual of Chinese Herbal Medicine and Acupuncture, 1997 Churchill Livingstone, London.

5. ACUPUNCTURE AND MOXIBUSTION The books included here fall into three broad categories: first, books that list each point (somewhat like the Materia Medica guides do for herbs) and present the relevant information; these books often also attach some information about treatment strategies; second, specialty books that deal with a particular type of therapy: ear acupuncture, scalp acupuncture, moxibustion, etc.; third, is books that are organized according to treatment of diseases (in these, it is assumed that the acupuncturist already knows about the individual points and the various treatment methods). For a book to be recommended, it must present both reliable standard and extensive information; there are plenty of books available that offer information that does not tie in to any standard theories or practices (the book is often highly personal) and several that provide too little detail to be of much use other than as a quick reminder for those who have learned the field very well (in which case, the book is probably not needed). Since acupuncture is usually practiced only after extensive training, the value of these books is to provide additional insights that might have been missed or forgotten.

Essential Reading/Reference Ellis A, Wiseman N, and Boss K, Fundamentals of Chinese Acupuncture, 1988 Paradigm Publications, Brookline, MA. Qiu Maoliang (Man. ed.), Chinese Acupuncture and Moxibustion, 1993 Churchill Livingstone, London.

Recommended Reading/Reference Chen Ken and Cui Yonquiang, Handbook to Chinese Auricular Therapy, 1990 Foreign Language Press, Beijing. Cheng Xinnong (chief editor), Chinese Acupuncture and Moxibustion, 1987 Foreign Languages Press, Beijing. Deadman P and Mazin AK, A Manual of Acupuncture, 1998 Journal of Chinese Medicine Publications, East Sussex, England. Ellis A, Wiseman N, and Boss K, Grasping the Wind, 1989 Paradigm Publications, Brookline, MA. Mingching Zhu, Zhu's Scalp Acupuncture, 1992 Eight Dragons Publishing, Hong Kong. O'Connor J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981, Eastland Press, Seattle, WA. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1996 Blue Poppy Press, Boulder, CO. Zhang Enquin (editor in chief), Chinese Acupuncture and Moxibustion, 1990 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai. Zhang Ru and Dong Zhilin, Modern Clinical Necessities for Acupuncture and Moxibustion, 1990 China Ocean Press, Beijing.

Advanced Reading/Reference Kong Yaoqi, Ren Xingsheng, and Lu Shoukang, The Acupuncture Treatment for Parlaysis, 1996 Science Press, Beijing. Ross J, Acupuncture Point Combinations: The Key to Clinical Success, 1995 Churchill Livingstone, London. Zhang Ruifu, Wu Xifen, and Wang NS, Illustrated Dictionary of Chinese Acupuncture, 1986 Sheep's Publication, U.S.A., San Francisco, CA. Mingching Zhu, A Handbook for Treatment of Acute Syndromes by Using Acupuncture and Moxibustion , 1992 Eight Dragons Publishing, Hong Kong.

Not Recommended Beijing College of TCM, et al., Essentials of Chinese Acupuncture, 1980 Foreign Language Press, Beijing. Cheng Danan, Acupuncture and Moxibustion Formulas and Treatments, 1996 Blue Poppy Press, Boulder, CO. Chinese Academy of Traditional Chinese Medicine, An Outline of Chinese Acupuncture, 1975 Foreign Languages Press, Beijing. [OP] Guillaume G and Chieu M, Rheumatology in Chinese Medicine, 1996 Eastland Press, Seattle, WA. Johns R, The Art of Acupuncture Techniques, 1996 North Atlantic Books, Berkeley, CA. Lee, M, Insights of a Senior Acupuncturist, 1992 Blue Poppy Press, Boulder, CO. Zhang Denbu, Acupuncture Cases from China, 1994 Churchill Livingstone, London. Zhong Meiquan, The Chinese Plum-Blossom Needle Therapy, 1984 The People's Medical Publishing House, Beijing.

6. FOOD AS MEDICINE In China, the border between foods and medicines is indefinite. The principles of therapy governing herbs are the same as those governing foods. Therefore, the study of food from the Chinese perspective is valuable to those who prescribe herbs. The books listed here have very diverse nature; for example, The Food of China and Food in Chinese Culture are academic studies of the historical introduction and reliance on various foods with only passing mention of their medicinal value, while most of the other books are about using the foods for specific healing actions.

Recommended Reading/Reference Chang Chaoliang, et al., Vegetables as Medicine, 1989 The Ram's Skull Press, Kuranda, Australia. [OP] Dai Yinfang and Liu Chengjun, Fruit as Medicine, 1986 The Ram's Skull Press, Kuranda, Australia. [OP] Lu HC, Chinese System of Food Cures, 1986 Sterling Publishing Co. Inc., New York. Ni MS, The Tao of Nutrition, 1987 College of Tao & Traditional Chinese Healing, Los Angeles, CA.

Advanced Reading/Reference Anderson EN, The Food of China, 1988 Yale University Press, New Haven, CT. Chang KC, Food in Chinese Culture, 1977 Yale University Press, New Haven, CT. Zhang Enquin (ed. in chief), Chinese Medicated Diet, 1988 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai.

7. GENERAL Essential Reading/Reference Maciocia G, The Foundations of Chinese Medicine, 1989, Churchill Livingstone, London.

Recommended Reading/Reference Chace C and Zhang Tingliang, A Qin Bowei Anthology, 1997 Paradigm Publications, Brookline, MA. Chen Zelin and Chen Meifang, A Comprehensive Guide to Chinese Herbal Medicine , 1992 Oriental Healing Arts Institute, Long Beach, CA. Fruehauf H, Five Organ Networks of Chinese Medicine, 1998 ITM, Portland, OR. Katpchuk TJ, The Web That Has No Weaver: Understanding Chinese Medicine, 1983 St. Martins Press, New York. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology , (4 vol.) 1995-6 New World Press, Beijing. Wang Qi and Dong Zhi Lin, New Practical Syndrome Differentiation of T.C.M., 1992 China Ocean Press, Beijing. [OP] Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, (21 vols.) 1989 Higher Education Press, Beijing.

Advanced Reading/Reference Chen Zelin and Chen Meifang, The Essence and Scientific Background of Tongue Diagnosis , 1989 Oriental Healing Arts Institute, Long Beach, CA. Hsu HY and Peacher WG, Chen's History of Chinese Medical Science, 1978 Oriental Healing Arts Institute, Long Beach, CA. Kleinman A, Kunstadter P, et al., Culture and Healing in Asian Societies, 1978 Schenkman Publishing Company, Cambridge, MA. Larre C and de la Vallée ER, Rooted in Spirit: The Heart of Chinese Medicine, 1995 Station Hill Press, Barrytown, NY. Larre C, Schatz J, and de la Vallée ER, Survey of Traditional Chinese Medicine, 1986 Traditional Acupuncture Institute, Columbia, MD. Leslie C (editor), Asian Medical Systems, 1976 University of California Press, Berkeley, CA. Sionneau P, Dui Yao: The Art of Combining Chinese Medicinals, 1997 Blue Poppy Press, Boulder, CO.

Not Recommended Hillier SM and Jewell JA, Health Care and Traditional Medicine in China 1800-1982, 1983 Routledge and Kegan Paul, London.

[OP] Hsu HY, How to Treat Yourself with Chinese Herbs, 1980 Oriental Healing Arts Institute, Long Beach, CA. Hyatt R, Healing with Chinese Herbs, 1990 Healing Arts Press, Rochester, VT. Toyohiko Kikutani, Combined Use of Western Therapies and Chinese Medicine, 1987 Oriental Healing Arts Institute, Long Beach, CA. Liu Zhengcai, The Mystery of Longevity, 1990 Foreign Language Press, Beijing. Ross J, Zang Fu: The Organ Systems of Traditional Chinese Medicine, 1989 Churchill Livingstone, London. Sivin N, Traditional Medicine in Contemporary China, 1987 University of Michigan, Ann Arbor, MI. Unschuld PU, Chinese Medicine, 1998 Paradigm Publications, Brookline, MA. Wiseman N, and Ellis A, Fundamentals of Chinese Medicine, 1985 Paradigm Pub., Brookline, MA.

8. MODERN RESEARCH ON HERBS Chemical, pharmacological, and clinical evaluation of herbs has been a major thrust of work in China (and other Asian countries, notably Japan) for fifty years. Additionally, during the past twenty years or so, Western researchers have taken up this subject. A difficulty with relying on books for this type of information is the rapidity with which they become outdated. The quality and type of research being conducted has improved greatly in recent years; this makes reliance on earlier and poorer quality research less useful. Still, while some areas of research are highly active, others are quite slow to show progress, so compilations of research in one place, as in some of these books, is a handy way to access it. Many of these books are already out of print, because research-oriented texts are usually produced in a single small print run. For practitioners who prescribe the herbs, these books will generally prove to be advanced reading; they are especially helpful to those who teach on the subject of research or who plan to conduct research. More up to date information is obtained from journals, though there are very few of them presenting full research reports in English. Unlike medical journals, these books always contain abstracted information and it is sometimes difficult to evaluate the validity and applicability of the reported findings.

Recommended Reading/Reference Zhu YP, Chinese Materia Medica: Chemistry, Pharmacology, and Applications, 1998 Harwood Academic Publishers, Amsterdam. Chang HM and But PPH (editors), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore. [OP; replaced by above title]

Advanced Reading/Reference Dong Zhilin and Yu Shufang, Modern Study and Application of Materia Medica, 1990 China Ocean Press, Beijing. [OP] Hsu HY, Chen YP, and Hong Ming, The Chemical Constituents of Oriental Herbs, 1982, Oriental Healing Arts Institute, Long Beach, CA. Chang HM, et al., Advances in Chinese Medicinal Materials Research, 1985 World Scientific, Singapore. [OP] Ko R and Au A, 1997-1998 Compendium of Asian Patent Medicines, 1998 California Department of Health Services, Sacramento, CA. Tang W and Eisenbrand G, Chinese Drugs of Plant Origin, 1992 Springer-Verlag, Berlin. [OP] Ying Jianzhe, Mao Xiadan, et al., Icones of Medicinal Fungi from China, 1987 Science Press, Beijing. [OP] Zhou Jinhuang, et al., Recent Advances in Chinese Herbal Drugs-Actions and Uses, 1991 Science Press, Beijing. [OP]

Not Recommended Zhu Liangfeng, Li Yonghua, et al., Aromatic Plants and Essential Constituents, 1993 Hai Feng Publishing; Peace Book Company, Hong Kong.

9. MEDICAL SPECIALTIES Individuals seeking treatment by Chinese medicine often prefer to have a specialist trained in their particular area of concern. In the West, there is little specialization, but the need for detailed knowledge in several fields remains. Examples of specializations that appear in the literature are dermatology, rheumatology, ophthalmology, gynecology, and pediatrics. These books usually have the same basic characteristics as those described above under the heading "Clinical Experience." Cancer treatment with herbs is a major area of clinical practice in China and is of growing interest to Westerners. There has been a substantial change in emphasis in China, from use of herbs to treat cancer to use of herbs as an adjunct to cancer therapies. The book Treating Cancer with Chinese Herbs is an example of one reporting on treatments with herbs alone, while Cancer Treatment with Fu Zheng Pei Ben Principle is an example of one that is limited to addressing adverse effects of modern cancer therapies. Some of these books are guides to the individual herbs that may be used for either of these purposes, such as Anticancer Medicinal Herbs. To be recommended reading, the book must present extensive information about the herbs or substantial details about treatment strategies; due to the fact that these books involve specialization, none have been rated as essential reading.

CANCER Recommended Reading/Reference Chang Minyi, Anticancer Medicinal Herbs, 1992 Hunan Science and Technology Publishing House, Changsha. Pan Mingji, Cancer Treatment with Fu Zheng Pei Ben Principle , 1992 Fujian Science and Technology Publishing House, Fujian. [OP] Advanced Reading/Reference Hsu HY, Treating Cancer with Chinese Herbs, 1990 Oriental Healing Arts Institute, Long Beach, CA.

Jia Kun, Prevention and Treatment of Carcinoma in Traditional Chinese Medicine, 1985 The Commercial Press, Hong Kong. Ou Ming, et al., An Illustrated Guide to Antineoplastic Chinese Herbal Medicine, 1990 The Commercial Press, Hong Kong. Shi Lanling and Shi Peiquan, Experience in Treating Carcinomas with Traditional Chinese Medicine , 1992 Shandong Science and Technology Press, Shandong. Not Recommended Binyan Sun, Cancer Treatment and Prevention, 1991 Offete Enterprises, San Mateo, CA. Lien E and Wen L, Structure Activity Relationship Analysis of Chinese Anti-Cancer Drugs and Related Plants , 1985 Oriental Healing Arts Institute, Long Beach, CA. Pan Mingji, How to Discover Cancer Through Self-Examination, 1992 Fujian Science and Technology Publishing House, Fujian. Sun Chiyuan, A Probing into the Treatment of Leukemia with Traditional Chinese Medicine , 1990 Hai Feng Publishing Company, Hong Kong. Zhang Daizhao, The Treatment of Cancer by Integrated Chinese-Western Medicine, 1989 Blue Poppy Press, Boulder, CO.

DERMATOLOGY Li Lin, Practical Traditional Chinese Dermatology, 1995 Hai Feng Publishing Company, Hong Kong. [RR] Liang Jianhui, A Handbook of Traditional Chinese Dermatology, 1988 Blue Poppy Press, Boulder, CO. [AR] Shen Dehui, Wu Xiufen, and Wang N, Manual of Dermatology in Chinese Medicine, 1995 Eastland Press, Seattle, WA. [NR] Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 16: Dermatology, 1991 Higher Education Press, Beijing. [RR]

GERONTOLOGY Liu Zhengcai, The Mystery of Longevity, 1990 Foreign Languages Press, Beijing. [AR] Yan Dexin, Aging and Blood Stasis: A New TCM Approach to Geriatrics, 1995 Blue Poppy Press, Boulder, CO. [AR]

INFECTIONS AND FEVERISH DISEASES Hou Jinglun, et al. (editors), Traditional Chinese Treatment of Infectious Diseases, 1997 Academy Press, Beijing. [AR] Wen JM and Seifert G, Warm Disease Theory, 2000 Paradigm Publications, Brookline, MA. [RR]

PEDIATRICS Cao Jiming, Su Xinming, and Cao Junqi (editors), Essentials of Traditional Chinese Pediatrics, 1990 Foreign Language Press, Beijing. [RR] Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 13: Pediatrics, 1991 Higher Education Press, Beijing. [RR] Xiao Shuqin, Zhang Xiwen, et al., Pediatric Bronchitis: Its TCM Cause, Diagnosis, and Treatment , 1991 Blue Poppy Press, Boulder, CO. [AR]

GYNECOLOGY/UROLOGY Furth C, A Flourishing Yin: Gender in China's Medical History, 960-1665, 1999 University of California Press, Berkeley, CA. [AR] Lin A, A Handbook of TCM Urology & Male Sexual Dysfunction, 1992 Blue Poppy Press, Boulder, CO. [NR] Shibata Y and Wu J, Kampo Treatment for Climacteric Disorders, 1997 Paradigm Publications, Brookline, MA. [AR] Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 12: Gynecology, 1990 Higher Education Press, Beijing. [RR]

NEUROLOGY Cheung CS, Lai YK, and Kaw UA, Mental Dysfunction as Treated by Traditional Chinese Medicine , 1981 Traditional Chinese Medicine Publisher, San Francisco, CA. [OP]

OPHTHALMOLOGY Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 17: Ophthalmology, 1994 Higher Education Press, Beijing. [RR] Kovacs J and Unschuld PU, Essential Subtleties on the Silver Sea, 1998 University of California Press, Berkeley, CA. [AR]

ORTHOPEDICS, TRAUMATOLOGY, AND RHEUMATOLOGY Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 14: Orthopedics and Traumatology, 1992 Higher Education Press, Beijing. [RR] Vangermeersch C, and Sun Peilin, Bi-Syndromes, 1994 SATAS, Belgium. [AR]

10. TRANSLATION GUIDES This section includes a wide range of books about Chinese characters, as well as some books that are specifically about Chinese medicine. Although practitioners of Chinese medicine can rely on dictionaries that translate terms from Chinese to English and English to Chinese, a knowledge of the basic Chinese characters may aid in deeper understanding of the concepts.

Recommended Reading/Reference

Anonymous, Learner's Chinese-English Dictionary, 5th ed., 1984 Nanyang Siang Pau and Umum Publisher, Singapore. Lindqvist C, China: Empire of Living Symbols, 1991 Addison-Wesley Publishing Co., NY. Wiseman N, English-Chinese, Chinese-English Dictionary of Chinese Medicine, 1995 Foreign Languages Press, Beijing.

Advanced Reading/Reference Fazzioli E, Chinese Calligraphy: From Pictograph to Ideogram: The History of 214 Essential Chinese/Japanese Characters, 1986 Abbeville Press, NY. Li Leyi, Tracing The Roots of Chinese Characters: 500 Cases, 1993 Beijing Language and Culture University Press, Beijing. Liao SJ (editor), Chinese-English Terminology of Traditional Chinese Medicine, 1981 Hunan Science and Technology Press, Hunan. Tan Huaypeng, Fun with Chinese Characters: The Straits Times Collection (3 volumes), 1980-1983 Federal Publications, Hong Kong. Wang Hongyuan, The Origins of Chinese Characters, 1993 Sinolingua, Beijing. Wieger L, Chinese Characters: Their Origin, Etymology, History, Classification, and Signification, 1965 Dover Publications, NY. Wilder GD and Ingram JH, Analysis of Chinese Characters, 1974 Dover Publications, NY. Wiseman N, and Boss K, Glossary of Chinese Medical Terms and Acupuncture Points, 1990 Paradigm Publications, Brookline, MA. Wiseman N and Ye Feng, A Practical Dictionary of Chinese Medicine, 1998 Paradigm Publications, Brookline, MA. Xie Zhufan and Huang Xiokai (editors), Dictionary of Traditional Chinese Medicine, 1984 Commercial Press, Hong Kong.

Not Recommended Liu F and Lui Yanmau, Chinese Medical Terminology, 1980 The Commercial Press, Ltd., Hong Kong. Unschuld PU, Approaches to Traditional Chinese Medical Literature, 1989 Kluwer Academic, Dordrecht, Holland.

11. TIBETAN MEDICINE Tibetan medicine is an integration of four traditions: Ayurvedic medicine and Buddhism from India, the pre-Buddhist shamanism that existed in Tibet, and Chinese medicine. Many of these books are difficult to obtain and provide limited information. However, for those who wish to know Tibetan medicine, a study of several of the books, especially those listed here as recommended reading, will provide a good overview.

Recommended Reading/Reference Clifford T, Tibetan Buddhist Medicine and Psychiatry: The Diamond Healing, 1984 Samuel Weiser, Inc., York Beach, ME. Norbu D, An Introduction to Tibetan Medicine, 1976 Tibetan Review, New Delhi. Rapgay L, et al., Mind and Mental Health in Tibetan Medicine, 1988 Potala Publications, New York. Tsarong TJ, Fundamentals of Tibetan Medicine, 1981 Tibetan Medical Centre, Dharamsala, India.

Advanced Reading/Reference Baker IA, The Tibetan Art of Healing, 1997 Thames and Hudson, London. Clark B, The Quintessence Tantras of Tibetan Medicine, 1995 Snow Lion Publications, Ithica, NY. Dash VB, Tibetan Medicine, with Special Reference to Yoga Sataka, 1985 Library of Tibetan Works and Archives, New Delhi. Dhönden Y, The Ambrosia Heart Tantra, 1977 Library of Tibetan Works and Archives, New Delhi. Rapgay L, The Art of Tibetan Medical Urinalysis, 1986 Tibetan Holistic Medical Series, Dharamsala, India. Rechung Rinpoche, Tibetan Medicine, 1976 University of California Press, Berkeley, CA. Tsarong TJ, Handbook of Traditional Tibetan Drugs, 1986 Tibetan Medical Publications, West Bengal, India.

Out of Print Dhönden Y and Kelsang J, Tibetan Medicine (Series #6), 1983 Library of Tibetan Works and Archives, New Delhi. Kilty G, Tibetan Medicine (Series No. 7), 1984 Library of Tibetan Works and Archives, New Delhi. Molvray M, Tibetan Medicine (Series No. 11), 1988 Library of Tibetan Works and Archives, New Delhi. Lobsang Rapgay, Tibetan Medicine (Series No. 3), 1981 Library of Tibetan Works and Archives, New Delhi.

Not Recommended Vaidya Bhagwan Dash, Formulary of Tibetan Medicine, 1988 Classics India Publication, Delhi. Finckh E, Studies in Tibetan Medicine, 1988 Snow Lion Publications, Ithaca, NY. Lobsang Dolma Khangkar, Lectures on Tibetan Medicine, 1986 Library of Tibetan Works and Archives, New Delhi.

12. AYURVEDIC MEDICINE Ayurvedic medicine differs markedly from Chinese medicine, but there are some areas of overlap: both systems were codified around the same time in civilizations at similar stages of development; both systems have many herbs in common; and both systems have strong emphasis on the value of food as medicine, the use of traditional formulations, and the application of physical exercises (e.g., yoga in India and taiji in China), and physical therapies (e.g., massage in India and acupuncture in China). A problem with Ayurvedic medicine that also plagues Chinese medicine, is that there are so many books produced that are not very true to the tradition. However, unlike

Chinese medicine, which has a large and growing profession in the West, Ayurveda is mostly taught to laypersons outside of India, so the demand for rigorous training is less. This has some effect on the quality of publications. Only two books have been deemed essential reading: Ayurveda: Life, Health, Longevity (for background on the entire field of Ayurvedic medicine) and the Indian Materia Medica, which has a good overview of the individual herbs from the traditional viewpoint (it was written more than 75 years ago, though republished more recently), with mention of many valued herb combinations.

Essential Reading/Reference Nadkarni KM, Indian Materia Medica, (2 vol.) 1976 Popular Prakashan Put. Ltd., Bombay. Svoboda R, Ayurveda: Life, Health, and Longevity, 1992 Penguin Books, India, New Delhi.

Recommended Reading/Reference Harish Johari, Ayurvedic Massage, 1996 Healing Arts Press, Rochester, VT. Verma V, Ayurveda: A Way of Life, 1985 Samuel Weiser, Inc., York Beach, ME.

Advanced Reading/Reference Kaviratna AC and Sharma P (translators), Caraka-Samhita, Second Revised Edition [5 volumes], 1996 Indian Books Centre, Delhi. Kutumbiah P, Ancient Indian Medicine, 1962 Orient Longman Ltd., Bombay. [OP] Svoboda R, Prakruti: Your Ayurvedic Constitution, 1989 Geocom, Albuquerque, NM. Svoboda R and Lade A, Tao and Dharma: Chinese Medicine and Ayurveda, 1995 The Lotus Press, Twin Lakes, WI. Zysk K, Asceticism and Healing in Ancient India, 1991 Oxford University Press, New York.

Not Recommended Gerson S, Ayurveda: The Ancient Indian Healing Art, 1993 Barnes and Noble Books, New York. Lad V, Ayurveda: The Science of Self-Healing, 1985 Lotus Press, Santa Fe, NM. Ros F, The Lost Secrets of Ayurvedic Acupuncture, 1994 The Lotus Press, Twin Lakes, WI. Svoboda R, The Hidden Secret of Ayurveda, 1994 The Ayurvedic Press, Albuquerque, NM. Tiwari M, Ayurveda: A Life of Balance, 1995 Healing Arts Press, Rochester, VT.

13. WESTERN HERBS AND WESTERN MEDICINE When patients present their Western diagnosis, it is important for the practitioner of traditional medicine to understand it, be able to discuss the matter within certain limits, and, as may be necessary, explain the traditional treatment in relation to the Western diagnosis and treatment. Western medicine includes general understanding of diagnosis and treatment, as presented in guides and encyclopedias, and reference to specific treatment methods, including drugs, nutritional supplements, and herbs. Books that have been found valuable for ITM presentation of information about disorders are listed here.

Essential Reading/Reference Berkow R (editor in chief), The Merck Manual (17th ed.), 1997 Merck & Co., Rahway, NJ.

Recommended Reading/Reference Boik J, Natural Compounds in Cancer Therapy, 2001 Oregon Medical Press, Princeton, MN. Clayman CB (editor), AMA Encyclopedia of Medicine, 1989 Random House, New York. Grieve M, A Modern Herbal, 1971 Dover Publications, New York. Murray M and Pizzorno J, Encyclopedia of Natural Medicine, 1990 Prima Publishing, Rocklin, CA. Rybacki JJ and Long JW, The Essential Guide to Prescription Drugs, 1997 HarperPerennial, New York. Werbach M, Foundations of Nutritional Medicine, 1997 Third Line Press, Tarzana, CA Werbach M, Healing Through Nutrition, 1993 HarperCollins, New York. Werbach M, Nutritional Influences on Illness, Second Edition 1993 Third Line Press, Tarzana, CA. Werbach M, Nutritional Influences on Mental Illness, Second Edition 1999 Third Line Press, Tarzana, CA.

Advanced Reading/Reference Blumental M, et al. The Complete German Commission E Monographs, 1998 American Botanical Council, Austin, TX. Blumental M, Goldberg A, and Brinckman J, Herbal Medicine: Expanded Commission E Monographs, 2000 American Botanical Council, Austin, TX.

Not Recommended Weiss RF and Volker F, Herbal Medicine, 2000 Thieme Verlag, Stuttgart.

Out of Print Cody V, Middleton Jr., E, and Harborne JB (editors), Plant Flavonoids in Biology and Medicine, 1987 Alan R. Liss, Inc., New York. Goth A, Medical Pharmacology, 1984 C.V. Mosby Co., St. Louis, MO. Leake CD, An Historical Account of Pharmacology to the Twentieth Century, 1975 Charles C. Thomas, Springfield, IL. Morton JF, Major Medicinal Plants: Botany, Culture, and Uses, Charles C. Thomas, Springfield, IL.

Tyler VE, Brady LR, and Robbers JE, Pharmacognosy, 1976 Lea & Febiger, Philadelphia, PA.

14. JOURNALS OF CHINESE MEDICINE Publishing a journal is an arduous task, and it is especially difficult when the number of subscribers is small (most journals of Chinese medicine number their subscribers only in the hundreds) and when the number of excellent reports is also small (few practitioners of Chinese medicine have received training that would lead to production of high quality reports). As a result, there are relatively few journals, and most of them have a short publication life. Following are the journals that have been received at ITM, either by subscription or donation. Though none are of such high quality as to be deemed essential reading, practitioners of Chinese medicine ought to have at least two research oriented journals, and (of the ones still available for subscription) the ones used most at ITM are Journal of Traditional Chinese Medicine, the International Journal of Oriental Medicine, and the Journal of Integrated Traditional and Western Medicine.

Recommended Reading/Reference Bulletin of the Oriental Healing Arts Institute (published 1976-1988; back issues available from Oriental Healing Arts Institute, Long Beach, CA). [OP] International Journal of Oriental Medicine (published since 1989; Oriental Healing Arts Institute, Long Beach, CA). Journal of the American College of Traditional Chinese Medicine (published 1982-1989; back issues available from the American College of TCM, San Francisco, CA). [OP] The Journal of Traditional Chinese Medicine (published since 1981; 18 Beixincang, Dongzhimen Nei, Beijing 100700).

Advanced Reading/Reference Abstracts of Chinese Medicine (published 1987-1996; Medicinal Materials Research Center, Chinese University of Hong Kong, Shatin, N.T., Hong Kong; back issues not available). [OP] Chinese Journal of Integrated Traditional and Western Medicine (Beijing; English language publication since 1995. Chinese Journal of Integrated Traditional and Western Medicine Press: 1 Caochang, Xiyuan, Beijing 100091 China).

Not Recommended European Journal of Oriental Medicine (179 Gloucester Place, London NW11 6DX, England). American Journal of Chinese Medicine (published since 1974; P.O. Box 555, Garden City, New York 11530). The Journal of Chinese Medicine (published since 1981; 22 Cromwell Road, Hove, Sussex BN3 3EB, England). Oriental Medicine (published since 1991; 3723 N. Southport, Chicago, IL).

15. OTHER JOURNALS Although not devoted to Chinese medicine or even to natural medicine, the Journal of the American Medical Association (JAMA) is strongly recommended for practitioners of Chinese medicine so that the latest advances in knowledge of medicine can be viewed. JAMA has recently published several articles on alternative medicine and provided clinical study reports about nutritional supplements and herbs.

Recommended Reading/Reference Herbalgram (American Botanical Council, P.O.Box 201660 Austin, TX 78720). Journal of the American Medical Association (515 N State St., Chicago, IL 60610).

Advanced Reading/Reference Journal of Naturopathic Medicine (Journal Management Group, Ten Morgan Ave., Norwalk, CT 06851). Protocol Journal of Botanical Medicine (published 1995-1997; P.O.Box 108, Harvard, MA 01451). [OP]

Not Recommended Alternative & Complimentary Therapies (Mary Ann Liebert, Inc., 2 Madison Ave., Larchmont, NY 10538). Journal of Alternative and Complimentary Medicine (Mary Ann Liebert, Inc., 2 Madison Ave., Larchmont, NY 10538).

August 2001

ITM Home Page | Article Index

Classical Physician Zhang Jingyue: The Rehmannia Doc by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Zhang Jingyue (c.1563-1640; original name: Zhang Jiebin) had an immense influence on the development of Chinese medicine at a time when the Ming Dynasty was collapsing to give way to the Qing Dynasty, the transition of power occurring in 1644. The two major works coming from Zhang’s years of learning and medical practice are the Leijing (a study of the Neijing) and Jingyue Yixue Quanshu(Collected Works; usually called simply Jingyue Quanshu); both of them are massive compilations (32 volumes and 64 volumes respectively). The Leijing basically combines the contents of the Neijing Suwen with that of the Lingshu, rearranging them according to topical categories and adding lengthy explanations of difficult or controversial passages. The first two sections of the Leijing, devoted to “nourishing life” and “yin/yang,” are relevant to the discussion to be presented here, but it is the information from the Quanshu, Zhang’s final preserved publication, that will be the focus of this paper. Jingyue Quanshu was completed in 1624. It summed up not only the therapeutic concepts and formulations of the author, but also of his predecessors. He analyzed the strong points of the schools of medicine that evolved during the Jin-Yuan period and persisted into the Ming Dynasty. Zhang belonged to the school of “warm tonification” (Chinese: wenbu) that came to the forefront in the mid-16th century. In this endeavor, he participated with the contemporary physician-scholars Xue Ji (1488-1558), Sun Yikui (1522-1619), Zhao Xianke (c.1567c.1644) and Li Zhongzi (1588-1655). This conceptual framework of tonification followed from the views of Li Gao, who was a key contributor to the Jin-Yuan reforms. Xue Ji (author of Neike Zhaiyao; A Synopsis of Internal Medicine)emphasized tonification of the spleen and stomach, using herbs such as atractylodes (baizhu), ginseng (renshen), astragalus (huangqi), and licorice (gancao). Zhao Xianke (author of Yiguan; Key Link of Medicine) further developed the teachings of Xue Ji with emphasis on the role of the gate of life (Chinese: mingmen). His efforts focused upon the idea of balancing the yin (water) and yang (fire) of the kidney and of the mingmen, using formulas such as Zhi Bai Dihuang Wan. Both Sun Yikui (author o f Yi An ; Medical Records), and Zhang Jingyue also followed this mingmen focal point, with their own slight modifications; in fact, this emphasis gave the warming tonification school the additional title of the mingmen school. Sun Yikui and then also Li Zhongzi (who, like Zhang Jingyue, wrote a commentary about the Neijing), began to move away from strict adherence to the importance of warming tonification, considering it one of several potentially useful approaches, but Li especially helped bring forward the concepts of this school into the evolving medical concepts of the Qing Dynasty period. Of these five leaders of warming tonification, our attention turns to the one who had the broadest impact on the later evolution of Chinese medicine. Zhang Jingyue was born in what is today Shaoxing County of Zhejiang Province (see map, right: the county in red; the province in orange); his hometown was near the eastern coast of China, south of Shanghai and east of Hangzhou. In his teens, Zhang went with his father to Beijing, where he eventually studied medicine, and became one of the Imperial physicians working for the Emperor Wanli. The situation in China when Zhang began practicing medicine in Beijing is laid out in Ray Huang’s 1982 book: 1587, A Year of No Significance: The Ming Dynasty in Decline (1). That book, aside from describing the social and political situation, nicely presents insights into how yin and yang were understood: they were especially utilized as terms depicting the management of government affairs and making strategic plans for battle. Zhang Jingyue, 24 years old in 1587, also frequently used the battle theme to describe his medical ideas; this orientation came out of his initial pursuit of a military career. Zhang depicted herbs as being like a deployment of troops against the enemy, the disease. He is well known for having elaborated the Eight Principles (bagang): yin/yang; biao/li; xu/shi; han/re, which apply the framework of the yin/yang concept. These eight principles (or yin/yang plus six principles) were utilized first to aid in diagnosis of disease and then to classify formula actions, which Zhang laid out as the “eight tactical arrays (bazhen).” This period—the latter part of the Ming Dynasty—was important for the future course of Chinese medicine in many ways. For example, it was at this time that Li Shizhen (1518-1593) compiled his Bencao Gangmu, which was turned over to the Wanli Emperor; the Emperor retained it in the Ministry of Rites, which was an action that actually inhibited its circulation. The Bencao Gangmu was published in 1596 (after Li Shizhen had died), but it wasn’t distributed until a revised version—with some of Li’s other writings included—was published in 1603, when Zhang Jingyue was 40 years old, and not yet an author. Matteo Ricci, a Catholic priest from Italy, lived in Beijing around 1600-1610. He translated a number of western works on anatomy and science into Chinese; he introduced the methods of preventing epidemics that had been developed in Europe (though they wouldn’t be widely incorporated in China until the late 1800s). Gong Tingxian (1522-1619) published his major work, Wanbing Huichun, in 1587 (that is, in the “year of no significance”); it greatly influenced Kampo medicine. The book was brought to Japan by one of Gong’s students and it turned out to be the last major Chinese medical work to inspire their system of medicine before it evolved on its own among Japanese physicians. Put simply, Zhang Jingyue’s life spanned a distinctive turning point in Chinese medical history; like the phoenix rising out of the ashes, a new phase of Chinese medicine was rising out of the downfall of the Ming Dynasty. One

may think also of Zhang Zhongjing, who worked in the declining years of the Han Dynasty; his works are guessed to have been published around the last year of the Han. Basic Ideas The relationship of yin and yang that came to Zhang Jingue’s attention was described in Ray Huang’s book about the conditions in 1587. In that year, Shen Shixing, the Grand-Secretary to the Wanli Emperor, made this observation: “The professed moral tone of government that enabled the bureaucrats to justify their lines of action was the yang, and their hidden desires and motivations was the yin.” He was noting that the lower echelon bureaucrats—who worked behind the scenes and unobserved—could undertake the initial “skirmishes” in the political maneuvers, and then the senior members would finally become involved, waiting for the time to be ripe to initiate a final showdown in which the decisive political change would become public (yang). Put more simply, the aspect that was exposed—the moral tone that was professed to the public—is yang, while that aspect which was hidden—the desires and motivations of the powerful ministers—was the yin; discerning the appropriate timing for blending and transitioning from yin to yang was the essential political skill. Shen went on to point out that “The mixing of yang with yin being a matter of degree, [one’s] adherence to principle therefore varied not only from one person to another but from time to time within the same person.” Simplifying: the yin and yang are not separate but coexist within each individual and each situation. Conditions are fluid and one must evaluate them repeatedly and make adjustments. The military hero, General Qi Jiguang (1528-1588), is said to have relied upon “a dialectic approach” in describing tactics in battle. As relayed by Huang: “Every posture had its duality: the static and kinetic aspects, the guarded and unguarded positions, the frontal and lateral alignment, the defensive and offensive potentials—in short, the yin and yang.” He considered that to succeed in battle one had to lure the opponent in until the proper time for a reversal; the “mastery of the art depended upon proper rhythm—or perfect timing in transforming the yin to the yang.” Looking at the bigger picture of the army in the society, at a most difficult time in the history of the Empire (the declining years of the Ming Dynasty), Qi believed that “the way to boost the fighting strength of the army had to come through compromise, mainly the blending of the yin with the yang.” In essence, if either the yang or the yin is overemphasized, weakness results; both are necessarily present in directing affairs of state and in leadership of war, but their relative preponderance and their interaction is critical. One then has to focus upon bringing about transformation at the right moment. The starting point for the process is developing the yin; the timing involves shifting to the yang; in the interim, there is some blending of the two. That which is hidden (yin) has a certain power. When the yin is unleashed (from its place of obscurity), it can catch the opponent unaware on indefensible terrain, because the offense comes unexpectedly—before there is time to select and attain the desirable defensible terrain. As a result, the enemy can be defeated, even if the attacker has other weaknesses. One may think of the “crouching tiger” that is very still but has great potential held in reserve in the compression of its muscles into its low and drawn-back position, a yin quality. The tiger then waits quietly and springs forward at the right moment as yin transforms to yang and the action has its intended consequences. That which is evident (yang) also has power, but unless that power can be concealed within the yin (delayed in exposing it), the extent of the power is revealed to all, and an opponent can opt to take prudent evasive action (yin) to become hidden by terrain or separated by distance, especially when that which has been revealed appears to be too strong (because the strength has been evident, there is time to take appropriate compensatory action). An army cannot run away for long, but it can retrench into an area offering greater protection and opportunity (yin), or it can join a larger reserve force (also yin). Large forces are slow moving (yin) and must be maintained in a protected area (yin) with plenty of supporting resources (yin), such as food and water. It can then wait for an appropriate time to make use of its ready forces that now become evident (yang). All this military thinking has application to medical matters. Evolving Medical View Paul Unschuld, in his book Medicine in China: A History of Ideas (2), provides the following background on Zhang Jingyue’s thinking (p. 199). Note: I have updated the physician name spelling; Unschuld has translated qi as “influences,” which I retain, and in brackets I provide background information for the physicians mentioned. Up to the age of 40 [1603], Zhang Jingyue followed the teachings of Liu Wansu [1120-1200; leader of the “cold/cooling school,” considering most ailments as involving pathogenic fire that was to be cooled] and Zhu Danxi [1281-1358; leader of the “nourishing yin school,” considering that the ministerial fire of mingmen easily tended to flare up, representing a pathological excess of yang qi, due to deficiency of kidney yin]. But then, as a result of his own experiences, he began to have doubts, and the precepts of Zhu Danxi in particular—namely, that a pathological surplus of yang qi is frequently present in the body—now seemed to him completely untenable. In accordance with the conclusions of Xue Ji [ca. 1488-1558] and Li Gao [1180-1251; leader of the “spleen/stomach school,” considering many health problems to arise from damage to the spleen/stomach through diet, overstrain, and mental agitation, recommending warming tonification of spleen qi, and giving rise to the “school of warm tonification”], he too now considered the yang component in the organism to be of primary importance and therefore advocated constant replenishment of the body with yang influences to treat and prevent illness. Zhang Jingyue’s arguments were formulated as follows: The influences that flow through the body form the yang component, while the structure of the body itself constitutes the yin component. Yin-Yang dualism requires that the yin component cannot exist without a yang component and vice versa. Applied to man, this signifies that bodily structure requires yang influences to come into existence and that the yang influences, in turn, requires this structure as their supporting mechanism. All living beings are therefore brought into existence by yang influences and given a physical structure by yin influences. This process of genesis proceeds indefinitely, ensuring the continuation of existence. An imbalance of yin and yang influences leads eventually to death. In this connection, Zhang Jingyue cited the following two

statements in the Huangdi Neijing: “When yin and yang influences work together, it is of great importance that the yang influences remain tightly sealed. In this way, strength can be maintained” and “Yang influences possess for man the same significance as does the sun for the heavens.” Zhang himself remarked: “This red globe of the sun is of utmost significance for heaven. The original yang influences alone represent the supreme value for man.” He then contrasted the precepts of Zhu Danxi with his own doctrine that the yang component could not form a pathological surplus, further supporting his views as follows: “The only possibility one need fear in regard to the yang component is that it might be insufficiently developed and, in the case of the yin component, that it might be overly developed. The yin component is, however, by itself incapable of reaching a state of excess, for this it requires a deficiency of yang….” With all his emphasis on the fundamental requirement for yang in life and health, Zhang Jingyue nonetheless became known as the “rehmannia doc.” He believed that to get adequate yang influences in the body, it was essential to assure that the yin was replete: supplementing yang without nourishing yin was a wasted tactic. He had learned well from the military strategists: the activity of yang needed a reserve, the yin had to be full. Sun Yikui had put it poetically (3): …[ministerial fire] is the fire within water, it is the dragon and thunder fire. When the dragon and thunder fire is wetted by yin and saturated with rain, its flames blaze up ever more. It may burn houses or decimate forests with a ferocity that cannot be resisted. Only when a ray of sunlight hits it will the fire extinguish itself. This is how water causes fire to blaze and fire causes fire to be extinguished. The kidney yin (water) does not extinguish ministerial fire; it enhances it. Since the mingmen school professed the value of this fire, it promoted the nourishing of yin to cause it to blaze more brightly. For Zhang, rehmannia (the processed root, called shudi) was the key herb for nourishing the yin, especially when the aim was to enhance yang. Huang Baoming, summarizing Zhang’s work (4), wrote: Rehmannia possesses “thick” (concentrated) taste and light qi. Within it, there is “yang in the midst of yin.” It has the ability to tonify the genuine yin of the five solid organs, making it an ideal herb for tonification….Its characteristics of calmness, heaviness, mild sweetness, and guarding action allow this herb to complement and/or counteract the side-effects of other herbs. These characteristics rebalance the yin and yang, water and fire, qi and blood, and the various organs, ultimately achieving the purpose of healing diseases. Dihuang Zhang: The Fearless Rehmannia Doc Today, rehmannia is often thought of first and foremost as the “cloying” herb, sticky sweet to the point of being nauseating. This herb thus comes with descriptions of being heavy, indigestible, and unpleasant, even though it is apparently necessary for modern practitioners to use cooked rehmannia because of its frequent appearance in traditional formulas. However, this is not the reputation it held in Zhang’s time. Rather, it was thought of as warming, fast acting, and dynamic in a gentle manner, efficient and peaceful in its effects. That it was somewhat difficult on the digestive system was evident, but not considered highly problematic. While today we learn about the use of alisma (zexie) or cardamom (sharen) to counter the rich nature of rehmannia (shudi), Zhang didn’t concern himself with that approach, and though he used and developed formulas similar to Rehmannia Six Formula (Liuwei Dihuang Wan), he did not include alisma. Indeed, the original purpose of alisma in the base formula (Rehmannia Eight Formula; Bawei Dihuang Wan), was not for countering the moistness of rehmannia but for regulating water movement in the body, in much the way it was used in Wuling San. When the modern physician Huang Baoming wrote about the use of rehmannia by Zhang Jingyue, he felt compelled to conclude the article with his thoughts on the “problem” of rehmannia saying (4): Some scholars consider rehmannia to have an undesirable stagnated, greasy, slippery, and wet nature. However, Zhang’s experience and clinical effects demonstrated that it is quite safe. He contended that since “Cui’s Pill for Kidney Qi” [this is one of the names given to Jingui Shenqi Wan , the Rehmannia Eight Formula of the Jingui Yaolue ] may be used in the treatment of floating phlegm, then why worry about its stagnated and greasy nature. Furthermore, the Pill of Eight Ingredients [another name for the same formula] is prescribed when the kidney is unable to hold essence, despite the herb’s slippery and wet nature. Still, suspicion of its stagnated and greasy nature exists and there is questionable application when tonifying blood. However, one ought to know that when the blood is deficient, it is like dry earth, an intense drought needing rain, withering yang desiring moisture. Zhang consistently advocated the use of rehmannia without fear. As a Chinese saying goes, “the incidence of choking should not deter one from eating.” As an example of his fearless use of rehmannia even in cases of phlegm excess, he presented the formula Jin Shui Liu Jun Jian (Formula of Metal and Water based on Liu Junzi Tang). This formula includes the phlegmresolving herbs fresh ginger (shengjiang), hoelen (fuling), pinellia (banxia), and citrus (chenpi), with rehmannia, tang-kuei (danggui) and baked licorice (zhigancao); viewed another way, this is Erchen Tang with rehmannia and tang-kuei. In modern presentations, advocates of Chinese medicine are sufficiently averse to using cooked rehmannia in cases of treating phlegm excess that they specify raw rehmannia for this prescription as though it belonged to the original formula, but that was not Zhang’s way. He recommended the formula for deficiency cold of lung and kidney, with flooding of water transforming into phlegm causing cough, vomiting, profuse sputum, and asthmatic breathing. The cooked rehmannia was to nourish the kidney yin, so as to help invigorate the kidney yang, to control the water and warm the lung, thereby resolving the phlegm accumulation. Two British doctors working in China at the end of the 19 th century, Smith and Stuart, compiled a book about Chinese herbs (5) relying on the Bencao Gangmu and the reports of contemporary Chinese physicians. Regarding

the preparation of shudihuang, they wrote that it is “made by taking juicy roots, washing in spirits, filling with the seeds of the bastard cardamom [sharen], steaming on a willow frame in a porcelain vessel, drying, and resteaming and redrying nine times.” The nine-fold processing is a reflection of ancient alchemical manipulation, and it was believed to enhance the warming and nourishing properties of the herb, helping to develop the yang within the yin. Its properties were: “to harmonize, increase, and cool the blood, and to strengthen the marrow. It is considered highly tonic…” The cooling of blood is associated with nourishing the blood, and thus retiring the heat. Including cardamom in the processing was a nod to the desire to alleviate the slippery nature of cooked rehmannia without requiring herbalists to add the ingredient to their formulas. As to the applications, it is “used in all wasting diseases and weakened conditions of the body. In diseases of pregnancy, puerperal difficulties, diseases of children, and wasting discharges, it is specially recommended.” The applications of Chinese herbs for pregnancy, postpartum recovery, and for young children were tackled by Zhang Jingyuen in the Quanshu, but also as a result of further developments in the uses of Rehmannia Six Formula during the Qing Dynasty period.

