Chinese and Botanical Medicines - Traditional Uses and Modern Scientific Approaches - Chun-Tao Che and Charmaine Tsang

Chinese and Botanical Medicines

Chinese and Botanical Medicines Traditional Uses and Modern Scientific Approaches

Raymond Cooper Chun-Tao Che Daniel Kam-Wah Mok and Charmaine Wing-Yee Tsang

CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2018 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4822-5758-8 (Hardback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www. copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Cooper, Raymond, author. | Che, Chun-Tao, author. | Mok, Daniel, author. | Tsang, Charmaine, author. Title: Chinese and botanical medicines : traditional uses and modern scientific approaches / Raymond Cooper, Chun-Tao Che, Daniel Mok and Charmaine Tsang. Description: Boca Raton : CRC Press, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2017025433| ISBN 9781482257588 (hardback : alk. paper) | ISBN 9781315118956 (ebook) Subjects: LCSH: Medicine, Chinese. | Materia medica, Vegetable. | Herbs--Therapeutic use. Classification: LCC R601 .C66 2017 | DDC 610.951--dc23 LC record available at https://lccn.loc.gov/2017025433 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com

Contents Foreword................................................................................................. ix Acknowledgment................................................................................... xi Authors..................................................................................................xiii Chapter 1 Background and content................................................... 1 Book contents........................................................................................... 4 Further suggested reading..................................................................... 6 Chapter 2 The beginning of TCM in China and TCM herbalism............................................................................. 7 Classical TCM herbal literature............................................................. 7 Botanical classification of TCM herbs................................................ 12 Identification of medicinal plants........................................................15 Medicinal botany...................................................................................16 TCM preparations..................................................................................17 Internationalization of TCM.................................................................18 Further suggested reading................................................................... 20 Chapter 3 TCM theory and practice................................................ 21 Introduction............................................................................................21 What is Chinese medicine?...................................................................21 Initiation of a theoretical system of Chinese medicine.....................21 Traditional categorization.................................................................... 22 Cardinal characteristics of Chinese medicine................................... 23 Yin and yang theory and application to Chinese medicine............. 25 Characteristics of yin and yang............................................................ 25 Wax and wane and transformation of yin–yang............................... 26 Summary of application of yin–yang theory in Chinese medicine............................................................................................... 26 The five elements................................................................................... 26 The meaning of qi, blood, body fluids, and essence......................... 30 v

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Function of qi......................................................................................... 30 Therapeutic modalities......................................................................... 30 Herbology...........................................................................................31 Acupuncture.......................................................................................31 Moxibustion........................................................................................31 Cupping...............................................................................................31 Exercise therapy.................................................................................31 Dietary therapy................................................................................. 32 Medical massage (Tui-Na) and manipulation............................... 32 Bone setting....................................................................................... 32 Diagnosis................................................................................................ 32 Palpation................................................................................................. 36 Pulse examination................................................................................. 36 Location of pulse............................................................................... 37 An example of a diagnosis.............................................................. 37 Further suggested reading................................................................... 39 Chapter 4 Traditional Chinese medicinal herbs........................... 41 Herbal drug character and property.................................................. 42 Herbal formulas..................................................................................... 44 TCM dietary therapy............................................................................ 49 Biologically active ingredients from TCM herbs.............................. 50 Future prospects.....................................................................................51 Further suggested reading................................................................... 52 Chapter 5 Examples of TCM formulas used in Chinese medicine............................................................................. 53 Herbal medicine.................................................................................... 53 Efficacy of TCM..................................................................................... 55 Some examples of complex formulas used in TCM......................... 55 Danggui-Buxue-Tang.............................................................................. 63 Four Gentlemen Decoction (Si Jun Zi Tang)....................................... 64 Suan Zao Ren Tang (Sour Jujube Decoction)....................................... 65 Further suggested reading................................................................... 66 Bibliography............................................................................................67 Chapter 6 Examples of single Chinese and botanical medicines derived from TCM....................................... 69 Introduction........................................................................................... 69 Evidence-based approach.................................................................... 70

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Artemisinin: A Chinese miracle drug................................................ 70 Malaria............................................................................................... 70 Ginkgo.................................................................................................... 73 Ginseng................................................................................................... 75 Introduction....................................................................................... 75 Ginsenoside variation and standardization.................................. 75 Ratio of Rg1 and Rb1 and the yin and the yang........................... 75 Adaptogen and effects on exercise performance......................... 77 Green tea................................................................................................. 78 Introduction....................................................................................... 78 Anticancer mechanisms of action.................................................. 79 Inhibition of NADH oxidase activity............................................. 79 Chinese Cordyceps: Winter Worm, Summer Grass......................... 80 Introduction....................................................................................... 80 Life cycle of Cordyceps sinensis..........................................................81 Perceived health benefits.................................................................. 82 Salvia (Danshen).................................................................................... 83 Red yeast rice, Monascus purpureus..................................................... 87 Dong quai, Angelica sinensis................................................................. 88 Garlic....................................................................................................... 89 Use of garlic in cardiovascular disease models............................ 90 Ephedra, Ephedra sinica......................................................................... 92 Further suggested reading................................................................... 94 Suggested reading on Ginkgo............................................................. 94 Suggested reading on Ginseng............................................................ 94 Suggested reading on Green tea......................................................... 94 Suggested reading on Cordyceps........................................................ 95 Suggested reading on Salvia................................................................ 95 Suggested reading on Garlic................................................................ 95 Chapter 7 TCM safety and regulations.......................................... 97 TCM safety concerns............................................................................ 97 Toxic compounds and contaminants in TCM herbs........................ 98 Aristolochia and Asarum species........................................................... 98 The toxic Aconitum plants....................................................................103 Datura metel L........................................................................................105 Xanthium sibiricum poisoning.............................................................106 Chinese medicinal products...............................................................107 Po Chai Pills......................................................................................107 PC-SPES.............................................................................................108

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Further suggested reading..................................................................111 Bibliography..........................................................................................111 Chapter 8 The current use of TCM in China, Hong Kong, and Southeast Asia........................................................ 113 China......................................................................................................113 TCM regulation in China....................................................................114 Class 1 to class 9 drugs in China.......................................................114 Malaysia.................................................................................................116 Singapore...............................................................................................117 Indonesia...............................................................................................117 Australia................................................................................................117 Hong Kong............................................................................................118 TCM as part of the medical system in Hong Kong.....................119 TCM trading in Hong Kong...........................................................120 TCM education in Hong Kong...................................................... 122 TCM regulations in Hong Kong................................................... 123 TCM monographs........................................................................... 123 TCM in Hong Kong: Present and future..................................... 123 Further suggested reading..................................................................124 Chapter 9 Global acceptance of TCM........................................... 125 Acceptance of TCM in the world...................................................... 125 Resurgence of consumer interest: A need for better science in botanical preparations................................................................... 128 TCM needs TQM..................................................................................129 Further suggested reading..................................................................131 Appendix: Plant names.133 Glossary of terms.137 Bibliography..........................................................................................141 Index......................................................................................................143