Mingmen: The Key to Life In Zhang’s teaching, the kidney plays a special role in the whole dynamic of human physiology. It was thought by many doctors of his time that the yin essence was retained in the left kidney (the kidney of water) and the yang essence in the right kidney (the kidney of fire); this concept was not based on any observation about the two kidneys themselves but on the long-standing tradition that the left was the yin side of the body and the right the yang side. The life gate (mingmen) was traditionally associated with the right kidney. The “fire” of the mingmen is identified as the “ministerial fire;” this designation distinguishes it from the fire of the heart, which is the “imperial fire” (the heart being the organ associated with the fire element). The mingmen, interpreted as a physiological-anatomical unit, is the storehouse of the jing (essence) and shen (spirit) that generates the qi. Sometimes, the mingmen was said to be located between the kidneys (e.g., by Zhao Xianke and Sun Yikui), rather than associated with the right kidney; the acupuncture point mingmen (GV-4) is located between the kidneys. Some thought the mingmen was equivalent to the kidneys (e.g., Hua Shou of the Yuan Dynasty). Zhang Jingyue maintained the idea of the left and right kidneys being the resource of yin and yang respectively, but considered the mingmen to encompass both kidneys and to be the basis of all bodily health. He wrote (2): The mingmen controls both kidneys and both kidneys belong to the mingmen. Mingmen is the mansion of both water and fire, the house of yin and yang, the sea of essence and blood, the nest of life and death. If the mingmen is depleted and damaged, the five zang and six fu lose their sustenance, and the yin and yang will become sick, causing all types of disorders. He also considered that the mingmen included the essence chamber of reproduction that corresponded to the womb in women and the semen reservoir (prostate) in men. His primary effort was to harmonize the many statements about mingmen in the ancient texts, which was a daunting task, but he wanted to counter the tendency for speculation that was not connected to the original descriptions. Zhang considered that if the ministerial fire was too strong it could be regulated by focusing proportionately more on nourishing of yin, but even then, not to the exclusion of nourishing yang. Zhang opposed the idea of incorporating cold or cool herbs with the purpose of inhibiting ministerial fire. Thus he differed from Zhu Danxi, a proponent of nourishing yin, who utilized phellodendron and other herbs that were deemed suitable for treating fire associated with yin deficiency. An example of a well-known Zhu Danxi formula is Hu Qian Wan (Pill of Hidden Tiger). It is comprised of the yin nourishing rehmannia and tortoise shell (guiban) with the deficiency-heat clearing herbs phellodendron (huangbo) and anemarrhena (zhimu), along with nine other ingredients. The formula was used for flaccidity of muscles and bones leading to difficult walking; the flaccidity and accompanying withering of the legs was thought to be a secondary effect of the yin being burned up by a feverish condition, hence the idea of clearing the heat. As a bone-fortifying and muscle strengthening ingredient, tiger bone (hugu), derived from the tiger leg, was one of its original ingredients. Rehmannia is now recognized as the key herb for nourishing yin and blood, and Zhang Jingyue is partly responsible for that emphasis. Zhang had organized 186 prescriptions of his own, presented in his Quanshu, of which 48 contained rehmannia. About this herb, he said (4): Rehmannia is needed to guard the yin in cases of deficiency that involve scattering of the spirit; the heaviness of rehmannia is needed to counter the rising fire of yin deficiency; the calming quality of rehmannia is needed for pacifying the agitation of yin deficiency; the mild sweetness of rehmannia is needed for relaxing the impulsive nature of yin deficiency; rehmannia is needed to restrict the flooding of water evil in cases of yin deficiency; rehmannia is needed to retrieve the scattered genuine qi back to its origin in the kidney; in yin deficiency with damage to the essence-blood and extreme emaciation, it is used to thicken the gastro-intestinal tract; the blood nourishing of rehmannia is used with dispersing agents for diaphoresis because sweat is transformed from blood; the yin nourishing of rehmannia is used with warming agents for retrieving yang qi because yang is rooted in yin. Of the warming tonification formulas that he presented, only a few are commonly used today and the best known of these are the kidney nourishing formulas; there is the pill and decoction for the left kidney, the pill and decoction for the right kidney, restoring the kidney pills, and great tonifying the original formula. In the table below, the herbs are laid out to show the similarities of the formulas (6): Zuo Gui Wan Rehmannia Dioscorea Lycium fruit Cornus Cuscuta Antler glue Cyathula Tortoise shell

Zuo Gui Yin Rehmannia Dioscorea Lycium fruit Cornus Licorice Hoelen

You Gui Wan Rehmannia Dioscorea Lycium fruit Cornus Cuscuta Eucommia Cinn. bark Aconite Antler Tang-kuei

You Gui Yin Rehmannia Dioscorea Lycium fruit Cornus Eucommia Cinn. bark Aconite Licorice

Gui Shen Wan Rehmannia Dioscorea Lycium fruit Cornus Cuscuta Eucommia Tang-kuei Hoelen

Da Bu Yuan Jian Rehmannia Dioscorea Lycium fruit Cornus Eucommia Licorice Tang-kuei Ginseng

The group of rehmannia, dioscorea, lycium fruit, and cornus is in all six formulas; the kidney yang (right kidney) formulas include eucommia, cinnamon bark, and aconite. To appreciate the modern views on the benefits of rehmannia, one can turn to an explanation of the well-known Rehmannia Six Formula (Liuwei Dihuang Wan ; developed by Qian Yi of the Song Dynasty, as a pediatric remedy for weak vitality). For example, the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (7) presents the current explanation of the formula based on TCM principles, giving a good overview of the treatment of kidney deficiency: This prescription is indicated for disorders due to kidney yin insufficiency and upward attack of deficiency fire. The lumbus houses the kidney, which controls the growth of bones, marrow, and teeth, so insufficient kidney yin may give rise to soreness and weakness of the lumbus and knees and loose teeth. The brain is the “sea of marrow,” and kidney yin deficiency may impede the production of marrow and the function of the brain, causing dizziness. When kidney yin is deficient, the essence cannot be sent to the ears, resulting in tinnitus and deafness. Since the kidney stores the essence, the ministerial fire may disturb the spermatic chamber when kidney yin is deficient, leading to nocturnal emission. Yin deficiency may lead to internal heat generation, resulting in hectic fever, a hot sensation in the soles and palms, diabetes, and night sweating. Yin deficiency in the lower body may induce an upward attack of deficiency fire, causing dry throat and red and dry tongue with little coating. The principle of treatment is to nourish yin and invigorate the kidney.

Addendum: On Herb Prescribing The following brief passage from the first chapter of Jingyue Quanshu is entirely relevant to herb prescribing issues that are present today as well as in Zhang’s time. This translation is from Steven Clavey (8): In diagnosis and treatment, aim for accuracy and exactitude. Every disease under heaven has a single root, despite many apparent variations; every prescription has a single consistent relationship with the condition it treats, no matter how many herbal constituents are adroitly added or deleted to keep pace with the alterations of the illness. If the diagnosis of cold is certain, then cold must be completely dispersed. If undeniably heat, then the pathogenic heat must be absolutely cleared. Once one has pulled up and disposed of the root of the illness, the other symptoms will eventually disappear by themselves. Thus the Su Wen (chapter 5) states: “In treatment of any illness, aim for the root.” Before one can aim for the root, using herbs for treatment, one must have determined its nature. If the observation or judgment of the disease state is not sufficiently accurate to begin treatment, it is better to wait a short time to allow the nature of the disease to become clear. Then a detailed examination may be made. Once a sure diagnosis is had, the use of one or two herbs can eradicate the pathogen. Even if the root is, as it were, firmly entrenched, so that the disease is stubborn, extended, and difficult to treat, an accurate diagnosis ensures that six, seven, or eight herbs will be sufficient. And these seven or eight herbs will only assist the main herbs, or guide the effects to this or that channel. The goal and plan behind the prescription has a single purpose. Only this makes a first-class physician. The doctors these days, though, when they run into a syndrome, act as if they are staring out into the uncharted wastes of a great ocean: they don't recognize a thing, there is nothing upon which to pin a diagnosis. So when it comes to using herbs, there is no goal, no grasp – no wonder their treatment is completely disorganized. It is like trying to corner and capture wild animals on a vast unbroken plain. They know that for a deficient condition they should tonify, but being afraid that this could cause problems they add dispersing herbs to control the tonifying herbs. They know that an excess condition needs to be dispersed, but for fear that dispersal would be dangerous they add tonifying herbs to control the dispersing herbs. The most ridiculous thing is that these doctors often use prescriptions that are neither hot nor cold, that contain both tonifying and reducing herbs – and then act as if everything is under control. How could this act to remedy the excesses or deficiencies of the condition, or repair the damage done by the disease? Some even use herbs for wind, herbs for fire, herbs for phlegm, and herbs for food stagnation all together in the same formula, and feel that all bases are now covered. Again, how can one even talk of treating the root or treating the branch? When they “use herbs to control other herbs” when do they get around to controlling the disease?! If these people happen to cure a disease, they do not know if it was the effect of the tonification or the effect of the attack on the pathogen. When the patient does not improve, they are not sure whether it is the fault of the dispersing or the tonifying herbs. They go on and on like this, practicing medicine until they are white haired and toothless and still they are no good. A whole life without improvement, simply from not having a clear perception of the problem, and not being able to use the simple essential methods necessary to resolve that specific problem. If the patient’s problem is simple, this is not greatly important. But if the life of the patient depends on the next moves of the physician, then even if the herbs are correctly selected, if the courage to use the required amounts is lacking, it is equivalent to tossing a glass of water on a raging blaze! At this stage of the game, who is going to try to grab both ends, to tonify and reduce?



References 1. Huang R, 1587, A Year of No Significance: The Ming Dynasty in Decline, 1981 Yale University Press, New Haven, CT. 2. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. 3. Ochs S, The liver and kidneys have the same source, Journal of Chinese Medicine 2005 (79): 16-22. 4. Cheung CS and Hirano M (translators), Huang BM, A brief discussion of the use of radix rehmannia by the ancient master Zhang Jingyue, Journal of the American College of Traditional Chinese Medicine 1982 (4): 33-37. 5. Smith FP and Stuart GA, Chinese Medicinal Herbs, 1973 Georgetown Press, San Francisco, CA. 6. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin. 7. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (vol. 3) 1995–6 New World Press, Beijing. 8. Clavey S, Treatise on treatment by Zhang Jiebin, The Lantern 1(1). The Lantern Website 2004: http://www.thelantern.com.au/resource_detail.php?id=3 June 2012

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THE LESSONS OF SHENNONG The Basis of Chinese Herb Medicine by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Shennong (the Divine Farmer) is the legendary originator of Chinese herbal medicine. It is believed that he was first known as Yan Di (Emperor of Fire), which is why he eventually became known by the full title Yandi Shennongshi (1). His depictions are numerous, mostly appearing as a leaf-draped recluse or a buffalo-horned guardian of the agrarian way of life (the water buffalo was used in virtually all farming activities, especially to pull plows through marshy rice fields; Shennong is credited with developing grain agriculture).

Paintings (left, from India; right from China) of Shennong; typically he has two "horns" at the top of his head, and is adorned with leaves, with a plant in his hand to be tasted.



Giant stone statue of Shennong in Shennongjia, Hubei Province.

Water buffalo pulling a plow through marshy rice fields.

There are two sites in China attributed to the origin of Shennong. The place that seems most likely to be the actual home of Shennong is near the eastern border in what is today Shaanxi Province, along the Jiang River, southwest of the Qi mountains. East and slightly north of the ancient Chinese capital of Xian lies Hua Shan Mountain, where, legend has it, Shennong was conceived, thanks to the intervention of a "divine dragon." In this area (now Fufeng county), an ancient civilization existed, and sophisticated artworks of metal construction have been found dating back nearly 3,000 years (see sample below). The descendents of Shennong have the ancient name Jiang, for the river, and this name is now the 60th most common surname in China. An alternative site for Shennong's home is at Lishan, a mountain in Hubei Province. Hubei is just to the southeast of Shaanxi, and this site is not far from Xian; it is a burial site for the first emperor. There is a cave there, called Shennong Cave, marking the area where he is believed to have lived. It is possible that descendents of Shennong established a home in this area, giving rise to the idea that it was a birthplace of Shennong.

Left: An artifact at the Shanghai Museum from about 800-900 B.C. found in the area where Shennong is believed to have lived (Fufeng County, Shaanxi). Right: A vessel from the same time period and region (Shaanxi Province, Western Zhou Dynasty) for preparing and storing liquids, like those made from herbs.

Shennong is said to have helped people transition from a diet of meat, clams, and wild fruits, to one based on grains and vegetables, and for developing herbal medicine. In addition to promoting agriculture (Shennong is translated as divine farmer), he is recognized for tasting hundreds of herbs-on one day, more than 70 herbs that had medicinal value-selecting those that were suitable as remedies, and describing their properties. As a result of his efforts, numerous herbs became routinely used for health care, and the knowledge was handed down by oral tradition for centuries. When these herbs were described in a formal manner, the book was named after Shennong, known today as the Shennong Bencao Jing (Herbal Classic of Shennong) . The earliest mention of a text called Shennong Jing (Classic of Shennong) is by authors who lived during the period immediately following the fall of the Han Dynasty (220 A.D.), suggesting that it might have been compiled during the latter part of the Han Dynasty. Further, the text that comes down to us mentions governmental regulations that applied during the latter Han Dynasty, indicating that this is when it was compiled. It is thought that Shennong lived from 2737 B.C. to 2697 B.C., nearly 5,000 years ago; this is why it is common to hear that Chinese medicine has a history of 5,000 years. However, we are able to access little information about how herbal medicines were used prior to the compilation of the Shennong herbal, about 1,800 years ago. The original Shennong herbal is long gone, but a version that was four chapters long (the first being general essays; the last three were sets of herb monographs) was used by Tao Hongjing (456-536 A.D.) to produce the Shennong Bencao Jing (published around 500 A.D.) that comes to us in copied form today (2). This text has twice as many herbs as the original, arranged by type of material (e.g., minerals, trees, herbs) and by categories of "upper, middle, and lower" grades (see Appendix 1). Sections copied from the original were in red ink, while new materials and commentaries of various herb authorities were written in a black ink, thus preserving a version of the original. An English language reconstruction of the ancient Shennong Bencao Jing has been published (3).

In addition to having a book named after him, Shennong has been honored by having a region rich in plant resources named after him as well: Shennong Jia (literally, Shennong's Bookshelf or Shennong's Ladder). Legend has it that Shennong carried out his investigation of herbs in this area, which is not far from his birthplace (4). Shennong Jia is a high plateau of central China with mountain ridges and rivers crisscrossing the area. The main forested area is in northwest Hubei Province, near Shaanxi, lying between the Yangtze River and the Han River. This area has become famous today as a place where the "bear man" (like "bigfoot" or "yeti," sometimes referred to as abominable snowman) resides. There are six mountain peaks that are about 3,000 meters high, the highest peak being 3,105 meters (nearly 10,000 feet). A large stream running through the area is called Shennong Stream or Shennong River. Much of Shennong Jia is now a nature preserve, where there are numerous rare plants; it is known for ginkgo trees, gastrodia lily, tremella fungus, codonopsis, and tang-kuei (5). Altogether, there are about 3,000 plant species in the area, with 34 endangered species under government protection.

Map showing Yangtze River and Shennong River (Stream) in the southern part of the Shennongjia area. Badong, the main city, is shown near the juncture of the two rivers.

LESSONS Today, practitioners of Chinese herbal medicine (outside of China) frequently study the names and properties of herbs, yet have little or no personal experience of the numerous individual herbs or the formulas that are made from them. This book knowledge is quite sterile compared to Shennong's approach of tasting each herb and experiencing its unique taste and discerning its properties. Thanks to Shennong and the many generations of herb doctors that followed him, as well as the input from modern research, we do not have to fear, in trying out the herbs, experiencing highly toxic ones, as Shennong did. The step of tasting each herb (directly, or cooking up a portion with appropriate dosage) and experiencing its effects is an important one, especially for the approximately 100 most commonly used herbs. Similarly, brewing up herbal decoctions or chewing of pills of standard formulas and tasting them would also be a great benefit, as would taking the herbs in small formulations for a short course of therapy to experience the effects. Herbalists who diligently pursue such a path, and who are careful not to have their own limited experience overshadow the vast experience of all those specialists who have gone before them, can be compared to Shennong and might be said to be his students. By contrast, those who only study herbs by name and recited properties are taking chances with their patients, not knowing, at a deep level, what it is they are prescribing and not understanding the basics of taste, nature, and effect of the herbs.

REFERENCES 1. Kuang Daren, Agricultural advance by Yandi Sennongshi and Hunan ancient rice culture, Agricultural Archeology 2000 (1): 129-141 [Tsao W, translator; Gordon B, editor] 2. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 3. Yang Shouzhong (translator), The Divine Farmer's Materia Medica, 1997 Blue Poppy Press, Boulder, CO. 4. Shennong Jia http://www.cq66.com/ENGLISH/newpage4.htm 5. http://www.yangtzecruises.com/gallery/plants/plantsherbs.html 6. Chen Ping (editor in chief), History and Development of Traditional Chinese Medicine, 1999 Science Press, Beijing.

January 2004

APPENDIX 1: Three Classes of Herbs

It is common practice for writers today, when describing Chinese herbs, to mention the classification of herbs into three groups, such as upper (or superior), middle, and lower (or inferior). This system was described by Tao Hongjing in his expanded rendition of the Shennong Bencao Jing. He claims, in the introduction, that this system already existed in the original work. Here is his description of the three types of herbs, as rendered by Paul Unschuld (2): The nature of the drugs in the upper class is quite capable of expelling illnesses. But the strength and function of these substances is gentle; they do not produce hasty results. If these drugs are consumed over years and months, though, a very beneficial effect is inevitable. All illnesses will be overcome and one's existence will be extended. The way of Heaven is characterized by] humaneness and creation. Therefore, it is said that the effect of these drugs corresponds to Heaven. The 120 drugs of this class should be referred to as representing the months yin, mao, chen, and si [note: these are months of spring and early summer]. They correspond to the time when all things come to life and flourish. The nature of the drugs in the middle class is more closely connected with curing of illnesses; one mentions them less frequently in connection with the liberation of the body from its material weight. If one takes these drugs to eliminate actual suffering, he should use them quickly; if they are supposed to increase one's life span, they should be taken gradually. Mankind harbors feelings and desires. Therefore, it is said that the effects of these drugs correspond to Man. The 120 drugs of this class should be referred to as representing the months wu, wei, shen, and you [note: these correspond to summer and early autumn]. They correspond to the time of completion and maturity of all things. The nature of the drugs of the lower class is especially suited for attack. The influences of these drugs with their markedly medicinal effectiveness upset the harmony of the organism. They are not to be consumed over an extended period of time. Once an illness is cured, the intake of such drugs must be stopped immediately. The principle of the Earth is to detain and kill. Therefore, it is said that the drugs of the lower class correspond to the Earth. The 125 drugs in this class should be referred to as representing the months xu, hai, zi, and chou [note: these correspond to late fall and winter]…. The drugs of this class correspond to the decay and final concealment of all things. According to the principles of combining, drugs to prescriptions, the drugs of this class must not be employed one-sidedly. They should be blended in accordance withy a patient's suffering and then act collectively…. These comments may be summarized as in the following table: Quality

Upper

Middle

Lower

heaven

man

earth

Principles

humaneness and creation

feelings and desires

detain and kill

Correspondence

come to life and flourish

completion and maturity

decay and burial

Nature

gentle, not hasty

quick or gradual

marked effect

months, years

short or long term

short term

Image

Duration of use Effect

protect health, prolong eliminate suffering or life prolong life

cure illness

The grouping of the herbs into three categories has been criticized. For example, in History and Development of Traditional Chinese Medicine (6) the authors note that the three levels have demarcations that are too vague and it is often difficult to grasp the criteria used. Thus, longan (longyanrou), which is a mild tonic herb, was classified in the middle level, while melon pedicle (guadi), which induces vomiting, was listed in the top grade. There are many such examples where the classification of the herb doesn't seem to follow the described pattern for the three categories.

APPENDIX 2: Dosage Forms of Herbs The method of herb preparation is not stated in the original Shennong Bencao Jing herb monographs, though preparation instructions for many of the herbs were added by Tao Hongjing in his publication. Some proponents of Chinese herbal medicine suggest that decoctions are the most appropriate and effective form of herb administration. In fact, throughout the history of Chinese medicine, powdered herbs (usually formed into pills, but also used for brief decoction to make a tea) have been widely used. Tao Hongjing gave some instructions about these forms. Here is a section from the first chapter of his book, translated by Paul Unschuld (2): All drugs used in the preparation of pills or powders must first be cut up into fine pieces. Then they are dried in the sun and pulverized. Whether a drug is to be pulverized individually or together with the other drugs in a prescription is determined by the prescription. For drugs containing a large amount of moisture, such as ophiopogon and rehmannia, the following is applicable. First, they are cut, dried, and pounded individually into small pieces. Remove the fine parts repeatedly, and tear the remaining portions. Then, they are dried again. If shady weather or rain arrives, they may also be roasted over a weak fire until they are dry. One waits a few moments until they have become cool again before they are pounded. All drugs containing moisture suffer great weight losses during the drying process. For this reason, the amounts must be carefully increased before drying. Weighed again afterwards, the amounts will be correct. This does not apply to drugs used in decoctions or medicinal wines. Decoctions are boiled gently over a small fire. The amount of water varies with the volume of the prescription. In general, one dou of water is used with twenty liang of drugs, reduced by boiling to four sheng [note: 1 dou = 10 sheng, so reduced to 40% the original volume]. This should serve as a standard. If one wishes to prepare a laxative decoction, by means of slight processing [note: rhubarb root was usually cooked only a short time to preserve its laxative effects], only a small amount of water should be used but a relatively large quantity of the boiled liquid shall be taken. If a restorative decoction is desired, which needs thorough processing [note: tonic herbs were often cooked for an hour or more], a large volume of water is used, boiled long enough so that only a small amount of liquid remains to be taken as medication.

For the monograph on the herb badou (the purgative croton seed), Tao indicated: "It should be pounded to a pulp separately from other possible ingredients in a prescription, and, finally, it is processed into pills and powders." In his introduction to the book, the preparation and dosage of decoctions is not given much further explanation, but for pills, such as those with strong agents like badou and gansui (this is another purgative, euphorbia) as medicinally effective components, he gave details of dosing, referring to the "scripture" of the original Shennong Bencao Jing: One ingredient, one medicinally effective drug, take one pill the size of small hemp seeds. Two ingredients, one medicinally effective drug, take two pills the size of large hemp seeds. Three ingredients, one medicinally effective drug, take three pills the size of small beans. Four ingredients, one medicinally effective drug, take four pills the size of large beans. Five ingredients, one medicinally effective ingredient, take five pills the size of hare droppings. Six ingredients, one medicinally effective drug, take six pill the use of wutong seeds [firmiana] The preparation of pills is determined by the number [of the ingredients]. The reference to "medicinally effective ingredient" is to a potent herb, usually of the lower class, while the other ingredients, though effective, are milder in nature and used to harmonize the activity of the main ingredient. The term applied in Chinese for these effective ingredients is du, which means toxin or poison. However, this epitaph is used as a contrast to the herbs that can be taken in large quantity and repeatedly, which are said to be free of toxins. In the story of Shennong, it is sometimes translated that he consumed "more than 70 poisonous herbs in one day," which is referring to this concept of medicinally effective herbs.

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UNDERSTANDING QI: The Four Gentleman Decoction by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Si Junzi Tang, commonly called the Four Gentlemen Decoction or the Decoction of Four Noble Drugs, is one of the well-known formulas of the Chinese tradition. In most modern texts, it is listed first among the qi-tonic prescriptions. It was recorded in the Taiping Huimin Hejiju Fang of the Song Dynasty (published around 1110 A.D.), developed from a prescription of the Shanghan Lun, which was written at the end of the Han Dynasty (ca. 220 A.D.). The name of the formula is unique, and stands in contrast to the standard naming method that had been used at the time, which was either to list the herb ingredients (typically done when there were fewer than five ingredients), to mention the main ingredient, or to mention the action of the formula. The same basic name for the formula is also applied to the modified versions, such as Liu Junzi Tang and Xiang Sha Liu Junzi Tang, also recorded in the Hejiju Fang. Si Junzi Tang has four ingredients: ginseng, licorice, atractylodes (baizhu), and hoelen (fuling); it is derived from Lizhong Wan (Pill for Warming the Center) of the Shanghan Lun by replacing the warming, spicy ginger with the bland, neutral hoelen. As a result of this single herb change, the earlier chill-dispelling prescription is altered to form a more moderate spleen-tonifying and moisture-resolving formula. By calling the formula “four gentlemen,” one of the implications is that the four ingredients all have an equal status in the formula. By comparison, many formulas are described as having a ruler (emperor), minister, assistant, and aid (see: Designing a personalized Chinese herb formula). Despite the formula’s name, some authors differentiate roles for each of its ingredients and specify that the four work harmoniously together (but are not equals). This explanation is not as satisfactory, since the characteristic of harmonious action among ingredients is attributed to many prescriptions that are named in the ordinary manner. Thus, for example, in the book Formulas and Strategies (1), which attempts to provide roles for individual ingredients of the formulas it describes, ginseng (or codonopsis, dangshen, used as a substitute) is said to be the ruler; atractylodes is the minister; hoelen is the assistant; and licorice is the envoy, yet each of the herbs has essentially the same function. Licorice is as much a key herb in the prescription as ginseng, though in many other formulas it is mainly used to moderate the strong flavor of a decoction or harmonize the action of ingredients with diverse properties. The term junzi is one that is well known in China; it comes from Confucianism, a doctrine that has been prominent throughout Chinese history since Kong Fuzi (Confucius) taught his principles of moral living about 2,500 years ago. According to Analysis of Chinese Characters (2), jun is “a princely man.” The character is composed of yin (a magistrate) and kou (mouth; uttering his decrees and orders), thus representing authority. In the book, Confucius Lives Next Door (3), T.R. Reid describes the term junzi this way: It is written with two characters that mean royal [jun] and person [zi]. This tells us that traditionally junzi referred to a prince, an aristocrat, someone who obtained a position of stature and power through birth. Confucius accepted the basic principle that certain people have the right to hold elite positions, but then he completely changed the rules for joining the ranks of the elite. To Confucius, the junzi—the term has been variously translated as “the noble man,” “the superior man,” the “gentleman”—was a person who had earned elite status. To be a gentleman, a person had to spend a lifetime studying and following the rules of virtuous conduct. Just being born right was not enough. A gentleman should be judged—just as Martin Luther King, Jr. would put it 25 centuries later—on the content of his character. The formula is so-named because the inherent character of the four herbs is royal and virtuous. They have a mild nature and support the body functions; they do no harm and their qualities are well suited to the organ system (stomach-spleen) that they are aimed at treating. Si Junzi Tang is traditionally to be given to those who are fatigued, pale, and have a quiet voice that results from their lack of qi; the person has a weak appetite, a low body weight, and a tendency to have loose stools. In general, there will be a tendency towards chilliness, little thirst, and an adverse reaction to eating rich foods, such as abdominal pain. These problems may have several sources, but all involve a weakening of the central qi. Among the possible causes are overwork, excessive anxiety and brooding, irregular eating habits, and repeated exposure to unfavorable weather conditions. The formula may be modified by adding pinellia (banxia) and citrus (chenpi) to yield Liu Junzi Tang (Six Gentleman). These added herbs invigorate the function of the stomach and resolve phlegm accumulation, a byproduct of stagnancy of food in the stomach. The formula is used for the same basic condition as Si Junzi Tang, except that there are complications of fullness in the chest, nausea (with possible vomiting), and cough with profuse thin and clear expectoration. Again, the formula may be modified by further adding saussurea (muxiang) and cardamom (sharen) when there is abdominal fullness and pain. The resulting formula is called Xiang Sha Liu Junzi Tang (xiang = muxiang; sha = sharen). THE PRINCIPAL FUNCTION OF SI JUNZI TANG The formula is often described primarily as a qi tonic, and this term conveys to many Westerners the idea that it increases one’s energy and is to be used in many cases of fatigue. While fatigue is one of the symptoms that can lead to a diagnosis implicating the use of Si Junzi Tang as a therapy, it is not the primary focus of the formula.

Rather, the formula improves the function of the spleen in transforming (fermenting) food essence and fluids (“grains and water”) and transporting those essences throughout the body. It might, therefore, be better understood as a nutritive formula, not in the sense that it provides nutrients, but that it helps the body to become better nourished by retrieving more from the food and having all the organs and body parts receive the beneficial essence. One of the primary indicators for use of the formula is pallor (both facial coloration and tongue color) that develops as a result of inadequate nutritional status and poor circulation. Ginseng (or the substitute, codonopsis) and licorice are intended to enliven the spleen so as to increase the desire for food, help transform the food to useful nutrition (producing of qi and blood), transport the essences to the spleen, and help the spleen to circulate the fluids. These herbs are indicated for treatment of poor appetite, lassitude, and tendency to have loose stool (because neither the food essence nor the fluids have been fully extracted from the food; they drain downward with the wastes rather than being borne upward to the spleen and upper burner). Atractylodes has the same basic function as ginseng and licorice for tonifying the central organs, but being bitter and spicy, it has an additional property of helping to dry excess fluids that make the spleen sluggish in its activities. Hoelen also has the same basic contribution to make, but being bland and spongy (in the sense of absorbing fluid), it is helpful in preparing excess fluids for elimination. While hoelen and atractylodes are especially valued for removing excess fluids impairing the yang aspect of the spleen and stomach, ginseng and licorice have moistening qualities that protect the yin of the stomach and spleen. These four herbs were deemed, during the Song Dynasty, to be the essential ones for improving stomach-spleen function for the specific symptoms indicated here. To understand the role of the spleen and its treatment by this formula, one can read the explanation of Li Dongyuan (1180–1251 A.D.) in his Treatise on the Spleen and Stomach (4): To live, humans must receive qi from water and grains. So-called clear qi, constructive qi, conveying qi, defensive qi, and the upbearing qi of spring are all synonymous with stomach qi. Stomach is the sea of water and grains. Having entered the stomach, food and drink float the essence qi and transport it up to the spleen. The spleen qi spreads essence which gathers in the lungs and frees the flow of the water passageways, transporting water essence down to the urinary bladder. One can see that the concern is for getting nourishment from food. Weakness and lassitude (low energy) are the secondary effects of poor nourishment, so the formula is indicated for treating fatigue in this particular context rather than serving as a sort of energy stimulant. A typical dosage pattern for Si Junzi Tang is: Ginseng 10 g Atractylodes 9 g Hoelen 9 g Licorice (baked) 6 g To add citrus and pinellia, about 9 grams of each are used; to add saussurea and cardamom, about 3–6 grams are used. CAUSES OF QI DEPLETION AND REPLENISHMENT: A Further Understanding of the Four Gentlemen Decoction Mencius (Mengzi) was a proponent of Confucianism who lived about a century after Confucius died. He provided a more detailed explanation of the Confucian philosophy than is found in the original succinct sayings (Analects), and he and his contemporaries gave a description of qi which, to this day, remains of value to those who wish to understand it more fully. Following is a representation of Mencius’ conception of qi relayed by Benjamin Schwartz (5), for which a lengthy passage is quoted, but edited slightly to improve the readability. The discussion begins with the matter of remaining serene in the face of outer disturbances, described as maintaining an “unmoved heart,” and proceeds with an investigation of how disturbance and pathological conditions (such as morally wrong behavior) can arise. In the current Chinese medical jargon, the basis for the unmoved heart corresponds to having strong qi and blood that protects and defends against external influences, so that the shen (spirit) is not disturbed and illness does not arise. As explained here, that strong qi is courage, will, virtue, and, most importantly, the dedication to living a good life: the life of a noble man (junzi). The crucial dialogue in the Mencian text opens with a discussion of the unmoved heart. Mencius— like Confucius and like many of his own contemporaries—remains profoundly concerned with the attainment of an attitude of inner peace, serene courage, and equanimity in the face of the anxiety-ridden world....Mencius points out that some men achieve a posture of stoic indifference to the vicissitudes of the outer world simply by cultivating within themselves a constant disposition of physical courage, and it is in connection with this disposition that the term ‘qi’ is first introduced as a crucial category along side ‘nature’ (xing) and ‘heart’ (xin).... Courage belongs to qi because it is fundamentally an emotional disposition, and emotional dispositions belong to the category of qi (a kind of psychophysical energy/substance). It seems possible for some men to cultivate this emotional disposition within themselves, just as others may build up their physique through exercise. Mencius, however, points out the narrow limitations of an unmoved heart which is maintained simply by this cultivation of physical courage: courage may serve any ends, and since it belongs to the realm of passions and emotions, it may, in fact, become subservient to unworthy purposes.