Foreword Chinese Medicine has been around for several thousand years. The early discoveries were necessarily empirical. Shen-Long was recognized as the “god” of agriculture and medicine for his fearless trials of hundreds of herbs and the systematic characterization of their clinical properties. Eventually, when written records were gathered, there were numerous physicians who had contributed to the advances of Chinese Medicine. Today, the international “norm” of clinical medicine is clearly that of Western medicine. It has taken advantage of modern science and technology and incorporated the findings into medical applications. In this manner, Western science and medicine were able to coevolve over the past 200 years. Chinese Medicine, on the other hand, has been relatively slow in exploiting these scientific and technological advances due to the difficulties of integrating these modern advances into the principles of Chinese Medicine, which were firmly established in the “pre-scientific” era. Nevertheless, Chinese Medicine plays a major role in the healthcare industry in China and other Chinese-speaking countries and communities. In addition, Chinese medicine is making inroads into the non-Chinese-speaking communities in the Western and other countries. However, the impact remains understandably limited due to the absence of proper translation of Chinese medicinal concepts into many other languages. In this day and age, it seems logical to start with English, which is generally accepted as the “default” language of internationalization and globalization. I must therefore applaud the effort of the authors of this book. This welcome book, titled Chinese and Botanical Medicines: Traditional Uses and Modern Scientific Approaches, provides an elementary framework of Chinese Medicine for the non-Chinese-speaking public. It will also serve as a simple reference book for Chinese Medicine practitioners to take up the further role, in addition to ix

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Foreword

treating patients: to introduce the very basic concepts of Chinese Medicine and the Chinese culture to global citizens, providing an introductory text to those wishing to learn more about the basic theory concepts and examples of Chinese medicines and herbals. Alex Law, PhD Professor, School of Biological Sciences Director (2012-2016), Double Degree Program in Biomedical Sciences and Chinese Medicine Nanyang Technological University Singapore

Acknowledgment The authors wish to thank Ailsa Yuen at the Hong Kong Polytechnic University, Hong Kong for help with the manuscript and Hilary LaFoe, senior acquisitions editor and Natasha Hallard, editorial assistant, Chemical and Life Sciences, CRC Press, Taylor & Francis Group.

Cover Acknowledgments The “Ginseng Longevity” is provided by Dr. & Mrs. Hung Hin Shiu Museum of Chinese Medicine, Hong Kong Baptist University, Hong Kong.

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Authors Raymond Cooper, PhD, was born in the United Kingdom, earned his PhD in organic chemistry, and, after 15 years in R&D in the pharmaceutical industry, moved to the dietary supplements industry, developing new Chinese botanicals as supplements. Currently, Dr. Cooper is a visiting professor and lecturer at the Hong Kong Polytechnic University and cofounder of PhytoScience LLC, a consulting company creating innovative botanical solutions and products. He is the recipient of the 2014 American Society Pharmacognosy Tyler Prize for his lifetime contributions to Botanical Research. He is also a Fellow of the Royal Chemical Society, UK. Dr. Cooper has recently published two books with Taylor & Francis (CRC Press): Natural Products Chemistry: Sources, Separations and Structures and Botanical Miracles: Chemistry of Plants that Changed the World. He has edited five books, most recently Botanical Medicine: From Bench to Bedside, and published more than 100 peer-reviewed scientific articles. Chun-Tao Che, PhD, earned his BSc and MPhil from the Chinese University of Hong Kong (CUHK), and PhD in pharmacognosy from the University of Illinois at Chicago (UIC). After receiving postdoctoral training at the Ludwig Institute for Cancer Research in Toronto and returning to UIC as a research assistant professor, Dr. Che joined the Department of Chemistry of the Hong Kong University of Science and Technology in 1991 as a founding faculty member. From 2000 to 2010, he served as the director of the new School of Chinese Medicine at CUHK. In 2010, Dr. Che rejoined UIC to become the Norman R. Farnsworth Professor of Pharmacognosy, the first endowed professorship in the 150-year history of the College of Pharmacy. He is xiii

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Authors

also the director of the World Health Organization Collaborating Center for Traditional Medicine at UIC. Dr. Che’s research interest focuses on traditional medicines and natural products chemistry, including the discovery of biologically active substances from medicinal plants and establishing quality standards for botanical products. He has published more than 300 scientific papers in the fields of pharmacognosy, natural products, and Chinese medicine. Daniel Kam-Wah Mok, PhD, was born in Hong Kong, where he received his formal education. He earned a PhD in theoretical chemistry from Hong Kong University, followed by a postdoctoral fellowship at the University of Cambridge. He returned to the Hong Kong Polytechnic University (PolyU) as a research fellow and was recently promoted to associate professor in the Department of Applied Biology and Chemical Technology. He is also the Director of the State Key Laboratory of Chinese Medicine and Molecular Pharmacology (Incubation base) established by PolyU in Shenzhen. Dr. Mok’s research focuses on adopting computation tools in the study of chemical and biological systems. He has been using multivariate statistical methods together with advanced analytical instruments to investigate the effects of herbs in the treatment of chronic diseases. Dr. Mok also has extensive experience in quality standards of Traditional Chinese Medicines, leading the PolyU team in the Hong Kong Chinese Materia Medica Standard project which develops monographs of Chinese Medicinal herbs used in Hong Kong. Dr. Mok has published a book titled Authentication for Valuable Chinese Materia Medica (in Chinese) as well as more than 100 peerreviewed scientific articles. Charmaine Wing-Yee Tsang, PhD, was born in Hong Kong and earned her first degree in physiotherapy in the United Kingdom. She then worked for a year in the healthcare industry in Hong Kong before studying Chinese Medicine at the Hong Kong Baptist University, where she earned a joint degree in Chinese Medicine and Biochemical Science. In 2015, she earned her PhD in gynecology from the Nanjing Chinese Medicine University. Dr. Tsang practices medicine in Hong Kong at a private clinic and is a visiting lecturer at the Hong Kong Polytechnic University,

Authors

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the Open University of Hong Kong, and the Hong Kong College of Technology, teaching Chinese Medicine and biological science. Through her volunteer work, Dr. Tsang is a cofounder of the charity organization Chinese Medicine for All, providing Traditional Chinese Medicine therapy to the poor and the needy around the world and to educate minorities on the therapeutic effects and benefits of Chinese Medicine. She runs educational programs teaching the local people the use of acupuncture so that they can help themselves.

chapter one

Background and content Great civilizations existed and flourished, based on simple terms on retention of their lands, ability to nourish their people, and remaining in reasonably good health. Since they required knowledge and wisdom, these traits were passed on to future generations. Cultivation, harvesting, seed retention and sowing, animal husbandry, and minimal hygiene kept civilizations alive. The ability of peoples to recognize and use the plants around them, which possessed healing properties, was important. Indeed, the great ancient Greek physician Hippocrates is often quoted as saying that “food is your medicine and medicine is your food.” Ancient Chinese people, over the centuries, have retained a remarkable record of plants used as medicines and they have passed down through the generations enormous volumes of information on traditional medicines, which have stood the test of time. There are other ancient civilizations, particularly India, with Ayurveda, and the Incas and the Aztecs, which flourished, due to their knowledge of medicinal and healing properties of plants. Over the years, we have witnessed the tremendous advances in Western medicine, yet most of the world’s population continues to use traditional remedies. However, although popular in many parts of China today, perceptions on Traditional Chinese Medicine (TCM) are quite diverse. A significant number of people have never tried TCM. Many of them do not consider that there is sufficient evidence supporting the practice of TCM. To stimulate a discourse, we have created an introductory course on TCM and have asked the students whether TCM is a “myth or a treasure?” Is TCM a treasure handed down from our ancestors, even though more scientific study is needed to fully appreciate the value? The aim of the book is twofold: to explain in simple terms some of the background, the logic, and the philosophy of TCM and to present new ideas to promote an understanding of basic concepts on TCM, and its practice using Chinese medicine.