The man of moral courage, however, is courageous only when he is right. Confucius is quoted as saying, ‘If in looking within, one finds oneself to be in the wrong, then even though one’s adversary be a coarsely clad commoner, should we not tremble with fear? If on looking within, one finds that one is right, one should move forward against men in the thousands.’ The Confucian man of unmoved heart obviously requires courage. His courage is, however, firmly based on unswerving righteousness. In Mencius as in Confucius, inner equanimity and virtue are inseparable. The discussion of courage as an emotional disposition introduces the crucial category of qi. The qi is a kind of energy/stuff (sometimes associated with the blood, as in Confucius’ xueqi: blood-qi) which circulates throughout the body and its organs, and which embraces all vitalities associated with the emotions, the passions, the appetites, and the desires....The constantly circulating and ever-changing passions, emotions, and appetites are the arena in which the disorders and perversions of the human person make themselves manifest within. It is the turbulence and disorders of the qi that most directly obstruct the growth of the ‘shoots’ of goodness in the human heart. Mencius does not regard the disturbed (or excessive) vital energy of the qi as the ultimate cause of evil behavior, for qi is associated with courage, which is in itself good. Indeed, when he speaks of the disorders of qi—using distinctly physicalist imagery—he speaks not of an excess of qi, but of a deficiency of qi. How is it then that qi within an individual can become the source of perversity and disharmony? When the qi ‘fills the body,’ all the senses and physical organs, with all their affective and perceptive properties, function precisely as they should within their proper domains. One might say that when all parts of the organism are full of qi—distended, as it were, to their proper limits but no further—there is a harmonious and just balance among them. It is when qi drains out of the body and becomes depleted that imbalances occur which relate directly to imbalances and disorders in the emotions and passions. In a passage of the Chuangzi [a text by the famous Taoist, known to us as Chuang-tzu, and a contemporary of Mencius], we find it stated that: ‘If the qi that is stored up in a man becomes dispersed, then he suffers a deficiency. If it ascends and does not descend, it causes him to be constantly irritable. If it descends but does not ascend, it causes him to be chronically forgetful. If it neither ascends nor descends but gathers in the middle of the body in the region of the heart, he becomes ill.’ In the Huainanzi [another Taoist text] we find the following highly revealing passage: ‘If the bloodqi can be concentrated in the five organs without drifting away, then the chest and stomach can be replenished and the lustful desires diminish. When the chest and stomach are full and the desires are diminished, the ears and eyes are clear and the senses of hearing and sight are penetrating: we call this clarity. The five organs are then subject to the rule of the heart and there is no deviation. The will dominates and behavior does not go astray. When the will dominates and behavior does not go astray, the spirit flourishes and the qi does not dissipate.’ What causes the depletion of qi and what causes its replenishment? The men of mere physical courage try to maintain their qi by cultivating a dominant emotional disposition which can, perhaps, control certain forms of depletion of qi, particularly loss of qi through fear....Yet, connected with the qi, there are many other irrational passions that physical courage cannot control and that may overwhelm physical courage, which is itself an organically-based emotion. Mencius points out that ‘what is not to be gotten from the heart is not to be sought in the qi.’ The spiritual basis of the unmoved heart should rest on something more solid than anything derived from the emotions and passions. What is it then, that causes the dispersion of the qi and the disorder of the passions which is sufficient to block the actualization of the heart’s potential for achieving the promise of its nature? The qi is very much affected by its interaction with the outer world and this interaction occurs in the realm of the senses that provides men with their channels of communication with the outer world. Kong Fuzi asks, ‘Though men are equally human, why are some great men and some small men?’ The answer is ‘that the organs of hearing [listening] and thinking are unable to think and can be misled by outer things [making a man ‘small’]. That is, the organ of the heart/mind can think: if it thinks it will obtain the right view; if it does not think, it will not obtain it.’ It is not the senses, through which interaction with the outer world takes place, that are the locus of evil. On the contrary, the senses belong to our heavenly nature: they are part of that nature which we share with the animals. It is entirely natural for the palate to love good tastes, the ear to love good sounds, and the eyes beautiful sights. Evil somehow arises in the area of the interaction between the qi and the senses. There is something in the nature of the qi and the senses as they operate within the human being that leads them to become fixated on and obsessed with or excessively repelled by various aspects of the outer world. The epicurean glutton does not simply enjoy good tastes, he becomes fixated on the limitless quantity and variety of good tastes. The unthinking senses can trigger either vast excesses of desire or of repulsion which completely upset the balance of the emotions and dissipate man’s vital qi. Where the vital qi is not drained off by these external obsessions, then the vital qi is maintained in balance.... Finally, how are the senses and the qi controlled? The key is found in the reference to the capacity of the heart/mind to “think;” there is either the will of the heart/mind to think, or the absence of the will to think....In concrete situations, one must make a choice between good and evil and this is a deliberate act of the intentional will. It is not the heart as the spontaneous vehicle of the good nature that brings order to the senses and harmony and replenishment to the qi, rather, it is the heart as the intentional organ of willing and thinking. Mencius does not simply assert that it is the heart that rules over the qi. He asserts that it is the will....It is only the conscious level of man’s mind that can—by its unceasing, ever-renewed moral effort—lead most humans to salvation....The sages live in a world of harmony with the universe on every level of their being. Their conscious hearts are always at one with their spontaneous hearts.

Their senses are under the complete control of their hearts and the fully nourished vital energies of qi are fully in balance within the body and in harmony with the cosmic qi.... The senses and the qi can be ultimately controlled only by the determination to act rightly—to accumulate righteousness in all the complex circumstances of life. A man who concentrates his whole mind on acting rightly will have found the loftiest and truest method of achieving an unmoved heart because he will be in full control of his appetites, emotions, and passions, and will thus constantly nourish his qi. The qi can then become the ‘flood-like qi’ which contributes to a kind of feed-back process: it is, in turn, a vital energy which nourishes and strengthens the innate propensity to goodness. One might say that goodness becomes imbedded in the character. A man who can thus realize all the potentialities of the heart will obviously share the totally unmoved heart of the Confucius of the Analects and will also be a man capable of saving the world [junzi]. In sum, the fullness of qi that brings harmony and serenity arises from one’s will to act rightly, which is the key step to becoming a gentleman (or gentlewoman; in Chinese, the term junzi does not connote a gender). Both Confucian and Taoist authors, as well as their Buddhist counterparts, seem to ultimately agree in this: the determination to act rightly, and the resulting moral behavior, leads to control over the qi and all good things develop from that. The herb formula named Si Junzi Tang might also be interpreted as “the decoction of four herbs that aid one in the effort to replenish qi, strengthen the will, sharpen the senses, improve the thoughts, cultivate virtue, and thereby become a superior person.” REFERENCES 1. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA. 2. Wilder GD and Ingram JH, Analysis of Chinese Characters, 1974 Dover Publications, NY. 3. Reid TR, Confucius Lives Next Door, 1999 Random House, New York. 4. Yang Shouzhong and Li Jianyong (translators), Li Dongyuan’s Treatise on the Spleen and Stomach, 1993 Blue Poppy Press, Boulder, CO. 5. Schwartz BI, The World of Thought in Ancient China, 1985 Belknap Press, Cambridge, MA. October 2010

Figure 1: Confucius.

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THE SIX QI AND SIX YIN by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The six qi (liuqi) refers to an ancient Chinese concept still relied upon in today’s discussions of traditional Chinese medical practices. The concept behind the term is that external (environmental) conditions can influence the functions of the body. When the environmental conditions are moderate and normal (e.g., “seasonable weather”) and the person is dressed properly and protected from over exposure, the sixqi have a positive influence. However, when the conditions become extreme, when they change rapidly, or when they do not follow the usual pattern, they are able to adversely affect health, and cause disease. In such cases, the six qi are known as liuyin (six excesses) or even liuxie (six evils). The term “qi” used in the description of the environmental conditions is the same as that used throughout the discussions of Chinese medicine, and refers, in this application, to the characteristics of the atmosphere and its influence on the body. The external qi can cause the internal qi to shift. On the positive side, this means that the six qi can nurture the body, carrying the heavenly cycle into the interior and assisting human development and expression, harmonizing the inner qi with nature. On the negative side, weather that is extreme or unseasonal can cause internal disruption and harm, pushing the qi out of balance. This is especially the case if the body is not fully nourished and the vessels are not rich in qi and blood: then there is insufficient protection from the potential adverse impact of the outside. It is commonly said that if disease enters the body, it is because the weiqi (protective qi) is deficient; the situation is also expressed as the vessels being “empty” and thus readily receiving the evil from the exterior. While the Chinese pictogram for qi describes the fragrant, moist, warm steam in a pot of cooking rice (see Qi: Drawing a concept), the more general meaning of qi is an influence, which is the translation term used by Paul Unschuld in his books on Chinese medical history. Hence, when the weather is moist and very warm (as occurs on a hot, humid summer day), that is something like the qi of the cooking pot; but one can also have a cold influence or a dry influence, and each of these is a type of qi. There is some difference in concepts between the modern ideas of weather or climate and the Chinese ideas of external qi, though there is considerable overlap. In recognition of the similarities that exist, the concept of six qi is often translated as the “six climatic influences.” The primary difference in the traditional versus modern thinking has to do with the extent of influence of climate on the internal environment; both agree that extremes can do harm, but the Chinese view is that the atmosphere can have more health effects. “Normal” weather in most places that humans live might cause one to feel chilly or warm, and it might cause one to feel other discomforts (e.g., flare up of arthralgia with moderately cold-damp weather), but, even when it is somewhat severe or unseasonable, it is not seen as a primary cause of diseases. That is, the weather has some ability to affect us, but we can easily overcome that, especially as we have accomplished in recent years through a combination of carefully-crafted protective clothing, well-built houses and cars, and climate control devices (such as heaters, air-conditioners, humidifiers, dehumidifiers, air filters, etc.). Today, vast numbers of people spend most of their time in climate-controlled environments. By contrast, this is the situation as described in a 12th century Chinese text (1): The six excesses are ordinary influences of heaven. If one fails to care about their assimilation in correct proportions, they will flow into the body, starting from the major conduits and network conduits [jing and luo] and, then, unite internally in the viscera and bowels [zang and fu]. They are causes of illness that have come from the outside.

In a 16th century text, this is said (2): Although the origins of illnesses are traceable to many causes, all of them result from something evil. Evil is the ultimate cause of all illness. That is to say, everything that is not part of the normal order in the human organism can cause illness, such as wind, cold, dampness, hunger, fullness, taxation, and idleness, is evil—and not solely the influences of demons and epidemic illnesses as some authors have claimed. Just as the fish exist in water, man lives surrounded by influences [qi]. If the water is turbid, the fish waste away. If the influences to which man is exposed are irregular, man falls ill. Because doctors in ancient times had fewer available explanations for illness (lacking information about viruses, bacteria, genetic factors, immune system disorders), the external qi were seen as being major and direct disease-causing factors. The six excesses (liuqi) was a concept that largely replaced the previously dominant explanation of external disease causation, which was the influence of demons (see: Demons as a cause of disease). The six excesses were not entirely replaced later by the concept of epidemic disease (diseases associated with a transmissible factor), but did become reduced in importance, at least among some doctors, as this new transmissible factor became a focus of attention, especially at the end of the 19th century. Modern explanations of disease causation place climatic factors mainly in the realm of indirect causes: we know, for example, that certain climatic conditions contribute to multiplication of pathogenic organisms, which can then infect the body. In that way, climate can indirectly determine whether one is at risk of experiencing diseases such as malaria, yellow fever, and a host of other tropical infections. Also, we know that dry climates are inhospitable to certain pollen-releasing plants and for many molds that cause inhalation-allergies, so that the climate can affect whether or not one experiences allergies (which may appear to traditional practitioners as cases of winddamp influences). It is known that cold weather affects the mucous membranes of the sinuses and lungs and weakens immune functions, leaving one open to viral infection. The modern view is that the disease is caused by the virus, not by the cold weather, though it is clear that the two factors work together to determine the risk of getting the disease. Similarly, multiple sclerosis tends to occur more frequently in people living in northern climates, which are relatively cold, but it is assumed that this is because certain pathogens, dietary habits, or other factors that are found in these northern areas cause the disease: not that the coldness causes it (once affected, the heat rather than cold exacerbates this disease). Today, doctors generally view the influence of weather on human health as something that might enhance risk of disease or might exacerbate existing disease, whereas the traditional view was that the six qi had direct influence on health, and that the six excesses caused the disease by their very nature. They were particularly concerned about the ability of wind to penetrate the body and cause severe consequences, including stroke. The Advanced Textbook of Traditional Chinese Medicine and Pharmacology (3) relates this traditional view: Wind, cold, summer-heat, damp, dryness, and fire are the six climatic factors which correspond to normal seasonal changes. Normally, they are known as the “six qi.” The growth of all living things depends on the existence of the six qi. They should not be harmful, rather, they should be helpful to human beings....Human beings have learned the laws of nature through the changing features of the seasons and have adapted themselves to these changes. Thus, the six qi normally will not cause diseases. However, if and when the six qi become abnormal or excessive, as happens in abrupt changes in environmental conditions, and if the body’s resistance is too weak to adapt to these variations, the six qi may become the six excesses: pathogenic factors that cause diseases. Because the six excesses are abnormal qi, they are known as the six unhealthy qi, or the six exogenous pathogenic factors. The reference to “the body’s resistance is too weak to adapt” concerns the idea of having the vessels full of qi and blood, as well as having the internal organs in a strong rather than compromised condition. The Oriental view is that the extremes in the environment that don’t cause drastic immediate results (as death or frostbite) are very likely to eventually cause illness. One can even suffer from the impact of normal (nonexcessive) weather patterns if one does not act harmoniously with them. In the Neijing Suwen, the situation is described in detail (4). For each season, the correct behaviors to harmonize with the seasonal influence [qi] are detailed, and the consequences of acting contrary are stated (see: Promoting Health During the Four Seasons for additional suggestions): Spring: He who acts contrary to these influences shall harm his liver; cold will form within him in summer, and little remains with him for the subsequent period of growth [next spring]. Summer: He who acts contrary to these influences shall damage his heart. In autumn he shall suffer from intermittent fevers, and little remains with him for the subsequent period of gathering. Severe illnesses will then occur at the winter solstice. Autumn: He who acts contrary to these influences shall harm his lung. Nourishment shall flow away from him in winter, and little will remain with him for the subsequent period of storing. Winter: He who acts contrary to these influences shall harm his kidneys and suffer from paralysis and cold limbs due to rising yang influences in the spring. Little will remain with him for the subsequent period of the creation of all things. Thus, the ancient view is that one must live in harmony with the season (specifically, its climatic quality) to avoid illnesses that will often appear later and which will leave one especially susceptible to weather-induced

patterns of the next season. The abnormal weather patterns include “unseasonal” conditions, such as cold days in summer, and storms: these are also thought to cause disease to arise. DEFINING THE SIX QI In China, the historical and generally accepted description of the seasons is similar to that in the West, in that there are four seasons falling into the same basic time periods. The discordance between having four seasons and five elements has led some to depict a five season pattern, or to apply a transitional pattern for each seasonal change (thus, with the earth element conditions prevailing at the seasonal transitions), but this is not something that has filtered throughout the Chinese culture. Cheng Wuji, in the Zhujie Shang Han Lun (1144 A.D.) wrote (2): The Comprehensive Treatise on Yin and Yang [Yin Yang Ying Xiang Da Lun ] states: the influences of spring are warm and pleasant; the influences of summer are hot and fiery; the influences of autumn are clear and cool; the influences of winter are bitingly cold. This, then, is the order of the regular influences associated with the four seasons. The characteristics of the seasons in China vary with the geography; China is a huge country. It has semitropical parts (e.g., Guangzhou, Hong Kong, Hainan Island, Taiwan), and deserts (vast areas in the northwest); it has high mountains (e.g., from Sichuan to Tibet), and northern coastal areas (e.g., Shandong). In each of these regions, the seasonal situations are considerably different. Further, it was believed that the various influences could penetrate the body to differing extents. Xu Dachun (5) outlined the situation (note: the term influence is again used to translate qi throughout): Man’s life depends on the influences of heaven and earth. Hence, the condition of his own influences and his body differ according to the geographic region where he resides. In the Northwest, the influences of heaven and earth enter the human body deeply, and they do so in rich quantities. When people in the Northwest are affected by wind-cold, it is difficult to drive the evil influences out again, and heavy preparations of dredging herbs are indicated. In the Southeast, the influences of heaven and earth remain at the body’s surface, and they do so only in small quantities. When these people are affected by wind-cold, it is easy to drain the evil influences, and light preparations of dredging drugs are indicated. Also, the Northwest is a cold region, and one should employ drugs with warm or hot nature. However, sometimes people are affected by accumulations of evil influences in the center of their body, and contrary to their normal condition, they become very hot internally. In such cases, one should use herbs with an acrid taste and a cold nature. The Southeast is a warm region, and one should employ cooling substances for treatment. However, it sometimes happens that both proper influences and evil influences disperse together, and, in such situations, one may easily lose one’s yang influences. In this case, then, it is advisable to use herbs with an acrid taste and with a warm nature. In the regions of Vietnam and Guangdong, sweat flows without end, and one is especially at risk of losing one’s yang influences. Here, aconite and cinnamon are often used substances. Also, the low-lying and damp territories of the central districts, or the dry territories in the high altitudes of Shanxi, these all require regimens in accordance with the specific conditions of these geographic regions. Hence, one must ask about climate, and customs, and closely adjust to them, as soon as one enters such territories. Differences exist not only between each prefecture; varying winds and influences exist even within one county. As one can see from this discourse, not only the weather but also the various effects of weather on the body must be evaluated before selecting a remedy. Thus, in the case where there is profuse sweating in oppressive hot conditions as found in the far south, cinnamon and aconite, two warming herbs, are used to recover the yang that is depleted through the continuous perspiration. Elaborating the Six Qi The six qi have been depicted in a number of ways. In modern times, the six qi and the six adverse influences are presented as essentially the same thing, though the list of six categories may vary between them. The six qi are usually depicted as wind, cold, heat, moisture, dryness, and fire. Note that heat (shu or re) and fire (huo) represent two differing manifestations, though this distinction becomes difficult to maintain. In recent texts on Chinese medicine, it has been said that the term heat represents an external influence, but the term fire should refer to an internal process. The six yin, or excesses, are: wind, cold, heat, moisture, dryness, and summer heat. Here also there are two designations of hot conditions. In the definitions of summer heat, there are two components: one corresponds to the original concept of “fire” as an external factor (scorching heat), so that the six qi and six yin are exactly overlapping, but the other is a particular combination of dampness and heat, and that is the dominant description relied upon today (see below: summer heat). Basically, the six qi refer to normal weather patterns, the six excesses refer to abnormalities that can cause disease. The group of environmental conditions comprised of hot/cold and wet/dry are pairs of opposites so easily observed that they are included as a standard part of all traditional medical systems. They represent both external conditions and internal conditions. Wind is a climatic condition that is observed everywhere, but given a heightened importance in the Chinese system. Summer heat is a relatively unique description in the Chinese system, one that appears to have been a later addition to the other five that were systematically corresponding to the five elements system (wood/wind, earth/wetness, water/cold, fire/heat, metal/dryness). Various combinations of these conditions may arise, and commonly do, so that one could have, for example, heat, moisture, and wind at the same time. It is beyond the scope of this article to explore each of the six qi, their combinations, and the development of

diseases from external causes as described in Chinese medicine; these concepts are depicted in numerous texts. However, three of the qi will be considered here in some greater depth: cold qi because of the importance attached to it by the Shang Han Lun, and the two qi that are somewhat unique to Chinese traditional medicine: summer heat and wind. COLD Coldness makes things more viscous, so cold was deemed a major cause of sluggish circulation and blocked circulation. Circulatory inhibition could cause pain, so one of the key characteristics of environmental cold influence (other than the most obvious: feeling chilled) is pain. With sufficient exposure to cold, the circulation is so badly damaged that tissues can be destroyed, as occurs with frostbite. Some diseases that affect circulation, such as Raynaud’s Syndrome, show a significant flare-up of symptoms with exposure to environment cold. Concern about the impact of cold was elevated to the highest position in Chinese medicine during the Song Dynasty with the revival of Zhang Zhongjing’s Shang Han Lun, a treatise about a severe disease or group of diseases related to coldness. The term han in the title means cold, and shanghan, a particular type of cold related disease, was first described in the Nei Jing (ca. 100 A.D.) and then in the famous book of Zhang Zhongjing. In his commentary on the Shang Han Lun, Chen Wuji comments (1): If one is affected by the influences of winter, that is called harm caused by cold. All harm received from any of the influences of the four seasons may result in an illness, but the harm caused by cold is considered to be the greatest poison because influences are involved here that cause more deaths and destruction than all the others. He goes on to explain that many illnesses that arise in Spring and Summer were due to the adverse influence of cold during Winter. For many centuries after the Shang Han Lun was written, and continuing up to the present, the significance of this book and its implication for medical practice has been debated. For example, concern developed about excessive use of warming herbs that resulted from some interpretations of the Shang Han Lun, and also about the use of the book’s theories and formulas to address what was eventually deemed a new or different kind of ailment: wenbing, or feverish disease. Avoiding coldness has long been an important lesson in Chinese medicine. Many students of Chinese medicine are alerted to this during the first days of classes, when instructors point out that common modern dietary practices, such as drinking iced beverages, eating raw foods (especially raw, refrigerated foods, as with salads and fruits), or consuming frozen foods (e.g., ice cream) are deemed extremely debilitating under the framework of traditional Chinese medicine. Such practices are thought to cool the stomach and spleen, reducing their ability to digest food, and, ultimately (with repeated experience) to cool the kidney, lowering the ability of the body to generate warmth, reproductive energy, and even brain power. In like manner, there is much concern expressed over failure to dress warmly for winter (especially, failing to protect the lower back and abdomen), turning to light clothing too early in the Spring, sitting in chilly air-conditioned rooms, and consuming cold-natured herbs. All this concern, whether justified or not, reflects both the historical importance of cold as a pathological feature in the field of Chinese medicine and also the particular situation in China. Although the Chinese had no refrigeration or air-conditioning, they learned early on that raw foods could cause extreme problems. This was not so much because of their rawness, as we know now, but actually because uncooked foods were usually contaminated with bacteria or worms that could have devastating and lasting effects on the digestive system as well as on the whole body. Similarly, non-boiled water was a serious problem, and it was not yet established that if water is boiled and saved in a clean, sealed container, it will remain safe to drink even if cool or cold. Instead, it was known that boiled water was safer than cold water. While it is true that consuming lots of cold drinks will chill the stomach and reduce the circulation in the stomach lining that influences digestion, the problem with iced drinks in modern times is not nearly so severe as the problem of non-boiled water was in China, so it is sometimes given exaggerated importance. WIND The Chinese concern about wind arises from ancient times. It appears that early beliefs were that the world was populated with vast numbers of benevolent spirits and malevolent ghosts that influenced the course of human events (and could be influenced by shamans of skill). If a person became ill, especially if the onset was sudden, the cause might be attributed to entry into the body of an evil spirit. As an example, if someone suffered a heart attack or stroke, or suddenly had a severe pain, loss of consciousness, loss of motor abilities, or died, it was thought that such a spirit had gotten in and caused it at that time. Since some of the demons were said to travel with the wind, such a disease was called “being struck by wind;” such terminology became especially prominent after demon-causation was devalued as the principle description of the problem. It did not necessarily mean that the person was standing outdoors in windy weather and the blowing wind itself caused the disease, though, this explanation had been applied in the past, and continues to be relied upon today. In the modern book English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (6) it is said that “Wind, prevailing in the Spring, exists all the year round. Wind in excess, called wind pathogen, can cause disease.” As the medical descriptions moved away from demon-caused disease to nature-caused disease, wind became the first and most important of the external causes. The concept soon evolved into the six qi and six yin. Though wind became specifically affiliated with the Spring season, this season is not necessarily the one in which there is more wind, as we conceive of wind today. In the English-Chinese Encyclopedia, it is explained: “Wind-pathogen is the predisposing factor contributing to exopathic [externally caused] diseases while all the other pathogenic factors, such as cold-pathogen, damp-pathogen, dry pathogen, usually invade the human body in association with wind pathogen.” This way of looking at wind focuses on the idea of invasion of a pathogenic influence, more so

than simple influence of the external conditions on the body. Wind-dispelling herbs, and some acupuncture treatments, were said to open up the pores through which the demons or, in later times, the invading wind-pathogen, could be let out. In this sense, many of the herbal therapies for wind disorders were used to induce diaphoresis (see: Eight methods of therapy), whether the treatment was for stroke, heart attack, common cold, sore throat, skin eruption, or any other disorder that arose suddenly. The importance of treating wind disease is described by Xiu Dachun (5): Whenever someone has been incidentally affected by wind-cold resulting in headache, fever, cough, and running nose, this is called, in everyday language, harm caused by wind....The fact is that the illness of harm caused by wind starts from the skin and its hair to enter the lung....All these conditions are considered minor illnesses, and the people affected by such problems neither avoid wind and cold, nor do they care about what they eat and drink. Over the years, and with every month, the workings of the illness penetrate the body deeper and deeper every day. In some cases, pathoconditions appear indicating the blood has been affected. Or the lung may cease to function properly, or panting may develop, or disquietude coupled with weakness. It is always the same, and the damage caused by erroneous treatments cannot be measured. As the proverb goes: “If one does not pay attention to harm caused by wind, the illness will change to fatigue.” Well said! But how to conduct a treatment? First, the wind is to be expelled with herbs like perilla leaf and schizonepeta; second, phlegm is to be dissolved with herbs like pinellia and fritillaria; third the influences are to be brought down with herbs like perilla seed and peucedanum; fourth; the constructive and protective influences are to be harmonized with herbs like cinnamon twig and peony; fifth, the body’s fluids are to be enriched with herbs like trichosanthes seed and scrophularia; sixth, the blood is to be nourished with herbs like tang-kuei and gelatin; seventh, the fire is to be cooled with herbs like scute and gardenia; and eighth, the lungs are to be regulated with herbs like morus bark and arctium. SUMMER HEAT The description of the six qi and six excesses, includes heat qi. Why did the Chinese add summer heat to the list of excesses? According to the Advanced Textbook..., “heat is an exogenous pathogenic factor that can be classified into various types, such as wind-heat, summer-heat, and damp-heat.” This suggests that heat is a factor that tends to alter others, such as wind and dampness. The reason for including summer heat as a separate entity is that there were certain diseases that stood out during summer that differed from heat disorders occurring at other times of year. The Advanced Textbook... says: “Diseases caused by summer-heat are only seen in this season....Summer heat is an exogenous pathogenic factor; there is no endogenous summer heat at all.” The other qi each have a corresponding internal cause (e.g., cold qi can occur internally from fear or from weakening of the yang of the kidney; wind qi can occur internally from anger or from deficiency of the liver blood and yin, etc.). Summer-heat disease can include symptoms of excess yang (high fever, fidgets, flushed face) and consumption of body fluid due to the heat (thirst, scanty urine), which corresponds to attack by “fire,” but the characteristic of summer-heat disease is the dampness syndrome. The description that arises is a pattern of fever, fidgets, thirst, weakness of the limbs (this occurs because of depletion of body fluids), tightness in the chest, nausea, loose stools, and sluggishness. Such conditions may be more common in wet summer situations in which the food and water become contaminated with micro-organisms (see Pill Curing and Huoxiang Zhengqi San). These pathogens taken in with food produce a symptom complex that may appear different than anything generated by internal processes or usual external influences, and occurs most often in the semi-tropical summers of southern China where it is rainy during that season. Summer heat could be a serious disease. Here is what Xu Dachun observed (5): I have seen people who had been hit by summerheat and who drank a bowl of strong ginger tea. They died as fast as it took them to turn their cup. If one takes a perilla leaf decoction, any cold will be dispersed immediately, and if the illness was caused by summer heat or ordinary heat, the intake of perilla leaf would not cause any damage either. The reason is that perilla leaf has a dispersing nature; it always disperses, regardless of the pathocondition present. Perilla leaf, known to the Japanese as shiso (the Chinese is zisu, or zisuye), is taken with raw fish to kill parasites that may be ingested with them. Today, Chinese physicians often rely on huoxiang (agastache or pogostemon) for the summer heat syndromes, along with or in place of perilla leaf. REFERENCES 1. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988, Kluwer Academic Publishers, Holland. 2. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. 3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (4 vol.) 1995–6 New World Press, Beijing. 4. Veith I, The Yellow Emperor’s Classic of Internal Medicine, 1966 University of California Press, Berkeley, CA. 5. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. 6. Xu Xiangcai (chief ed.), The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, (21 vols.) 1989 Higher Education Press, Beijing.

November 2010



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SUN SIMIAO Author of the Earliest Chinese Encyclopedia for Clinical Practice by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Sun Simiao is one of the most, if not the most, interesting figures in the history of Chinese medicine. It is not too difficult to support this judgment, even though biographical details of this Tang physician are only fragmentary. In his lifetime, Sun Simiao was a famous clinician and alchemist; to posterity, he left voluminous formularies that have been influential until the present. - Paul Unschuld, 2000 Medicine in China: Historical Artifacts and Images Sun Simiao was born in the 6th Century, around 581 A.D., at the beginning of the short-lived Sui Dynasty (581-618 A.D.) and just prior to the unification of north and south China (589 A.D.). He carried out his medical work and writing during the Tang Dynasty (618907 A.D.) and died in 682 A.D., having completed two 30-volume works on medical practice that would establish his place as a central figure in the field of herbal medicine. Sun Simiao has been worshipped as the "Medicine God" (actually, the Medicine Buddha, a deity invoked during healing practices) or, more commonly, as the "King of Medicine" ( yaowang; referring to herb medicines, yao). During the Ming Dynasty, in 1527 A.D., eight stone tablets engraved with quotations from his works were erected in his birthplace (Huayuan, in Yaoxian County, Shanxi Province) and to this day there are activities each year in his hometown celebrating his memory. In Beijing, a Temple to the King of Medicine was constructed; another temple to Sun Simiao was built in Kiangxi. His life story is relayed in numerous modern texts (2, 5, 6) and articles (1), with the primary facts derived from the Tang Dynasty history by Wei Zheng and its retellings and embellishments that have survived to the present. Portions of his works have been translated to English (see Appendix 1 for samples), including an entire work on Daoist alchemical longevity prescriptions (11). Catherine Despeux, professor at the National Institute of Oriental Language and Civilization in Paris, has translated portions of his books on acupuncture and Taoism into French. Paul Unschuld, head of the Institute for the History of Medicine at Munich University, devoted considerable attention to Sun's position on medical ethics (3) and the iconography of Sun's legend (16; see Figures 1-4). It is said that Sun studied very hard and mastered various Chinese classics by the age of 20. He had been sickly as a child and took up medicine as an adult, strengthening his own health (though still suffering various ailments), treating relatives and neighbors, and then practicing in the countryside of Huguan, not far from the capital city of Chang'an. He traveled great distances, perhaps as far as Sichuan province, to learn about useful prescriptions. After gaining a great reputation and completing his first book, he lived mostly in seclusion on Wubai Mountain (later to be known as Medicine King Mountain, Yaowang Shan), where he followed Taoist principles (Taoism was strongly supported during the Tang Dynasty) and integrated them with Buddhism and Confucianism. Noblemen would come to him to learn from his vast knowledge and experience. A cave where Sun lived in Taoist retreat and received such visitors has long been the destination of pilgrims; a pool where he is said to have washed herbs is located nearby. Sun refused at least three official court positions offered to him: by the Emperor Wendi of the Sui Dynasty and by the Emperors Taizong and Gaozong of the Tang Dynasty. He preferred to provide treatment for ordinary people in the rural setting, though he accompanied Emperor Gaozong for a time. His medical orientation was described in an official history of the Tang Dynasty, as relayed by Paul Unschuld (3): "His biography describes him as an extraordinarily talented man, who devoted himself to the teachings of the Yi Jing [I-Ching], of Lao Zi [Lao-tzu; author of the Dao De Jing], and of the yin-yang philosophers, and he also took an interest in the magical calculation of numbers." His work emphasized the five elements and yin-yang systems of influences that are based on correspondences between features of the external environment and the internal structures and workings of the body. He is considered the first to have presented issues related to ethics of medical treatment, depicting the characteristics of a great physician and cautioning physicians about behavior that was inappropriate to their profession. He was especially concerned, as emphasized in Taoist philosophy, about physicians being influenced by a desire for rewards, including financial rewards, fame, or favors granted to them: they should not have these as their goal. Patients should be treated equally, regardless of rank, wealth, age, or beauty. Sun Simiao recorded his experience with herb formulas and his knowledge of medicine in his famous 30 volume work, printed in 652 A.D.: Prescriptions for Emergencies Worth a Thousand Gold (Beiji Qianjin Yaofang ), the title usually shortened to Prescriptions Worth a Thousand Gold (Qianjin Yaofang ). The book presented life saving remedies, hence the title reflecting their great value (i.e., a life is worth more than a thousand gold coins). A mystical origin was attributed to some of the formulas, as with this story from the Song Dynasty (660-1279 A.D.): Sun Simiao once saved the dragon of the Kunming Lake (in Yunnan Province) and, as a reward, got 30 magical recipes from the Dragon Palace. The Qianjin Yaofang was not merely a collection of formulas (of which there were an astonishing 4,500), but a treatise on medical practice that reviewed the work since the Han Dynasty, starting with the concepts of the Neijing (ca. 100 B.C.). He included treatises on acupuncture, moxibustion, massage, diet, and exercises. So comprehensive in scope was this treatise that later authorities declared it the first encyclopedia of clinical practice. Sun Simiao is probably best known for his intense interest in the identification and preparation of herbs and his definitive work with formulation principles. He emphasized the importance of gathering herbs at the right time, saying: "If you do not know the proper seasons when they should be placed in the shade or in the sun to dry, the result will be that you know their names but do not obtain their intended effects. If you gather them at an improper time, they will be good for nothing just like rotten wood, and you will have made a futile effort." Further, he insisted that the herbs must be from the genuine source, saying: "Without knowing where the medicines are from, and whether or not they are genuine and fresh, they cannot cure five or six patients out of ten." He described 519 different genuine

medicinal materials that could be found in 133 counties (prefectures). The formulas he collected came from both famous physicians of the past and from numerous contemporary physicians, including those of minority groups and even foreigners. He paired down formulas to get rid of extraneous ingredients, with most of his published formulas having only 4-12 ingredients. His book gave special attention to treatment of women and children, with the first three volumes devoted to woman's disorders (including pregnancy and post-partum disorders) and the next two about diseases of infants and about breast-feeding. His work was relied upon as a basis by the famous Song Dynasty specialists in gynecology, obstetrics, and pediatrics who influenced all subsequent work on these subjects. A second book by Sun Simiao is a supplement to his early one: it is called Qianjin Yifang. The content is based on 30 years of subsequent experience with special attention to folk remedies; it was printed at the end of his life in 682 A.D. This work of 30 volumes also serves as a Materia Medica with 800 medicinal materials, providing details about the collection and preparation of 200 of them. He presented some new herbs, especially ones from foreign countries, notably from India (the source of the Buddhist tradition that he pursued), from whence came Terminalia chebula (hezi). Two volumes were devoted to study of the formulas and treatment strategies of the Shanghan Lun (ca. 220 A.D.). In addition, the supplement presented about 2000 more formulas, though these have not been studied and retained by future generations to the extent of the formulas from the earlier text. Sun's second book also included considerable reference to mystical and magical practices, such as exorcisms. He mentioned 32 drugs that were said to be effective against demons, and he carefully described the 13 acupuncture points that were known as demon-releasing points. The last two volumes included talismans, amulets, and incantations. Both of Sun's books are still reprinted today, compiled as one: the Qianjin Fang. Although the information about medical practice that he recorded influenced all subsequent generations of Chinese scholarphysicians, today, the main legacy is a small number of his formulations (see Appendix 2). The formula best known to Western practitioners, and still widely used in China, is Duhuo Jisheng Tang (Tu-hou and Loranthus Combination), a prescription used for pain syndromes affecting the lower back and legs (see: Chinese herb therapies for sciatica and lumbago). A formula frequently referenced in China and used as a basis of numerous formulations used in modern times is Xijiao Dihuang Tang (Rhino and Rehmannia Combination), a prescription for blood-heat syndrome causing bleeding from the nose and mouth or causing severe mental distress. Sun Simiao is credited with recognizing that goiter occurred in mountainous regions and could be cured by prescribing both seaweeds (which contain iodine) and thyroid glands (which contain thyroid hormone) from deer and sheep. He successfully treated night blindness with livers from oxen and sheep, which contain vitamin A, and treated beriberi (leg edema due to vitamin B 1 deficiency) by using unpolished rice (the outer layer of rice and other grains are rich in B vitamins), based on Buddhist practices from India. Sun also contributed to the utilization of placenta for treatment of weakness as well as for regulating menstruation and relieving difficult labor. He presented 25 formulas for treatment of malaria, 17 of them containing changshan (dichroa). Some Chinese authorities have suggested that Sun Simiao authored the ophthalmology classic Yinhai Jingwei , but the evidence supports a much later date for the work, at least during the Song Dynasty, perhaps afterward (7). Nonetheless, Sun devoted an entire volume of his work to ophthalmology and is credited with being the first to elaborate the causes and treatments for ophthalmic disorders. As to his general philosophy of health, he believed people should keep moving, saying that "running water is never stale and a door hinge does not become worm-eaten because they never stop moving." But, he thought it was damaging to do too much hard labor, saying: "The way to keep in good health lies in doing light work frequently without fatiguing yourself doing what you cannot." He was an advocate of good nutrition, having noted that many diseases were curable by consuming the proper foods and that diseases could be caused by eating food that was uncooked, unclean, or poisonous, or by overeating or not chewing one's food well. He advocated the use of massage therapies, physical exercises, and breathing exercises. Sun suggested that travelers should take with them some remedies and a guidebook to formulas so that they could deal with emergencies that might crop up, such as injuries, bites, skin sores, etc. Taoist alchemists considered Sun the source of several works on alchemy, and he is believed to have practiced alchemy on himself, contributing to his lifespan of 101 years. The primary alchemical text attributed to Sun is the Taiqing Danjing Yaojue (Essentials of the Elixir Manuals for Oral Transmission; ca. 640 A.D.), which has been translated by Nathan Sivin and presented along with an extensive analysis of the historical records of Sun Simiao's life (11). Many of Sun's alchemical formulas involved ingestion of metallic substances, such as realgar and cinnabar. According to the Taoist writer Shen Fen, in his book Xu Xian Chuan (Further Biographies of the Immortals, ca. 930 A.D.), when Sun Simiao died, his body remained without decay for many weeks. "After more than a month had passed, there was no change in his appearance, and when the corpse was raised to be placed in the coffin, it was light as a bundle of empty clothes. Truly, this was release from the mortal part." Needham has speculated that Sun had been taking the mercury and arsenic elixirs he had described in his last book, resulting in the preservation of this body at death (14). Only a few decades after his death, Sun's first book had a strong influence on the Japanese practice of Chinese medicine, which had become popular in the 8 th Century. In the 10th century, a Japanese physician compiled a book, the Ishimpo, largely based on the Qianjin Fang, selecting 481 formulas from it. It became a required textbook for the study of medicine in Japan.

BIBLIOGRAPHY AND REFERENCES 1. Zheng Bocheng, The King of Medicine: Sun Simiao, Journal of Traditional Chinese Medicine 1986; 6(4): 210-211. 2. Hsu HY and Peacher WG, Chen's History of Chinese Medical Science, 1977 Modern Drug Publishers, Co. Taipei, Taiwan. 3. Unschuld PU, Medical Ethics in Imperial China, A Study in Historical Anthropology, 1979 University of California Press, Berkeley, CA. 4. Furth C., A Flourishing Yin: Gender in China's Medical History, 960-1665, 1999 University of California Press, Berkeley, CA. 5. Chen Ping (editor in chief), History and Development of Traditional Chinese Medicine, 1999 Science Press, Beijing.

6. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, volume 1, 1995 New World Press, Beijing. 7. Kovacs J and Unschuld PU (translators, annotators), Essential Subtleties on the Silver Sea: The Yinhai Jingwei; A Chinese Classic on Ophthalmology, 1998 University of California Press, Berkeley, CA. 8. Unschuld PU, Medicine in China: A History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 9. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. 10. Wong KC and Wu LT, History of Chinese Medicine: Being a Chronicle of Medical Happenings in China from Ancient Times to the Present Period, 1936 National Quarantine Service, Shanghai. 11. Sivin N, Chinese Alchemy: Preliminary Studies, 1968 Harvard University Press, Cambridge, MA. 12. Hsu HY and Hsu CS, Commonly Used Chinese Herbal Formulas Companion Handbook, 2nd revised edition, 1997 Oriental Healing Arts Institute, Long Beach, CA. 13. Huang Binshan and Wang Yuxia (chief compilers), Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, 1993 Heilongjiang Education Press, Harbin. 14. Needham J, Science and Civilization in China, volume 5, number 2, 1974 Cambridge University Press, London. 15. Kohn L, The Taoist Experience, 1993 State University of New York Press, Albany, NY. 16. Unschuld PU, Medicine in China: Historical Artifacts and Images, 2000 Prestel Verlag, Munich. November 2001

APPENDIX 1: Writings of Sun Simiao The following is from a translation provided by Paul Unschuld (3). The words are as valuable today as when they were written, some 13 centuries ago. The saying goes back to Chang Chan [4th Century]: The difficult parts and the fine points in the [medical] classics and the literature on the prescriptions date back to the distant past. Nowadays, we have diseases that take a similar course with different patients, yet from the outside they appear to be different; and there are others that take a different course with different persons, yet from the outside they appear to be similar. For this reason, it will never suffice to examine exclusively with ears and eyes the symptoms of excess or deficiency in the five zang and the six f u as well as the flow or the blocking of the blood and the pulses, and the constructive and protective qi [ying and wei]. In the first place, one has to examine the symptoms of an illness, which can be felt in the pulses to determine the specific ailment. Only someone who gives his undivided mental attention can begin to elaborate on these symptoms. This undivided attention must be given even to the last details which are related to the irregularities in the depth and the marking of the various kinds of pulsations, which condition the variations in the position of the acupuncture points and which are responsible for the deviations in the thickness and strength of the flesh and bones. Today, however, the prevailing effort is to grasp the most subtle details with the crudest and most superficial thought. This is truly dangerous! If there is an excess and we still increase it; if there exists a deficiency and even more is taken away; if a congestion prevails and is further intensified; if there is a flow and still more is drained; if there is a chill and further cooling is applied; and if in the case of heat an increase in temperature is brought about, then the specific illness has to deteriorate exceedingly. When there is still hope for life, I then see the approach of death! It has indeed never happened that spirits distributed the understanding for the difficult aspects and the details which are necessary for physicians, people versed in prescriptions, soothsayers, and magicians. But how else can a person gain access to these secrets? At all times, fools could be found who studied the prescriptions for three years and then they simply maintained that there was no disease in the world which could not be cured. Thereafter they treated diseases for three years and reached the conclusion that there was no useful prescription in the world. Thence ensues that it is absolutely necessary for the student to master the foundations of medicine in its most general significance, and to work energetically and unceasingly. He is not to gossip, but has to devote his words exclusively to the medical teachings. Only then will he avoid errors. Whenever a great physician treats diseases, he has to be mentally calm and his disposition firm. He should not give way to wishes and desires, but has to develop first a marked attitude of compassion. He should commit himself firmly to the willingness to take the effort to save every living creature. If someone seeks help because of illness, or on the ground of another difficulty, a great physician should not pay attention to status, wealth, or age; neither should he question whether the particular person is attractive or unattractive, whether he is an enemy or a friend, whether he is Chinese or a foreigner, or finally, whether he is uneducated or educated. He should meet everyone on equal ground; he should always act as if he were thinking of himself. He should not desire anything and should ignore all consequences; he is not to ponder over his own fortune or misfortune and thus preserve life and have compassion for it. He should look upon those who have come to grief as if he himself had been struck, and he should sympathize with them deep in his heart. Neither dangerous mountain passes nor the time of day, neither weather conditions nor hunger, thirst nor fatigue should keep him from helping whole-heartedly. Whoever acts in this manner is a great physician for the living. Whoever acts contrary to these demands is a great thief for those who still have their spirits! From early times famous persons frequently used certain living creatures for the treatment of diseases, in order to thus help others in situations of need. To be sure, it is said: "Little esteem for the beast and high esteem for man," but when love of life is concerned, man and animal are equal. If one's cattle are mistreated, no use can be expected from it; object and sentiments suffer equally. How much more applicable is this to man! Whoever destroys life in order to save life places life at an even greater distance. This is my good reason for the fact that I

do not suggest the use of any living creature as medicament in the present collection of prescriptions. This does not concern the gadflies and the leeches. They have already perished when they reach the market, and it is therefore permissible to use them. As to the hen's eggs, we have to say the following: before their content has been hatched out, they can be used in very urgent cases. Otherwise, one should not burden oneself with this. To avoid their use is a sign of great wisdom, but this will never be attained. Whoever suffers from abominable things, such as ulcers or diarrhea, will be looked upon with contempt by people. Yet even in such cases, this is my view, an attitude of compassion, of sympathy, and of care should develop; by no means should there arise an attitude of rejection. Therefore, a great physician should possess a clear mind in order to look at himself; he should make a dignified appearance, neither luminous nor somber. It is his duty to reduce diseases and to diagnose sufferings and for this purpose to examine carefully the external indications and the symptoms appearing in the pulse. He has to include all the details, and should not overlook anything. In the decision over the subsequent treatment with acupuncture or with medicaments, nothing should occur that is contrary to regulations. The saying goes: "In case of a disease, one has to help quickly," yet it is nevertheless indispensable to acquaint oneself fully with the particular situation so that there remain no doubts. It is important that the examination be carried out with perseverance. Wherever someone's life is at stake, one should neither act hastily, nor rely on one's own superiority and ability, and least of all keep one's own reputation in mind. This would not correspond to the demands of humaneness! In visiting the sick, whatever beautiful silks and fabrics fill the eye, the physician is not allowed to look out for them either to the left or to the right. Where the sounds of string instruments and instruments of bamboo fill the ear, he should not evoke the impression that he delights in them. Where delicious food is offered in stunning succession, he is to eat as if he experienced no taste. Finally, where liquors are placed one next to the other, he will look at them as if they did not exist. Such manners have their origin in the assumption that if one single guest is not contented, the whole party cannot be merry. A patient's aches and pains release one from this obligation less than ever! However, if a physician is tranquil and engrossed in merry thoughts, in addition to being conceited and complacent, this is shameful for any human frame of mind. Such conduct is not suitable to man and conceals the true meaning of medicine. According to the reputations of medicine, it is not permissible to be talkative and make provocative speeches, to make fun of others and raise one's voice, to decide over right and wrong, and to discuss other people and their business. Finally, it is inappropriate to emphasize one's reputation, to belittle the rest of the physicians, and to praise one's own virtue. Indeed, in actual life someone who has accidentally healed a disease then strides around with his head raised, shows conceit, and announces that no one in the entire world could measure up to him. In this respect, all physicians are evidently incurable! Lao Zi has said: When the conduct of men visibly reveals virtue, the humans themselves will reward it. If, however, men commit virtues secretly, the spirits will reward them. When the conduct of men visibly reveals misdeeds, the humans themselves will take retribution. If, however, men commit their misdeeds secretly, the spirits will take retribution. When comparing these alternatives and the respective rewards that will be given in the time after this life and still during this life, how could one ever make a wrong decision? Consequently, physicians should not rely on their own excellence, neither should they strive with their whole heart for material goods. On the contrary, they should develop an attitude of good will. If they move on the right path, concealed from the eyes of their contemporaries, they will receive great happiness as a reward without asking for it. The wealth of others should not be the reason to prescribe precious and expensive drugs, and thus make the access to help more difficult and underscore one's own merits and abilities. Such conduct has to be regarded as contrary to the teaching of magnanimity. The object is help. Therefore, I enter into all the problems in such detail here. Who ever studies medicine should not consider these problems insignificant! The next quotation is derived from the section of Sun's book that was devoted to women's disorders (there were a total of three chapters on this subject, all presented at the beginning of his book). According to Charlotte Furth (4), "almost every important writer on the subject [of women's disorders] quoted some or all of Sun's compelling account of the female medical body." Here is Furth's translation: It is said that the reason there are separate prescriptions for women is because they get pregnant, give birth, and suffer form uterine damage. This is why women's disorders are ten times more difficult to cure than those of males. The Classic [Neijing] says: "women are a gathering place for yin influences, swelling in dampness." From the age of fourteen on, their yin qi wells up and a hundred thoughts run through their minds, damaging their organ systems within and ruining their beauty without. Their monthly courses flow out or are retained within, now early, now late, stagnating and congesting blood, and interrupting the function of the central pathways. The injuries from this cannot be enumerated in words. Internal organs are now cold, now hot, now replete, now depleted. Bad blood within leaks out, and meridians are used up and drained empty. Sometimes immoderate diet causes damage, sometimes they have sexual intercourse before their [vaginal] itching sores have healed. Sometimes as they relieve themselves at the privy, wind from below enters, causing the twelve chronic illnesses. All of this is why women have separate prescriptions. If an illness is due to the qi of the four seasons, or to the divisions of day and night, or to imbalance of cold and heat, or of repletion or depletion, it is no different from that of men; only potent medicines are to be avoided if they fall ill when pregnant. For miscellaneous disorders that are the same in women and men, one should consult the main chapters of this work. Nonetheless, females' longings and desires are more intense than those of their husbands, and they are more frequently stimulated to become ill. Add to this that in women envy and dislike, compassion and love, grief and sorrow, attachments and aversions are all especially stubborn and deep-seated. They cannot themselves control these emotions and from this the roots of their illnesses are deep, and their cure is difficult. Following is a portion of Sun's Taoist text Cunshen Lianqi Ming (Visualization of Spirit and Refinement of Qi), translated by Kohn (15): The body is the habitation of spirit [shen] and qi. As long as spirit and qi are there, the body is healthy and strong. As soon as spirit and qi scatter, the body dies. Therefore, if you wish to preserve yourself whole, first calm spirit and qi. Understand:

qi is the mother of spirit; spirit is the son of qi. Only when qi and spirit are together can you live long and not die. If you, therefore, wish to calm spirit, first refine primordial qi. When this refined qi resides in the body, spirit is calm and qi is like an ocean. With the sea of qi full to overflowing, the mind [heart] is calm and the spirit stable. When this stability is not disturbed, body and mind are gathered in tranquility. Tranquility then attains to concentration, and the body continues to exist for years eternal. Just stay all the time with the deep source of the Tao, and you will naturally become a sage. Then qi pervades spirit and all mental projections; spirit pervades all insight and destiny. With destiny established and the body preserved, you can unite both with your true inner nature. Then you will reach an age as old as the sun and moon. Your Tao is perfected. This introductory section follows the typical Taoist description of cultivating qi in order to calm spirit, and in tranquility gaining longevity. It is followed by instructions for meditation (persistent focus of the mind, especially on the cinnabar field, dantian, just below the naval). Five phases of the mind are described by Sun, starting with the agitated mind, and then progressing to greater degrees of tranquility. Having attained tranquility, there are then seven phases of the body that one can pass through. These begin with the healing of diseases, followed by recovery of youth, extension of the life span, refining the physical form to a radiant body, further refinement to pure spirit, unification of spirit with the world, and, finally, going beyond all beings to reside in the numinous realm. As to how these refinements of the body are to be accomplished, nothing is said, but the practitioner is warned to diligently study the Tao and follow the orally transmitted teachings, which are never written down. The next quotes come from the section of Sun's book on eye disorders, presented by Kovacs and Unschuld (7): All people older than 45 years have the feeling of a gradual decrease in vision. After the age of sixty, vision gradually brightens up again. Therapeutic patterns are such that prior to age fifty it is advisable to take the 'decoction to drain the liver' [Xiegan Tang]. After age fifty, one should no longer drain the liver. If an illness is in the eyes, one can apply such medication as the 'powder with shidan' [Shidan San]. In case there is no illness, this powder must not be applied recklessly; rather, one should simply supplement the liver. If someone's vision is obscured or blinded because of wind-heat in the liver, one should moxa the liver transportation points and take several tens of doses of decoctions, pill, or powders eliminating wind. This should bring relief. Pathogenic causes of eye disorders listed by Sun Simiao were these: consumption of the five spices in raw state hot beverages and food to eat hot wheat-based food to drink wine without end unrestrained sexual activity to overexert the eyes by looking into the distance to often look into the sun or moon to look into the fire of the stars at night to read small script during the night to read under the moonlight

to copy books for many years to carve or engrave fine handicraft to play chess without pause to stay with a smoking fire for long to weep excessively excessive bleeding after the head was acupunctured fast riding and hunting braving wind and frost pursuing wild animals against the wind failure to rest day or night.

In modern terms, summarizing these causes, there is: eye strain due to too much use of the eyes, especially in dim light; overexposure to bright light (we can be reminded of how bright the moon and stars appeared when the sky was completely dark at night); exposure to smoke or to wind; consumption of hot and spicy foods; and poor lifestyle (including smoking, drinking, excessive sexual activity, and not enough rest). The next section comes from Sun's volume on dietary therapy, translated by Paul Unschuld (8): Zhang Zhongjing has said: For the human body to remain in a healthy and balanced state, nothing else is required but to care about its nourishment. By no means should drugs be consumed recklessly. The strength of drugs is one-sided, and there are occasions where they are of help. But, they can lead to an imbalance of the qi in man's zang organs, and, consequently, an affliction will easily be acquired form outside sources. Living beings have always depended on food to maintain their life. But, at the same time, they are unaware of the fact that even food has positive and negative aspects. Food is in daily use with all the people, but one knows little about it. Water and fire are very near but difficult to comprehend! I regretted this and have, therefore-when I had spare time from my other writings-compiled a treatise on dietetic therapy emphasizing harms and benefits that can result form the five tastes, in order to inform our youth….Now, those who practice medicine must first recognize the origin of an illness; they must know which violations have caused the suffering. Then they must treat it with dietary means. If dietary therapy does not cure the illness, only then can they employ drugs. The nature of drugs is violent, just like that of the imperial soldiers. Because the soldiers are so wild, how could anybody deploy them recklessly? If they are deployed inappropriately, harm and destruction will result everywhere. Similarly, excessive calamities are the consequence if drugs are thrown against illnesses carelessly. The alarmist language about use of herbs may seem strange given the very large number of herbs and formulas described in his books. However, if one examines his formulas (especially those that are no longer relied upon today), it is evident that he tended to rely on herbs of somewhat extreme nature: very cold, very hot, purging herbs, diaphoretic herbs, etc. Thus, he aimed at having highly effective drugs that must be given with great care, and usually used for emergency situations or when dietary therapies have failed.

APPENDIX 2: Some Formulas of Sun Simiao Referenced in Modern Texts Following are formulas from Sun Simiao's Qianjin Yaofang (and two formulas from Qianjin Yifang), from texts on traditional Chinese medicine published in recent times. Formulas that have an English common name in parentheses are from Commonly Used Chinese

Herb Formulas will Illustrations Companion Guide (12) and the others are from Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (13). In a few cases, the formulas are presented in both books. They have been organized here by therapeutic pattern.

Purgative Formulas Zi Yuan (Croton and Hematite Formula) with croton, hematite, apricot seed, and kaolin; used for abdominal edematous distention in persons who suffer damage from improper eating. This formula alleviates constipation, purges fluids, and lowers rising qi. Wenpi Tang with rhubarb, mirabilitum, aconite, dry ginger, ginseng licorice, tang-kuei; for spleen yang deficiency with abdominal pain and constipation. Sanhuang Tang, with rhubarb, scute, gardenia, and licorice; used for heat in the lower warmer with constipation.

Chill-dispelling Formulas Qianjin Danggui Tang (Tang-kuei Combination): with tang-kuei, cinnamon, zanthoxylum, dry ginger, licorice, pinellia, magnolia bark, ginseng, astragalus, and peony; used for cold spleen/stomach with pain in the chest and/or abdomen. Jianzhong Tang (Hoelen and Jujube Combination) with hoelen, dried ginger, cinnamon, licorice, peony, jujube, and pinellia; used for cold in the spleen and stomach causing belching, vomiting, and/or stomach pain. Duzhong Jiu, with eucommia, photinia, chiang-huo, and aconite, prepared as a wine; for rheumatic pain in lower back and/or knees in persons with cold of spleen and kidney.

Wind-dispelling Formulas Xiao Xuming Tang (Ma-huang and Peony Combination) with ma-huang, apricot seed, cinnamon, peony, fresh ginger, ginseng, licorice, cnidium, siler, stephania, aconite, and scute; used for invasion of wind-cold that causes paralysis, unconsciousness, mental confusion, and/or spasms. Duhuo Jisheng Tang (Tu-huo and Loranthus Combination) with tu-huo, loranthus, chin-chiu, siler, asarum, cinnamon bark, eucommia, rehmannia, achyranthes, tang-kuei, peony, cnidium, ginseng, hoelen, and licorice; used for bi syndrome (specifically wind-damp-cold affecting the lower back and legs) in persons with deficiency of liver and kidney.

Treatments for Diarrhea Zhujiu Wan with coptis, dry ginger, tang-kuei, and gelatin, prepared as a pill; for diarrhea due to damp-heat. Zhuchi Baili Fang with kaolin, dragon bone, dry ginger, and coptis; for diarrhea of all types.

Pregnancy and Post-partum Formulas Zhuli Tang with bamboo sap, siler, scute, ophiopogon, and hoelen; for restlessness and irritability during pregnancy. Neibu Danggui Jianzhong Tang with tang-kuei, peony, fresh ginger, licorice, cinnamon bark, and jujube (this is Cinnamon Combination from the Shanghan Lun with cinnamon bark substituted for cinnamon twig and tang-kuei added); used for post-partum deficiency with abdominal pain. Anxin Tang with polygala, licorice, ginseng hoelen, tang-kuei, peony, ophiopogon, and jujube; used for postpartum mental distress accompanied by shortness of breath. Dahuang Tang with rhubarb, tang-kuei, licorice, fresh ginger, moutan, peony, evodia; used for post-partum leukorrhea.

Cough-relieving Formulas Weijing Tang with coix, persica, benincasa, and phragmites; used for cough with pulmonary abscess. Feishang Tang with ginseng, dry ginger, cinnamon bark, gelatin aster, maltose, rehmannia, and morus; used to treat lung insufficiency with shortness of breath and coughing. [from Qianjin Yifang]

Miscellaneous Other Formulas Xijiao Dihuang Tang (Rhino and Rehmannia Formula) with rhino horn (substituted today by buffalo horn), raw rehmannia, red peony, and moutan; used for heat in the blood causing bleeding, especially hemoptysis and nose bleeds; also for febrile diseases causing mental disturbance. Changyong Tang (Coix and Persica Combination) with coix, persica, moutan, and benincasa; used for hot mass in the abdomen (infection with abscess). Huanshao Dan with rehmannia, cistanche, altaica, eucommia, morus, cornus, lycium, schizandra, achyranthes, morinda, dioscorea, hoelen, polygala, and fennel, made as honey pills; used for kidney deficiency syndrome with symptoms such as lumbar pain, dizziness, blurred vision, hair loss, poor memory, and heart palpitation. Danggui Jianzhong Tang with tang-kuei, cinnamon, peony, baked licorice, fresh ginger, jujube and maltose (this is Cinnamon Combination from the Shanghan Lun with tang-kuei and maltose added); for abdominal cramps dues to deficiency syndrome of spleen and stomach with blood deficiency. [from Qianjin Yifang] The following figures are from books by Paul Unschuld (8, 16). Most often, Sun Simiao is depicted with a tiger below, representing yin, and a dragon above, representing yang. His Taoist skills are illustrated by this command of the yin and yang forces.

Figure 1: Wooden statue of Sun Simiao as the Medicine God, seated on a tiger and holding a dragon above him.

Figure 2: 19th Century painting of Sun Simiao (left) in dialogue. He sits on a tiger and a dragon is held in his left hand.

Figure 3: Painting of Sun Simiao depicting him as a serious scholar.

Figure 4: Qing Dynasty illustration of Sun Simiao (center) demonstrating his complete control of the tiger and dragon.

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ESSENTIALS OF TAOISM and the Taoist Influence on Herbal Medicine Literature by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Note on transliteration: In most ITM documents, Chinese words are transliterated via the pinyin system that was widely adopted during the 1980s. Taoism was extensively discussed in English-language literature prior to the 1980s, so that there is considerable transliteration already well-established based on the earlier Wade-Giles system. In this situation, the transliteration adopted for the current article is based on simplified Wade-Giles, leaving out the apostrophes that were used to develop more precision. The term "Tao" is transliterated in pinyin as Dao, but Taoism, a term long used in the West, is not a Chinese word and shifting to Daoism is a questionable approach to dealing with transliteration. The book of Taoism commonly known as the Tao Te Ching would be written in pinyin Dao De Jing, and this would be appropriate, except that few people will find one of its many English translations with the title spelled that way. Taoism was a highly influential philosophy that evolved about 2,500 years ago in China. Its principle proponent was Lao Tsu (Lao Tzu) who was a contemporary of Confucius, the originator of another highly influential and differently-oriented philosophy. The essence of Taoism was preserved in the writings attributed to Lao Tsu called the Tao Te Ching, written in 81 short chapters, with a total of about 5,000 characters. From this base, Taoism developed rich and varied manifestations in Chinese culture. A subgroup of the Taoists pursued alchemy and medicine, and their work had a substantial impact on the development of herbal medicine. Taoism remains of interest to many people around the world today, even though its influence in China has waned considerably from its former level. It has been said that there are more translations of the Tao Te Ching than any other book besides the Christian bible. The Tao Te Ching has many sayings that are inspirational, and many sayings that are mysterious (difficult to understand). In this essay, I present what I perceive as the core teaching of Taoism by extracting certain lines from the Tao Te Ching as illustrations of the fundamentals. For that purpose, I will quote from the translation by Gia-fu Feng and Jane English (Lao Tsu Tao Te Ching , 1972 Random House, New York). Another valuable translation is by Thomas Miles (Tao Te Ching , 1992 Avery Publishing, New York). I also propose to describe, in less prosaic terms than in the original text, the basic concept of Taoism.

The Core Teaching Perhaps the most frequently portrayed aspect of Taoism is the image of the unobstructed flow of life. In the Tao Te Ching (chapter 48) it is said: "The world is ruled by letting things take their course, it cannot be ruled by interfering." An image of water flowing through a stream bed is sometimes used to convey the concept. That the flow of water has great potential, as one can see by the deep gorges in solid rock carved by a stream, is also mentioned (chapter 78): "Nothing is more soft and yielding than water, yet for attacking the solid and the strong, nothing is better." Letting things take their course is often described as "being in harmony with nature." Nature is one with the Tao, and to not go against nature is to be in harmony with nature. Harmony with nature requires yielding, but it results in great things. The Tao, often translated as the Way (capitalized because it is beyond ordinary description), might be called the "yielding way;" Te is usually translated as power; the book title Tao Te Ching means, roughly, the classic about the power of the yielding way. Despite the common reference to this aspect of Taoism, I think that this view of the teaching, when taken out of the larger context of the Tao Te Ching , is usually too difficult to put into practice because it is so abstract. What does it mean to lead a life that flows like water and harmonizes with nature? In this article, I want to call attention to another aspect of the Taoist teaching that may prove more practical, because it answers the question in relation to how humans live: not just with nature, but with each other and with the powers and vagaries of one's own mind. The underlying principle presented in the Tao Te Ching is that one should take care of things that are in need of doing, and then move on to the next thing that needs to be done, without any attachment to the accomplishment. By avoiding any "attachment to the accomplishment" it is meant that one should not dwell in such things as taking credit for it, accumulating rewards (including material things and power), or spending time with retelling it in order to get recognition. Along these lines also, one should not bother doing things other than what needs to be done. For example, one should not spend time at efforts that are aimed specifically at collecting wealth, accumulating power, or gaining praise, or even bothering others by taking up their time with unnecessary things. Moving from one moment to the next, taking care of what is necessary, and not straying from that, is the Way: so long as one follows this teaching, things will progress smoothly; but as one deviates, one will only find obstacles and heartache. Because one does not dwell upon accomplishments nor make efforts to gain things, the Tao Te Ching says repeatedly that in following the Tao, nothing is done. One should understand, however, that this does not mean that one simply sits around, avoiding doing anything or that one skirts obvious responsibilities. In presenting the following portion of the Tao Te Ching , I am specifically turning attention away from another substantial portion of the text, one that attempts to depict the Tao as a fundamental aspect of nature that is difficult, actually impossible, to describe or to comprehend, except by living in the Tao. Thus, I have bypassed statements such as this (chapter 1): "The Tao that can be told is not the eternal Tao" and this (chapter 14): "Look, it cannot be seen-it is beyond form. Listen, it cannot be heard-it is beyond sound. Grasp, it cannot be held-it is intangible. These three are indefinable; therefore they are joined in one," There are dozens of statements along these lines that attempt to lead one to a view of what the Tao is, by saying what it is not. However, since the ultimate experience of Tao occurs when following the fundamental rules regarding how one deals with daily activities, I have opted to focus on those aspects of the text. Doing and Moving On Here are some sample quotations that reflect this view. Keep in mind that "not doing" (Chinese: wu wei) really means not stopping to take recognition of what is being done, and not doing things that do not need to be done. Chapter 2:

"Creating, yet not possessing. Working, yet not taking credit. Work is done, then forgotten. Therefore, it lasts forever." Chapter 3: "If nothing is done, then all will be well." Chapter 7: "The sage stays behind, thus he is ahead. He is detached, thus at one with all. Through selfless action, he attains fulfillment." Chapter 9: "Amass a store of gold and jade, and no one can protect it. Claim wealth and titles, and disaster will follow. Retire when the work is done. This is the way of heaven." ["Retire when the work is done" here means that one should not try to make anything further of the accomplishment.] Chapter 10: "Giving birth and nourishing, bearing yet not possessing, working yet not taking credit, leading yet not dominating, this is the primal virtue." Chapter 13: "Surrender yourself humbly; then you can be trusted to care for things. Love the world as your own self; then you can truly care for all things." Chapter 15: "Who can remain still until the moment of action? Observers of the Tao do not seek fulfillment, not seeking fulfillment, they are not swayed by desire for change." ["Remain still" here means that one is not constantly pursuing selfish fulfillment between the actions that are essential.] Chapter 22: "Wise men embrace the one and set an example to all. Not putting on a display, they shine forth; not justifying themselves, they are distinguished; not boasting, they receive recognition; not bragging, they never falter." Chapter 24: "He who stands on tiptoe is not steady; he who strides cannot maintain the pace; he who makes a show is not enlightened; he who is selfrighteous is not respected; he who boasts achieves nothing; he who brags will not endure. According to followers of the Tao, 'these are extra food and unnecessary luggage.' They do not bring happiness, therefore followers of the Tao avoid them." Chapter 30: Achieve results, but never glory in them. Achieve results, but never boast. Achieve results, but never be proud. Achieve results, because this is the natural way." Chapter 38: "A truly good man does nothing, yet leaves nothing undone. A foolish man is always doing yet much remains to be done." ["Always doing" here means that he is wasting time doing unnecessary things.] Chapter 77: "The sage works without recognition. He achieves what has to be done without dwelling on it. He does not try to show his knowledge."

The Things to Be Done and the Way to Do Them What are the essential actions, the things to be taken care of? How is one to know what is needed and what ought not to be done? What is one to be like in day to day affairs? As the following quotes display, one can know what to do if one focuses on such virtuous things as meditation, gentleness, kindness, truthfulness, competence, alertness, simplicity, yielding (rather than obstructing), constancy, openheartedness, caring, perseverance, willingness to take on difficult tasks, mercy, economy, generosity, humility, gentleness, etc., and avoids such things as extremes, excesses, complacency, abandoning those in need, trying to do too much at once rather than take the small steps that are necessary, ignoring what is known, having desires for unnecessary things, and rigidity in ideas, as well as avoiding those concerns described earlier, such as boasting, accumulating wealth and power, and seeking rewards. Here are some sample quotations: Chapter 8: "In dwelling, be close to the land, in meditation, go deep in the heart, in dealing with others, be gentle and kind, in speech, be true, in ruling, be just, in business, be competent, in action, watch the timing." Chapter 9: "Alert, like men aware of danger, courteous, like visiting guests, yielding, like ice about to melt, simple, like uncarved blocks of wood...." Chapter 16: "Knowing constancy is insight, not knowing constancy leads to disaster. Knowing constancy, the mind is open; with an open mind, you will be openhearted. Being openhearted, you will act royally. Being royal, you will attain the divine. Being divine, you will be at one with the Tao." Chapter 27: "The sage takes care of all men and abandons no one. He takes care of all things and abandons nothing." Chapter 29:

"The sage avoids extremes, excesses, and complacency." Chapter 33: "Perseverance is a sign of will power. He who stays where he is endures." Chapter 38: "The truly great man dwells on what is real and not what is on the surface." Chapter 46: "There is no greater sin than desire, no greater curse than discontent, no greater misfortune than wanting something for oneself. Therefore, he who knows that enough is enough will always have enough." Chapter 51: "All things arise from Tao. By virtue they are nourished, developed, cared for, sheltered, comforted, grown, and protected." Chapter 52: "Keep your mouth shut, guard the senses, and life is ever full. Open your mouth, always be busy, and life is beyond hope." Chapter 54: "Cultivate virtue in yourself and virtue will be real; cultivate virtue in the family, and virtue will abound; cultivate virtue in the village, and virtue will grow...." "Chapter 55: "Knowing harmony is constancy, knowing constancy is enlightenment." Chapter 59: "In caring for others and serving heaven, there is nothing like restraint. Restraint begins with giving up one's own ideas. This depends on virtue gathered in the past. If there is a good store of virtue, then nothing is impossible." Chapter 63: "Reward bitterness with care. See simplicity in the complicated. Achieve greatness in little things. In the universe the difficult things are done as if they are easy. In the universe, great acts are made up of small deeds. The sage does not attempt anything very big, and thus achieves greatness. Easy promises make for little trust. Taking things lightly results in great difficulty. Because the sage always confronts difficulties, he never experiences them." ["Difficult things are done as if they are easy" here means that one undertakes them without making a big deal out of the fact that they are difficult; because one doesn't make a big deal about difficulties and simply takes the necessary action, it is said that in confronting difficulty, difficulty is not experienced.] Chapter 64: "The sage seeks freedom from desire. He does not collect precious things. He learns not to hold on to ideas. He brings men back to what they have lost." Chapter 67: "From mercy comes courage; from economy comes generosity; from humility comes leadership." Chapter 68: "A good soldier is not violent; a good fighter is not angry; a good winner is not vengeful; a good employer is humble. This is known as the virtue of not striving. This is known as ability to deal with people." ["A good soldier is not violent" here means that he follows the commands and carries out his duties, which may necessarily include violence, but he does not let a violent nature take control of his actions and does not view violence as a desired end.] Chapter 71: "Knowing ignorance is strength; ignoring knowledge is sickness." Chapter 76: A man is born gentle and weak; at his death he is hard and stiff. Green plants are tender and filled with sap; at their death they are withered and dry. Therefore, the stiff and unbending is a disciple of death; the gentle and yielding is a disciple of life." Chapter 81: "The sage never tries to store things up; the more he does for others, the more he has; the more he gives to others, the greater his abundance."

Why This Teaching Is Important Many of the recommendations of the Tao Te Ching may seem obvious or inconsequential. By thinking this way about these sayings, one disregards the reality and only sees the surface. Even those who have achieved great equanimity know that one can again and again experience failings, and thus, must be reminded and brought back to what has been lost. As it is said in the Tao Te Ching (chapter 78): "Under heaven everyone knows this; yet no one puts it into practice."

Practical Applications In today's fast-paced world of competition, it may have become the norm to minimize the efforts undertaken to attain a position of status, and to rely, instead, on excessive talk and promotion, known as hyperbole, or, in the modern jargon "hype." Thus, for example, people who study herbs superficially but who wish to attract much attention to themselves can call themselves "master herbalists" with callous disregard for the meaning of mastering something. Practitioners of Chinese medicine, or other "alternative" therapeutics, often compete with the dominant Western medical profession

(there are about 750 medical doctors for each acupuncturist in the U.S., each doctor having about three to four times as many patient office visits as an acupuncturist). In so doing, they may resort to boasting about their experience, clinical achievements, the value of their techniques, and superiority of their field in an attempt to attract clients away from Western doctors, or, at least, away from total reliance on Western doctors. From the Taoist perspective, all this is unnecessary action. Chinese medicine is a legitimate pursuit; in fact, aside from being a field of considerable cultural interest, it is a legally recognized medical field in much of the U.S., and its successful practice simply requires of the practitioner a certain degree of careful attention accompanying a suitable level of training. As detailed repeatedly in the Chinese literature on the subject, the practitioner is expected to diligently study the classics (in the modern era, this would be expanded to include the current publications about Chinese medicine), to meditate and think upon the fundamental teachings, to give full attention and consideration to the patient, and to apply one's experience and knowledge to the best of one's ability in each case. In so doing, it becomes unnecessary to inflate one's status, or the capabilities of either the medical specialty or the specific therapeutics by exaggerated claims. It is important, on the other hand, to make known the availability of the services and their true capabilities and limitations, so that people who need or desire the services may be able to access them and may judge whether or not the undertaking would likely be of value to them. The situation that arises today-a hurried focus on accomplishment-is not unique: it has been repeated throughout the history of Chinese medicine, and the only difference is that the modern world more easily allows one to separate from the past and makes it easier to broadcast widely ones claims. I will quote here from Hsu Ta-chun writing 240 years ago: Today's physicians possess no skills. They do not read a single book. Hence those who merely browse through the medical literature appear [become prevalent]....Those browsers believe themselves to be increasingly right after some time. [Yet], in the beginning they harm other people through mistaken treatments; then they harm their relatives through their mistaken treatments; in the end, they harm themselves through mistaken treatments." Physicians whose training is insufficient may still avoid harming people as long as they are able to follow proper principles. And if they are able to remain modest, and if they attach great importance to studying, their knowledge will progress every day, and each of their therapies will result in a cure. Hence their fame and reputation will increase and many people will seek their help as a consequence-with riches following them. If one searches for nothing but riches, one will miss both fame and riches. Why do the physicians increase their own problems by neglecting one [studying] and going for the other [seeking rewards]? Eighteen centuries ago, Chang Chung-ching wrote similarly about his contemporaries: They do little but vie for fame and power and delight themselves with improving their physical appearance while neglecting their spiritual development. During a serious epidemic, victims of disease become terrified and do not know what to do. Under present circumstances, they must submit themselves to the care of witch doctors or depend upon divine providence.... The situation today is not, as best I can tell, quite as serious as that depicted by these respected scholars. But, their concerns reflect the Taoist ideal of the harmonious value of taking care of the immediate needs (a function which included study, according to both the Taoists and Confucians) and to avoid the pitfalls of being immodest and seeking rewards (rewards will naturally come to those who pursue the Taoist course anyway). In each clinical encounter, one can learn something, most especially one can learn about one's limitations in knowledge and capability, and this immediately presents "what needs to be done" in the sense suggested by the teachings of the Tao Te Ching . In each case of clinical success, one can perceive the responsibility of making such success available to others, and, again, ones sees what needs to be done. By taking care of these things, there is no extra time for wasteful pursuits, and one will automatically achieve that which may have been sought, mistakenly, through taking credit, seeking status and rewards, or making unnecessary proclamations. The complaints of scholar-physicians about their contemporaries' failings are continual reminders that the teachings of the Tao Te Ching are not automatically adopted by those who pursue medicine. Rather, these teachings must be reviewed regularly as a reminder and prompter to appropriate action and non-action.

Taoism and Herbal Medicine: The Crooked Road Taoism had a great impact on the development of herbal medicine. However, it was what might be called a "divergent sect" of Taoists that pursued alchemy and immortality and aimed the field in a certain direction. Around the fourth century B.C., an idea developed and spread: that there existed a group of beings known as immortals (Chinese: hsien)-ordinary humans who had found a way to attain immortality. The relationship to Taoism is strong, and I would like to suggest the nature of the connection by a brief story. Mr. Li, upon arising one day, went to the entrance of his hut, stepped outside briefly, and noted that the weather was unusually cold. In response, he put on his warm clothing before going out for the day. Mr. Lao, upon arising that day, went to the entrance of his hut, stepped outside briefly, and also noted that the weather was unusually cold. Having developed a reputation in his village for being especially strong and living above the laws of nature and man, he purposefully put on his light clothing before going out for the day. "This will enhance my reputation," he thought. Mr. Wu, upon arising that day, had much on his mind. He had deceived Mr. Chang last week, and Chang was asking to see him today. Mr. Wu did not think to step outside and check the weather. Instead, since it had been warm the previous week, he absent-mindedly put on his light clothing. Mr. Li had the reputation in his village of being a wise man. He led a simple life and seemed to follow the laws of nature. He would dress according to the weather; he would eat until he was reasonably full, but then stop; he would go to bed early and get up early, filling his day with tasks that were often helpful to his family and his village or that increased his knowledge and wisdom; he did not chase after women. Because of these actions, it was thought, he looked much younger than his years, and he seemed content and happy. Mr. Lao had a reputation, among those who were shallow, of being a great and mighty being. He could defy nature, wearing clothing inappropriate to the weather, eating and drinking to excess, staying up late and sleeping 'til late in the morning, always having plenty of

women to keep him happy. He looked roughened and somewhat battered (he did, in fact, get into some nasty fights), and this seemed to only enhance his image as a rogue. But most others saw that he was just a bully and a braggart. He didn't care well for his family and did nothing for his village except to encourage those who were gullible to behave like him. He was irritable in the morning, and complained of fierce headaches. He would sometimes become severely ill, and he looked aged beyond his years, having lost most of his teeth, the suppleness of his skin, and the color of his hair. Mr. Wu was seen as a poor figure. He was constantly worrying because he was always cutting corners and making excuses. He seemed frail and timid, yet he could work up his courage and make quite a pretense of being in a position of considerable power. Sometimes he would temporarily be in a great position, with things apparently going his way, and he would make himself quite visible, a bit intrusive. Yet the next moment things were falling apart and he went into seclusion. His hair had turned grey early and he had little physical strength even though he had been quite sturdy has a youngster. As the story illustrates, it came to be felt by many that by living in harmony with nature, in a humble, simple, and thoughtful life, one could retain youthfulness, remain free of disease, and live a long time. Presumably, the more consistently one behaved in tune with nature, the longer one would live. But, what was the limit? In observing nature, one could see that some creatures lived for a long time (such as the tortoise that lives for well over 100 years), and other creatures lived only briefly (some insects last only days). Was man's life limited, and, if not, what was the key to a very long life, a key which, no doubt, had much to do with living according to the Taoist ideal? Tales of beings who lived for several hundred years arose, to suggest that people living the right way could extend their lifespan markedly (see Appendix 1). Perhaps the seminal transition in thinking about human lifespan arose from the work of metallurgists, who were actually the earliest alchemists. Metals have an incredible range of properties. Iron, for example, quickly deteriorates; after rusting and pitting, a piece of iron left in the moist earth will soon flake apart. Gold, on the other hand, is affected by nothing. It seems to last forever (one only has to worry about thieves or tax collectors taking it away). Of course, it could be that iron and gold, like insects and tortoises, have their own inherent and unalterable natures. However, in working with metals, it appeared that a skilled alchemist could transform one material into another as illustrated by the transformation of fluid mercury to solid cinnabar (and the process could be reversed). From such observations, and thinking about the possible implications, there arose the concept that one could transmute a material that easily decayed into one that was free of decay. By analogy, one could think that the different qualities, including lifespan, found in nature were each attainable by humans, and one simply had to undertake the appropriate steps to access them. As alchemists sought to transform "base metal" into gold (successfully producing some metals that appeared similar to gold, as do brass and iron pyrite, and were claimed by the practitioners to be gold), some Taoists thought that one could, by taking special steps, transform an aging mortal man into a youth-retaining immortal (see Appendix 2). A central thought in the process setting Taoists down the road of seeking immortality was that this pursuit of transformation and immortality was not going against nature. If one clung to the idea that it is natural to go through a life-cycle that included aging and death, then by simply pursuing what needs to be done in the Taoist way, one would smoothly go through that life cycle. By virtue of living in harmony with nature, one would stay youthful longer and live somewhat longer: going against nature was thought to not only cause harm to one's mind and social position, but also to one's body and life span. However, if transmutation (as observed by alchemists) was a part of nature, and if all of nature's different qualities were ultimately accessible, then one could, by following an appropriate course, become like gold: pure and immortal. This might require some special techniques not ordinarily undertaken by people, but it would not be against nature. So the myth of the mountain- and forest-dwelling "immortals" and the direct experience of the alchemists combined to suggest a Taoist path to immortality. The Taoists began a course of experimenting with longevity-attaining methods. These included physical exercises (movement, breathing, specialized massage, etc.) that today are known as Qi Gong and Dao Yin; mental exercises such as meditation and visualization; sexual practices (restraining the semen, which preserved the original essence and also would be transformed into a special nourishment for the brain); dietary practices (consuming special essence-enhancing foods and herbs, and avoiding those which were thought to harm the essence); rituals (that were thought to bring the practitioner in touch with heavenly dictates); and alchemical practices (a range of activities including transforming metals, ingesting the substances involved in transformation and the end products, and even drinking out of goblets made with the alchemically-derived materials). Each of these practices was viewed as a way of harmonizing with nature. One can easily look upon that view, in hindsight, as an after-the-fact explanation given by persons attached to an idea that was not really in keeping with the Taoist ideal. Many contemporary Taoists thought that these longevity-seekers were off on the wrong track, at least by virtue of their special techniques (see Appendix 3). One could hardly argue with some of the practices undertaken, but some of the more intense physical and mental exercises, and the attempts at sexual restraint might put some of the practitioners psychologically over the edge. It was the alchemical practices, however, that today look appalling. The practitioners generally were exposed to poisons, including substantial amounts of mercury and arsenic (some of those who did not go so far as to ingest the materials were poisoned by breathing the vapors or by absorption through the skin). This caused many of them to lose appetite and weight, which was taken as a sign that they were attaining immortality, since the hsien were being depicted as being extremely light weight and able to float in the sky (sometimes on the back of birds; see Figure 1) and needing no earthly nourishment. Arsenic, in small amounts, increases one's energy and libido, which was no doubt taken as a positive sign when the practices started. It probably took considerable mental gymnastics, however, to deal with the observation that one's colleagues were dying left and right at an early age, without turning from this path. In fact, the Taoist alchemists began to believe that corpse-preservation, as sometimes occurred because arsenic and mercury prevent putrefaction, was the necessary sign of immortality (see Appendix 4). Many of the herbs listed in the first formal Chinese materia medica, the Shen Nong Pen Tsao Ching , were reputed to calm the spirit, lower the body weight, prevent spermatorrhea (loss of semen), and confer immortality if taken over an extended period of time. These proclaimed properties came straight out of the Taoist longevity literature. By the time the Shen Nong Pen Tsao Ching was written, about 400 years after the Taoist immortality attempts were underway, the focus on toxic minerals had given way, to a limited extent, to a pursuit of non-toxic plants, of which well-known herbs such as ginseng and ganoderma were central. The "upper class" of herbs, separated off by Tao Hung-ching in the 6th century A.D., were largely comprised of the Taoist's longevity agents. Cinnabar, the king of the alchemical transformational products, remained until recent decades an incredibly important part of Chinese herbal medicine.