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Chinese and botanical medicines

From ancient times, TCM has gained support continuing from its traditional base, surviving historical events in China, and has now become mainstream medicine in modern China. First, it should be emphasized that in modern China, TCM is not the realm of private enthusiasts, spiritual advisors, or folk healers. It has been institutionalized and incorporated into China’s State medical system, given full backing in the universities, and administered by the State. Historical note: In the nineteenth century, coinciding with China’s growing unease of its place in the world, especially feeling humiliated over the Opium Wars and threatened on all sides, the country struggled for a path forward. By the 1920s, the Nationalist government took great interest in public health for China’s revival. There was a need to organize and regulate doctors, but by this time traditional and Western doctors had formed separate medical associations. In 1929, there were efforts ongoing to abolish TCM. However, a nationwide strike over the closure of pharmacies and clinics across the country resulted in the formation of two separate and parallel government institutions for doctors: one “Chinese” and the other “Western.” In 1935, a resolution was passed demanding “equal treatment for Western and Chinese medicine.” The political needs of the early People’s Republic required TCM as part of health care. Even with the events of the Cultural Revolution, TCM organizations remained virtually intact. By 2012, TCM institutes and companies received an extra $1 billion in government money, over and above the regular budget. Indeed, TCM is a $60 billion industry in mainland China and Hong Kong. Almost every major Chinese city has a TCM hospital and university. During the period between the eighteenth and nineteenth centuries, in the developing history of modern Western medicine, three important aspects have revolutionized the science: (a) germ theory, (b) anesthesia, and (c) public sanitation. It was inevitable that the gulf between the medicine in the West and that in China would widen. Eventually, with elements of misunderstandings, mistrust,

Chapter one: Background and content

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and lack of quality parameters, skepticism began to take hold. As an example, Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, has been critical and stated that the most fundamental problem is that TCM researchers use science not to test but to prove their assumptions. Strictly speaking, this amounts to an abuse of science. It introduces bias on all levels and to such a degree that it is often impossible to identify based on the published research. However, two important aspects cannot be overlooked. First, although botanicals or herbal medicines have been in use for thousands of years, more recently, the use of botanicals and natural products as therapeutic agents has gained popularity and has expanded globally. These botanical medicines and herbs have long been used in primary health care of underdeveloped countries. They continue to be their major source of medicines and are gaining an ever-wider acceptance in developed countries as many health issues associated with the modern living style cannot be treated effectively with conventional medicine. Examples include preparations and formulae of TCM, Ayurvedic medicine, Kampo medicine, African traditional medicinal plants, and American Indian traditional medicine. Furthermore, botanicals are also the source of many conventional drugs now used in the West as pharmaceutical medicines. A second point of importance is that, over the past several decades, both the scientific and popular literature reflect an increased interest in natural products by the public, which has helped fuel a greater scientific awareness of botanical medicines and natural product drugs. Increased migrations of people to various countries have been accompanied by the movement of their respective traditional medicines. We are witnessing greater use of Western medicine in developing countries, and a counterflow of traditional medicines, for example, from China, India, and other ASEAN countries. This renewed use of traditional herbal medicines has also contributed to a resurgence of interest, particularly in the United States and Europe; including a demand for more evidence-based information. The longtime use of these herbal remedies suggests that there exists some measure of pharmaceutical activity. This fact has raised

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an urgent need to promote the scientific inquiry on the study and use of botanicals, natural products, and Chinese Medicine to secure a global understanding and acceptance. More science is needed to better understand and gain acceptance of these preparations and formulae within the scientific and international communities. Despite the worldwide efforts in the past century, the scientific inquiry of botanicals remains a very challenging task. Botanicals usually contain complex chemical mixtures and their interaction in the human body may be much more complicated to follow than a single entity drug. Although outside the scope of this book, it should be recognized that the reductionist approach—to isolate compounds and evaluate their individual activities—has not been sufficient to fully elucidate the biological interactions of the botanicals in the body. The recent advances in systems biology, metabolomics, and chemometrics offer new technological platforms to study complex mixtures and to evaluate corresponding biological responses more effectively. These approaches are holistic, more integrated, and may provide a new tool to advance our understanding of the complex actions of botanicals and natural products in our body at an unprecedented level.

Book contents TCM is gaining a lot of interest among physicians, scientists, and consumers both in Asia and in the West. It is a complex subject, requiring significant understanding of the theory and practice of a medicine not well understood outside China and certainly not in the West. In our current role as university teachers presenting an introductory course in this field, we note that there is no satisfactory textbook that is readily available for such a course, and with this book we hope to fill a void. Second, we believe the timing of publication of this book is important as both the industry and regulatory authorities in China, Hong Kong, and elsewhere seek better and harmonized approaches to maintain safety and the highest standards of botanical preparations. There are opportunities for harmonizing standards, adapting the latest research methodologies including “omics” and spectroscopic tools, now in use, to evaluate the actions of botanicals and natural products for the development of better remedies. Yet without a well-founded understanding of the principles of TCM, it is hard to see how these modern applications will be successfully

Chapter one: Background and content

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applied to strategies that provide scientific data and could substantiate the health claims to support a wider acceptance of TCM. This book will be useful also for teaching a similar course in the United States and other Western countries. As a scientific text and written in English, it most certainly will be of significant interest in China and in many ASEAN countries where TCM is popular. We make note of this fact, as currently, although there are other TCM books available, many are either written in Chinese, or are quite complex and are not considered as “student friendly.” In some cases, they are presented with the political aim of “selling TCM” theory, rather than a balanced and sensible approach to recognize that there are two different but important systems (TCM and Western), and much can be learned and adopted from both. We try to offer a balanced view of the science and recognize that not all aspects are well understood. In fact, where necessary, we offer a critique of some of the current challenges and failings in Chinese Medicine. The chapters outlined in this book attempt to provide a broad introduction to the science and philosophy in the development and use of TCM. The intent is to give an overview of the principles, methods, and development of TCM, and the modern applications as an alternative to Western medicine for medical care and health protection. This first chapter presents a basic understanding on traditional principles of TCM. For the development and modern application of TCM, the transformation of traditional wisdom into evidence-based use is described using selected TCM formulas, with a description of the concepts and clinical practice in TCM. Later chapters cover the beneficial uses of the herbs: efficacy, quality, safety, and regulatory aspects have been integrated into this part. Specifically, we cover the following: 1. An overview and an introduction to some of the principles, methods, and development of TCM. 2. A discussion on the consideration of the modern application of TCM as an alternative to Western medicine for medical care and health protection. 3. An introduction to some of the scientific methods for collecting data and supporting evidence for the efficacy and safety of a drug. 4. A reflection on the different views on health, disease, and therapy and their impacts on the relationship between man and nature.

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5. A discussion on the current trends in the improvement and modernization of TCM. 6. Methodology of TCM: diagnosis and treatment. Finally, we add a note on style and nomenclature. All the Latin plant names are presented in italics (see Table 2.3). We use italics for Chinese words and phrases and names of formulas phrases, quotation marks for any English words needing explanation, and we provide a glossary to describe and define any uncommon words or phrases.

Further suggested reading Adams JD, Lien EJ. 2013. Traditional Chinese Medicine: Scientific Basis for Its Use. RSC Publishing, Cambridge. Briggs, J. 2013. Perspectives on complementary and alternative medicine research. The Journal of the American Medical Association 310(7): 691–692. Cooper R, Deakin JJ. 2016. Botanical Miracles: Chemistry of Plants That Changed the World. CRC Press, Boca Raton, FL. Cutler SJ, Cutler HG. 2000. Biologically Active Natural Products: Pharmaceuticals. CRC Press, Boca Raton, FL. Kaptchuk TK. 2000. The Web That Has No Weaver: Understanding Chinese Medicine. 2nd Ed. McGraw-Hill, Chicago. Kayne SB. 2010. Traditional Medicine. Pharmaceutical Press, London. Leung PC, Fong H, Xue C (Eds.). 2006. Current review of Chinese medicine: Quality control of herbs and herbal materials. In: Annals of Traditional Chinese Medicine, Vol. 2. World Scientific Press, Singapore. Luo G, Wang Y, Liang Q, Liu Q. 2012. Systems Biology for Traditional Chinese Medicine. Wiley, Hoboken. McNamara S, Song XK. 1995. Traditional Chinese Medicine. Hamish Hamilton, London. Scheid V. 2002. Chinese Medicine in Contemporary China: Plurality and Synthesis. Duke University Press, Durham, NC. The Art and Science of Traditional Medicine Part 1. 2014. TCM today—A case for integration. Science 346(6216): 1569. The Art and Science of Traditional Medicine Part 2. 2015. Multidisciplinary approaches for studying traditional medicine. Science 347(6219): 337. The Art and Science of Traditional Medicine Part 3. 2015. The global impact of traditional medicine. Science 350(6262): 871. Wang ZG, Chen P, Xie PP. 1999. History and Development of Traditional Chinese Medicine. Science Press, Beijing. Yuan C-S. 2011. Traditional Chinese Medicine. CRC Press, Boca Raton, FL.

chapter two

The beginning of TCM in China and TCM herbalism Chinese medicine, with a span of 5000 years, forms an integral part of Chinese culture. It is derived from the experiences of generations of human experimentation. The beginnings of TCM date back to time immemorial, long before written records appeared. This medical and medicinal knowledge has evolved out of the necessity of our ancestors to fight against illnesses and to maintain good health. During the struggle against ailments and injuries, and through trial and error, mankind came to realize the therapeutic benefits of using herbs and other natural resources (such as minerals, animals, and stone needles) to cure diseases and to stay healthy. Future generations kept on updating the knowledge and retained the best strategies for use. Owing to prolonged experiential learning, many ailments were treated using the appropriate herbal preparations of one kind or another. Over time, various medical modalities were developed, such as acupuncture, moxibustion, herbalism, and physical exercise (see Chapter 3). Of these, herbalism remains the centerpiece of the Chinese medical system.

Classical TCM herbal literature The medical knowledge of TCM not only was passed down through the generations by word of mouth, but also through written records. Chinese medicine, as the oldest continuous surviving medical tradition in the world, is supported by large volumes of well-preserved literature, (see Chinese bibliography on page 141). Archaeological discoveries show that early Chinese characters described human illnesses and were inscribed on tortoise shells, ox bones, and stones, which appeared as far back as 3000 years ago. The vast volumes of medicinal literature are collectively known in China as Bencao (formerly spelled as Pen T’sao), equivalent to the encyclopedic compendium or pharmacopoeia nowadays. It is 7

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a special format of medicinal literature that focuses on the use and other relevant aspects of pharmaceuticals of the time. They evolved from the dawn of TCM and have followed an uninterrupted course of expansion and revision up to the early 1900s, spanning over 2000 years. Up until the turn of the nineteenth century, there were about 30 major published works of Bencao literature. Today, Bencao studies are largely replaced by scientific studies in medicinal botany, pharmacognosy, ethnopharmacology, and other related disciplines. The oldest complete written work of medicinal knowledge can be traced to the period of 200–300 B.C. The most seminal and authoritative medical text is the Shen-Nong Materia Medica (ShenNong Bencaojing), which describes the usage of 365 kinds of drugs, of which 252 are of plant origin, 67 of animal origin, and 46 of mineral origin. Shen-Nong (the “Divine Ploughman”) is a mythical figure who allegedly imparted his knowledge in agriculture to the early farmers and tasted hundreds of herbs himself to determine their medicinal properties and therapeutic applications. Such a trial-anderror exercise is considered an experimental model of clinical trial in the ancient era. The book was the first pharmacopoeia which described selected natural materials with medicinal properties and was useful for treating illnesses. Furthermore, Shen-Nong tasted 100 of these herbs and allegedly identified and classified 70 plants as poisons in a day. In a depiction of this classification, there is a depiction of the “Medicinal Beast” (Figure 2.1) who tastes the herbs for the ShenNong Materia Medica. The beast is shown with a transparent belly, indicating the herbal action in the body and those meridians which the herbs affect. The 365 materials described in the Shen-Nong Materia Medica are divided into three parts (Table 2.1). Part 1 embraces 120 drugs of the “Upper Class,” each of which is harmless to humans and recommended for use in preventing ailments and maintaining good health. Many of them are considered to be tonifying substances. Part 2 includes 120 entries of drugs of the “Middle Class,” which possess therapeutic properties, but will cause undesirable side effects if used inappropriately. They are therapeutic agents. Part 3, the “Lower Class,” includes 125 kinds of drugs that possess strong or violent pharmacological properties; they should be used with great care to avoid intoxication. Materials and herbs in this category will cause strong reactions and have only narrow therapeutic

Chapter two: The beginning of TCM in China and TCM herbalism

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Figure 2.1 Shen-Nong, the Farmer God, tasting herbs to discover their qualities. (Li Ung Bing, Outline of Chinese History, Shanghai 1914.) Table 2.1 Classification of medicinal materials in the Shen-Nong Materia Medica Upper-class drugs • 120 kinds of “noble” drugs • For nourishment and longevity • Nontoxic • For prolonged use without harm Middle-class drugs • 120 kinds of “minister” drugs • For treating diseases • May or may not be toxic • Must be used in an appropriate manner • For combating ailments and replenishing deficiency, and exhaustion Lower-class drugs • 125 kinds of “inferior” drugs • Toxic • Not for prolonged use • For eliminating coldness, heat, or evils from the body

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windows. Clearly, Shen-Nong Materia Medica is one of the world’s earliest written records of natural history and medicinal knowledge to provide crucial perspectives on herbal application and safety. The classification system adopted in this work is primitive yet practical. Most impressively, it reflects the early concepts of therapy and toxicity of mankind. The Shen-Nong Materia Medica serves as the prototype of all Bencao versions to follow. The first official pharmacopoeia of TCM appeared during the Tang Dynasty (ca. 659 AD) and is known as “Tang Bencao.” For the very first time, plants were classified based on their natural appearance and resemblance to one another. Thus, 850 types of medicinal materials were categorized into six classes: stones (minerals), herbs, animals, fruits, vegetables, and cereals (Figures 2.2 and 2.3).