In fact, Chinese herbal pills would be coated with a thin layer of cinnabar and then labeled "dan" (referring to cinnabar, but also meaning elixir) instead of the simple "wan" (pill), to call forth the powerful influence of cinnabar. Even today, many Chinese medicine pills are found to contain mercury, not as a contaminant in processing, but as an intentional component in manufacturing: cinnabar is a mercury compound. Cinnabar was listed as a upper class drug by Tao Hung-ching. Opriment and realgar, two arsenic agents, were demoted to middle class. The Taoist pursuit of immortality continued through to the current century in China, but it largely gave way to other trends. The Taoist immortalists lost face when they were called in by successive Chinese Emperors to help give immortality to the holder of the Imperial Throne, only to leave the throne empty time and again as the Emperor was poisoned by heavy metals. It took the work of Chang Chung-ching (his efforts written down around 220 A.D.) to shift the focus of herbal medicine away from the Taoist immortality attempts that were prominent during the Han Dynasty period (200 B.C. to 200 A.D.) to the treatment of epidemic and other serious diseases. His complaint about "witch doctors" in the introduction to his book was partly aimed at the Taoists. Still, the famous Sun Ssumo and Ko Hung of the 4th Century A.D. continued to promote the Taoist immortality works and a full shift to the use of materia medica for the practice of medicine awaited the Song Dynasty, in the 10th Century. Today, when one reads traditional descriptions of herbs, it is not uncommon to see reference to control of spermatorrhea, calming the spirit (shen), keeping the hair from turning grey, and prolonging the lifespan. These are remnants of the Taoist influence. One should be cautious in accepting these effects as realistic. While the Taoist immortality seekers, like other Chinese herbalists, had centuries of experience to relate in their writings, their interpretations of herbal properties may have been skewed by their intense concerns about transformation of mortals to immortals, leading to unjustified claims. It seems to me that the immortality pursuers took a wrong turn. They were possibly influenced by the personal desire for immortality and the power that was implied by such attainment (thus, in opposition to the Taoist teachings that they presumably upheld) rather than the true pursuit of harmony with nature. One could hardly doubt the sincere efforts of some of alchemists, nor can one challenge some of the chemical, metallurgical, and even medical achievements of these early experimenters. An apparently incorrect conclusion, which may have affected even the most sincere and competent devotees to fundamental Taoist doctrine, was drawn from early metallurgical work suggesting that transformation-indeed transmutation-was a common feature in nature. Thus, for example, Ko Hung believed that all substances might be subject to transmutation under careful refining. Actual transformation of one chemical element to another was not accomplished by humans and their technologies until this century, with the development of "atom smashing" and nuclear fusion. Though the modern alternative medicine community may have been deceived by the sloppy science suggesting that the human body continually transformed chemical elements (e.g., silicon into calcium), the fact remains that transformation of one chemical element to another lies mainly in the realm of radioactive materials and high technology, not in natural biological processes (so far as we know today). We cannot know with certainty if pursuit of immortality is either counter to true Taoism or aiming for an impossible goal, but we can see fairly clearly that the Taoists didn't get the desired results by their pursuits. Modern scientists looking into the matter of human lifespan currently suggest that the natural limits are about 140 years of age (an individual in Iran was recently identified who is purportedly of that age, though this is not formally confirmed; the oldest living person with a confirmed birth date is a French women who turned 120 years old in 1997). There are several efforts aimed at helping people attain that limit. These include taking antioxidants (that reduce accumulating damage of cellular components), a broad spectrum of nutrients (that are absent from the diet in sufficient amount, poorly absorbed, or needed in larger quantity to help assure long life), and hormone replacements (which help restore youthfulness and prevent deterioration of the bones, muscles, and brain), as well as following some of the basic practices that the Taoists recommended in a simplified form: getting regular exercise, eating nutritious foods, and avoiding activities that are harmful, such as smoking, eating too much, drinking too much alcohol, etc. Still, it is thought (based on good evidence) that the biggest influence on lifespan is genetics, followed by nutritional status, and by medical interventions in cases of disease; with life-style factors and supplements (including the hormones) probably having the potential benefit of adding about ten years. Today, there are millions of people in the world who reach age 100 (only a very small percentage of those living in China, however), while a hundred and fifty years ago, prior to modern medicine and modern nutrition, to reach age 60 was an accomplishment. Today, it is a great rarity to reach age 120, but who can tell what the next century will bring? The benefits of antioxidants, high dosage nutrients, and hormones has only been suggested and made available during the lifetime of the current generations. Researchers have shown that there are distinctive benefits to sleeping an appropriate amount of time (about 8 hours; too much or too little is associated with shorter life span), eating a healthful diet (mostly comprised of natural foods, especially vegetables, fruits, and fish), maintaining a normal body weight (too heavy or too thin is associated with shorter life span), getting regular exercise (prevents clogging of the arteries and deterioration of the bones; also, although a direct causative correlation has not yet proven, women who exercise regularly are less likely to get breast cancer), and avoiding stress (much of which may arise from doing too much that is unnecessary). The fundamentals of Taoism may well be correct in many ways, including benefiting health and lifespan. But the pathway that a group of the early Taoists pursued towards immortality (rather than simple longevity) via alchemy, and even herbal remedies, appears to have been a crooked road leading to a dead end. One should therefore be cautious in reading traditional herbal literature to avoid being led astray. Still, we may find that some of the non-toxic remedies that the Taoists promoted, such as ganoderma, lycium fruit, and chyrsanthemum flowers, might have health benefits that include prevention of disease and slight prolongation of life span.

Appendix 1: Stories of Extreme Longevity From the book The Mystery of Longevity, by Liu Zhengcai (1990 Foreign Languages Press, Beijing: pages 2-3) Note on transliteration: This book was published in China recently and utilizes pinyin throughout. The term Daoist, in the text, was changed to Taoist in this rendering. All other pinyin was retained. Tradition says that famous ancient Chinese scholars enjoyed still longer life spans. For instance, Peng Zu, noted for his high skills

in cuisine and the arts of daoyin and qigong in the times of Yao of Tang, lived to the age of 767 when he went away without anybody knowing where. Lao Zi, author of the Taoist classic The Canon of the Way (Dao De Jing), reportedly lived 300 years. A mysterious, rather shadowy figure in the Warring States Period (475 B.C.-221 B.C.) named Gui Gu Zi (Master of Ghost Valley) was said to have lived for several hundred years. He was highly skilled in bodybuilding practices, meditation, and political and military strategy. As a true Taoist, he never dabbled in politics, but several of his disciples became distinguished statesmen serving in different rivaling states. History has recorded personages of longevity in all dynasties, and they were especially numerous prior to the Jin Dynasty (265420). In the reign of First Emperor of Qin (246 B.C.-210 B.C.), Cui Wen Zi, a Taoist good at caring for life, reportedly lived to the age of 300. In the period of Emperor Wu Di of Han, who rivaled the First Emperor in his intense interest in the way of immortality as well as in military exploits, a man named Li Gen of Xuxian County (present Xuchang County, Henan Province) was so well-versed in the secret of preserving life that he lived to be over 700. In the Eastern Han Dynasty (25-200), the famous physician Li Changzai wrote a book Prescriptions of Li, saying he could walk 800 li (400 kilometers) a day. He was popularly believed to have lived 800 years. In the Three Kingdoms period (220-265) the villain-hero Cao Cao, ruler of the Kingdom of Wei, had three worthy scholars at his service. One of them was Gan Shi, a practitioner of higher skills of qigong. (A qigong practitioner attains the higher stage when he can make qi flow and circulate at will in his body. He undergoes unusual biological changes and can even walk on water or soar up into the sky.) Another was Zuo Ci, skilled in sexual techniques to make semen nourish the brain. The third was Xi Jian who could "dispense with cereals and only take fuling (Poria cocos, a subterranean fungus) as food." Well-known among their contemporaries for the art of preserving life, they each lived 300 years or more. In the Jin Dynasty, a Handan native named Wang Lie looked young in his old age because he often ate sealwort ( Rhizome polygonati). Later he went into the Taihang Mountains to take ascetic religious training. He also lived to the age of 300. It is impossible to discuss all such personages of longevity. Ge Hong (284-364), famous alchemist in the Jin Dynasty, wrote a book Stories of Immortals (Shen Xian Zhuan) in which he described ninety-four personages of longevity well known in folklore and legend. Of course, legends of those who lived several hundred years may not be too reliable, but there have indeed been a considerable number of authentic centenarians throughout China's history. The blind court musician Grandpa Dou (350 B.C.-170 B.C.) of the Western Han Dynasty lived to the age of 180. When asked by Han Emperor Wen Di about the secret of his longevity, Grandpa Dou replied that when he became blind at the age of 13 his parents taught him the arts of daoyin and lute playing. Apart from this he had no other secret. The topic was picked up by Ji Kang, one of the socalled Seven Sages of the Bamboo Grove in the Jin Dynasty, in his book Preserving Life. He said, "Grandpa Dou lived to the age of a hundred and eighty without taking any special tonics or nourishing foods or doing any particular body-building exercises. Didn't he achieve this because he felt tranquil from lute playing, which brought harmony to his mind? This is a way of nurturing the mind." Ji Kang suggests that music gave Grandpa Dou a long life. Prime Minister Zhang Chang (?-152 B.C.), during the reign of Han Emperor Wen Di, often drank human milk and is said to have lived more than 100 years.

Appendix 2. Alchemy, Macrobiotics, and Immortality From the book Science & Civilisation in China by Joseph Needham (1974 Cambridge University Press, London; volume 5(2): pages 914). The profound influence of Taoism on Chinese science, proto-science and medicine has been emphasized throughout our volumes. At an earlier stage we had occasion to speak about the primitive shamans of Chinese society, the wu, and there can be no doubt that Taoist philosophy and religion took its origin from a kind of alliance between these ancient magicians and those Chinese philosophers who, in ancient times, believed that the study of Nature was more important for man than the administration of human society, upon which the Confucians so much prided themselves, and that his moral perfection depended much more on his integration with the natural cosmos than on his social relations with other men. At the heart of ancient Taoism there was an artisanal element, for both the wizards and the philosophers, the diviners and the cosmological thinkers were convinced that important and useful results could be achieved by using one's hands. They did not share the mentality of the feudal lords or Confucian scholar-administrators who sat on high in their tribunals issuing orders and never employing their hands except in reading and writing. This is why it came about that wherever in ancient China one finds the sprouts of any of the natural sciences the Taoists were sure to be involved, and chemistry was no exception. The fang shih- technicians, [miracle-performers], adepts, or 'gentlemen possessing magical recipes'-of whom we hear so much between the 5th century B.C. and 5th century A.D., were certainly in general Taoist.... [The following sections describe, in relation to the underlying ideas about attaining immortality, the alchemical arts of aurifiction, aurifaction, and macrobiotics, with each term defined. One issue, distinguishing aurifiction and aurifaction, is the underlying knowledge of what was actually being produced.] Aurifiction we define as the conscious imitation of gold (and by extension, with suitable variation of nomenclature, silver and other precious substances such as gems and pearls), often with specific intent to deceive-whether by 'diluting' gold and silver with other metals, or by making gold-like or silver-like alloys with copper, tin, zinc, nickel, etc., or by the surface-enrichment of such mixtures containing gold or by amalgamation gilding, or by the deposition of surface films of appropriate tints produced by exposure of the metal to the vapors of sulphur, mercury and arsenic, or volatile compounds containing these elements. The deception of the client, or the aim of deception, is not essential in this definition, for he may be quite content with substances of a gold-like appearance, imitations which may serve his purpose, but the proto-chemical artisan must be aware that his product would not stand up to the fundamental test of cupellation [which separates oxidizable metals from those that don't oxidize]. He must therefore know it to be, in the workshop sense, 'false'; though the very same processes may be employed by the philosophical alchemist to give a result which was considered, in the philosophical sense, 'genuine'. This paradox will become more understandable in what follows.

Aurifaction, on the other hand, we define as the belief that it is possible to make gold (or 'a' gold, or an artificial 'gold') indistinguishable from, and as good as (if not better than), natural gold, from other quite different substances, notably the ignoble metals. This was the conviction of philosophers rather than artisans, as we shall see. The self-deception of the alchemical philosopher is essential in this definition, not because of any credulity or unworthiness on his part but because in an age before the visualization of the persistence of the atoms of the separate metals in the alloy, certain properties or qualities of the artificial 'gold' were precisely what justified its name. It was not thought necessary that all the properties of the yellow metal should be identical with those of natural gold so long as at least one of them was-heaviness, softness, ductility, malleability, internal uniformity, but color was always by far the most important. As the poet said: 'the glitter is the gold'. We believe that the alchemical philosophers, both in East and West, often did not know of the test of cupellation (and for this we shall suggest a sociological reason), but even when they did they probably regarded it as irrelevant to their nomenclature, taking 'gold' to mean whatever had the form, accidents or qualities, more or less, of gold. This complex of ideas is, of course, that which has so often been thought in the past to comprise the whole of 'alchemy', but we find it extremely helpful in clarification to distinguish an aurifactive element from a macrobiotic element. Macrobiotics is a convenient term for the belief that it is possible to prepare, with the aid of botanical, zoological, mineralogical and above all chemical, knowledge, drugs or elixirs (tan) which will prolong human life beyond old age, rejuvenating the body and its spiritual parts so that the adept can endure through centuries of longevity, finally attaining the status of eternal life and arising with etheralised body as a true Immortal. Such was the Taoist concept of material immortality.... But there was another predisposing cause for alchemical ideas in China, the absence of any prejudice against the use of mineral drugs analogous to that which existed so long under the Galenical domination in Europe; indeed the Chinese went to the other extreme, compounding with remarkable persistence through the centuries all kinds of dangerous elixirs containing metallic and other elements (mercury, arsenic, lead, etc., as well as gold) which caused untold harm to those who resolutely took them. However the Taoist, if he chose, could avoid these dangers, for there were many other techniques available in the quest for material immortality, not only alchemical and pharmaceutical but also dietetic, respiratory, gymnastic, sexual, heliotherapeutic and meditational. With all these could he aspire to incorporation into the ranks of the invisible bureaucracy of the universe as a Heavenly Immortal; or else seek for transformation into an Earthly Immortal, purified, ethereal and free, able to spend the rest of eternity wandering as a kind of wraith through the mountains and forests, enjoying the company of similar enlightened spirits and the cycle of the seasons ever repeated yet with glory ever renewed. These are the beings that one can discern, tiny against the immensity of the landscape, flitting across remote ravines in many beautiful Chinese paintings.... The two ideas of macrobiotics and aurifaction came together first in the minds of the Chinese alchemists from the time of Tsou Yen in the 4th century B.C. onwards, for the first time, it seems, in any civilization....There was aurifiction in China too, sufficiently widespread to evoke an imperial edict in 144 B.C. forbidding unauthorized private minting and the making of 'false yellow gold'....But only a few decades after those activities, by 133 B.C., when Li Shao-chun was urging the emperor to support his researches, and 125 B.C., when Liu An's group of natural philosophers was compiling the Huai Nan Tzu book, the connection between aurifaction and longevity-immortality is clearly recognizable. Thus began that association between the manufacture of the imperishable metal, gold, and the attainment by man of earthly imperishability, which was to spread in later centuries throughout the whole world. At first, it took the form that plate and vessels of artificial gold possessed a magical property of conferring longevity or immortality upon whoever should eat or drink from them, functioning doubtless as containers for the elixir substances of vegetable origins, the 'herbs of deathlessness' which the feudal princes of the Warring States, and then the First Emperor, Chhin Shih Huang Ti himself, had been so eagerly looking for since the middle of the 1st millennium B.C....The idea that that artificial or natural gold should not be confined to rustless vessels but should actually be ingested, taken into the human body in one form or other, was also growing up....Older adepts had tried consuming powdered cinnabar, with other mineral and metallic substances....An official report of the physician Shunyu I tells how in 160 B.C. he attended another medical man who had made himself ill by taking excessive amounts of mineral drugs.... The thought linkage thus established between aurifaction and immortality was destined to have nearly twenty centuries of life, taking on, in due course, the formulation that all other metals, rusting and corroding, suffered from the same illness as mortal man, so that the philosophers' stone [that which converts rusting metal to gold] would be the supreme medicine of men as well as of metals.... [with] Taoism, medicine and alchemy were always intimately connected, not only theoretically but in practicing individuals time after time.

Appendix 3: Is Seeking Immortality by Special Techniques Appropriate? From the book Medicine in China: A History of Ideas by Paul U. Unschuld (1985 University of California Press, Berkeley; pages 124125). Again and again, the Hsiang-erh commentary stresses the senselessness and foolishness of the widespread tricks for prolonging life, in particular the sexual techniques which attempted to protect against loss of semen by returning this precious substance to the brain. The numerous passages dealing with this problem underscore the intention of shaking the faith in mechanistic, and therefore amoral, longevity practices, and drawing adherence to an ethic of the true Tao, on the one hand, and the enjoyment of the longest possible life free from illness, on the other hand: Men who conduct their lives in accordance with the doctrine of Tao accumulate essence and their spirit realizes its full potential. Unfortunately, these days several tricks masquerade under the name of "Tao." In following the writings of the Yellow Emperor, the mystical maiden, Kung-tzu, and Jung Ch'eng, some men spend their lives in incessant pursuit of the female sex, hoping to strengthen their mental faculties through the return of the [seminal] essence. For these people, mind and spirit no longer form a whole; in reality, they lose that which they thought to preserve.... The corporeal soul [po] is white and therefore the [semen] essence is white; the primordial influence [to which man owes his life] has the same color. The body is a wagon loaded with [semen] essence. If this essence flows out, more must be loaded to reestablish the correct proportion. When the spirit has realized its full potential, the essences flow into the body until the correct level has been reached again. One now desires to maintain continually the achieved level [of essence] and not lose the unity [of mind and spirit]. If this unity is attained, it signifies the [complete harmony of personal existence with the] Tao. But how is the presence of this harmony in the body to be understood? How can this unity be preserved in the body? It is not present in the body from the very beginning, and this is why the widespread tricks that are concerned with

the body do not [conform to the] true Tao. The harmony comes from beyond heaven and earth, entering from there the region between heaven and earth. When it then enters the body, it does not occupy one specific spot, but fills the entire space enclosed by the skin. He who today conducts his life in accordance with the ethical precepts of the Tao, he who heeds this ethic and does not violate it, shall preserve harmony. He who does not conform to this ethic shall lose harmony.

Appendix 4. Death as a Result of Taking Immortality Elixirs From the book Science & Civilisation in China by Joseph Needham (1974 Cambridge University Press, London; volume 5 (2): pages 297-298). But even when the unmistakable death of the elixir-taker supervened, all was not necessarily lost for the doctrine. If the corpse was preserved from natural decay, in recognisable identity, that was a wonder in itself; almost a proof indeed that the adept was living on as one of the immortals, having taken with him a sufficient simulacrum of his bodily appearance to keep the constituent spirits and 'souls' in union together. This would be one kind of 'announcement of immortality,' or 'release from the mortal part.' Or perhaps he was just sleeping, and made use of the uncorrupt body, in full animation, when the Taoists and their disciples were not viewing it. That would be one form of 'taking flight to attain the state of immortality.' There were many terms and phrases of this kind, some twenty occurring in the Li Shih Chen Hsien Thi Tao Thung Chien (Comprehensive Mirror of the Embodiment of the Tao by Adepts and Immortals throughout History), a vast compilation, probably made in Yuan times, by Chao Tao-I. One thing is certain, or at least constantly averred, namely that the bodies of some alchemical adepts did not decay. For example, in the Hsu Hsien Chuan (Further Biographies of the Immortals), a work written by Shen Fen between 923 and 936 A.D., it is related that when Sun Ssu-Mo died in 682 at the age of a hundred or slightly more, no visible sign of putrefaction was noticed during a period of many weeks. 'After more than a month had passed there was no change in his appearance, and when the corpse was raised to be placed in the coffin it was as light as (a bundle of) empty clothes. Truly this was release from the mortal part. As Ho Ping-Yu & Needham remarked, possibly this great 7th-century alchemist, physician and pharmacist had taken one of the many elixirs containing arsenic or mercury described in his own work ThaiChhing Tan Ching Yao Chueh (Essentials of the Elixir Manuals for Oral Transmission…), or Thai-Chhing Chen Fen Ta Tan (The Great Elixirs of the Adepts…), written about 640 A.D. The doses of metallic substances recommended here, such as mercury, gold, and the arsenical sulfides, are generally much more drastic than in Sun's own medical books. There were three ways in which such freedom from decay could happen. First it is a commonplace among experts in forensic medicine that putrefaction is to a great extent inhibited in victims of poisoning by metallic compounds, and especially by arsenic. In his authoritative work Glaister says that 'the preservative influence of arsenic upon the tissues of those poisoned by this substance has been repeatedly observed, and noted following exhumation, despite assertions to the contrary. Presumably the bacteria themselves are poisoned by the arsenic. It is thus more than likely that the bodies of those who died from elixir poisoning remained comparatively undecomposed, and this could be adduced by the Taoists as one more piece of evidence for the efficacy of their chemistry. In such cases the features would be well preserved and the body would have a natural look, with little or not odour of decay....

May 1997

A common depiction of one of the hsien, a "divergent sect" of Taoists that pursued alchemy and immortality.

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TASTE AND ACTION OF CHINESE HERBS Traditional and Modern Viewpoints by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Since ancient times, Chinese herbalists have classified medicinal materials according to their tastes (Chinese: wei). The taste was understood to have a relationship to the effect of the herb when ingested. This relationship was seen as having great importance in guiding the combining of herbs within formulas. In most traditional Chinese herb books, taste was the first property of an herb to be mentioned, helping to orient the reader to the information that followed. There are five tastes—sweet, salty, sour, bitter, and acrid (sometimes called pungent or spicy)—consistent with the five element concept. Additionally, some herbs are said to be bland in taste, meaning that there is hardly any taste sensation on the tongue when the herb is tested. This term “bland,” however, doesn’t quite capture the Chinese meaning: that the taste is natural, unspoiled, or pure. The bland taste is sometimes considered a subdivision of the sweet taste. Whereas sweet herbs can contribute to accumulation of dampness if taken in too great a quantity, the bland tasting herbs tend to be diuretic, a property that counteracts dampness. There is additionally the designation astringent, which is often considered a subcategory of the sour taste. Some materials—especially minerals and shells—can be astringing without an obvious sour sensation on the tongue, while most sour tasting herbs also have an astringent action. In some texts, astringent taste is added to the basic group of five flavors plus bland herbs, thus yielding seven categories. It is reasonable to raise the question whether or not the tastes really have a strong correlation with herbal effects now that there is so much more known about the actions of herbs as the result of long historical experience and modern research methods. The answer to this might influence modern herbalists in their decisions about which herbs are appropriate to combine within a formulation. Unless noted otherwise, the traditional designation of taste for herbs mentioned in this article comes from Oriental Materia Medica (1). In several instances, other texts may provide different designations; this is most often the case when an herb is said to have two or more tastes. 1. SWEET TASTE The sweet taste of herb materials—and foods—is traditionally associated with a tonic effect. The main sweet tasting constituents in nature are now known to be carbohydrates (including simple sugars, complex starches, pectins, and polysaccharides) and proteins. There are some rare exceptions, such as the glycyrrhizin in licorice which is about 50 times as sweet as sugar but is not a type of sugar; still this relatively rare exception basically proves the rule that sweets are sugars, simple or complex. Raw licorice is often used as a detoxicant and anti-inflammatory, as one would do with bitter herbs (see below), and licorice does contain bitter components. To fully utilize licorice as a tonic herb, it is first baked with a substantial amount of honey—adding considerable sugar and possibly neutralizing some of the bitter, cooling, and anti-inflammatory components. The sweet taste is one of the few in nature that is inherently pleasing to all, young and old and regardless of culture. This situation is no doubt a biological survival mechanism by which humans are “directed” to consume nutritious substances as food: of the three basic macro-substances needed in nutrition, sugar and protein tend to be sweet, while the third, fat, appears to elicit appreciation for other flavors, especially sweetness. In nature, fat usually accompanies protein (as in nuts and meat), and thus the food with substantial fat is usually sweet. It is rare that sweet tasting natural substances are poisonous, which is why it is the only inherently pleasing taste (especially to young children who are exposed first to the sweet taste of mother’s milk). Although the full range of tastes are associated with a relatively limited non-toxic part of our natural environment, most of them are acquired tastes, things that are first approved by those who have survived eating them, and then, with some convincing, passed on to the next generation. Green vegetables, with their slight to strong bitter component, are normally avoided by children, and by quite a large portion of the adult population in America, despite persisting pressure to eat them because of their healthful value. In a modern culture inundated by isolated sugars, it may be hard to imagine how sweet tasting things can be considered beneficial to health, but in the native culture of China there was little in the way of isolated sweets or even overly sweet native foods. Thus, the sweet tasting food substances in Chinese culture were usually starches (such as rice), which have a very mild sweet taste, and meats (mainly chicken and pork). Relying on a natural diet, one tends to be more sensitive to the sweetness of complex sugars (a perception which seems to vanish with the experience of refined sugars), and more appreciative of their healthful qualities. Most modern research regarding dietary simple sugars is aimed at showing their negative impact, because of the large amounts consumed. Complex carbohydrates are repeatedly demonstrated to be of benefit (at least up to a certain proportion of the diet), and that focus of dietary research comes, in part, from our modern reliance on refined simple sugars replacing complex carbohydrates as the sweet part of the diet. Actually, both types of sugars can be beneficial in the appropriate amounts. Too much of some complex carbohydrates can be detrimental. Very simple sugars, such as glucose, fructose, and sucrose, are not only nutrients, but they are calming to the body. That is one reason why they are so often sought out now in the form of “treats.” In modest amounts, they not only calm agitation, they also invigorate basic energy as a fundamental nutrient. Sugars also soothe irritated

membranes and are thus used successfully in making cough syrups, throat lozenges, and the like. In China, simple sedative formulas are made from jujube, wheat, licorice, maltose, and other sweet herbs; honey-based cough syrups have been used since ancient times. The modern experience of children becoming uncontrollable when consuming sweets reflects two problems: disharmony in the child’s body and carbohydrate consumption that far exceeds the amounts that would provide a soothing effect. Complex sugars are even better at soothing irritated membranes, and they also bind water in such a way that they can help treat mild diarrhea. Pueraria starch and the pectin-like materials of hoelen are examples. Certain complex sugars interact with cell membranes and promote immune functions: these are polysaccharides that have been of growing interest since their isolation and testing in the late 1960’s. Astragalus has been a major source of such sugars. As an illustration of the connection between traditional and modern approaches to taste and medicinal activity, at a 1981 international conference in Harbin, China, a researcher described how she had decided to test astragalus polysaccharides, one of several types of the herb’s active constituents for immune-promoting. She said that in traditional Chinese medicine, the tonic quality of astragalus was associated with the sweet taste; she reasoned that the sweet taste would likely be made up of sugars, and so she isolated various saccharides, and tested them for a tonic action, namely, for increasing resistance to disease as measured by specific immunological tests. Her studies showed that the astragalus polysaccharides had a marked effect on several immune responses; this work was followed up in the U.S. and became the basis of recommending astragalus for treatment of cancer patients suffering from chemotherapy-induced leukopenia. Plant parts that have a notable sweet taste are usually fruits and roots/rhizomes/tubers. The reason fruits are sweet is that this attracts fruit eaters among the animals who will then deposit the seeds at some distance from the plant on which the fruit grew, giving a sort of mobility to the plant that it would not otherwise have. The sweet fruit may also attract certain kinds of bacteria and fungi into the process of decay when the fruit falls, providing useful nutrients to the plant. Sweet roots and tubers are storing sugars for the plant to use in growing in the early spring. These roots usually become large and sweet in the late summer or autumn. Given the natural roles of polysaccharides as a medium for energy metabolism, as a structural material, and as a means of storage under difficult conditions, it is not surprising that the sweet tasting materials are “tonic” in effect when ingested: energizing, building, and storing. Protein is the structural substrate for biological activity. It is the substance of enzymes, muscles, and neurotransmitters. A substantial amount of protein in the human diet is usually obtained from animal sources. Legumes and nuts are the main edible plant sources of protein. Seeds and other reproductive materials (e.g., pollen) have high amounts of protein; it is utilized to initiate the growth process. Some seeds are too tough to eat and others are poisonous (biological mechanisms to aid survival in some cases), so we usually rely on a limited range of them. The taste of the meats, legumes, and nuts are mildly sweet; it is common practice to add salt to them in order to broaden the taste experience in meals. Most of the foods that are consumed in substantial quantity (e.g., grains, beans, meats, many fruits) are classified by the Chinese as having a sweet taste (they may have other tastes as well) and a tonic nature. They are considered by Chinese diet specialists as tonic to the spleen system (though the different foods can also be subdivided according to benefits to each of the five zang), which is the organ system responsible for distributing the qi from food. That is, good food benefits the spleen and builds up the qi. Our modern understanding of sweet tasting herbs has close correspondence with the traditional classifications: 1. According to five element systematic correspondence, the sweet taste is associated with the spleen, which has functions that revolve around digestion and absorption of nutrients. 2. According to the taste/action dogma, the sweet taste is associated with tonification therapy, and also calming, reducing irritation (soothing), and generating fluid (this latter function is often associated with the ability to overcome thirst and is related to tonification of qi). Of 71 tonic herbs listed as such in Oriental Materia Medica, 38% are roots, rhizomes, and tubers, 21% are animal materials, 13% are seeds, and 11% are fruits, and 17% are from all other types of materials combined, including two mushrooms and maltose (a simple natural sugar product). Since edible animals, fruits, and seeds are more commonly listed in diet therapy rather than in herb therapy, one can understand why this herb book mainly lists the roots, rhizomes, and tubers. Not all the items in the tonic sections mentioned here have a sweet taste: of the 58 items (82% of the total materials listed) with a sweet taste, 34% are roots, rhizomes, and tubers, 21% are animal materials, 12% are fruits, 11% are seeds and 22% are all other materials combined. Some tonic herbs with sweet taste as the sole classification given (e.g., not sweet and bitter): Qi Tonics Astragalus Dioscorea Codonopsis Ginseng leaf Licorice Oryza (rice sprout) Polygonatum Maltose

Blood Tonics Gelatin Longan Lycium Rehmannia (cooked)

Yang Tonics Astragalus seed Antler gelatin Cordyceps Cynomorium Walnut Oryza (seed) Stalactite (animal source)

Yin Tonics Broussonetia Dendrobium Gallus (chicken gizzard) Soja (black soybean) Fish swimbladder Lily Orobanche Polygonatum (yuzhu)

Tremella







Jujube







2. SOUR TASTE The sour taste is relatively rare among the herbs of the Chinese Materia Medica, but is fairly prominent in foods, specifically fruits. A variety of organic acids common to the fruits contribute the presence of sour flavor. These include citric, malic, and ascorbic acids. It is also the fruits that mostly contribute a sour flavor among the herbs in the Oriental Materia Medica (examples of fruit and fruit rind herbs with sour taste are mume, schizandra, terminallia, rubus, rose, cornus, pomegranate, crataegus, chaenomeles, and phaeseolus. Wine (with tartaric acid) and vinegar (mainly comprised of acetic acid) are sometimes used to process herbs that are to be utilized as liver and blood tonics because of their influence on the herb properties that is similar to that of other sour materials. Some herbs have a sour taste due to ingredients other than organic acids. Alum, haloysite, and oxycalcite are classified sour tasting minerals. Roots and stems, such as peony, achyranthes, sanguisorba, and cistanche, have a variety of complex active components that produce a sour taste. There are two major connotations of the sour taste in Chinese medical theory: 1. In five element systematic correspondence, the sour taste is associated with the liver. It has a moistening and softening effect, usually reducing contraction of the ligaments and tendons. Persons who are overly flexible may find that the sour tasting herbs worsen that condition. Peony, cornus, achyranthes, and chaenomeles are among the main sour herbs used to affect the liver function and said to relax the tendons. 2. According to the taste/action dogma, the sour taste has an astringent and fluid recollecting function (that is, helping to reabsorb fluids as they begin to escape). Chinese medicine considers the sour and astringent qualities as restraining the leakage of any fluid, including perspiration, sputum, semen, vaginal fluids, and blood. Tannins, a class of complex molecules with notable astringent effect, are present in some of the herbs. Schizandra, terminallia, cornus, and sanguisorba are commonly used as astringents. Herbs with Sour Taste Achyranthes: nourishes the liver, promotes blood circulation, and relieves contraction of the limbs Alum: controls bleeding, diarrhea, and mucus discharge Campsis: nourishes the liver and relieves wind and spasm Chaenomeles: nourishes the liver to relax ligaments Cistanche: controls spermatorrhea Crataegus: nourishes the liver and relieves spasms Cornus: retains the essence, restrains the urine Eclipta: stops bleeding and restrains the yin Halloysite: astringes intestines, controls diarrhea and bleeding, absorbs dampness topically Mume: restrains the body fluids and generates new fluids Papaver: astringes lung and intestines Peony: nourishes the liver and relaxes contracture of limbs; collects sweat, restrains the yin Phaeseolis (chixiaodou): alleviates diarrhea Pomegranate: astringes intestines Portulaca: alleviates diarrhea, bleeding, and leukorrhea Red peony: promotes circulation of blood, relieves spasms. Rose: astringes sperm, controls diarrhea, inhibits urinary secretion Rubus: alleviates spermatorrhea, enuresis, and urinary frequency Sanguisorba: alleviates diarrhea and intestinal bleeding Schizandra: reduces perspiration, restrains the lung fluid, restrains essence Terminalia: astringes lungs and intestines Trichosanthes root: reduces fluid swellings Among the items mentioned above are minerals which astringe fluid discharge and numerous fruits. 3. BITTER TASTE The bitter taste is the most common one found among medicinal herb ingredients, especially among the plant materials. It has been suggested that the bitter taste is generally unpleasant because it warns of potentially toxic ingredients. These toxins are strong medicines, and it is because of this that they become common among the ingredients of herbal medicines. Alkaloids, which often affect the nervous system, are consistently bitter, and glycosides, which usually affect the circulatory system, are frequently bitter; so are most flavonoids, which have broad beneficial health effects if taken in sufficient quantities. There are two basic qualities associated with bitter taste: 1. According to the five element systematic correspondence, the bitter taste is associated with the heart system. The alkaloids and glycosides commonly found in bitter plants help explain this relationship, as the Chinese heart system corresponds mainly to the nervous system and circulatory system of Western medicine, the two systems most strongly impacted by these types of active constituents. 2. According to the taste/action dogma, bitter herbs have a cleansing action (removing heat and toxin). The cleansing action of bitters mainly refers to their antimicrobial and anti-inflammatory effects, which are found

with alkaloids, glycosides, and flavonoids. The bitter herbs also dry dampness, and this refers mainly to reduction of mucous membrane secretions; we can recognize today that increased mucus secretion is usually secondary to inflammation and infection. There are so many bitter herbs that one could hardly begin to list them. However, it is in the category of “firepurging” herbs that the bitter taste is most frequently found. Some of the intensely bitter herbs include: Andrographis Belamcanda Coptis

Dictamnus Gardenia Gentiana

Phellodendron Picrorrhiza Pulsatilla

Sankezhen Scute Sophora

These herbs inhibit infections, reduce inflammation, and, in many cases, inhibit tumors. 4. ACRID TASTE The acrid taste indicates a certain burning or numbing sensation of the tongue, which is elicited by a variety of ingredients, but most frequently by essential oils. Most of the essential oils are highly volatile, giving them a notable fragrance and a dispersing quality. Essential oils may cause the surface blood vessels to dilate, causing sweating and changes in the circulation in the skin and joints. They also tend to stimulate mucus secretion and movement in the lungs and sinuses (see: The use of aromatic agents for regulating qi, vitalizing blood, and relieving pain for additional information about applications and constituents). There are five sections of the Materia Medica that contain a large percentage of acrid herbs, with one section dominated by acrid tasting herbs: the surface-relieving category. Although not all the herbs that relieve the surface contain essential oils as active constituents (ma-huang is an obvious exception, it has an alkaloid as the principal effective ingredient), the majority are rich in essential oils that stimulate circulation and, with adequate dosage and proper administration, induce perspiration. Among the acrid herbs for relieving the surface with essential oils as dominant ingredients are: Angelica Asarum Chiang-huo Chrysanthemum

Cimicifuga Cinnamon Coriander Elsholtzia

Ginger Kao-pen Magnolia flower Mentha

Perilla Schizonepeta Siler Vitex

The other associations of acrid taste in traditional Chinese medicine are: 1. According to five element systematic correspondence, the acrid taste is associated with the lungs. In relation to the surface-relieving herbs, the lungs are the viscera that control the surface circulation. Additionally, some acrid herbs relieve coughing (e.g., aster, tussilago, perilla seed, peucedanum, platycodon) by helping to assure the lungs downward movement of qi. 2. According to the taste/action dogma, the acrid taste is associated activating circulation of qi and dispersing accumulation of moisture. Acrid herbs with these effects include citrus, aquilaria, cyperus, lindera, saussurea, magnolia bark, and pogostemon. From a Western perspective, we know that essential oils are penetrating and have circulation-altering actions. 5. SALTY TASTE The salty taste has two predominant associations in traditional Chinese medicine: 1. According to five element systematic correspondence, the salty taste is associated with the kidneys. Examples of kidney essence (jing) tonics with salty taste are deer antler, gecko, placenta, sea horse, turtle shell, tortoise shell, and mantis; all from animal sources. Actinolitum, a mineral, and cistanche, a root, are salty yang tonics. The frequently used sour fruits cornus and schizandra also have a salty taste: they are used to both nourish and astringe the essence. 2. According to the taste/action dogma, the salty taste is associated with dissolving masses, removing moisture and phlegm, and softening hardness. These actions fall under the general heading of resolving therapies. Examples of herbs with these actions are laminaria, sargassum, oyster shell, pumice, turtle shell, arca shell, and cuttle bone. These materials are from the sea, though not all the salty resolving agents come from this source: lithospermum, scrophularia, and isatis are land plants with a salty taste used for treating toxic swellings. From a Western perspective, we have come to associate salt (sodium chloride) as being harmful to the kidneys and a cause of fluid retention. However, the primary activity of salty tasting herbs is usually not the result of adding substantial amounts of sodium salts to the body. According to the philosophy of the Nei Jing, herbs with a salty taste are directed to act upon and benefit the kidney, while consumption of large amounts of salt will harm the kidneys. The herbs for resolving swellings (in most cases, these are not the kidney tonics) usually have a cold nature, and are thus to be used cautiously in persons with cold syndromes, including yang-deficiency diarrhea. They are considered somewhat deleterious if taken over a long period of time by persons with weak stomach/spleen functions. The salty kidney tonic herbs are predominantly of warm nature (turtle and tortoise shell are exceptions) and they should be used cautiously in persons with deficiency fire syndromes. Herbs with Salty Taste (only frequently used items are included) Actinolite: tonifies yang