Figure 2.2 A page from the Shen-Nong Bencaojing.


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Figure 2.3 A page from Bencao Gangmu, showing both the text and pictures of herbs.

By 1590 AD (in the Ming Dynasty), the number of Chinese medicinal materials increased to 1,898, as recorded in Li Shizhen’s “Bencao Gang-Mu” (Compendium of Materia Medica). The physician and herbalist Li gave a comprehensive account of the morphology, ethnopharmacology, and applications of natural drugs (largely herbs, with some animal parts and minerals). His work marked the climax of the development of premodern Chinese pharmaceutical knowledge and it became an icon in Chinese herbalism. In 2011, Bencao Gang-Mu received global recognition when it was registered in United Nations Educational, Scientific and Cultural Organization (UNESCO)’s Memory of the World Register. In Li’s work, herbal drugs are systematically classified into different categories, which are closer to the more modern ideas of classification. Thus, TCM materials are classified into groups (Gang), namely, grass, cereal, vegetables, fruits, and trees (Table 2.2). Under each Gang, there are further subclassifications into subgroups

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Chinese and botanical medicines Table 2.2 Classification of medicinal herbs in the Compendium of Materia Medica Materia medica (medicinal materials)

Minerals

Plants

Water Fire Soil Metals

Glasses Cereals Vegetables Fruits Trees

Animals

Others

Small animals Scaled animals Shelled animals Birds Other animals Humans

Hillside grasses Fragrant grasses Wetland grasses Poisonous grasses Creepers Aquatic grasses Grasses between rocks Bryophyte Weeds

Clothing and utensils

Turtle/Tortoise shellfish

16 Categories (“Gang”)

60 subcategories (“Mu”)

called Mu. For example, under the class of grasses, there are hillside grasses, fragrant grasses, wetland grasses, poisonous grasses, creepers, aquatic grasses, grasses growing on rocks, bryophytes, and weeds. In this manner, all medicinal plants are classified into groups, in accord with their growing habitat, morphological features, or organoleptic and pharmacological properties.

Botanical classification of TCM herbs As described above, the botanical classification system in TCM was largely and artificially based on general features of the plant, such as gross morphology, growing habitat, and organoleptic properties, as presented in the Bancao literature. The modern system of plant taxonomy (classification of plants) was not developed until 1892, when Adolf Engler published a plant classification system, subsequently known as the Engler system. Since then, there have been modifications of the Engler system and other systems emphasizing on a phylogenetic relationship, such as the Cronquist system (1981) and the Angiosperm Phylogeny Group (APG III) system (2009). Nowadays, TCM plants are scientifically classified in accord with these taxonomic groups and every plant is identified


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Table 2.3 The binomial system of botanical nomenclature A scientific name of a plant is a formal system of naming plant species. It is referred to as the Binomial system (the "two-name system), in which each plant name consists of a genus name and a species name, using Latin. The first part of the name identifies the genus to which the species belong; the second part identifies the species within the genus. In some cases, an infra-specific name (subspecies or variety) is included to become a ternary name. The binomial name is followed by the authority name, which is the name of the person who gave the name to the plant. Author's name may be abbreviated. Example of the Binomial system of botanical nomenclature: Panax ginseng C.A. Mey.

Genus name

Species name

Author name

First letter capitalized ltalized or underlined

First letter not capitalized ltalized or underlined

Abbreviated for Carl Anton van Meyer Non-italized

using a scientific name. An example of botanical nomenclature is illustrated in Table 2.3 and all plants are described with a Latin name. Medicinal plants may sometimes be identified by their common or vernacular names (Table 2.4). For example, Glycyrrhiza glabra is commonly known as licorice, and Panax ginseng as ginseng. However, common names are not universally recognized and can lead to confusion, because they are not unique. In fact, the use of common names is inadequate, as the same plant may have more than one common name, and a common name may refer to more than one plant species. Star anise, for example, is not only the common name for the star-shaped pericarp of the fruit of Illicium verum (the Chinese star anise), which is a common spice as well as a TCM material with little known toxicity, but also refers to the fruit of a closely related plant species growing in Japan, Illicium anisatum (sometimes known as Japanese star anise) and both plants are shown in Figure 2.4. The Japanese species of star anise contains potentially toxic ingredients such as anisatin (Figure 2.5) and the related compound, shikimin, which cause severe inflammation of the kidney, urinary tract, and digestive organs. Although the two kinds of

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Chinese and botanical medicines Table 2.4 Examples of the common names of medicinal herbs Licorice European and Middle Eastern licorice Chinese licorice

Glycyrrhiza glabra Glycyrrhiza uralensis or G. inflata

Ginseng American ginseng Brazilian ginseng Chinese and Korean ginseng Indian ginseng Japanese ginseng Peruvian ginseng Sanqi ginseng Siberian ginseng

Panax quinquefolius Pfaffia paniculata Panax ginseng Withania somnifera Panax japonicus Lepidium meyenii Panax notoginseng Eleutherococcus senticosus

Mistletoe American mistletoe European mistletoe

Phoradendron leucarpum Viscum album

star anise look alike, Japanese star anise is not edible due to the presence of toxic chemical compounds. To avoid confusion between the two species and to minimize the chance of intoxication, they must therefore be properly identified by their scientific names (see also Chapter 7).

Figure 2.4 Star anise, left, Illicium verum and the Japanese star anise, Illicium anisatum, right.

Chapter two: The beginning of TCM in China and TCM herbalism H

O

15

H

O O H

O

O

O O

H

O H

Figure 2.5 Chemical structure of anisatin.

Identification of medicinal plants It is indisputable that in support of any herbal medicinal preparation, there must be evidence of quality, safety, and effectiveness. It is essential to start with the proper identification of the chosen plant. The process is often referred to as botanical authentication. Plant identification is not a trivial matter; it requires skillful application of a combination of techniques. Until recent years, plants have been identified mainly through organoleptic and macroscopic examinations. The organoleptic approach refers to the examination of aroma, taste, and appearance of a plant; and macroscopic examination involves the observation of morphological features such as the shape, size, color, texture, and arrangement of fruits, flowers, and vegetable parts (leaves and roots). The information so obtained is compared with herbarium reference specimens and monographs to establish the identity. Botanical authentication of plants often includes microscopic examination of the cross-sectional views of plant parts under a light microscope or an electron microscope, to characterize the plant tissues and the presence of specific structures such as hair, oil gland, vascular bundle, starch grain, crystal, and pollen. In addition to the morphological approaches, during the past 20 years or so, technologies for the molecular analysis of plant cells, such as DNA fingerprinting, sequencing, and barcoding techniques, have become available, and they have been successfully

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applied to examine the plant taxonomic relationship. DNA databases are available for more accurate botanical identification at the molecular level.

Medicinal botany The discipline of medicinal botany deals with the understanding of how plants and plant products are used in medicine. It is intimately related to traditional medicinal systems. The discipline documents, preserves, and studies plant species, which affect human health, embracing studies on the morphology, classification, pharmacology, cultivation, history, and sustainable development, etc. of medicinal plants. The medicinal property of a plant can vary depending on a series of intrinsic and extrinsic factors such as genetic influence, organ specificity, seasonal variation, and growing conditions (soil, light, water, and nutrient supply). Typically, plants consist of vegetative organs (roots, stems, and leaves) with flowers, fruits, and seeds in the reproductive cycle. Chemical biosynthesis normally starts from the leaves where photosynthesis takes place, and the products are transported to other parts of the plant, where further biotransformation may occur to produce other compounds. Accumulation and storage of these chemical compounds then take place in specific organs. Consequently, the chemical composition of each organ (plant part) within the same plant can differ from one another. Through clinical experience, certain specific plant parts were selected for medicinal use, even though the identities of active ingredients remain unknown. Owing to the plant organ specificity, only certain plant part(s) of a medicinal plant should be used. Herbal drugs may therefore be classified into morphological groups such as barks, roots, leaves, seeds, etc. as described in Table 2.5. In some cases, substances derived from plant tissues are used as well. They are the “unorganized” materials such as fixed oils, volatile oils, resins, and latex. Seasonal variation is another factor that affects the chemical content including the medicinal properties of plants. Biosynthesis and degradation of chemical compounds within a plant is a dynamic process that occurs at different rates during various seasons (the growing stages). The best collection time of a medicinal plant is, in principle, the time when maximum chemical accumulation occurs.


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Table 2.5 Examples of TCM derived from different plant parts Organized drugs Above-ground parts

Stem/branch/vine Stem bark Wood Leaf Flower/inflorescence

Fruit Seed Root

Root bark Rhizome

Ephedra sinica (ephedra); Artemisia annua (Sweet wormwood herb); Mentha haplocalyx (peppermint) Cinnamomum cassia (cassia twig); Uncaria rhynchophylla Cinnamomum cassia (cinnamon); Eucommia ulmoides Santalum album (sandalwood); Caesalpinia sappan (sappan wood) Ginkgo biloba (ginkgo); Cassia angustifolia (senna) Datura metal (Datura flower); Lonicera japonica (honeysuckle flower) Illicium vernum (star anise); Ziziphus jujube (Chinese date) Nelumbo nucifera (lotus seed); Myristica fragrans (nutmeg) Panax ginseng (ginseng); Rheum palmatum (rhubarb); Angelica sinensis (Chinese angelica) Paeonia suffructicosa (peony bark) Zingiber officinale (ginger); Dioscorea opposite (yam)

Unorganized drugs Fixed oil Volatile oil Resin/oleoresin Dried juice Latex

Castor oil; linseed oil Menthol oil; cinnamon oil Myrrh; frankincense; turpentine Aloe Opium

TCM preparations The most common method of applying herb therapies in TCM is to make a tea or soup by simmering or boiling the herbal materials in water for a specific period. The concentrated extract is sometimes called a decoction, which is often a dark-brown colored liquid with

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a strong aromatic smell and may often possess a bitter taste. From a chemical point of view, it is nothing but a hot aqueous extract of the plant materials containing a complex mixture of chemical ingredients. Such herbal decoctions are taken orally. Other traditional forms of TCM preparation include honeybased tablets, powder, given orally, tincture, which can be used either internally or externally (for the treatment of soft tissue injuries), and poultices, used solely for topical applications to relieve muscular soreness and dermal inflammation. Other than the traditional preparations, modern pharmaceutical formulations have been developed for TCM and they have become more acceptable to the patients. The two popular forms to replace the traditional preparations are extract powders (or granules) and easy-to-swallow tablets or capsules. The plant materials are first extracted, followed by the removal of excessive solvent (e.g., water), and dried to a powder or tiny pellets; the resulting material can be further processed to make water-soluble granules, which are taken with water or redissolved in hot water to make a tea. Tablets and capsules may contain either powdered herbs or dried extracts or a combination of the two.

Internationalization of TCM The development of TCM did not happen in complete isolation. It spread outward from China as contacts developed with neighboring countries. Buddhist monks were mostly responsible for the transmission of medical knowledge to other places. Historical note: The period between the seventh and ninth centuries AD witnessed frequent contacts between China and Japan, Korea, and Vietnam, as well as an interchange of medical knowledge with India and the Arabic world along the Silk Route. Consequently, medical knowledge was introduced to, and from, West Asia and medical doctors were sent from China to Korea and Japan. There was also frequent trading of medicinal herbs with these countries. While the countries to which TCM reached often already had their own indigenous medical


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system, they were heavily influenced and enriched by such contacts. For example, both the Japanese Kampo medicine system and the Korean Hangul medicine system are founded on TCM theories. While there have been connections between China and the West over many centuries, TCM contact with the West was not appreciable until the late sixteenth century with the arrival of the Jesuits and other missionaries, who introduced Western medical books and practice to China. By the late 1600s, acupuncture was already known in Europe.

We noted earlier that in the Western world, TCM experienced an expansion during the nineteenth and twentieth centuries, but its strong influence on the West can be considered more recent with the advent of global interest in complementary and alternative medicine and natural products. Acupuncture and herbal remedies have gained much attention and wider applications as part of integrative health. Increasingly, patients turn to the use of nonWestern traditional healing modalities, particularly when modern medicine fails to offer adequate and satisfactory solutions, for example, in areas of allergy, immune disorders, chronic pain, and cancers. Furthermore, people in modern society are becoming more aware and concerned about their wellness and quality of life. To this end, TCM offers health benefits such as better selfdefense against, and thus, prevention of, diseases. Hence, the past 40 years have witnessed a global boom in the “health-food” market. Today, many products are offered as nutraceuticals, functional foods, dietary supplements, or medical foods, particularly in the Western countries, and many of them are herb-based. Among those herbal products, TCM herbs serve as an important source material. Indeed, many claims of these health-food products are made based on Chinese medicine theories, such as the energyenhancing effect of ginseng root (Panax ginseng), blood-nourishing function of angelica root (Angelica sinensis), and the general healthpromoting action of Astragalus root (Astragalus membranaceus) shown in Figure 2.6.

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Figure 2.6 Astragalus membranaceus plant and root (Astragali Radix).

Further suggested reading Bliss B. 1980. Chinese Medicinal Herbs. Georgetown Press, San Francisco, California. Curran J. 2008. The yellow emperor’s classic of medicine. British Medical Journal 336: 777. Unschuld PU. 2000. Medicine in China: A History of Pharmaceutics. University of California Press, Oakland, California. Wilms S. 2016. Shen Nong Bencao Jing: the Divine Farmer’s Classic of Materia Medica. Happy Goat Productions, Corbett, Oregon.

chapter three

TCM theory and practice Introduction No matter how healthy we think we may be, we almost certainly have caught a cold at least once or twice in a lifetime. Have you ever thought of why you caught a cold? Have you ever experienced a time when you took the same medication for cold as did your brother or sister? They recovered but you did not for a very long time. Why do some people always feel hot and thirsty even in cold weather and others do not? When we are sick, even if we may choose to consult a Chinese medicine doctor, many of us believe that Chinese medicine is nonscientific and practiced solely based on experience. Chinese medicine uses a means to diagnose and treat patients without any use of extra physiological and pharmacological tools and is a completely different approach to Western medicine. In this chapter, some of the underlying concepts related to diagnosis of Chinese medicine are explored.