Agkistrodon: resolves toxic swellings Antelope horn: relieves swelling of eyes and toxic swellings Arca shell: softens masses, disperses static blood, clears phlegm accumulations Cassia: relieves constipation, reduces swelling of eyes Cistanche: tonifies yang and essence, relieves constipation Clematis: relieves phlegm accumulation in abdomen, purges excess moisture Cuttle bone: relieves swelling of genitals, relieves corneal opacity Deer antler: tonifies yang and essence Earthworm: removes excess moisture, clears urinary obstruction Gecko: tonifies yang and essence Gleditsia: resolves abscesses and toxic swellings Haliotis: relieves corneal opacity Isatis leaf: resolves toxic swellings Laminaria: eliminates excess moisture, reduces thyroid swelling, relieves swelling of testis Leech: resolves static blood, gynecologic tumors, and abdominal lumps Lithospermum: resolves toxic swellings, relieves dry constipation Lysimachia (desmodium): resolves kidney and gallstones Margarite (pearl): relieves corneal opacity, resolves toxic swellings Mirabilitum: softens masses, relieves dry constipation Oyster shell: softens firm masses, dissolves phlegm Placenta: nourishes essence Pumice: softens firm masses, clears thick sputum, resolves lymphatic swelling Sappan: resolves static blood, relieves postpartum distention Sargassum: softens firm masses, removes excess moisture, relieves swelling of thyroid, lymph, and testis Schizandra: astringes essence Scrophularia: resolves swollen lymph glands, relieves constipation Tortoise shell: nourishes yin Turtle shell: nourishes yin, resolves firm lumps and abdominal tumors It is unclear, from the modern viewpoint, how a salty taste fits with the above listed herbal properties, except that large amounts of salts, as found in the seaweeds, could have an impact on clumping of cells and other phenomena that might yield swellings and could affect diuresis. Assigned Tastes In the article “The characteristics and functions of traditional Chinese drugs,” presented in the Journal of Traditional Chinese Medicine (2), this is reported: “The flavors [of herbs; here called drugs] don’t necessarily refer to the real tastes of the drugs. Sometimes, they are sorted out according to the drugs’ actions other than tastes. Therefore, the flavors of some drugs introduced in books on materia medica are often different from their true tastes.” Anyone who has tasted ginseng roots recognizes the strong bitter flavor, and may feel hard pressed to note the sweet taste, apart from those fresh roots that have been preserved with sugar. The ginseng root contains a substantial amount of starch and sugar, and a small amount of the immune-enhancing polysaccharides. The bitter taste derives from its content of saponin glycosides—the principle active constituents at usual dosages; the more glycosides a root has, the more potent the root is, in terms of tonification. A saponin is a steroid-like molecule and a glycoside is a combination of a complex molecule, such as a steroid, with a sugar (which often has the effect of enhancing absorption). The sweet taste may have been attributed to ginseng for any number of reasons, including the possibility that when the taste was first assigned in an herbal text, the available roots were from a different plant species (one like codonopsis) which are sweeter than the current ones. No matter the original designation, the reputation of ginseng as a spleen tonic and the description of ginseng as a sweet tasting herb (with mild, bitter quality), coincides with the dogma that the sweet taste is tonic, and especially that it tonifies the spleen. Therefore, the emphasis on ginseng’s sweet taste remains. In similar manner, the essentially white ginseng roots are described as being yellow, consistent with the five element systematic correspondence of the yellow color and the spleen. By contrast with ginseng, astragalus and codonopsis are notably sweet in taste (like many herbs, they also have some bitter quality). These two herbs, like ginseng, are said to tonify the spleen and lung. Although ginseng is considered the “stronger” qi tonic, it is not sweeter than the others. Thus, the degree of sweetness of an herb is not necessarily associated with the traditionally described degree of tonic effect. Nor is the degree of sweetness by tasting necessarily associated with the degree of sweetness described by herbalists: maltose is a sugary material that is listed in Oriental Materia Medica as having only mild sweetness (others list it as sweet), while tremella, a polysacchariderich mushroom, has barely detectable sweetness, but is described in Oriental Materia Medica as being sweet (not mildly so). Ganoderma is an example of a tonic herb (it is classified as a tonic sedative in some books) that is said to have a sweet, mild flavor. Anyone who has tasted the ganoderma extracts notes that it is extremely bitter. This is because of its content of triterpenes, which are molecules quite similar to the saponin glycosides of ginseng. In this herb, both the immune-promoting polysaccharides and the triterpenoids play key roles in providing a healing action. The triterpenoids are responsible for the sedative effect, as well as some other actions, including better oxygen utilization (hence improving energy), and the bitter components of ginseng do the same. The description of ganoderma as a sweet herb may follow, rather than precede, its description as a tonic agent. Thus, while traditional herbalists were able to properly associate the sweet tasting component of herb materials with tonic effects that we can now confirm experimentally, there are considerable limitations to this simple system based on general observations of nature. Modern investigations raise questions about the emphasis on describing, for

example, a sweet taste as a designation of tonic properties of several herbs. The tastes assigned to herbs has sometimes changed over time, and, even today, herb specialists may debate about which designation is correct. In the Zhenzhu Nang (Bag of Pearls), written around 1200 A.D., siler (fangfeng) is described simply as being sweet (not sweet and acrid as it is today), and its effects are described as eliminating wind from the body, especially wind that is moving upwards (3). The acrid quality of siler is emphasized in modern texts, which matches with the dispersing (wind-dispelling) properties that are still attributed to it. According to Heiner Fruehauf, all the traditional texts, in designating the wei of an herb, are referring to the immaterial function rather than the material basis of the herbs. Therefore, when translating wei to taste, one finds many discrepancies because the word usually implies, to Westerners, only the effect of the substance on the tongue. In sum, one can find modern confirmation of at least some of the traditional assignment of taste as a characteristic associated with herb action. One can also find many situations in which the traditional designations do not seem to make very much sense in light of common knowledge. At least partial resolution of some of the apparent discrepancies may lie in the interpretation of the Chinese term wei; but some of the designations remain the subject of debate among herbal authorities. Changing Views The association of taste with effects on humans was described in detail for the first time in the Neijing Suwen, around 100 A.D. Anyone who has studied this text in detail finds that there are some contradictory statements about the relationship between taste, usually that of foods, and the parts of the body affected and the nature of the affect. Variations in the description of taste and effect continued for some time. Here is a description from the Bencao Yanyi, written early in the 12th century (3): “When heaven and earth had already been separated, the creation of all things was due solely to the five qi [this is like the six qi of hot, cold, wind, damp, etc.]. After the five qi had been determined, the five tastes arose. Following the genesis of the five tastes, the thousand transformations and ten thousand changes continued without end. Thus it is said that the qi bring forth things, and the tastes complete them. That which was created individually becomes a pair when complete; that which was created as a pair becomes an individual entity when complete. Cold hardens; thus the corresponding taste [salty] can be used to draw things together. Hot influences draw things together, thus the corresponding taste [bitter] hardens things. The influence of wind disperses; thus the corresponding taste [sour] can be used to gather. The influence of dryness gathers; thus the corresponding taste [acrid] can be used to disperse. The zhong influences [central] originate in the soil. They are able to harmonize everything; thus the corresponding taste [sweet] can be used to soothe. If the qi is firm, strength results. For this reason, the qi [circulating in the body] can be nourished by bitter things. If the vessels are drawn together, they are in harmony. Thus, the vessels can be nourished with salty things. If the bones are gathered together, they are strong. Therefore, the bones can be nourished with sour things. If the muscles are dispersed, they are not cramped. Thus, the muscles can be nourished with acrid things. If the flesh is soothed, it can not be blocked. Therefore, flesh can be nourished with sweet things. If a soothing effect is wanted, the sweet things should be used; if soothing is not wanted, the sweet things should not be used. No applications may be exaggerated; excessive amounts can also cause illness. Anyone in ancient times who wanted to nourish life and cure suffering first had to understand what has been said here. Only very rarely is suffering relieved without such understanding.” While some of the above statements correspond to traditional dogma conveyed today, some of them do not. Though practitioners do not often think of salty things drawing together in the most general sense, calcined oyster shell and alum are examples of salty astringents used to tighten up membranes and stop dripping of fluid. Most practitioners probably don’t think of qi being nourished by bitter things, vessels being nourished by salty things, or bones being nourished by sour things; these represent areas where the associations have changed. Here is a description in the Tangye Bencao, written during the 13th century (3): If the liver suffers from tensions, sweet herbs should quickly be taken in order to relieve these tensions. Licorice is advisable in this case. If one wishes to disperse obstructions, acrid herbs should be taken quickly. Cnidium is advisable in this case. With acrid herbs, one replenishes the liver, asarum is appropriate. With sour herbs, one drains the liver; peony is appropriate....Bitter herbs replenish the kidneys; rehmannia and phellodendron are appropriate. These descriptions seem somewhat at odds with the dogma of today’s traditional approach. Liver tensions are often treated with bitter herbs (such as bupleurum and chih-shih); asarum would be deemed inappropriate for a liver deficiency syndrome; the sour herb peony is described as nourishing the blood and astringing the yin, rather than draining; and bitter herbs are used to deplete kidney fire rather than replenish the kidney, though by reducing the deficiency fire, the yin can be naturally restored. Some of the apparent discrepancies and variations might be explained by applications of different aspects of the five elements system (which includes the nurturing and controlling relationships), but others simply represent differing views that arose during the long history of Chinese medicine. Using Taste Designations Today What can not yet be answered is this: is it still an important concern for herbalists today to combine herbs according to their tastes? Was the emphasis on taste of an herb something that was required in earlier times no longer required with detailed information about the constituents and their pharmacological effects? In the 1995 publication Advanced Textbook of Traditional Chinese Medicine and Pharmacology (4), this is

said: “Since the flavors of drugs have an intrinsic relationship with their efficacies, understanding the characteristics of the five tastes is of great importance in guiding the administration of drugs.” Yet, despite this statement, the relationship is not raised again after the single page that includes a few examples of taste associated with therapeutic effect. One example from this page is that “Drugs such as perilla leaf and mentha for inducing perspiration and relieving exterior syndrome and citrus and saussurea for activating qi are all acrid.” Yet, in the text describing individual herbs, the section on surface-relieving includes the non-acrid cicada skin (salty and slightly sweet), morus leaf (bitter and sweet), and chrysanthemum flower (sweet and bitter); the section on activating qi includes the nonacrid melia (bitter). While the majority of herbs in these two sections have an acrid taste (often combined with another taste), these exceptions do not elicit any commentary. In the U.S., the taste of an herb is one of the required pieces of information for students to learn, yet descriptions of taste and effect rarely crop up in the American literature, except as simple recitation of the current standard dogma. Herb tastes is a subject left out of the portion of the NCCA examination devoted to herbs that most American acupuncturists now take. Undoubtedly, persons who strongly respect the traditional methods would argue that there is still be too little known about the herbs to disregard the taste as a distinguishing feature. By contrast, persons who follow the modern scientific approach to herbalism may suggest that it is the actions of the main active constituents that determine the effect of a formula, and it does not matter what the actual taste is, since the taste can be influenced by so many different ingredients within the material, some of them not seemingly relevant to the effects. Thus, for example, the lignans of schizandra are deemed especially important components by modern researchers, but these contribute only a bitter taste to the “five flavored fruit.” The sour flavor, conferred by organic acids as found in many other fruits, probably contributes relatively little medicinal action except, possibly, when high dosage decoctions (or dried decoctions) are relied upon. Observing modern practitioners of traditional Chinese medicine designing treatments for patients reveals two patterns of behavior that suggest there is actually less emphasis on taste than when it was suggested, several centuries ago, as a critical factor in attaining success. First, many doctors use large prescriptions, containing a dozen or more herbs, and with such large prescriptions, one usually finds a complex mix of all five tastes regardless of the therapeutic action intended; it is not clear that an effort was made to coordinate the tastes in coming up with the final formulation. By contrast, taste of herbs in a formula is often raised in descriptions of small ancient prescriptions, such as Cinnamon Combination and Rehmannia Six Formula. Second, it is common to see a base formula developed for treatment of a disease condition which is then modified by various added ingredients for specific symptoms, constitutional patterns, or signs. The additions clearly alter the taste of the formula, but it does not seem to be the case that the taste of the additions is a major consideration; rather, it is their defined actions based on either modern or ancient indications. Still, disregarding taste may be one of the steps, like so many others taken in modern times, that isolates the herb practitioner from an important interaction of humans with nature: experiencing and responding to a fundamental sensory perception and leaving behind the traditional methods of describing natural phenomena (such as herb actions). It is easy to be overwhelmed by the power of clinical experience and modern research. Without disregarding what has become available through the modern efforts, one may wish to keep aware of the traditional methods with regard to taste and formulation. At the least, one should examine the traditional ideas—in all their variations over time and among authors—until something more definitive can be established by the work that is currently underway to determine how herbs affect human health. REFERENCES 1. Hsu HY, et al., Oriental Materia Medica, 1986 Oriental Healing Arts Institute, Long Beach, CA. 2. Zhang Enqin, The characters and functions of traditional Chinese drugs, Journal of Traditional Chinese Medicine 1990; 10(3):229–234. 3. Unschuld PU, Medicine in China: A History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 4. State Administration of Traditional Chinese Medicine, Advanced Textbook of Traditional Chinese Medicine and Pharmacology, volume II, 1995 New World Press, Beijing. October 2010



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WRITING A THESIS PAPER: Instructions for Students of Oriental Medicine essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The purpose of writing a thesis paper is to advance your capabilities that will aid in developing your career. Among the things you will learn are: 1. How to select an area of specialization and what the implications of that choice will be on the evolution of your career. When you select your thesis topic, you will be determining an area where you will have specific knowledge; this action is parallel to choosing a medical specialty. 2. What the range of information resources available to you is, and what limitations exist. When you research your topic, you will have to look through a broad range of information resources and will find some items difficult to retrieve or access, and there will be presentations of varying quality. You will become more familiar with this situation as, in the scope of your practice, you are presented with patients having difficult or unusual conditions. 3. The process of sifting through information in order to sort out the valuable from that which has little or no value. As you read through the resource materials, you will find that some information is clearly useful but that other information may lead you down the wrong path because it is not based on accurate, well-organized, and truthful pursuit of knowledge. Learning to recognize the varying quality of information will help you avoid providing information-and treatment regimensthat have no foundation. 4. How to organize the knowledge you gain into groups of related concepts so that you can get a more complete picture of what the various resources are showing you. Many disparate facts will be collected, but will only make sense if organized into groups that have some internal consistency. This activity will also help you organize the disparate symptom and sign information that is presented by patients into a coherent diagnostic understanding that will lead to successful treatment. 5. How to describe what you've learned to others in such a way that they can understand it clearly. The process of writing the thesis will teach you how to interpret what others have written, because you will understand the process that they went through to make their presentation. It will assist you in conveying the knowledge you gain over the years to less experienced practitioners and to describe the concepts of traditional medicine to patients. Having learned these facts, processes, and methods, you should then be able to: better interview patients about their medical history to gain the facts you need for determining a treatment; research the available treatment options in order to enhance the outcome of the therapies you provide; interpret the responses that patients present to you about their experience of the therapies; produce chart notes that present a clear picture of each case which can be understood not only by you but also by other practitioners (and insurers); and help you teach others about what you've learned once you've gained considerable experience. The art of preparing a thesis paper is supposed to be taught first in middle school and high school (book reports and library projects) and then in college courses which may have included term papers. It reaches a higher level when a person prepares a master's thesis, and its highest level when a person prepares a Ph.D. thesis. At the Ph.D. level, the individual not only carries out library research in preparation of a thesis paper, but also conducts new research, collecting facts that have not been previously published. In that way, the person who accomplishes the task learns not only the above-mentioned things, but also how to conduct research so that the reported results are meaningful. As a result, the graduate has learned how to interpret other research reports in a critical manner.

THESIS ADVISOR The first step in developing a thesis project is to be assigned an advisor. The advisor is a professional with many years experience in the field you are studying, who has already prepared one or more formal thesis papers (or their equivalent in the form of technical articles subject to review). The advisor's experience includes carrying out a thesis project that is at least as stringent and extensive as the one now being assigned (e.g., the one that leads to a Masters or Ph.D.). The advisor is familiar with the pitfalls in the literature so as to assist a student in picking out an appropriate topic, getting to the correct resources, and presenting information that is of value to the profession. There are four essential meetings with the thesis advisor prior to writing the final thesis paper. There may be a need for even more contact, in order to clarify various issues as they arise. First, the thesis advisor and student should meet in order to get a mutual understanding of what is involved in the thesis project and what is expected. A second meeting is essential once the student is ready to propose a topic; the advisor may suggest a different topic (for example, if the selected one has inadequate literature resources), a modified topic (perhaps a more limited aspect of the selected area of concern), or a particular approach to the topic (e.g., focusing on collecting data from the field or focusing on doing a literature search). Once the project is underway, a third meeting should take place, in which the student should present the advisor with an outline of what is pictured as the overall thesis presentation, the basic information sources that have been accessed, and the focal point of the work. This will give the advisor a chance to suggest modifications before the work of writing the thesis proceeds too far. A draft of the thesis will next be presented in a fourth meeting so that the advisor can get an idea of whether or not the student has grasped the fundamentals and can point out any significant weak areas. Obtaining guidance from those who have more experience is an important lesson in itself. Traditional medicine is an art that is passed on from accomplished physicians and scholars to those who are entering the field. If one gets into the habit of ignoring the wealth of knowledge and experience of those who have been there before, then the tradition cannot be passed on. If one goes to the advisor seeking too much help, depending on the advisor's knowledge rather than doing the hard work involved in the thesis project, the advisor

may inform you that you need to learn how to perform certain tasks yourself. Thus, there is a balance between two essential methods of gaining knowledge: learning how to do things oneself and learning how to recognize one's own limitations and get guidance from others.

SELECTION OF TOPICS The process of selecting a topic for the thesis is an important one. Too often, the student is bound up in his or her personal interests and wants to select a topic that will satisfy an immediate need rather than considering one's profession as a whole. Thus, for example, a student may first wish to pick a thesis topic that will address a disease condition that is suffered by the student or the student's family member or friend. While such a selection may appear to give meaning to the project (because it is perceived as having an immediate application), it is usually not the method that is most appropriate to developing a professional specialty. Some subjects are not sufficiently addressed in the available literature to satisfy the needs of a thesis paper. For example, if you are concerned about a disorder that is not being successfully treated by modern medicine, you have to consider first whether that disorder, or one like it, is even mentioned in the traditional literature. Further, if it is a relatively rare condition, you will have to consider whether or not pursuing such an unusual case will really help with your professional development (it may or may not). A student is not expected to know what area of specialization they will eventually end up in (if any; some will remain in a general practice with no specialty). The thesis subject may inspire one to pursue that area of specialization or it may reveal that it is an area that is not so desirable after all. Still, you should pick a subject that represents a potential area of specialization, if not for you, then for some of your colleagues who will be able to read your thesis and be inspired by it. Unless the thesis project, during its assignment, has been limited to a certain subject area (e.g., treatment of a disease), you should consider a variety of potential areas: history of medicine, analysis of a specific technique (diagnosis or therapy), basic concepts of the medical field, and so on. Whatever the subject selected, there must be a body of information that can be relied upon to prepare the thesis report. It will not do to simply take a subject that is of interest and then write what you think about it based on what you already have learned, even if you can expand upon it by adding a couple of interesting facts. A major purpose of the project is to discover something new by wading through a considerable amount of information.

THESIS OR PAPER? In the first section of this essay, I've used the term thesis to describe the project, but it may only be a paper (article). The term thesis implies that you will propose something and then find out if it is true or not. A paper simply describes an area of interest; in most cases, people begin writing a paper with a specific idea in mind that would correspond to a thesis. However, their interest may not be in finding out whether or not the underlying thesis is true, but just in supporting their underlying idea. In that case, if some facts point a different way, they might be simply ignored, which develops an unhealthy habit of dealing with information in a prejudiced manner. There are a variety of subjects that can be raised surrounding a topic. For example, suppose that you have decided to write something about the traditional Chinese medical treatment for diabetes. You can simply review the literature and present what you find (a paper, not a thesis). However, if there is a thesis required in the project, your thesis might be a variety of things that would orient the development of your paper. Consider the following sample topics: Traditional Chinese medicine offers a successful treatment for diabetes . This thesis topic would require you to find and evaluate literature that purports to show success of treatments, and would require that you access other literature about how one evaluates such claims. Traditional Chinese medicine has a long history of diabetes treatment. This thesis topic doesn't require you to evaluate the effectiveness of treatment, but does require an analysis of historical records and determining, for example, whether a condition described in ancient literature really is diabetes. Traditional Chinese medicine practitioners treat diabetes as a yin deficiency syndrome . This thesis topic doesn't require you to evaluate either the effectiveness of treatment or history, but does require you to analyze the reported treatment methods and to determine whether or not they correspond to the proposed syndrome. Traditional Chinese medical approaches to diabetes are applicable to patients who are being treated by modern methods . This thesis would require an analysis of both the modern and traditional methods of treatment and an evaluation of the extent to which they are compatible. The results of any such "integrated treatment" reported in the literature would be critically reviewed. Rehmannia is an herb that should be evaluated for potential effectiveness in treatment of diabetes. This thesis would require an analysis of the herb and the studies of it in relation to diabetes, which might include chemical, pharmacological, and clinical evaluations suggesting its potential benefits. For each of these thesis topics, the literature research that is done may confirm the proposal, may contradict the proposal, or may give a result that neither supports nor contradicts the proposal. Therefore, one has to be open minded about what is found in the literature. The point of the thesis paper is not to prove that the initial proposal is true, but to use the initial proposal as a basis for collecting and presenting information. Before settling on a topic, it is a good idea to review some of the literature and see whether or not there is something there that addresses the specific thesis. If it turns out that there is little supporting or contrary evidence, then the thesis paper will not be very inspiring. In that situation, whether you present a simple paper or thesis, it may be necessary to shift the thesis topic to one that can be reasonably addressed by the existing literature. Your advisor should be able to help you determine whether or not you've succeeded in accessing the main body of literature for the chosen subject.

SEARCHING THE LITERATURE Whether you are conducting a literature-only search, or are planning to do some field research, it is necessary to find out what has been done before, so a literature search is always the initial step. Field research, collecting information that is not published, should never be done without carefully investigating what has been published first. Research is always based on following up something that has been done before. The school that assigns a thesis project should already have a library that offers a wide range of valuable literature, and this is the

best starting point. There are three basic types of resources: 1. Books. Books have the advantage of presenting an extensive review of a subject or placing a subject of interest within a broader context. Books have the disadvantage of sometimes being out of date and, especially if not a formally prepared text book, of not having any requirements placed on the author to verify the source or validity of statements made. Text books have the advantage of containing information that is widely recognized, but they have the disadvantage of often lacking in depth. 2. Formal journals. Journals have the advantage of offering new information and, to varying extents, having information that is properly referenced and that has been evaluated by others with experience in the field before being allowed into the publication. It is important to read several articles (whether or not on the thesis subject) from high quality journals in order to gain a perspective on what is required in those journals (examples: Journal of the American Medical Association; New England Journal of Medicine; Science; Nature). These most-formal journals will help you determine whether or not the presentation you read on the subject of choice in other journals is up to a reasonable standard and will alert you to what may be missing. Journal articles also have the advantage of presenting more details than found in most books. 3. Informal journals and newsletters, popular books. Informal publications, usually without any attempt at a scholarly style of presentation, are rarely of any help in preparing a thesis article and should be avoided. Books and articles that have proper referencing to their sources of information will assist you in the process of discovering which sources are not present in the library. You must determine whether or not other potentially valuable resources can be obtained elsewhere. An increasing amount of information is accessible via internet search mechanisms, including such interlibrary services as MedLine for medical information (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi).

FIELD RESEARCH Field research, that is, collecting information that is not available in publications, is usually not a possibility for thesis projects and should only be taken on if practical. Well-conducted research is usually very time consuming and very expensive, which is why it is not normally part of thesis projects outside of major universities. Interviews and surveys can often be conducted, though even these methods may turn out to be much more difficult than perceived at first. An area of field research that is usually manageable is a survey of local resources. As an example, a thesis paper may be aimed at describing what Oriental medical services are available in the local community, who is providing services, what is the cost, etc. In order to conduct and report on such a survey, it is important to first research the general matter of survey techniques to learn about how to avoid relaying incorrect information and how to deal with missing information. Evaluating the effect of a treatment is usually not manageable: this is clinical research and is amongst the most difficult of all research projects to do well, even by professional researchers. The school where the thesis paper is required may have its own clinical facility. Field research at this facility might be aimed at determining what disorders are being treated, how often patients come to the clinic, what is the typical duration of therapy, etc. However, such projects are still quite difficult and should not be encouraged, as they require the student to examine confidential files and it is usually not possible to check the recorded information by interviewing the busy practitioners or interviewing patients who are not expecting to participate in such a study.

ORGANIZING THE INFORMATION Each time a piece of relevant information is found, it must be preserved. This can either be done by making a photocopy, by copying it down (if short), or by keeping a reference so that it can be retrieved again later. Ultimately, each source of information must be referenced in the article. It is important to know proper referencing methods, and the best resource is a formal journal publication (see above); always use a referencing method that corresponds with what is used in this type of publication. There are slight variations amongst the publications, but one should stick to a style once it is selected. The reference information will include the author(s), title, and source (for journals, journal name, volume, number, and pages; for books, book title, publisher, publisher location, pages). If you take information for your report from a source and don't have the proper reference information, you will have to retrieve it again later, so always get the reference information at the time it is first found. The information to be presented will eventually have to be organized into subjects, such as general description, historical information, research information, etc. After reading through the sources that have been obtained, an outline of the planned report should be made, displaying the types of information that are now available to you, in sets that are logically connected.

WRITING THE THESIS A rough draft of the thesis can be initiated by writing out what you've learned from the research in a manner that is simply comfortable for you to do in a short time, with the understanding that it will take several drafts to reach the form of an acceptable thesis article. However, before writing down each sentence, ask yourself "why am I including this information?" Sometimes, information is put into a thesis paper only because it is available, not because it is relevant. For example, suppose you are writing about a traditional Chinese treatment strategy for a particular disease. Why spend three pages of text writing about how many cases of the disease there are, or even describing at length the modern treatment methods? Is it relevant to the presentation? If not, don't include it; if it is partly relevant, include only the essential points. It is important to keep in mind basic writing skills: sentence structure and paragraph form. These aspects of your writing are independent of the nature of the topic or the fact that it is a thesis paper. As each draft of the paper is worked though, the structural quality of the sentences and paragraphs should improve. This will reflect not only your review of the existing document to find errors or shortcomings, but also your increasing understanding of the subject as you try to explain it to others. For the follow-up drafts, it is necessary to review each of the sentences and ask yourself: "How do I know this?" In a thesis paper, most statements must be backed up by something authoritative, with a reference to the source material. Not every sentence or every paragraph will have a reference, but it should be entirely clear to both you and the reader how you have come up with your statement. If you have stated something that you believe but for which there is no supporting information, then you are obligated to either leave it out

or to make it clear that this statement is what you personally believe. There is one exception to the rule, which must be pursued carefully. If there is generally known, broadly accepted information, then it need not be referred to a source. As a trivial example, if you want to point out that the sky is blue, you don't have to reference that to an authority nor indicate that this is just your opinion. Most statements of this nature are transitional; that is, they link one piece of referenced information to another, otherwise, they would be nonessential because they are widely known. When you make reference to historical information or to the opinions expressed by experts, it is often wise to provide a direct quote. By contrast, if one is making reference to scientific findings or to other statements of fact, it is not necessary to make a direct quote from the original source but only necessary that you accurately portray the information. For the final drafts, it is important to review each statement to make sure that what it is referring to is correct. For example, if you are referring to a report in a journal about a study, make sure that you refer to the report, not to the study (e.g., you may indicate that you have an English language report, but it is not "an English-language study"). Be careful of words such as "this" and "it," that may be unclear as to the subject to which they refer. Remember to differentiate a medical system from the people who are involved in it; if you say "TCM believes...," this is an error, because it is people that believe, not TCM (further, you may have to specify which people believe what you have indicated, as there can be divergent opinions held within the profession). TCM doesn't have beliefs, it may be said to have certain dogma or generally accepted facts (you may have to specify the current status of the statement; Who agrees with it now?). Be careful of unusual methods of presenting terms: excessive capitalization and excessive use of quotation marks around words are common problems in thesis papers on traditional medicine. It is also necessary to review the order in which the information has been presented to make sure it provides a logical progression of idea to the reader.

THE LESSON The completed thesis project should provide new information and insight to the thesis advisor, the other faculty members, and other students who read it. The author is able to accomplish this goal by having delved into literature on a special subject that may not have been previously reviewed by those who read the thesis, or at least, the subject has not been previously reviewed at the same depth and/or with the same focus. What is reported in the thesis should be able to stimulate the interested reader to examine certain areas further, and reveal even more. The writer of the thesis has become familiar with literature resources that will be useful for future needs as a practitioner, scholar, and/or teacher. Most importantly, the writer will have learned the process by which information is transmitted from one person to another and realize that: some information is simply generated by the person's internal thought processes, influenced by one's own limited experiences and prejudices: it is a belief that is held but not necessarily supported by any other source and not necessarily shared in general; some information is passed on without proper critical evaluation, where errors are transmitted as freely as valid information and it is difficult to distinguish fact from fiction; some information is passed on with critical insight, allowing the field of knowledge to evolve. The information is not just repeated, but put into the new context that arises as time passes and the world changes. By recognizing these different ways in which information is generated and passed on, you become a responsible member of the community of educated people that deals with retaining, passing on, and developing knowledge. By properly carrying out the thesis project, you are welcomed into the world of respected knowledge-bearers. You will be able to better assist others in recognizing the varying quality of information in circulation, saving them from many dead-end paths. Both traditional medicine and modern science eventually come together with this procedure of evaluating and transmitting knowledge. Unsupported contentions are gradually weeded out, allowing the contentions that retain support, as well as those that are still in need of evaluation, to show through. As a result of the process, both traditional medicine and modern medicine offer successful methods of dealing with human health and provide valuable insights into how to live so as to maintain and improve health. These medical and scientific fields also offer a never ending wealth of areas for investigation and development. August 2000

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UNDERSTANDING CHINESE MEDICINE essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Chinese medicine is a vast entity involving more than 2,000 years of history, thousands of renowned scholars, tens of thousands of modern practitioners, a collection of classic texts, modern journals, private reports, and a wealth of ideas. It is beyond anyone's capability to fully grasp and understand such a huge human enterprise. Rather, one can seek its principal trends and characteristics, and then try to elucidate them with the hope of shedding light on as much of the rest of it as possible. Most people who have some understanding of Chinese medicine are its practitioners: those who have learned the techniques of diagnosis and treatment and the theory of disease causation. One aspect of comprehending the medical system is to know the six climatic and seven emotional factors; master the patterns of the pulse, tongue, and symptomatic indicators; learn the meridians and their acupuncture points and how to select and stimulate them; and to recognize the herbs and be able to combine them to match the diagnostic pattern. But another, equally important aspect is to understand what makes Chinese medicine unique among medical systems and to understand the challenges it faces in its current context. This article reveals four underlying features of Chinese medicine that will aid practitioners and their patients in understanding the system of therapy with which they are now involved. The four features are: 1. The quasi-religious nature of traditional Chinese medicine; 2. The personalization of medical practices; 3. The impetus to collect therapeutic patterns; and 4. The ongoing attempt to correct and improve medical practices. In a book subtitled Understanding Chinese Medicine, Ted Kaptchuk briefly explained some of the tensions between the Chinese and Western medical systems and then launched into a detailed description of the doctrines of yin-yang, five elements, internal organs, causes of disease, a review of acupuncture meridians and points, and the like. For years, this book, with the main title The Web That Has No Weaver, was the first text for most practitioners. Other books aimed at explaining Chinese medicine cover the same basic subjects and may add a discussion of herbs and formulas (which was not in Kaptchuk's book), as well as survey typical treatment strategies. The current article, which takes a different approach, is based on the assumption that the reader either already has familiarity with those other subjects or is about to undertake a study of them. The focus, instead, is on the processes that drive the growth and development of Chinese medicine and define its underlying nature. For each of the features listed here, advantages and disadvantages will be described in relation to the situation faced by the modern practitioner. Certain difficulties and dilemmas will be pointed out; it is not the purpose of this article to propose solutions to the highly complex problems.

1: THE QUASI-RELIGIOUS NATURE OF TRADITIONAL CHINESE MEDICINE The world's major religions have a fundamental book or collection of books that contain the absolute knowledge that forms the religious base. In addition, they all have one or more divine human figures of the past who are representatives of potential that is beyond normal human limitations. These divine human figures have generally delivered the books or the teachings contained in the books. Participation in the religion involves, as a minimum, undertaking some activities and having some thoughts that refer to the contents of the fundamental book(s) and to the divine human figure(s). The devotee aims, through religious practice, to come in contact with the ultimate truth and to lead a better and more meaningful life. A greater level of participation in the religion is attained by carefully studying the teachings, interpreting them for oneself and others, and putting them to practice in daily life; in other words, embracing the teachings. Chinese medicine has much of this religious character, as do the other major traditional medical systems, such as Ayurvedic medicine and Tibetan medicine. However, although it was sometimes done in the past, Chinese doctors usually do not make prayers nor call upon the images of the divine beings as an essential part of their practice of traditional medicine. Rather, they give the divine beings due respect as founders of the medical tradition. In Tibet, which is now part of China, the traditional medical system does call upon Buddha (in particular, the Medicine Buddha) as part of the medical practice, but this is different from what takes place in China in relation to traditional Chinese medicine. In the Chinese system, there are the three god-like figures of ancient times: Fu Xi, who provided the people with writing, divination, the yin-yang and five element concepts, and acupuncture; Shen Nong, who provided the people with the plow and agriculture as well as herbal medicine; and Huang Di, who provided the people with technology, music (with the aid of his assistant Ling Lun), and medical theories (with his physician associate Qi Bo, and with contributions from his other assistants Lei Gong, Shao Yu, Bo Gao, etc.). While today these ancient god-like figures may be regarded as mythological beings, until the 20th Century, most Chinese simply viewed them as divine historical individuals (see Figure 1 for a depiction of the medicine god, Sun Simiao, along with the above three gods). In relation to medicine, these three form the tripod of all medical practice: acupuncture, herbalism, and essential medical theories, respectively. Many of the ancient texts are presented as a question and answer session between a divine figure and someone who represents an accomplished human seeking to gain further knowledge. In particular, Huang Di carries out a dialogue with his chief associate, Qi Bo, an accomplished physician, in the Huangdi Neijing (Yellow Emperor's Classic of Internal Medicine ). In this case, Huang Di asks the questions and Qi Bo gives his answers, as if he is being tested. The Neijing is the central book of Chinese medicine, its "bible." This book is divided into two volumes, one is the Suwen (Plain Questions) and the other is the Lingshu (Spiritual Pivot) . Any doctor or scholar who wishes to expound upon a medical treatment-and give his exposition authority-will refer to a statement in the Neijing in

support of what is being said. In the Neijing Suwen, the key to healthy living that will result in attainment of an old age is outlined. There is a story explaining the origins of this view of how to be healthy: The Yellow Emperor had ruled for 15 years but he worried because the world was not well-ordered; so he withdrew, resting himself in the Palace of the Great Court. He purified his heart and submitted his body (to plain living). For three months he himself had nothing to do with carrying out the affairs of state. Once he had a daytime dream about traveling around the state of the Huaxu clan. This was a natural place, where people had no cravings and did not die prematurely. They did not think about clinging to life, nor did think about the fear of death. (Ideas about) beauty and ugliness did not grow in their hearts, mountains and valleys did not cause them to stop walking, and they lived happily. When the Yellow Emperor awoke he felt happy and contented; he now understood the greatest Dao. For the next 28 years the world was very well regulated, resembling the state of the Huaxu (in his dream). The Neijing is the first and oldest of all existent medical books referenced in the Chinese tradition; it is the source book for virtually all of the important medical commentaries in subsequent centuries. It focuses on Fu Xi's systems of describing nature in terms of yin-yang and the five elements, and his method of therapy: acupuncture. Although archeologists have dug up pre-Neijing writings on medicine, such writings are not mentioned at anytime throughout the recorded history of traditional Chinese medicine. In other words, they were superceded by the Huangdi Neijing. In the Neijing itself, former classics are mentioned, but these did not survive other than in the retained quotations. Even today, in modern Chinese medical journals, articles about treatment methods will sometimes refer to what was said in the Neijing (sometimes described simply as: "the ancients said..."). Before the introduction of Western science and its reporting style, talking about the Neijing was an essential part of medical discourse. In the modernization of China and Chinese medicine, efforts have been made to purge such references from the publications, or to only make them in passing, not as a focal point of discussion. The first and the most central materia medica of China is attributed to Shen Nong (see Figure 2) and is known as the Shen Nong Bencao Jing (Classic of Materia Medica by Shen Nong). When discussing individual herbs, it is natural to refer to whether or not the herb is mentioned in the Shen Nong Bencao Jing, since its inclusion in this work demonstrates a certain additional positive aspect of the herb. The brief description of the herb in this ancient text is usually quoted. In essence, all Materia Medica books that followed this one were modeled after it and considered expansions of it, at least until the Bencao Gangmu (Great Compendium of Herbs) written during the 16th Century (see: Li Shizhen: scholar worthy of emulation), in which some innovative forms of organization and presentation were introduced. In the Chinese medical system, herbal medicine is based on use of formulas, and the central guide to formulas appears to have been written by an historical figure, a doctor named Jiang Zhongjing who lived at the end of the Han Dynasty period (his book is typically dated at the end of the Han Dynasty, about 220 A.D.). The book, Shang Han Lun, was later divided into two works, one called Shang Han Lun (Treatise on Diseases Caused by Cold ) and Jin Gui Yao Lue (Prescriptions of the Golden Cabinet). Despite its possible basis in an historical figure who was an ordinary human, the doctor, his work, and, in particular, his formulas, have attained a divine nature. Zhang might be described, borrowing from the Catholic religion, as a Patron Saint of herbal formulas. For centuries afterward, doctors who strayed from Zhang's work were warned by others that they needed to study it in order to avoid dangerous therapies. Xu Dachun, a well-known medical commentator of the 18th Century (see Figure 3) said: The wisdom of the sages of antiquity was truly identical with the essentials of Heaven and Earth; it can not be reached by the mind and by the thoughts of ordinary men....Then, Zhang Zhongjing provided clear instructions about using the ancient prescriptions. He clarified various difficult issues and he offered instructions on the main pathoconditions cured by these prescriptions. His works Shang Han Lun and Jin Gui Yao Lue combined the great achievements of thousands of sages preceding him. Those books carry on what was before to instruct those who come later. Their scope is so encompassing that even ten thousand generations will not be able to transcend it. They are so-called ancient prescriptions. Together with the Neijing, they will never cease to flourish. He proceeded next to complain about contemporary physicians who loosely referred to their use of ancient prescriptions. He cautioned that: "If one speaks of the prescriptions of high antiquity, there are almost none except those transmitted by Zhang Zhongjing." In Japan, where traditional medicine was revived after the second World War with government assistance, many of the leading physicians express true wonder at the prescriptions of this ancient text, stating that the formulas cannot be improved upon: one can only endeavor to better understand them. One of Japan's most famous herb doctors, Keisetsu Otsuka, explained the situation in the introduction (written in 1959) to his book 30 Years of Kanpo: After the Tokugawa era [ended 1867], Chinese herbal medicine in Japan subdivided into several schools. Among them, the main ones are the school of old formulas, the school of classic formulas, and the school of posterity formulas. Mr. Yumoto was representative of the school of old formulas during the Showa era [1926-1989], and following him I learned the old formulas. The school of old formulas asserts that only two works need to be consulted: the Shang Han Lun and Jin Gui Yao Lue. Further, the school stipulates that to learn Chinese medicine, one need read nothing later than the Song and Tang Dynasties. The Tang Dynasty was when Chinese medicine first came to Japan and the Song Dynasty was when the Shang Han Lun and Jin Gui Yao Lui were rescued from being lost (with only damaged copies having been retained at the Imperial library). While the Chinese medical system has other great historical figures and historical works, its treatment of the above-mentioned divine figures, books, and the contributions attributed to them, has a defining role in the development and practice of the medicine. The importance of these individuals highlights the religious nature of Chinese medicine: to which, it is a system based on looking to the past. A scholar or practitioner of Chinese medicine looks back in time, a thousand years or more, but at least a century or two, for guidance, refreshment, knowledge, wisdom, and authority. In the Chinese system, one would barely contemplate considering that the ancient teachings may have been wrong or are now irrelevant. It is possible to expand upon the original teachings and to interpret them in light of