What is Chinese medicine? Chinese medicine has a long medical practice for over 5000 years, influenced by ancient philosophical thinking including monism of qi, yin, and yang and the five elements, which are discussed below. Life, in the philosophy of Chinese medicine is of material, a unity of opposites of yin and yang, and as an endlessly developmental and changeable process. There is also a belief that illness can be both prevented and treated.

Initiation of a theoretical system of Chinese medicine There are four well-known medical classics that have had a strong influence on the development of Chinese medicine up to the

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present day and possibly for the near future. Details are presented in Chapter 2, and only a summary is offered here. 1. Huangdi’s inner classic of medicine This book is believed to be the earliest medical classic in history and was written by many medical experts. It expounds the regularity of life and the integrity of man with his external surroundings. The human morphological structure is described together with its physiology, pathology as well as diagnosis, prevention, and treatment of diseases. 2. Classic texts on medical problems This is also named as Eighty-One Medical Problems. As its name suggests, this book adopts the question-and-answer model to illustrate the contents of viscera, meridians, pulse lore, pathology, and acupuncture technique. Many questions are further elaborated and the theories, which were written in Huangdi’s Inner Classic of Medicine, are expanded. 3. Treatise on cold pathogenic and miscellaneous disease Written by Zhang Zhongjing at the end of the Han Dynasty (206 BC–220 AD), this treatise is divided into two parts with one focusing on cold pathogenic diseases and the other describing many internal diseases. It is a summary of the past success in the prevention and treatment of diseases by practitioners before the time of the Han Dynasty. Zhang invented the 6-meridian syndrome differentiation and viscera syndrome differentiation for diagnosing and treating patients, which has since been widely used up until modern times. 4. Shen-Nong’s classic of medical herbs In this earliest monograph of Materia Medica existing in China, 365 kinds of medicinal materials were recorded and divided into three different grades. The upper grades, named as “heaven,” are medicinal and mainly used to strengthen physical health; the middle grades, named as “man,” are also medicinal and are used to treat mental health; and the lower grade is medicinal, used for treating diseases, which corresponds to “earth.”

Traditional categorization The traditional categorizations and classifications, which can still be found today, are generalized into pharmaceutical theories in

Chapter three: TCM theory and practice

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the form of the four natures (hot, warmth, coolness, and cold); hot and warm herbs are used to treat cold diseases, while cool and cold herbs are used to treat heat diseases. Then there are the neutral and the five flavors in herbs (sourness, bitterness, sweetness, pungency, and saltiness). Substances may also have more than one flavor, or none (i.e., a “bland” flavor). Each of the five flavors corresponds to one of the zàng organs (known as a meridian), which in turn corresponds to one of the five phases. A flavor implies certain properties and therapeutic actions of a substance; for example, saltiness drains downward and softens hard masses, while sweetness is supplementing, harmonizing, and moistening. In the classification, which is in accord with the zàng organ (including its associated meridian), it is expected to be primarily affected by a given medicinal herb. There is a categorization which is in accord with a specific function. These categories are grouped as follows: 1. Exterior-releasing or exterior-resolving, heat-clearing, downward-draining or precipitating. Then there are categories related to “damp.” These include wind-damp-dispelling, dampness-transforming, promoting the movement of water and percolating dampness. 2. qi-Regulating or qi-rectifying; dispersing food accumulation or food-dispersing. 3. Stopping bleeding or “quickening” the blood and dispelling stasis. 4. Transforming phlegm, stopping coughing and calming, wheezing and suppressing coughing and panting. 5. Calming the liver and expelling wind.

Cardinal characteristics of Chinese medicine Two basic concepts of Chinese medicine are its holistic approaches and treatments based on syndrome differentiation. Within the concept of holism, first, the human body is regarded as an organic whole, which is structurally inseparable, functionally coordinative, and interactive and pathologically inter-influencing. The human body comprises of five Zang viscera and six Fu viscera, as shown in Figure 3.1.

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Sea of marrow (brain)

Throat Vertebral column

Pharynx Lungs Pericardium Heart

Heart vessels to various organ systems

Diaphragm Spleen

Liver

Stomach

Gall bladder

Pylorus Kidney

Small intestine Appendix Large intestine Bladder Rectum Urinary orifice

Anus Vital gate

Spermatic vessel

Figure 3.1 The human body as an organic whole indicating the five Zang viscera, six Fu viscera, supported by the essence, qi, blood, body fluids, connected by Meridians, and restricted by synergistic actions. (Reproduced with permission from https://clinic-tcm.com/.)


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The body is supported by an essence, known as qi, related to blood and body fluids, which are connected by meridians and restricted by synergistic actions. Chinese medicine emphasizes the coexistence, interdependence, and interconnection between the body and the mind. Hence, forces of nature may affect the functions of viscera, for example, the weather, environment, altitude, day, and night. The human energy level is seen to change from day to night and when our energy level is running at a low level, we feel tired.

Yin and yang theory and application to Chinese medicine All things and phenomena may be generalized as two opposite sides of yin and yang, as there is an intrinsic interaction between yin and yang. Thus, the beginning, the developing, and the changing of all natural things are consequences of the movements of yin and yang. YIN refers to things that bear the properties of being static, internal, descending, cold, dim, visible, and organic. YANG generally refers to things that bear the properties of being active, external, ascending, warm, bright, invisible, and functional From a Chinese medicinal point of view, anything with the f unction that can regenerate, warm, or excite can be classified with a yang feature; whereas yin refers to things with the function to condense, moisturize, control in the body and thus, is classified with a yin feature.

Characteristics of yin and yang There is opposition and interdependence of yin and yang, meaning there exists contrary attributes of two opposite aspects in all kinds of things and phenomena in nature (Figure 3.2). For example: day and night/warm and cold/rising and descending. Interdependence indicates the existence of its counterpart as the prerequisite for the existence of its own and no one part can exist without its counterparts. Thus, these features are inseparable with restriction

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Chinese and botanical medicines Yin (black) and Yang (white) are apparently opposite and contrary elements They are complementary to each other and bound together to form a mutual whole (the circle)

Yang Yin

They are interconnected They are interdependent They interact dynamically They give rise to each other as they interrelate

Figure 3.2 A simple expression of the yin–yang relationship.

characteristics, such that yin cannot generate without yang and vice versa. In the event that the body has too much yang, there is a cooling effect, whereas too much yin results in a warming effect. A wellknown example might be the use of ginger in cold weather to warm up the body.

Wax and wane and transformation of yin–yang We define wane to mean decrease; wax means increase. These two characteristics are acting in two different ways: one wanes while the other waxes; one waxes while the other wanes or one wanes and the other also wanes; one waxes and the other also waxes.

Summary of application of yin–yang theory in Chinese medicine Yin and yang summarize the property and acting tendency of each medicinal herb and therefore are an extremely important guide to the treatments. The aim is to establish sound yin and firm yang to achieve a healthy body and mind (Table 3.1).