modern developments, but not to contradict them or to ignore them. Just as a religious system has its central book(s) and central divine figure(s), it also has its essential doctrines that these individuals and books have elucidated. In the Chinese medical system, there are certain fixed doctrines that are essential to learning and applying it. These include: yin-yang; three essences (qi, shen, jing; that is, qi, spirit, essence); three humors (qi, blood, moisture); five elements; five zang and six fu; six environmental influences; seven emotions; and 14 meridians. These doctrines define how the body works and how the therapeutic methods that are applied will interact with the body and its diseases. They are fixed ideas that yield the medical system itself. It is not possible, by modern scientific means, to alter the system; for example, one cannot conduct some studies that would show that the ancients omitted a sixth element that should now be included, or that there were only five environmental influences because one of them is redundant with another. One can add new meridians and new points, add new herbs and new formulas, but one cannot say, on the other hand, that the old meridians and points, the original herbs (of Shen Nong) and formulas (of Zhang Zhongjing) were not correctly chosen and presented. Similarly, a scholar during any period of Chinese history might argue that one of these doctrines was being interpreted incorrectly, but could not change the essential doctrine. In outlining the basic theoretical framework of Chinese medicine, the well-known Japanese doctor Yakazu Domei quoted from The Outline of Chinese Medicine Sciences (1980): "The theory of yin-yang and the five elements connects every aspect that is important to the theoretical system." Quoting from the Neijing Suwen: "Yin-yang is the law of the universe. It rules all-it is the parent of transformation, the origin of life and death, and the house of the gods." He also points out that "Throughout the Shang Han Lun, the yin-yang theory is the governing principle....The five elements and yin-yang theory also dominate the Jin Gui Yao Lue ." Further, "The descendent medical schools [four schools of the Jin-Yuan period] emphasized the theory of yin-yang and the five elements." The details of these doctrines (which are beyond the scope of the current article) are described in numerous works. As the major religions each have one or more mystical sects (one can think of the tantric yogis of Tibetan Buddhism or the Kabbalic mystics of Judaism), Chinese medicine has its own mystical sects. These tend to involve the bagua (eight triagrams) or the five elements. Indeed, for Western practitioners, there is a well-established sect of "Five Element Acupuncturists," with the leading figure being a British acupuncturist: Worsley. This sect focuses intensively on the relation of emotions to the internal organs and on the interrelationship of each of the five elements, as it influences the selection of acupuncture points; it is largely based on one segment of the Neijing. This orientation to Chinese medicine is contrasted to the somewhat standardized Chinese medicine taught in mainland China that is sometimes referred to as the "Eight Entities" sect (yin/yang, cold/hot, interior/exterior, deficiency/excess), because of the emphasis on diagnosis via study of opposing pairs of qualities, a reflection and expansion of the basic yin/yang doctrine. This doctrine is seen, by certain Chinese authorities, as being reasonably consistent with both modern science and dialectical materialism, and, therefore, can be emphasized within the current political structure of China. As occurs in religious practice, each sect believes that it has found the most essential and vital doctrine within the religion. New sects arise from time to time. Recently, in the U.S., Dr. Tan has introduced a form of acupuncture treatment that relies on treatment of distal points that correspond (in a systematic way) with the area of the body where the disease is localized. The selection of distal (rather than local) points is justified on the basis of ancient teachings. In his book, Kaptchuk relays some underlying impressions of Chinese medicine that exist among Westerners who view it. He describes one group that is …deeply and often justifiably disturbed by many of the products of Western science and culture. They assume that the Chinese system, because it is felt to be more ancient, more spiritual, or more holistic, is also more 'true' than Western medicine. This attitude threatens to turn Chinese medicine from a rational body of knowledge into a religious faith system. While one can imbue the Chinese system with a greater degree of religious character than it already has, the fact is that it is not correct to depict the system as a "rational body of knowledge." It is described here as "quasi-religious" in that it is not purely a faithbased practice (as would be miraculous healings attributed to a few individuals who have been given the power by God), but a system that incorporates several aspects of religion. The idea that Chinese medicine is more "true" than Western medicine is, indeed, one that has been held by many practitioners in the West and is based on a system of beliefs and personal observations. The fixed nature of the various doctrines that characterized traditional Chinese medicine from its inception has had a defining role in how the medicine developed over the centuries. The fixed doctrines prevented each subsequent generation of doctors from reinvestigating the basis of medical practice, and, instead, direct them to fit their experiences into the patterns described by the doctrines. Thus, if a patient presents a set of symptoms and signs that does not seem, at first glance, to fit into the fixed patterns that have been described in the essential texts, it is the role of the experienced doctor or scholar to see through the confusion and find an explanation of how the doctrine fits perfectly well. Similarly, if a therapy has not worked well, it is important to consult the basic doctrines to determine where an error might have been made; failure is not attributed to any fundamental limitation of the doctrines themselves, only their incorrect application. New developments in Chinese medicine can take place where the original texts are relatively silent. Thus, for example, in the Ming Dynasty period it was proposed that "where there is mental disorder there is phlegm." The Neijing gives some clues as to causes of mental disorders (in relation to pathologies of the heart and the stomach), but doesn't go into much detail, so there is room for pronouncing a seemingly new principle. Of course, any such new principle can be accepted or rejected by subsequent doctors simply because it is not firmly grounded in the Neijing. In this particular case, it is supported. The Neijing says: When the stomach qi rebels upward, the transformed products of the stomach stagnate. Over time, they turn into phlegm. The phlegm courses upward with the stomach qi, congesting the lung and heart....If the phlegm disturbs only the heart (and not the lung), there is trouble sleeping....As the ancient classic Xia Jing (Classic of Medicine) stated, 'when the stomach is in disharmony, one cannot sleep peacefully at night.' Thus, there is already a precedent for the situation of phlegm congesting the heart and disturbing the sleep (which is evidence of it disturbing the spirit). One can delete the specific reference to the stomach qi and to the sleep, and retain the problem of phlegm congestion and spirit disturbance.

The quasi-religious nature of traditional Chinese medicine is one of its great appeals to some, while it represents a key obstacle to others. In particular, for those who find modern medicine and modern science objectionable, due to unappealing descriptions of living organisms and treatments that appear too technological and not human or natural enough, a religious type of medical system can be quite attractive, as Kaptchuk had noted. Many people feel that the body is more than a mechanical system; that it may be infused with various forces that cannot be explained by modern science. The traditional Chinese medical system, with its description of the mysterious qi and its reliance on a system of correspondence (with five elements and yin/yang) where the internal organ systems can be linked to external phenomena, provide an attractive alternative. By contrast, to someone who finds scientific progress appealing, the attachment to old ideas (such as the common cold and a cerebral infarction each being caused by invasion of wind) and to mythical figures (or poorly defined but revered historical figures) can be objectionable. It is possible, in the modern era, to simply reject the historical and religious aspects of traditional medicine and begin the scientific study of the herbs and acupuncture therapies that have come down to the present, with the objective of finding what parts of the system are effective and which parts are not. Such rejection of old concepts and materials is standard practice in the West. Modern medicine constantly re-evaluates its treatment methods and simply tosses out old ones in favor of ones that are shown, by scientific evaluation, to be superior; or, it subdivides treatment and limits the old treatments to certain situations and provides new treatments for other situations. A modern physician would hardly look to a book a few decades old for inspiration or information, but would rather read the latest medical journal and attend the conferences where ground-breaking accomplishments are revealed. In this sense, modern medicine is forward looking, always hoping for an unanticipated improvement (e.g., gene-splicing solutions that could not have been imagined a century earlier); one looks back mainly to experience the wonder of how we could have been so naive. There is a strong drive now, even among many practitioners of traditional Chinese medicine, to discard the reverential and ancient aspects and simply focus on what seems to work, regardless of its origins. For example, in the introductory article to the 2001 issue of the Journal of Traditional Chinese Medicine (the premier traditional medical journal of China), the Vice Minster of the Health Ministry (who is also Director-General of the State Administration of Traditional Chinese Medicine) wrote on the subject of promoting the development of traditional Chinese medicine in the new century. Regarding the ancient aspects of the system, he was careful to avoid any religious undertones, but mentioned the importance of looking to the past, describing it as "inheritance:" Traditional Chinese medicine and pharmacology is a great treasure house. With the development of science and technology, people will derive constant new ideas and discoveries from the treasure house. It is the value and basis of inheritance. Inheritance is mainly involved in TCM's profound theories, therapeutic principles for prevention and treatment of disease, rich clinical experience, and unique methods of diagnosis and treatment. The purpose of relying on inheritance is development. We will try to make a breakthrough in the study of TCM theory by organizing scientific research personnel from TCM and other related disciplines and utilizing the technology of bioengineering, bioinformation, and microscopic investigation, in combination with epidemiology. TCM clinical researches are aimed at improving the ability to prevent and treat common diseases....Discovery of new phenomena and revelation of new law will provide mankind with a new train of thought and new approaches in disease prevention and treatment. The process of TCM modernization is picking up speed. The end result of such a process will be the isolation of a few therapeutically viable items (the few that can be adequately tested by increasingly cumbersome research protocols) with eventual disposal of everything else. From such an exercise, we can obtain some useful drugs from the active ingredients of herbs, and may find that specific acupuncture treatments treat certain specific diseases in a way that is as good as or better than other existing therapies. Such modernization will not yield a revitalized traditional Chinese medicine. To retain traditional Chinese medicine, one has to retain its quasi-religious nature, otherwise, one has to dispose of the tradition and absorb small parts only. A third route-to view Chinese medicine as a rational body of knowledge and simply overlook its religious aspects-is unlikely to have an end different from the proposed modernization. This is because Chinese medicine must exist within the dominant modern medical system that increasingly can replace the small niches that have been carved out for its practice in the West (e.g., modern medicine can develop immune regulating therapies, an area where Chinese medicine has been briefly viewed as a unique resource). Here then is the dilemma for the practitioner of Chinese medicine in the 21st Century: one may accept the religious qualities of the tradition, but then has to face its incongruity with the overwhelming modern medical system; or one may reject the religious qualities of the tradition, but then has to face the question of whether or not much of the system really works, since so much of it is based on ancient teachings and not confirmed by modern investigations. One of the great disappointments to those who have been involved with Chinese medicine during this transitional period (the past few decades) is that the concept that something which has been done for a long period of time is necessarily justified by that historical experience. In actuality, practitioners now view some remedies that were relied on for many centuries to be toxic (e.g., use of cinnabar that contains mercury, as one of the essential ingredients of many formulas) and other remedies that were deemed highly effective to be of limited value (e.g., traditional acupuncture is being replaced by new ways to perform it). Sometimes, modern practitioners accept the religious aspects of the system when they go through their initial training, but then gradually reject or simply let go of those aspects while living in a community in which few other persons accept it. All religions emphasize the importance of having a religious community and of having public ceremonies that bring together adherents. If a person simply goes off on his own, it is natural for the religious teachings to be lost in the absence of such reinforcement. Similarly, practitioners who are not involved in intensively interacting communities with other practitioners or, at the least, with others who live within a Chinese cultural context, may easily adopt heretical viewpoints and practices. Soon, they are no longer practicing traditional Chinese medicine, but some amalgam of theories and practices that are unrelated to one another.

2: THE PERSONALIZATION OF MEDICAL PRACTICES In a background of highly conservative medical ideas, with emphasis on referring to the knowledge, wisdom, and practices recorded in a small number of essential texts, Chinese medicine allows for a tremendous amount of diversity via personalization of medical practices. Each practitioner may specialize in some aspect of Chinese medicine, not just a medical specialty like gynecology or dermatology, but a focus on one particular portion of the theory or one particular technique. It is even conceived that there are hidden niches in the ancient wisdom that can be accessed only by extraordinary methods, allowing one to pursue concepts that appear, at first glance, to fall outside

the tradition. Therefore, there are an unlimited number of potential avenues within the larger matrix of the medical tradition that can be pursued. Paul Unschuld, in his book Chinese Medicine: History of Ideas, wrote: The common underlying conceptual basis of all these practitioners [those who were well-educated in the tradition] was exceedingly narrow, being limited to the acknowledgement of certain surviving works as classic texts and a belief in the fundamental truth of the central theories of the five phases and the all-encompassing dualism of yin-yang. But, even the interpretation of the universally revered classics, as well as the application of these theories to the concrete realities of daily life, gave rise to numerous contradictions, fragmenting the large community of private scholars and professional medical practitioners seeking solutions to health-related problems into countless individuals, groups, and traditions. Thus, for example, doctors could specialize in acupuncture or moxibustion, in herb therapies of various types (topical applications, internal remedies, pills, alcoholic preparations, decoctions, etc.), or in various physical exercises, each of which could follow a number of divergent pathways. Within one disciple, such as acupuncture, each practitioner could rely on different parts of the doctrine and different techniques. A patient who sequentially visited two doctors for treatment might well receive two entirely different therapeutic regimens; and visiting ten doctors, receive ten different treatments. Although those differences might merely reflect different levels of skills, most often it represents a different way of applying the fundamental doctrines and reliance on various personal (sometimes secret) techniques. Throughout the history of China, it was common practice for individual doctors to retain secret treatment methods, typically involving unique herbal preparations or unique acupuncture combinations or techniques, that would only be passed on generation to generation, but not readily revealed to others. Xu Dachun pointed out that such a practice was encouraged by the Yellow Emperor (in the Ling Shu); the widespread practice of keeping secret prescriptions was further elaborated by Xu: The prescriptions that are kept secret have a meaning that cannot be explained, and their working mechanism is not entirely accessible. Their transmission, often enough, originated from strange persons, scholars living in seclusion, hermits in the mountains, Bodhisattvas, demons, or spirits. To meet such a being is quite difficult, and therefore, these prescriptions are extremely well guarded. If they are handed on to others carelessly, they will only generate a disrespectful attitude. Hence, most prescription masters guard them as a most precious belonging....In secret prescriptions, the herbs are composed in accordance with extraordinary patterns. The way the herbs are combined is ingenious. Such prescriptions usurp all the authority of yin and yang, and they look deeply into the workings of creation. It is utterly imperative to be sincere and devout. Even the slightest violation of any prohibitions renders the herbs ineffective. If, therefore, someone lightheartedly teaches such prescriptions to others, the influences of the prescriptions leak away, and their application no longer yields miraculous results. The personalization of medical practice was rarely discouraged by leading members of the medical community unless it was noted that too many patients died under the doctor's care. Then, it would be argued that the doctor with this poor patient survival record had veered too far away from the central doctrines and had become reckless. One could turn to the classics and find that the doctor had not paid attention to some key element in the diagnosis or understanding of therapeutic principles, explaining the harm that came to the patients. Personalization of medical practice was expected. On a broad scale, it had been observed that, due to geographic and climatic variations, people in different villages would suffer from different diseases. For example, they might be influenced by the cold in northern climates or the heat of southern climates, by the diet of salted fish in coastal areas, or by the particular mineral content of a stream used for drinking water in inland areas. As a result, certain therapies would be emphasized and would develop separately in these areas. In China, it is common for people to talk about the specialties of their province, their region within the province, or their own village; this sense of local uniqueness carries over to the medical system. Further, China had numerous philosophical systems vying for the hearts and minds of the people, including Confucianism, Taoism, and Buddhism. Such strong cultural forces could lead doctors to different conceptions of how medicine was to be applied. On a more limited and personal scale, it was understood that each physician had certain talents, and that the expression of these talents included a particular approach to administering medical care. Thus, for example, one person would become a pulse master; another could diagnose just by looking at the face; still another would turn to finding the sensitive (ashi) points on the body, having an uncanny ability to aim straight for those points on the first try. The personalization of medical practices brings both advantages and disadvantages. For the practitioner, a primary advantage is the sense of ownership over the medical practice, while being able to still count oneself a member of the larger community by sharing in the basic traditional medical doctrines. Doctors working with very diverse approaches to treatment of disease could still claim to be working within the same core of yin-yang and five elements. For the patient, the diversity of practices provides an opportunity to make an important selection choice from among well-respected practitioners and to have an alternative should one fail. A disadvantage of this diversification is the inability to develop any consensus on an effective therapy. Each practitioner comes to believe that his or her therapies are particularly successful, so that, in essence, each and every therapy of every doctor is described as an effective one. If a young practitioner becomes concerned that his or her techniques are not, in fact, adequate, the remedy is to take on the techniques of someone else who is viewed as being successful, and later, to personalize it. The concept that the combined extensive experience of thousands of practitioners could yield a single superior therapy didn't arise until the modern era when Western medicine influenced the system. Even with this idea being present, it is rare for two doctors to use the same therapy: a standard herb formula will still be modified to make it unique to the practitioner's work. By contrast, the ideal in modern medicine is to have a multi-centered trial involving a single treatment and to determine if it works significantly better than another widely used and tested treatment. If this treatment is found to be superior, it will then displace the other. An ideal in modern medicine is to have a patient receive the same state-of-the-art treatment by a doctor working in a major hospital in a big city as would be received by another doctor in a small hospital in a rural town. If this is not possible, patients with serious ailments are recommended to travel to the major hospital, to assure the state of the art diagnostics and therapeutics.

For the modern practitioner of Chinese medicine, the unique position of being able to practice according to one's sense of what is right and what works best rather than according to what is deemed state-of-the-art is often viewed as one of the most attractive aspects of the career. Each patient can be treated individually and receive highly personalized services. Indeed, whenever adequate training has been received-so as to permit the practitioner to develop his or her own therapies-that practitioner will object to reliance on any set formulas (point formulas or herb formulas), stating that the superior method is to make each and every treatment unique. From time to time, a particular formulation (of herbs or acupuncture points) may be recommended and adopted widely, but it is soon displaced by others. In other words, no centralization of medicine is accepted. For the modern consumer of health care services, the personalization is at once an attraction and also a concern. Western medical practices are often seen as being highly impersonal. Individuals are given treatments based on the statistical outcomes of huge studies, and the person can easily feel like just one of the statistical components. Doctors seem to be all the same. Thus, when turning to a Chinese medical practitioner, the attention the consumer gets, the personalized practices of the practitioner, as well as individualized treatments, all appear attractive. On the other hand, the modern consumer of medical services may have become used to the ability of doctors to clearly inform them the current state of the art. It may be confusing to find that each practitioner of Chinese medicine has a different diagnosis and a different therapy to offer. The question then arises: which one is correct? Paul Unschuld, in his book on medical ethics in China, described the problem with personalization that was recognized during the Ming Dynasty: Gong Xin (ca. 1600 A.D.) distinguishes his group [of Confucian practitioners] from that of 'common physicians' by the fact that he discourages his colleagues from soliciting patients by emphasizing individual skills. Here again we encounter a very important element in the efforts directed at professionalization, and one which is still found in our present society. Patient solicitation, through emphasis on individual skills by one member of the group, implies that he is better than at least some of his colleagues. This kind of patient solicitation is therefore injurious to the group as a whole, because the public's attention is drawn to differences in performance. Differences in performance, in their turn, cause a lack of trust, and thus lessen the readiness of the public to entrust the same tasks to every member of the group. In other words, the public can quickly become skeptical of practitioners of Chinese medicine, because each practitioner is implying, through adopting and promoting the highly personalized approaches, that many of the other practitioners are not as valuable to visit. Worried by the apparent lack of consistency and implied inferiority of many members of the profession, this situation reduces the number of people who will try or who will continue to utilize Chinese medical services. By contrast, the message with modern medicine is that the most important thing is simply to go to a doctor and follow the advice. Therefore, "see your doctor" may be the most commonly used phrase, and the result is intensive use of the medical system.

3: THE IMPETUS TO COLLECT THERAPEUTIC PATTERNS Throughout the history of Chinese medicine, inspiring stories are told of famous doctor-scholars that spent years, often several decades, collecting information-from medical books and from current doctors-to produce a new compendium of treatment strategies. Often, the Emperor himself would order such projects be undertaken by his large staff of medical scholars. As a result of these efforts, many large collections of knowledge have been published. The collection activities result in marked expansion of the Materia Medica guides. Starting with the 365 herbs of the Shen Nong Bencao Jing, the number doubled to 730 herbs with the revision by Tao Hongjing, reached over 1,000 in the books of the Song Dynasty, then growing to 1,892 herbs in the Bencao Gangmu, arriving finally at the modern books that boast over 6,000 medicinal materials. Dr. Chen Keji, one of the prominent researchers and authors of modern Chinese medicine said in a recent article: "China has about 12,807 kinds of medicinal materials; there are 11,146 kinds of botanical materials, 1,581 kinds of medicinal animals, and 80 kinds of medicinal minerals." There is clearly a great pride in maximizing the number of materials and enumerating them precisely. Herbal prescriptions also would be gathered together, so that the initial group of just over 200 formulas in the Shang Han Lun would grow to collections of over 10,000 prescriptions by the Ming Dynasty (Li Shizhen's Bencao Gangmu had over 11,000, of which about 8,000 were added by Li to earlier collections). Acupuncture meridians and points grew in numbers, and acupuncturists began collecting entire zones of treatment, so that there was a specialty of hand/wrist acupuncture, foot/ankle acupuncture, nose acupuncture, and so on, with the most modern additions being ear acupuncture and scalp acupuncture. For each treatment zone, a basic set of points would grow to include numerous new ones, often within just a few years or decades. In a recent Chinese book on ear acupuncture, a chart is presented with the main points, showing 103. One of the popular subjects in acupuncture books today is the study of the socalled "extra meridians." As occurred with herb formulas, acupuncturists developed therapies based on particular sets of points-point formulas-for which there were thousands recorded. Many acupuncture books today do little more than relay numerous such formulas based on the unique practices of respected physicians. The collecting of knowledge characteristic of this medical system is illustrated by the following brief descriptions of two works written at about the same time Li Shizhen was compiling his great herbal. This is relayed in the book History and Development of Chinese Medicine: Guijin Yitong Daquan (A Great Collection of Medical Works, Ancient and Modern ) was written in 1556 by Xu Chunfu, a famous physician in the Jiaqing age of the Ming Dynasty who once worked in the Institute of Imperial Physicians. The book consisted of 100 volumes, which quote the medical contents of 390 sources from Confucian classics, history, philosophy, and other important contributions before the middle Ming. It is a comprehensive collection with an overall summary of the basic theories and clinical departments of traditional Chinese medicine, including physician's biographies through the ages, different schools, pulse-taking methods, doctrine on five elements and six natural influences, channels and collaterals, acupuncture and moxibustion, materia medica, health preservation, and treating in clinical practice of different departments and medical cases. Jingyue Quanshu (Complete Works of Zhang Jingyue) was compiled in 1624 by Zhang Jiebin, a famous physician of the Ming. The works consist of 12 parts, 24 volumes, and 64 books with more than one million characters. The works includes basic theories of traditional Chinese medicine, diagnosis and treatment, various clinical departments, herbs and

formulas, etc. The attempts to collect, and, thereby, preserve all kinds of medical techniques had the advantage of retaining a wide range of knowledge that might be otherwise be lost. However, it also had the disadvantage of being non-selective: vast numbers of things were being recorded, but there was little basis for determining which statements and which formulas were truly of value. As described above, personalization of the medical practices essentially conferred equal value to all therapeutics; the drive to collect all treatment techniques and substances reflected the equal value assigned to all the collected items. Although some attempts were made to weed through the literature and get rid of items deemed to be of lesser value, it was often difficult to determine which items to delete, because there was little theoretical basis for valuation; the determination was highly personal. The situation stands in contrast to modern medicine. Even though the number of therapies grows year by year, there is a continual process of comparative evaluation, so that certain therapies remain in the foreground and others drop out. A medical researcher might review the therapies that were developed over the years to provide an historical perspective, but would not expect readers to give a value to the older therapies that equals that of the newer ones. The rare exceptions, such as on-going use of aspirin, morphine, or penicillin, are remedies that are only about a century or two old; even so, their dosage form, indications, and method of use have been significantly altered. Similarly, even though Western medicine was at one time characterized by its unique development of surgery (based on careful anatomical studies), modern surgical practices are very different than past ones that made it famous, such as replacement of the largeincision abdominal surgeries with small-incision laparoscopic surgeries, and modern use of fiber optics and lasers. No one bothers to collect or refer to the prior surgical techniques. Collecting therapeutic patterns is partly a response to the personalization of medical practices-aimed at assuring retention of the valuable individual experiences-and partly a response to the high respect for things that belong to the past. Key medical documents had formerly been lost (as occurred during the great book burning of the Han Dynasty) and others nearly lost (as occurred with the Shang Han Lun). To avoid any further tragedies to the medical record, the reports of leading physicians have been kept intact during recent centuries. Modern capabilities of book publication make it possible to continue the process of recording more and more medical techniques, substances, and frameworks for their use.

4: THE ONGOING ATTEMPT TO CORRECT AND IMPROVE MEDICAL PRACTICES A medical system that looks back to ancient times, that is highly personalized, and that collects vast numbers of suggestions that have no true hierarchy, could easily become diffused and lifeless. One can imagine it degenerating into a collection of individuals working at virtual odds with each other, relying on rote repetition of principles personally selected out of a sea of possibilities. Indeed, substantial periods of relative stagnation and decline can readily be identified in the history of the Chinese medical system, such as the 750 year interval between the end of the Han Dynasty and the beginning of the Song Dynasty. Further, one can observe this negative outcome as a characteristic of some parts of the existing Chinese medical system today. However, traditional Chinese medicine has retained considerable vigor into the modern era by its inclusion of a healthy debate about how it is to be best applied. In this, it is unique as a traditional medical system. For example, stagnation in the neighboring Indian Ayurvedic tradition, where critical debate about medical issues has been lacking, has left it dulled and difficult to revive. A key vitalizing element of the Chinese system is that which serves as a counterbalance to personalization: critical evaluations undertaken from time to time by highly respected scholars. Attempts to reign in practitioners who go too far off from a central zone of unifying principles is critical in preventing the medical system from disintegrating into an incoherent mass of activities. Xu Dachun made the following comments, among others, critical of his contemporaries that illustrate this concern that physicians must be chastised for going too far from the basics: Today's physicians have given up the good old methods of the Sages entirely. The tradition of the true teachings of medicine has been lost. The physicians of later times do not even know the general names of the illnesses. In recent times, those who select a physician, and those who practice medicine, they are all equally ignorant and have no way to distinguish good from bad. The unfounded statements now in fashion are not worth listening to. In other words, he was appalled at the extent to which the doctors had deviated from the core of the tradition: ignoring the true teachings of the ancients, not learning the basics, and adopting all kinds of unfounded medical principles and erroneous facts. This is precisely the problem to be expected from the personalization of medical practice, and is something that he, and certain other scholars working in a position of respect, hoped to counter by pointing out the deficiencies. Concerns about how medicine was being practiced have been illustrated by Paul Unschuld's examination of medical ethics in China. Quoting from a number of famous physicians, it becomes clear that there were certain failings that were constantly the subject of complaints. The leading problems had nothing to do with the medical system itself, but with the context in which practitioners applied it, such as the recurrent tendency of doctors focusing their efforts on getting paid (i.e., not treating poor people, only treating the rich); the solution was to remind physicians that they must first and foremost be humane and compassionate. At a second level, the complaints had to do with the lack of attention physicians were giving to the task at hand. As with Xu Dachun's concerns above, this involved observations that physicians didn't adequately study the basic doctrines and techniques; further, they didn't give adequate time to correctly diagnose the patient and didn't think enough about the correct principles of treatment. As a result of these flaws, patients would suffer. To remedy this, some physicians devised mandates that any principled practitioner should follow. Those who study traditional Chinese medicine today are unlikely to be exposed to the part of the historical record that includes such criticisms and demands for reforms. This is because there has been a concerted effort to show the achievements of traditional Chinese medicine, as if there has been a continuous progress towards a highly effective system that is purported to exist today. Indeed, Paul Unschuld is one of the few who has quoted those who complained about the status of Chinese medicine. That medical practices fall short of the ideal is not unusual and should not be hidden; the fact that the faults were vigorously addressed is a key element of the Chinese

system, keeping it on track as a viable method of health care. The Imperial examination system served as a stabilizing force. It led to growth of a class of Confucian doctors who could work in official positions (mainly the Imperial Medical Academy) after passing the examinations. This procedure maintained the basic medical system by assuring that the practitioners had a common knowledge and understanding of the classics. While some individuals who were interested in medicine could become itinerant doctors or folk practitioners who did pretty much as they pleased (using a combination of amulets and other demon dispellers, secret pills, and various physical therapies), others could gain a higher social status by becoming official doctors who would have a uniform basic training. Working in the Imperial Medical Academy, the highest position in China, was also a more formal and restrictive setting than doctors would experience anywhere else. In addition to keeping practitioners on track in their individual practices, the Chinese system also involves constant work at reinterpretation of the basic doctrines. Unschuld illustrates this best in his translation of the Nan Jing (Classic of Difficult Issues, ca. 260 A.D.), in which he incorporated comments of several physicians who lived in subsequent centuries. The Nan Jing is itself a book about interpreting the Nei Jing , and these commentators then carried on the process. Two well-known attempts at aiding interpretation of the Nei Jing during the Ming Dynasty were Ma Shi's explanatory texts on the Su Wen and Ling Shu, and Zhang Jiebin's Lei Jing (Organized Classic; 1624 A.D.). Similarly, further work on the Shang Han Lun was carried out during the Qing Dynasty, starting with Shang Han LunTiao Bian (Systematic Differentiation of the Shang Han Lun; 1589 A.D.). Rather than merely passing on the ancient texts, the Chinese system encouraged and rewarded efforts to make the texts more accessible and understandable to practitioners of later generations. The doctrines could not be changed, but the ancient texts were often so cursory and poorly organized that they were ripe for elaboration and reshuffling. Another way to improve Chinese medical practices was by carefully observing the current medical conditions, and recommending practices were consistent with these conditions that differed from the past. For example, Zhang Yuansu (13 th Century A.D.) noted that practitioners were using ancient formulas to treat diseases that were different than the pathologies for which the formulas had been designed; he therefore recommended that new formulas be written to suit the current conditions. His contemporaries and students became famous as leaders of the Jin-Yuan Medical Reform by directing physicians to look at alternative explanations for the cause, development, and treatment of contemporary diseases, rather than relying on a sole theory that had been dominant since the end of the Han Dynasty (based on the Shang Han Lun). During the latter part of the Ming Dynasty, Wu Youxing wrote the Wenyi Lun (Treatise on Acute Epidemic Feverish Diseases) and described the concept of a transmissible pathologic agent that was responsible for epidemics. Such diseases were devastating much of the Chinese population, in a similar manner to the Black Plague that reduced Europe's population by two-thirds in earlier centuries. Previously, this concept of transmissible elements had been poorly developed. As a result of Wu's work, numerous authors expounded upon the theory (see Figure 4), which eventually led to a certain degree of consistency between traditional Chinese medicine and modern medicine in the field of infectious diseases. During the modern era, from the Qing Dynasty until now, the greatest challenge to Chinese medicine has been the introduction of Western medicine to China (followed, much later, by the introduction of Chinese medicine to non-Oriental countries). From the 18tth Century to the present, the role of each of the medical systems has been one hotly debated. Some Chinese argued vigorously against the use of any Western medicine; others argued that it was superior to Chinese medicine and should supplant it, while still others wanted to pick and choose among the two systems to retain the best of each. One of the famous medical reformers during this time was Wang Qingren. He relied heavily on traditional treatment principles, but wanted to adopt Western anatomical descriptions, based on dissection of cadavers. Many of his contemporaries were not impressed, saying: "the more he corrected our past mistakes, the more mistakes he introduced." They meant to say that, in fact, they were not mistaken in the past at all and such revisionism is uncalled for. A variety of attempts have been made to integrate traditional Chinese medicine and modern medicine in a way that is respectful of each. One well-known effort was that of Zhang Xichun (1860-1933) who wrote the book Yixue Zhongzhong Canxi Lu (which has been interpreted as meaning "Chinese at Heart, with Western Practices"). Zhang's view was that it should not be difficult to combine Chinese and Western medicine, as most Western medical therapies were implicit in traditional Chinese ones. This view was popular in China during the 1930s and 1940s, and led to free intermixing of traditional and Western medical diagnostics and therapeutics. After the Chinese communist revolution, a slogan was adopted in relation to the development of traditional Chinese medicine: "Weed through the past to bring forth the new." The implication was that the traditional medical system was full of extraneous matter that must be left behind, but that it contained certain gems that should be retained. It was referred to as a treasure house, a place where one could find great things. Although coarse in its meaning and application, this slogan really differed little in basic intent compared to earlier efforts by famous physicians to correct numerous mistakes in the literature, toss out suggestions that no longer made sense, and make room to add new items. Among the new items to be introduced were Western medicines and natural resources in China that had not yet been fully exploited. Although there will remain a tension between the two systems, more than their coexistence is essential if traditional Chinese medicine is to survive: they must eventually become integrated, if not as a single medical system, then integrated into the social system in which medical practice exists. Most Chinese medicine practiced in China today is a form of integrated medicine. Only in foreign countries has there been an attempt to keep the two systems isolated, largely based on the adoption of Chinese medicine as a rebellion against the existing medical system. The ongoing re-evaluation of Chinese medicine and its practical applications is advantageous, in that it prevents stagnation and disintegration. However, there are some evident disadvantages in the manner in which this process has been carried out in the past. In particular, there is rarely a good basis for determining who is right when one physician criticizes another or when one scholar offers a different interpretation from that given by the other. Unlike modern medicine, in which the re-evaluation of the system is based on research efforts (which, themselves, can yield considerable controversy), the Chinese attempts at re-evaluation are usually philosophically based and argumentative: there is no well-established factual base for the opinion that has been rendered. Therefore, upon reading medical works, it becomes obvious that there is a lot of criticism, but not a conclusion to it: there is no evident consensus outside the basic tenet that practitioners must be humane and must pay attention to the performance of their craft. The continuing efforts to criticize and reevaluate helps keep practitioners thinking about what they are doing, as opposed to allowing rote action on the basis of a past practice or allowing one's personal ambitions and problems get in the way of proper

administration of medicine. The practitioner of Chinese medicine is expected to respect the past and turn to it for guidance, but not be blind to the current situation, which requires an attentive, and sometimes revised, application of the principles and methods of the past.

SUMMARY AND CONCLUDING REMARKS Chinese medicine is a quasi-religious system relying heavily on ancient doctrines and a small number of ancient texts. Doctors personalize the medical system to suit their own orientation and they treat each patient uniquely, thus making a system that has tremendous diversity, to the point that it is not expected to present a uniform appearance. It is an expansive system that collects techniques and substances and fits them into the underlying medical framework. Chinese medicine retains knowledge of as many of the past experiences and recommendations as possible. Several medical scholars have attempted to define the central core of traditional medicine by clarifying the basic theories and pointing out practices that appear to be inconsistent with them. The Chinese medical system typifies diversity and expansion based on a limited set of basic principles. The tension between its expansive qualities and its conservative philosophy, along with the influence of critical thinkers who question its excesses, keeps the system vibrant. A crossroads stands before the traditional Chinese system as Western medicine shows rapid progress. Not wanting to appear inferior, practitioners portray certain advantages to the traditional system. In particular, they point to the naturalist philosophy embodied in yin-yang and five elements, the non-invasive and non-toxic qualities of its therapeutic techniques, and the aim of holistic health care rather than repair of individual diseases or alleviation of individual symptoms. However, these apparent advantages are challenged by questions of how useful such basic philosophies are in the complex modern world, how effective the mild therapeutics can be (and how safe they really are), and whether or not the way Chinese medicine is applied is actually holistic or merely a one-to-one substitute for Western medical approaches. To respond to the challenges, it is necessary first to grasp the unique features of the Chinese medical system and observe their positive and negative features in relation to the modern situation. Therefore, one must look beyond the doctrines and practices themselves and observe the organizing principles that make the system work. This essay is one attempt at promoting an understanding of Chinese medicine that may aid in developing a valuable dialogue.

BIBLIOGRAPHY Chen Ping, History and Development of Traditional Chinese Medicine, 1999 Science Press, Beijing. Kaptchuk TJ, The Web that Has no Weaver: Understanding Chinese Medicine, 1983 St. Martins, NY. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Pub., Brookline, MA. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 U. of California Press, Berkeley, CA. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, CA. Unschuld PU, Medicine in China: Nan-Ching, 1986 University of California Press, Berkeley, CA. Unschuld PU, Medical Ethics in Imperial China, 1979 University of California Press, Berkeley, CA. Wong KC and Wu LT, History of Chinese Medicine, 1973 AMS Press, Inc., NY. August 2001

Figure 1: Sculpture of Sun Simiao (581-682 A.D.), a famous physician who became popularly known as "The Medicine God," seated on the tiger. Among those depicted above him are Fu Xi (center), to his left Huang Di, and to his right Shen Nong.

Figure 2: Depiction of Shen Nong. He is clothed in herbs and tasting an herb to detect its medicinal potency.

Figure 3: Xu Dachun (1693-1771 A.D.), a well-known medical critic of the Qing Dynasty period.

Figure 4: Depiction of famous physicians involved in the development of warm disease theory during the Ming and Qing Dynasty periods.





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HOW TO SEARCH THE WEB FOR MEDICAL INFORMATION by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The internet is becoming an excellent resource for medical information, surpassing many books and journals as a first step in gaining information. The advantage of the internet system over publication of medical books is that it is easy to update regularly during this time of rapid advances in medical knowledge; its advantage over medical journals is that it is easier to search for information from multiple journals over several years. One disadvantage of the internet, in terms of getting medical information, is that a person who is not familiar with the internet structure may end up finding reports that are intended to sell health-related products. Such sales-dominated sites provide information skewed to promote the sales rather than providing purely educational reports. Also, it is relatively easy to encounter journalistic reports that overstate the potential of a new research project or treatment, as well as to encounter reports from foreign countries telling of treatments that sound good but are inaccessible (and often based on shoddy research). Increasingly, patients bring to their providers some of these non-academic and poor quality reports, seeking confirmation of the claims or access to the treatments. For the health care provider, it is important to avoid such traps and to focus on certain search mechanisms that can provide the most valuable academic information quickly. In this article, three search systems will be briefly described. These three may be sufficient to gain access to most of the information of interest. 1. The National Library of Medicine's PubMed. This is the site medical doctors and researchers rely on to get abstracts of virtually all the medical literature. It is an expansion of the previous site known as MedLine (and incorporating the previous MedLine content). The full site address is: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi. You will see a screen that starts with "Search PubMed for" and then leaves the blank space for you to fill in disease names, herb names, subject matter, author names, and so on. The system quickly retrieves relevant journal article titles, some of which have abstracts (if not, the statement "no abstract" is clearly indicated). If a title is particularly relevant, you can click on the "related articles" button on the right; this will perform a secondary search based on the key terms associated with the selected article. If the full text of the article is available on the web, the link to it will be there on the abstract page. Increasingly, full articles are being posted (sometimes, you are directed to a site for which a membership fee is required in order to obtain full articles). For tips on broader searching of PubMed see http://www.bastyr.edu/library/resources/researchguide. 2. The primary medical news web site is WebMD. The full site address for the medical information search page is http://www.webmd.com/. This site is far less technical than PubMed, and provides information that is suitable for patients to read. However, because it is set up to provide medical news in a readable form, the site provides good summaries of up to date information on common medical topics. Therefore, when seeking an overview of a subject, this site is easier to use than PubMed, and can serve in a role similar to medical encyclopedias. 3. One of the best search engines for the internet is Google. The full site address is http://www.google.com/. The order in which the search terms are typed into the search box can strongly affect the outcome, as Google is a prioritizing system, seeking the greatest level of matches to the terms in the order presented. After finding a relevant site, it is often possible to improve search results by entering specific terms revealed in the site's information that may help retrieve other valuable information. Since Google returns the most thorough results on the internet, the potential problem of getting hits to commercial sites and unreliable sites is there, so one has to examine the site information carefully. The Google search results include short phrases from the site showing where the search terms showed up. When carrying out medical searches, it may be evident that certain sites are associated with the FDA (Food and Drug Administration), NIH (National Institutes of Health), various Universities, and other mainstream medical organizations.

HERB-RELATED INFORMATION When searching for herb related information, it is most valuable to use the botanical name as a search term, rather than various common names, since the botanical name is most often used in keyword entries. When searching for applications of herbs, it may be best to use the term "clinical trials" in the search field to first narrow the topics to use of the herbs in people; otherwise, your initial search may include animal studies, in vitro studies, or studies related to the plant materials that have nothing to do with health applications. In some cases, it is possible to combine a medical term (e.g., disease name) and a general herb term (e.g., Chinese herbs) to get only the specific information available on that subject. In order to hone the relevance of your search results, enclose multiple-word search terms in quote marks. This will direct the search engine to locate the whole term rather than either word; i.e., "Chinese herbs" would return pages that featured the term Chinese herbs, not Chinese and/or herbs. One way to weed out some of the misinformation on general web sites is to take any claims made and search for articles in support of those claims, particularly on the technical search sites PubMed and WebMD (or again on the general sites, with appropriate caution in interpreting the claims). It is sometimes possible to find sites that contain information specifically debunking the claims (for example, Quackwatch; the full site address is http://www.quackwatch.com/ghindex.html). It is common for people to search the internet and find articles from China or other countries describing an herb-related remedy for a disease. The person who conducts the search may then wish to purchase the product. In most cases, the material cannot be purchased. What is being published on the internet, often as an abstract or informal paper, is no more than the report of some work done at a research center. The material that was tested may have been specially prepared for the research project, or may be a product that is not an export item. In almost all cases, there is not enough information to indicate what the test material actually contained, so that it cannot be replicated. This kind of publication is usually not intended to generate current sales of a product, but only to report on a research project, with the potential for product sales in the future (rarely realized, because no one will invest on the basis of such limited research). Once a product has been exported and is available, it will appear (via internet search) on an internet site for purchase, easily found by a search on Google with the product name or even detailed references to its uses, constituents, or other related information. Failure to find any reference to sale of the product generally means that it is not accessible.

In order to get more information about a subject than may have been revealed on an initial search, any abstracts, articles, or references that show up in the first search may be the source of other key terms that can be the subject of a follow-up search. For example, there are sometimes organizations, commissions, or authors who have tackled a particular subject and might be briefly mentioned in the first search results. A new search, based on those names, with cross-reference to the subject matter of interest, could yield additional highly relevant reports. Continuing this procedure just a few times will usually reveal virtually all web pages related to the desired subject. One can also switch to a different search engine, such as AlltheWeb, Lycos, AltaVista or Yahoo, which may catch a useful site missed by the Google system. Each of the search engines has a mechanism for updating its information, and the different systems may be able to retrieve new web pages at different times. Those interested in accurate information about herbal medicine topics must be cautioned, unfortunately, about visiting web sites that are specifically oriented towards the general subjects of herbs, natural health care, alternative medicine, and similar categories. Many of these sites provide information that is filtered not for veracity but for being favorable to the cause. For this reason, academic sites that might include information about herbs but that are not specifically dedicated to that subject are recommended here. The ITM web site (http://www.itmonline.org) is dedicated to providing a balanced presentation, including numerous cautionary articles; even so, because it is a resource for traditional medicine, the majority of its information is related to reports that have an overall favorable view of the subject. August 2001

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XING: On The Nature Of Herbs and the Misuse of the term Temperature essay by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

It is somewhat surprising to me how many Western practitioners of Chinese medicine refer to the nature [ xing] or qi of an herb as the herb’s temperature, which is not a suitable translation term and ought not to be used in this context. Temperature has a very distinct meaning in the Western world, as we speak of temperature on a daily basis in terms of the weather and indoor environment, water that we enter (e.g., swimming pool or spa), in relation to cooking of food, and our body. These are references to measurements that have a consistent application and meaning in relation to thermal energy. Because of the wide-spread use of the term, it carries with it certain connotations based on shared experiences. Yet, one can find descriptions of Chinese herb properties aimed at nonpractitioners who have no way to know the actual meaning, such as this: The way that an herb acts within the body—and hence its therapeutic effect—is determined by its temperature, its taste and the channels/meridians that it enters. An herb’s temperature is classified as hot, warm, neutral, cool or cold. In line with common sense, cool and cold herbs are used to treat hot conditions, while warm and hot herbs are used to treat cold conditions. Indeed, hot conditions and cold conditions are often not associated with changed body temperature; further, there are several instances where warming herbs are used in treating “hot” conditions, so the common sense really applies only to actual temperature issues, which are not the focus of herbal properties or diagnostic categories. Surprisingly, the term temperature in this context enters into well-known academic texts. For example, in the introductory section of Chinese Herbal Medicine: Materia Medica (1), a common text book in Western colleges, it is stated that: The ‘Properties’ section in the main text of this book includes information about two major aspects of the medicinal substances. One is the four qi. In discussions about medicinal substances this term usually refers to the temperature characteristic.... Chinese writers who make reference to the Western texts in their works, as occurs in Chinese Materia Medica: Chemistry, Pharmacology, and Applications (2), end up adopting this terminology without comment: “The phrase ‘property’ refers to the temperature characteristics of Chinese herbs.” “Property” is being used initially as the author’s reference to xing, which is an acceptable (if not the best) designation for xing, but then the words “temperature characteristics” ruin the presentation. The “properties” of Chinese herbs, described as cold, cool, warm, and hot, are not descriptions of temperature despite the similarity in terms that have been selected to describe the nature of an herb and the temperature of a substance. The temperature of herbs is room temperature; when we make a decoction, the temperature of the herbs reaches that of boiling water (100° C). Gypsum has the same temperature as evodia whether the two are on the same shelf or in the same pot, even though they have markedly different natures, described as cold and hot, respectively. This is not a matter of being picky about a term; rather it is an issue of properly understanding what is involved in describing the “nature” of an herb. The use of the incorrect term temperature can lead to misconceptions, such as the idea that mixing a hot herb with a cold herb yields a neutral formulation, much in the way that hot water and cold water mixed together yield tepid water. The idea that herbs have a characteristic defined as temperature can lead to confusion about the formulation principles that were used in making traditional prescriptions, and, thereby, influence the way in which one produces new formulas. It can also mislead one when attempting to analyze the appropriate use of herbs and interpreting the responses of patients to consuming herbs. THE NATURE OF AN HERB: XING OR QI In traditional medical systems worldwide, the numerous effects of herbs were always summarized by placing them within in a small number of categories, each having a small number of divisions. This limited categorization was an essential aspect of retaining information in early societies, in which herb knowledge was mainly passed on orally, requiring memorization, and where writing was difficult and not accessible to all in the manner we are used to today. Limited categories are also important when the kind of detailed analysis of herbs, as done in modern laboratories, could not be made. In China, the Shennong Bencao Jing (3), which long served as the model for written reporting about herbs, provided only a few characters to describe each herb. An entry included the names of the herb, the type of environment where it could be found (e.g., mountains, valleys, or rivers), a brief description of its medical effects, and a summary of its nature in terms of two concepts: taste (wei; see: Taste and action of Chinese herbs...) and nature. The nature of the herb was thus deemed an important aspect of how the herb would perform as a medicine. There are two terms that the Chinese use to describe the nature of an herb: xing and qi. Although these two terms are not directly interchangeable in meaning, they are both applied to the same underlying concept when it comes to herbal properties. Most modern authors translate xing (or qi) as nature. Thus, the nature of chrysanthemum is cool; the nature of atractylodes is warm. The Chinese character xing (see Figure 1) has two parts. The main descriptive portion, which lends to the pronunciation, is sheng (see Figure 2), a commonly used character that depicts the growing of a plant (the bottom

line is the earth; the vertical line is the stalk; the two horizontal lines along the stalk are leaves sprouted successively as the plant grows). The term is used to designate birth, generation, and growth; it tends to suggest primordial qualities (rawness, newness, essential nature) and to emphasize vitality (vigor, activity):

Figure 1: xing, in modern characters, comprised of the heart radical (xin) and the generation phonetic (sheng).

Figure 2: sheng, the old version, right, shows a growing plant (the middle line is the extra one showing growth); the modern version relies on the standardized brush strokes.

Figure 3: xin, the standard character; right is a depiction of the heart organ; the radical (category modifier) on the left is simplified; note the slight difference in stroke from Figure 1.

In front of the character for sheng is the radical (modifier) that means the same as xin (heart; see Figure 3). Used as a modifier, it tends to mean inherent quality. Put together, xin preceding sheng means the inherent direction of development. In referring to people, xing captures the sense of a person’s nature, temperament, character, and personality. It is what makes each person unique and what guides their actions in any given situation. When referring to substances, such as herbs, it means their properties, essence, character, nature, and quality: what makes that substance unique and what determines the responses to it when used as a medicine. Thus, xing is the herb’s essence as applies toits potential for making changes, but not its temperature. Qi, a term that is widely used in the descriptions of Chinese medicine, has a slightly different implication than xing, though it does sometimes also represent the idea of basic nature. The qi of an herb, in the context of medicine, is more accurately described as its penetrating influence and has been described as the “odor” of the herb, suggesting its fragrant and penetrating potential. The early effort to describe the nature (xing) of an herb as its qi was questioned by Gou Zongshi in the Bencao Yanyi (1119 A.D.). He wrote that (4): In the introductory section [of the Shennong Bencao Jing] it is written: “Drugs possess the five tastes— sour, salty, sweet, bitter, and acrid—and, in addition, the four qi: cold, hot, warm, and cool.” I would like to examine the statement further. Always, when the term qi is used, an odor is meant. Cold, hot, warm, and cool are, however, the nature [xing] of drugs. Thus, as the monograph on the common goose reads: “The fat of the white goose possesses cold xing.” Cold qi would be impossible here, for it is, of course, the nature [xing] of drugs that is being discussed. When the four qi are mentioned what is meant is aromatic-fragrant, putrid, penetrating, and strong-smelling. There is no connection to cold, hot, warm, and cool. If we take garlic, asafetida, dried fish, or sweating socks, as examples, their odor can be described as putrid. The odor of the flesh of chickens, fish, duck, and snake can be termed penetrating. The odor of kidneys, foxes, white horse penis, underwear attached to the genitals, as well as urinary sediments can be described as strong. Finally, the odors of aquilaria, sandalwood, camphor, and musk can be characterized as aromatic. In such cases, the use of the term qi is appropriate. I fear that the character qi was mistakenly placed in the introductory sections later. It should be changed to xing, which would correspond exactly. In this description of qi as odor, Gou is relying on the original use of this term to depict a vapor (e.g., the steam in a rice pot). In that sense, the cold or hot nature of an herb would not be properly described as its qi. An example of an medical scholar who linked qi with odor is Zhang Chicong, in the Bencao Zhongyuan. In describing the nature of all things in heaven and earth, he mentions that (4): “The qi are constituted by the five odors: penetrating, burnt, aromatic, strong, and putrid.” He believed that the nature [xing] of things was the confluence of all the properties, categorized in fives according to the system of five elements: place of origin (geographical direction), season of development, color, odor, taste, etc. Everything in fives; for herbs, that would mean that the properties [xing] of cold, cool, hot, and warm would be joined by neutral, as is common practice today. Other authors maintained that the five tastes certainly fit the five element system, but thought that the nature of the herbs was part of the yin/yang system (which allows for an even number of designations: hot, warm, cool, cold). Xu Dajun (5, 6) took yet another tact to distinguishing the herb’s xing from its other aspects,such as taste and qi. “If a drug reaches the mouth, one can recognize its taste (wei); if it reaches the stomach, one can feel its nature (xing).” Its nature, as felt in the stomach, was different from its odor (or qi): “When drugs are used, they should be selected according to odor, taste, color, appearance, nature, time of genesis, or place of origin....” This distinction between xing (nature) and qi (as odor) has not been followed by all subsequent writers, many of whom interchange xing and qi as terms to describe the nature of the herb. DESIGNATIONS FOR THE NATURE OF HERBS The nature of herbs was originally described as sixing (four xing) or siqi (four qi). The four designations were hot, warm, cool, and cold. With hot and cold designations for the extremes of yang and yin respectively; there are intermediate designations of warm and cool, which are given to those herbs that have a moderate action. Essentially, herbs that alleviated acute heat syndromes were designated cool or cold (depending on the intensity of their action), while those that alleviated acute cold syndromes were designated warm or hot. For chronic disorders, the situation is entirely complex.

A fifth category, of neutral or mild, has been added, yet, according to some authorities, all herbs fall into the basic four categories. As stated in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (7), “Some drugs are not marked as cold or hot, and are considered mild drugs. Actually, they must be slightly cool or slightly warm. Therefore, the properties of all drugs fall into the four categories.” A substance that is designated as having a hot nature will cause a burning sensation in the mouth (especially the tongue) when tasted and will also produce a burning sensation in the stomach when a quantity of it is ingested at once. Secondarily, it will stimulate metabolism and alleviate feelings of chilliness. Certainly, a hot drink of water (here, it is the temperature that is hot) will also do the same, though the effects will be of shorter duration. Only a very small number of herbs, such as zanthoxylum, piper, and other “hot peppers,” (as we describe them), dry ginger, evodia, aconite, and a few other herbs are described as hot. A substance designated as cold, however, will usually not cause a cold sensation in the mouth when tasted, and will usually not make a person feel chilly. Rather, a cold substance will reduce a fever and thus take away a hot sensation that is part of a disease process. When gypsum is administered to test animals, it will lower a fever but not lower the body temperature of an animal that lacks a fever. The cold properties of herbs are determined by their ability to alleviate disease symptoms; they may also have adverse effects on digestion if the dosage is high enough or the duration of administration long enough. As stated in the Advanced Textbook: “...in a hot case accompanied by such symptoms as high fever, irritability, and thirst, if the symptoms can be relieved by administering gypsum and coptis, we know that these drugs have cold properties.” A cold substance may also quell the “digestive fire,” thus weakening some aspect of the digestive process if it is not in excess already, at least if taken for a long-enough period of time. In modern terms, these cold substances may reduce hydrochloric acid levels (typical of the calcium-based minerals) or inhibit intestinal bacteria that are a part of the total digestive process (typical effect of the alkaloid-containing bitter, cold herbs). Not all the cold or cool herbs adversely affect digestion; several herbs that have a warming quality can produce digestive system reactions in some users. Short term use of “cold” natured herbs is not problematic for digestion. The nature and taste of an herb are not considered separate properties, but two intermingled qualities. A spicy warm herb, such as perilla leaf, is not comprised of two component properties, as would be suggested by a temperature and a flavor, but, rather by a spicy-warm composite quality. As such, all Materia Medica guides describe taste and nature together. As stated in the Advanced Textbook: “When studying and identifying drug properties, qi and wei must not be separated.” In traditional literature, the flavor is considered the yin aspect of the herbal property, while the qi or xing is considered the yang aspect of the herbal property; thus, they both reflect the nature of the herb, in terms of its basic essence and type of effect. The nature of herbs is deemed one of the important aspects to be learned by all herbalists. Liu Yiren, a famous herbalist of the 19th century, described the important herbs with the terms hot, warm, cold, and cool nature and concluded (8): “The above is an outline of medicinal natures: one should get it by heart as a secret art.” Indeed, some Chinese authors felt that the nature (xing) of herbs included not only warming or cooling aspects, but whether they were supplementing or draining, and whether they had ascending or descending qualities, as described in the 1616 A.D. publication Shou Shi Pao Yuan by Gong Tingxian (4). These are aspects of the herb that help define how it will be used without detailing the specific medical applications that have been developed for it. HOT AND COLD WITHIN ONE HERB In the Bencao Mengchuan, the following description of warming and cooling influences is presented: Expert application of drugs is achieved if qi and taste are considered important. The qi belong to heaven [the taste belongs to earth]; there are four such qi. Warm and hot correspond to the yang qi of heaven; cold and cool correspond to the yin qi of heaven. That which is yang rises; that which is yin descends....It is possible for one drug to have two or even three tastes or for there to be two qi combined within one drug. If a strong hot qi and a weak cold qi are combined in one drug, the cold qi will not take effect as such. If a strong cold qi and a weak hot qi are combined, the hot qi will not be detected as such. If cold and hot qi are of equal proportions, the qi will appear warm. In some cases, the warm qi is so distinct it appears to be hot; in other cases, the cool qi is so strongly developed it appears to be cold. Careful distinctions must be made here. In addition, if cold and hot qi are of equal proportions, the hot portion may be dominant when the drug is taken during the day and the effect will rise in the body; if the same drug is taken at night, the cold portion may dominate, and the effect will descend in the body. On clear, bright days, the hot qi is decisive; on dark days the effects follow the cold qi.” As this passage indicates, cold and hot qualities can coexist within an herb, they do not blend as would a temperature-type quality; the more extreme can dominate, or the two qi can manifest under different circumstances. Thus, the cold or hot qi within the herb is said, by this author, to become manifest in accordance with the external qi: an herb can have a hot or cold influence depending on the environmental conditions when it is administered. In like manner, when combining two herbs together in a formula, the hot and cold qi of individual herbs does not simply blend into something in-between; rather the hot and cold qualities are each present and may manifest differently according to the nature of the prescription and when it is given. The same is true with the tastes, namely, combining tastes does not eliminate the individual tastes though one taste may ameliorate the extreme quality of another (such as sweet to help reduce the strong sense reaction to bitter). Since the nature of herbs is listed in a small number of subdivisions (four or five), the designations are incomplete. As noted by Jiao Shude (9): “aconite and dried ginger are hot-natured medicinals, but their heat is

different; gypsum and coptis are both cold-natured medicinals, but their coldness is different…” The nature of herbs is not fixed. The nature of a plant material can be changed by traditional processing, which is viewed as a transformative function. Ginseng, as collected, is cooling, but processed ginseng is warming; the same is true of rehmannia. This change in nature illustrates the dependence of an herb’s nature on its interaction with man. Beyond the effects of processing, the influence of the herbs will also depend on herb combining within formulas (see below), as well as the conditions within the body of the person consuming them and, in some cases, the environmental conditions when they are consumed. COMBINING HERBS In his book on combining herbs (10), Sionneau mentions combining herbs with opposite properties and is generally careful to avoid suggesting that when the herbs are used together they simply balance each other out. Still, under the heading of combining the cold herb gypsum with the warm herb cinnamon twig, he proposes that this results in a decoction of cool nature. In fact, cinnamon twig does not reduce the ability of gypsum to lower high fevers or to reduce stomach fire. While gypsum may impede the ability of cinnamon twig to induce sweating, because of its astringent nature, it does not reduce the ability of cinnamon twig to warm the kidney, alleviate cold pain, and promote circulation. It is possible to have a warm herb counteract or protect against specific influences of a cold herb, without losing its nature. Still, it is more common to design formulas in such a way that two herbs act on different aspects of the individual’s constitution rather than to have them counteracting each other. There are a few commonly-cited traditional examples of herbs of extreme nature being combined in one formulation. Examples are combining coptis and cinnamon bark and coptis and evodia. These pairs were not designed to have one herb quellthe extreme nature of the other, but, rather, to have one herb alleviate a heat syndrome and the other alleviate a cold syndrome that coexists in an individual. Thus, where coptis would purge heart fire, cinnamon bark would warm the kidney and help the fire settle in the lower warmer; together they treat mental agitation and insomnia. Where coptis would purge heat in the stomach, evodia would disperse stagnant qi; together they treat nausea, vomiting, and acid reflux. Generally, when one wishes to protect against an extreme nature of an herb, it is done by means other than using an herb of opposite nature. For example, to protect the yin of the kidney from the hot spicy nature of aconite, cinnamon bark, or dry ginger, use of cooked rehmannia (which is warm in nature) is often the strategy employed. Rehmannia nourishes the yin in order to provide the desired protective effects. Similarly, when one wishes to protect the stomach from the cold nature of gypsum, oryza is often used. Although oryza (sprouted rice) has a mildly warm quality, its warm nature is not the reason that it is selected for this particular role; rather the herb promotes appetite, harmonizes the spleen and stomach, and strengthens the spleen, doing so in a gentle manner which does not introduce other actions that are not desired (e.g., dispersing damp), which is why it is chosen for this role. The idea that the nature of one herb would simply counteract the nature of another has been raised in the past. Xu Dajun argued against this view (5), he said: “The fact is that drugs will always make full use of the potential associated with their nature.” Herb properties may be transformed by the formulation strategy. Jiao Shude gives an example of use of the herb schizonepeta (jingjie), which is utilized in formulas for both cold and heat type disorders: “When combined with siler (fangfeng) and perilla leaf (suye), it acts as a warm, acrid, exterior resolving medicinal, but when combined with mentha (bohe) and chrysanthemum (juhua), it acts as a cool, acrid, exterior resolving medicinal.” CONCLUSION When Chinese concepts that were developed in ancient times are depicted by terminology from a modern culture with a markedly different background, it is not uncommon for something to be lost in the translation. In this case, because the mundane terms hot, warm, cool, and cold have been used as categories for the nature of herbs, the modern concept of temperature has been off-handedly applied to capture the meaning. But, there are distinct differences between the concept the Chinese were putting forth in regard to an herb’s nature and the one which is broadly understood today as temperature. Two results of this selection of an inappropriate term are the ideas that mixing cold and hot herbs yields a tepid intermediate, and that taking cold natured herbs can make a person feel chilly. Neither of these notions were intended by the Chinese who wrote about the nature of herbs. REFERENCES 1. Bensky D and Gamble A, Chinese Herbal Medicine: Materia Medica, 1993 rev. ed., Eastland Press, Seattle, WA. 2. Zhu Youping, Chinese Materia Medica: Chemistry, Pharmacology, and Applications, 1998 Harwood Academic Publishers, Amsterdam. 3. Yang Shou-zhong (translator), The Divine Farmer’s Materia Medica, 1998 Blue Poppy Press, Boulder, CO. 4. Unschuld PU, Introductory Readings in Classical Chinese Medicine, 1988, Kluwer Academic Publishers, Holland. 5. Unschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications, Brookline, MA. 6. Unschuld PU, Medicine in China: History of Pharmaceutics, 1986 University of California Press, Berkeley, CA. 7. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (4 vol.) 1995–6 New World Press, Beijing. 8. Yang Shouzhong (translator), The Heart Transmission of Medicine, 1997 Blue Poppy Press, Boulder, CO. 9. Sionneau P, Dui Yao: The Art of Combining Chinese Medicinals, 1997 Blue Poppy Press, Boulder, CO. 10. Jiao Shude, Ten Lectures on the Use of Medicinals, 2003 Paradigm Publications, Brookline, MA.

October 2010

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What is the Meaning of "Yiqi" in Buzhong Yiqi Tang? Implications for Use of Various Yiqi Ingredients in Formulas by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Buzhong Yiqi Tang is a formula that was described in an important text of the Chinese tradition, the Pi Wei Lun (Treatise on Spleen and Stomach, 1249 A.D.), which is available in English translation (1). Its author, Li Gao (also known as Li Dongyuan) was considered the leader of the "Spleen/Stomach School," a movement within the evolving ancient tradition that focused on deficiency of spleen and stomach as the origin of numerous diseases. This was one of four leading schools of thought that developed during the Chinese medicine reforms of the Jin-Yuan Dynastic period (see: Jin-Yuan Medical Reforms). Li had good reason to focus on this area: he suffered from such a disorder himself. In the course of describing how to use herbs in treating the spleen-stomach disorders, Li wrote: I myself suffered from a disease of long-standing weakness of the spleen and stomach resulting in my vision and hearing being reduced by half. This was a disease of excessive yin overwhelming the yang. In addition, my qi was limited, my essence-spirit was insufficient, and my pulse was thin and wiry. This was a deficiency disease. It was due to speaking too much. All this indicated decrepit and weak yang qi, which, being confined within the yin, was unable to smoothly flow where it should. Before discussing his herbal formulas and the terminology used in depicting their actions, it is worthwhile to note that a prescription based on Li's work-but described by a later author, Ni Weide-is specifically designed for this condition of weak yang qi leading to loss of visual and auditory acuity: it is called Yiqi Congming Tang. These are also indications for Buzhong Yiqi Tang. Li has ascribed an unusual causative factor to his syndrome: speaking too much. No doubt, he had much to tell people and, apparently, they were sufficiently willing to make up an audience to keep him talking, perhaps for hours on end. This is a type of "taxation," that is, an overstraining of the body or its parts, which can weaken the qi. When taxation is repeated often enough the qi is drained and one becomes susceptible to various illnesses that can further damage the qi. Li's focus of concern was the yang qi. A substantial discussion of this concept was provided much earlier in the first pages of the Neijing Suwen. The translation of this renowned text by Maoshing Ni is especially easy to understand, and I have added in brackets some explanatory comments (2): The yang qi moves like the sun. As the sun begins to rise at dawn, the yang qi begins to move to the outer body [muscles, skin, and hairs; moving from the inner regions, the viscera], and the pores open. The peak of the yang qi is at noon, and when the yang qi is most active [which occurs around this time] it is advisable to relax and stay quiet so that the yang qi does not escape [i.e., through sweating]. As the sun sets, the yang qi moves inward and the pores begin to close. At this time, it is harmful to engage in strenuous physical activity [when the yang qi should settle inward and not be forced again to the surface] or expose oneself to cold, damp, mist, or fog [that is, to yin influences]. If one violates the natural order of the yang qi as it emerges, peaks, and sets, the body will gradually be weakened by pathogenic factors and be subject to disease and degeneration. Yin is the essence of the organs and the fountain of the qi. Yang protects the exterior of the body against pathogens and makes the muscles function. When the yin fails to contain the yang, the flow in the channels will become rapid, causing the yang qi to become reckless. If, on the other hand, the yang qi is deficient and unable to counterbalance the yin, communication between the viscera will be disrupted, and the nine orifices will cease to function [this includes the eyes and ears as two orifices; also the mouth, in terms of taste, and the nose in terms of smell, so the sensory organs of the upper body will be impaired]. Buzhong Yiqi Tang is sometimes named Ginseng and Astragalus Combination after two of its key spleen-tonifying ingredients, and its name is often translated as "The Decoction to Tonify the Center and Boost the Qi." The term "bu" appears often in the description of Chinese therapeutics and in the name of herbal formulas. It is usually translated as "tonify" or "supplement," and it is a term typically used in combination with the four primary essences: buqi, buyang, buxue, buyin (to supplement, respectively, the qi, yang, blood, and yin). The implication of bu is actually to refill: to replenish something that has been depleted. Zhong means the "center" of the body, and refers to the central organ, the spleen (and its associated organ, stomach); this is as opposed to the upper organs (lung and heart) and lower organs (liver and kidney). So, the formula's action, described by buzhong, is to tonify or supplement the depleted spleen and enliven the impaired stomach function. Tang is a decoction, which was the original preparation of the formula. Today, one can also get the herbs in pill form (wan), usually made from powdered herbs (according to the Pharmacopoeia of the PRC). Thus, this is a decoction to replenish the deficient qi, and provide another action, yiqi. The term "yi" is often translated today as "to benefit;" it may also indicate to increase, prolong, and enlarge. These latter terms are somewhat different than what is implied by bu, because they don't have to refer to replenishing a deficiency, they can indicate growth beyond what is usually present. This term was introduced for herbal formulas by Li Gao and he made it clear in his Pi Wei Lun that the main concern was with the raising of yang qi as part of the healthy digestive process; the contrary condition is sinking of yang qi, but this downward flow is not its appropriate direction in relation to the spleen function. To raise up the yang qi is described by yet another term: "shengyang" (some authors now translate this as "upbearing" the yang). Li used the term yiqi for a similar concept, but it also implies shoring up the organs from the bottom, to assure that the qi doesn't have a chance to sink down, but, will rise up instead as it is supposed to. To shore up from the bottom, the impetus must come from below. To sum up, Li's key formula Buzhong Yiqi Tang is intended to replenish the deficiency of spleen and stomach and to prevent the yang qi from sinking, aiding it in rising. This is the main "benefit" to the qi. He described the basis for this concept as follows: After water and grain enter the stomach, yang qi ascends. Fluids and qi enter the heart and penetrate the lungs to replenish the skin and hair and to disperse throughout the hundreds of vessels. The spleen receives qi from the stomach to irrigate the

four limbs and nourish the qi and blood. If, on the other hand, the stomach is injured by improper food and drink and the spleen is damaged by being overwhelmed [taxation fatigue], they become deficient. This yang qi that ascends is a clear essence (a fluid) derived from food and beverage which is then distributed by the spleen to the upper viscera (the heart and lungs), and from there to the body surface. A share of this essence "rains down" from the lungs to the lower organs, where it can replenish the yin and essence of the kidney; a portion of that essence that has properly been deployed to the lower body is then circulated upward by the "steaming" action of the kidney yang. However, with the deficiency of spleen and stomach, a substantial fraction of the yang qi doesn't ascend and the body is not properly nourished. Further, one can develop a downward flow of the yang qi: Generally speaking, if the spleen and stomach are deficient and weak, yang qi is unable to grow and rise up….When the spleen is diseased, yang qi flows down to overwhelm the kidneys. That is, the earth element restrains the water element and, as a result, there occur weak and flaccid bones….It causes the bones to become deficient in marrow and the legs are unable to walk on the ground. This is an imposition of yin qi, a pattern of excess yin and deficient yang. The description of "weak and flaccid bones" may seem odd, but the reference is to increasing difficulty in walking with the sensation that the normally strong bones are not holding one up. In fact, using modern descriptions we would mainly indicate that this is a syndrome of weakening of the muscles, possibly accompanying a weakening of the nerve signals to the muscles so that they are no longer very responsive. The excess of yin may reveal itself as fluid-filled limbs, or overall obesity. The downward flow of yang qi is also depicted in Li's chapter about deficiency syndromes: "When the spleen and stomach are severely deficient, the qi of damp earth slides down below the umbilicus and the kidneys and bladder suffer from evils." One can almost picture a hillside where the topsoil is not well connected to the surface below, and, upon becoming wet, slides down as heavy mud, pouring into a stream that it blocks and disrupts. As to the remedy for this problem, Li points out first that: "the foot yangming is the sea of the 12 channels governing the movement of qi and all the channels depend upon it for their supply of qi." Hence, he recommends using herbs that benefit this channel. The foot yangming channel is the stomach channel, and it has, among other essential acupuncture points, the most commonly used of all the tonifying points: ST-36 (zusanli). Li had selected four herbs to focus on for the purpose of elevating yangqi via the stomach channel, three of them are in Buzhong Yiqi Tang: cimicifuga, bupleurum, astragalus, and the other is pueraria. He described the role of the first two of these herbs as follows: The pattern of insufficient spleen and stomach requires a small quantity of cimicifuga, a medicinal which conducts to the foot yangming and taiyin channels. Yang qi will thus be made to travel the yang tract and turn right from the spleen and stomach [turning right means to rise rather than sink]….Enriching the harmonizing qi of shaoyang with a small quantity of bupleurum used in addition to the cimicifuga turns the various channels right [their flow in the proper direction] so as to generate and effuse the qi of the yangming. Jiao Shude, in his lectures on the use of medicinals (3), presents a similar picture for use of bupleurum in raising the yang qi: Bupleurum conducts clear qi upward to treat downward fall of clear yang characterized by spleen-stomach deficiency, shortness of breath, sagging in the abdomen, persistent diarrhea, sagging in the anus, heaviness in the lower back and abdomen, profuse menstruation, frequent urination, prolapse of the internal organs, and prolapse of the uterus. For this, it is combined with medicinals such as astragalus, atractylodes, cimicifuga, pueraria, and codonopsis. One can see the extended listing of symptoms where fluids are pouring downward (diarrhea, frequent urination, and profuse menstruation) and where the lower body feels heavy or is actually sagging down in prolapse. Here, he lists the other yang qi raising herbs astragalus, cimicifuga, and pueraria, along with the spleen qi tonics atractylodes and codonopsis (ginseng is often indicated here, but China has used codonopsis as a substitute for ginseng for several decades). The roles of astragalus and pueraria are to aid movement of the qi to the skin and muscles respectively. When referring to the skin (usually as "skin and hair") this means that the qi circulating at the surface is strengthened so that the opening and closing of the pores can be regulated, and, specifically, that the pores can be closed in order to prevent evil influences from entering or to prevent too much perspiration from escaping, carrying with it valuable essences. The hair referred to here is not the hair at the top of the head, but the hairs along the body surface that are thought to accompany the pores. When referring to movement of qi in the muscles, this means the qi circulates and helps them to either contract or relax, and, in particular, to be able to relax as needed so that the body is in harmonious form, while being strong enough to contract to hold up the body structure, such as when walking or lifting. Pueraria is especially important for relaxing the muscles of the upper back, shoulders, neck, and head. Li Gao listed several formulas that fit this pattern of therapy in his book, several of them include yiqi in the formula name (the designation "tang" is left out of the titles here): YIQI FORMULAS (By Li Dongyuan, Except Yiqi Congming, Adapted by Ni Weide) Buzhong Yiqi Cimicifuga

Qingshen Yiqi Cimicifuga

Qingshu Yiqi Cimicifuga

Bupleurum Astragalus

Tiaozhong Yiqi Cimicifuga

Cimicifuga

Bupleurum Astragalus

Astragalus

Pueraria Ginseng

Yiqi Congming

Ginseng

Astragalus Pueraria

Ginseng

Ginseng

Licorice

Licorice

Atractylodes

Atractylodes, red

Ginger, fresh

Ginger, fresh Citrus

Tang-kuei

Tang-kuei

Jujube

Hoelen

Licorice

Atractylodes, red/white Atractylodes, red

Citrus Alisma

Licorice

Citrus

Alisma Phellodendron

Phellodendron

Shen-Chu, Blue Citrus, Saussurea Ophiopogon, Schizandra

Vitex, Peony

It can be seen that all of the "yiqi" formulas contain cimicifuga and most contain astragalus. The "buzhong" portion of the formula includes astragalus with ginseng, licorice, and atractylodes, which are three of the four ingredients of Si Junzi Tang, the primary spleen qi tonic of Chinese medicine. But, these formulas are not as intensively focused on draining damp as Si Junzi Tang, so (with one exception) they do not include the fourth ingredient, hoelen. In the next table are Li Gao's "shengyang" formulas. These have a similar structure, but add the ingredient chiang-huo, which is intended to help carry the yang qi upward; this herb is sometimes accompanied by others that are similar in action (and are botanically related): siler and/or tu-huo. SHENGYANG FORMULAS (By Li Dongyuang) Shengyang

Shengyang Chushi

Bupi Weixie Yinhuo Shengyang

Shengyang Sanhuo

Cimicifuga

Cimicifuga

Cimicifuga

Cimicifuga

Bupleurum

Bupleurum

Bupleurum

Bupleurum

Astragalus

Astragalus

Shengyang Yiwei

Bupleurum Astragalus

Pueraria Licorice Citrus

Ginseng

Ginseng

Ginseng

Licorice

Licorice

Licorice

Licorice

Atractylodes, red

Atractylodes, red

Atractylodes, white

Citrus

Citrus

Alisma

Alisma

Chiang-huo

Chiang-huo

Siler

Chiang-huo

Chiang-huo

Tu-huo

Tu-huo

Siler

Siler

Coptis

Coptis

Pinellia Tang-Kuei, Carthamus Malt, Polyporus, Alpinia, Shen-Chu

Pinellia Scute, Gypsum

Peony

Hoelen

Clearly, these " yiqi" and "shengyang" methods of therapy loomed large in Li's approach to healing. This may be because Li's case of weakened spleen and stomach was not a minor one. He continued his description: "Now, in my case, the intruding evil of excessive cold dampness was sapping the internal qi via the exterior and that was happening in a violent way." Though he didn't specify the violence he might have experienced, it is possible that he suffered symptoms of abdominal pain, digestive disturbance, and other results of visceral deficiency and invasion of cold and damp. In other words, with the yang qi weakened (by speaking too much), he was subject to the invasion of external evils, and he was struck by the yin evils of cold dampness. These adverse influences then further weakened his qi. While it is possible that the excess yin simply overwhelms the yang, leading to progressively more cold syndromes (as depicted in the Neijing Suwen), it is also possible for the imbalance to lead to a mix of cold and fire symptoms. In the Pi Wei Lun, Li describes how this mix of conditions can arise: Dietary irregularity and immoderate eating of cold and warm foods may damage the spleen and stomach, while joy, anger, worry, and fright may consume and cause detriment to the original qi. If the spleen and stomach qi becomes decrepit and the original qi becomes insufficient, heart fire may become effulgent on its own. This heart fire is a yin fire. It starts from the lower burner and links to the heart. The heart does not reign exclusively; ministerial fire is its deputy. Ministerial fire is the fire of the pericardium developing from the lower burner. It is a foe to the original qi. This yin fire and the original qi are mutually irreconcilable. If one is victorious, the other must be the loser. When spleen and stomach qi becomes deficient and their qi consequently sinks down into the kidneys, yin fire is given a chance to overwhelm the earth phase. As in the earlier description, the damp earth sinks down to the lower region and disrupts the normal flow and function. While one may easily envision this dampness quenching the fire of the kidney, in fact, the better analogy is that the damp earth disrupts the stream, causing it to change its course. It no longer proceeds to and cools the area where yang resides. The balance of yin and yang is thereby

further disrupted and the deficiency fire flares to the pericardium and heart, and from there flares further upward to affect the sensory organs and the brain function. This outcome is the reason that some of the "yiqi" formulas include coptis, phellodendron, scute or other heat-clearing herbs in a base of warming tonification for the spleen and stomach. This situation is also depicted in the Yinhai Jingwei, a classic text on eye diseases (4): A condition to be treated is where the yang cannot overcome the yin, because the yin flourishes and the yang is depleted. As a result, the nine orifices [including the eyes, ears, and nostrils] are not passable. Now, a light-green shade appears at the inner canthi of the eyes, because both the foot yangming [stomach channel] and foot shaoyin [kidney channel] are obstructed. The qi of the foot jueyin [liver channel] cannot freely rise upward….One should make the yang qi of the organs in the yangming and shaoyin channels at the bottom rush up to the heaven [to the head]. This means one should first supplement [and raise] the yang qi. Then, one drains the fire of the foot jueyin from the head of the yangming channel. That above and that below are then balanced in the yang, and the yin is under control. The recommended formula for such a condition is similar to Buzhong Yiqi Tang , with the addition of several herbs, including chiang-huo, tu-huo, and siler, ingredients found in some of Li's other formulas for raising qi (shengyang) The method of treatment in this ophthalmology text involves using these herbs to raise yang qi in the morning and then use herbs to drain the fire and benefit yin in the evening. However, most physicians combine these methods of therapy into a single formula to be taken twice daily. The practitioner considering use of a "yiqi" formula should determine whether the yang qi deficiency and descent has developed into a simple cold syndrome or a mixed syndrome of spleen/stomach cold with deficiency heat of the kidney in order to design or select the most appropriate prescription.

REFERENCES 1. Yang Shouzhong and Li Jianyong (translators), Li Dongyuan's Treatise on the Spleen and Stomach, 1993 Blue Poppy Press, Boulder, CO. 2. Maoshing Ni, The Yellow Emperor's Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA. 3. Mitchell C, et al. (translators), Ten Lectures on the Use of Medicinals from the Personal Experience of Jiao Shude, 2003 Paradigm Publications, Brookline, MA. 4. Kovacs J and Unschuld PU, Essential Subtleties on the Silver Sea, 1998 University of California Press, Berkeley, CA.

The foot yangming (stomach channel). It connects the foot to the eye and near the ear to affect sight and hearing; it passes by the spleen and stomach and connects internally to the stomach.

September 2004