The five elements We now turn our attention to the theory of the Five Elements (Table 3.2). These are represented in the following way: Wood: bends and strengthens Fire: burns and flares up Earth: provides for sowing and reaping


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Table 3.1 Summary of the basic concepts related to Yin and Yang Yin

Yang

Natures Cold, cool

Warm, hot

Flavors Sour, bitter, salty

Acrid, sweet

Acting tendency Descending, sinking

Ascending, floating

Table 3.2 Relationship of the five elements to the five major visceral organs Five Elements

Wood

Fire

Earth

Metal

Water

5 Zang viscera

Liver

Heart

Spleen

Lung

Kidney

6 Fu viscera

Gall Bladder

Small intestines

Stomach

Large Intestines

Urinary bladder

5 Constituents

Tendon

Vessel

Muscle

Skin

Bones

5 Brilliances

Nail

Face

Lips

Fine hairs

Hair

5 sense organs

Eye

Tongue

Mouth

Nose

Ear

7 Emotions

Anger

Joy

Thought

Sorrow

Fear

Metal: works for change Water: Moistens and flows downward In ancient times, people depended on the availability of five indispensable substances (the five elements): earth, wood, fire, metal, and water. Each of these substances is seen not only to possess unique characteristic properties, but also to have an active and

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Wood liver

Fire heart

Water kidney

Metal lung

Promation (Generation)

Earth spleen

Restrain (Inhibition)

Figure 3.3 Dynamic relationships among the five elements and the major visceral organs.

dynamic relationship with each other. They constantly interact with each other in either a promoting or restraining manner (Figure 3.3). The doctrine of the five elements thus describes two cycles: a promoting cycle, and a restraining cycle, of interactions between the elements. Within Chinese medicine, the effects of these two main relations are further elaborated to explain how different parts of the body work and how diseases are formed. The concept is further extended to guide the selection of the treatment strategy. For example, the five major visceral organs (i.e., heart, liver, spleen, lung, and kidney) are mapped onto the five elements with the notion that the former interplays with each other in the same manner as the latter. Furthermore, these five visceral organs possess properties which exhibit similarity to one of the five elements, and therefore there are correlations between the functions of the five visceral organs. Thus, the attributes of one element can


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be established: the kidney corresponds to the element of water because it regulates water metabolism; liver is associated with the element of wood because of its ability to promote the flow of qi (and is similar to the manner that plants flourish during the spring season); and the heart belongs to the element of fire because of its role to circulate the blood to keep the body warm, like fire-producing heat. In clinical terms, the function of the kidney (water) can enhance the function of the liver (wood) just like water can help the growth of trees, and therefore, in order to treat diseases caused by the weakened liver, herbs may be given to nourish and strengthen the kidney functions. On the other hand, in the case where the liver (wood) is exceptionally strong and overacts to restrain the normal functions of the spleen (earth), treatment would focus on either calming (reducing) the liver activity and/or strengthening the spleen function in order to counteract the subduing action of the liver (Figure 3.4). Thus, apart from the control of clinical symptoms, the Chinese medicine regimen often aims at the modification of the functions of internal organs that are not directly involved in pathological changes.

Nature

Human

Heart

Liver Spleen

Lung

Kidney

Figure 3.4 Close relation of the human being with its surroundings in nature.

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The meaning of qi, blood, body fluids, and essence It is accepted that treatment determination is based on syndrome differentiation. To establish the concept of syndrome, it is important to understand the definition of disease, and the signs and symptoms of the disease. 1. Disease is a complete morbid process including cause, mode of onset, typical clinical presentation, development, and outcome. 2. Symptom is a discomfort felt subjectively by the patient, for example, pain, dizziness, nausea, whereas the sign is objectively presented and is to be recognized by doctors and practitioners such as a red tip on the tongue or a rapid pulse. 3. Syndrome is a pathological summary identified at a given stage or the course of the disease and, upon examination by a practitioner, includes: a. The cause of disease (wind and heat) b. Focus of disease (external, internal in a viscus) c. Nature of disease (cold and heat) d. Situation of disease (chronic, acute, severe, mild) e. Relationship between the pathogenic and the vita (deficiency and excess)

Function of qi It is generally considered in TCM that the function of the qi is to propel growth and development. It has a warming effect. The general belief is that blood represents the combination of nutritive qi and the body fluids. Body fluid is a general term for all normal liquids in the body. One definition is that blood = nutritive qi + body fluids. The functions include: nourishing and moistening every part of the body by circulating through the vessels and is the material basis for mental activities.

Therapeutic modalities There are several major therapeutic modalities in Chinese medicine. These include the following: herbology, acupuncture, moxibustion, cupping, exercise therapy, dietary therapy, medical massage and


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manipulation therapy, and bone setting. These modalities are not covered in detail in this book but a summary of the definitions of each one is presented below.

Herbology The term means the use of herbs to treat diseases. In this case, the term “herb” is used in a wider context to include minerals and animal products, which are also used, albeit less frequently, in medicinal prescriptions.

Acupuncture This refers to a technique whereby fine needles are used to puncture the surface of the skin at specific positions known as acupoints along the energy pathways of meridians. Either local or distal effects, or both, can be achieved through the stimulation of qi along the meridian channel. Electro-acupuncture is a modern development in which an electric current is applied to the needles to provide mild electrical stimulation to the acupoint.

Moxibustion This is a therapeutic technique in which a burning stick (the moxa) made from the leaves of Artemisia vulgaris is placed on top of the acupoints to warm the meridians and promote the flow of qi and blood.

Cupping Cupping is a form of therapy in which a cup is placed on the body surface after a negative pressure is created inside the cup by passing a flame into it. Cupping warms the meridians, dispels coldness, and stimulates the flow of qi and blood.

Exercise therapy This therapy may be represented by Tai-Chi and Qi-Gong as common forms of mind–body therapy. The proper control of breath, a peaceful mind, different postures, and body movements are beneficial to promote the flow of qi and blood, calm the spirit, regulate the emotion, and strengthen internal organs.

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Dietary therapy Dietary therapy refers to adding medicinal herbs to the diet to treat acute or chronic disorders. Some medicated diets tonify qi, whereas others supplement yin and yang and nourish blood; yet others may clear heat or warm up the cold conditions of the body.

Medical massage (Tui-Na) and manipulation These techniques are applied to the soft tissues and joins to remove obstructions in the superficial tissues, improve circulation, and relax muscles. In general, pressure is applied to the acupoints along the meridians by a special kneading motion. It has not only a local effect by promoting blood circulation and relaxing muscular stress, but also regulates the function of the meridians and internal organs.

Bone setting This is considered as a special manipulation to correct dislocated joins and bone fracture.

Diagnosis One of the most important steps in the diagnosis of TCM is the tongue examination (Figure 3.5). For a normal tongue, signs to look for include the proper size, whether it is soft in quality and has freedom of motion, and generally whether the tongue is pale red in color, together with a thin layer of white coating which is neither dry nor overly moist. During the examination, the TCM clinician will look for abnormal signs, with an indication being related to zang-fu functions, abundance in qi, blood, and body fluids. Different parts of the tongue correspond to different internal organs (Figure 3.6). The tip of the tongue relates to the heart and lungs; the middle part to the spleen and stomach; the root of the tongue to the kidneys; and both sides of the tongue relate to the liver and gallbladder. Observations will include the presence of vitality, which is indicated if the tongue is healthy: bright red, moist, and moves freely. Conversely, a “wizened” tongue will appear dark, or dull, and moves with difficulty.


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Figure 3.5 Figure showing a normal tongue.

There are various tongue colors: pale red, pale, red, crimson, bluish, and purple indicated below. 1. Pale red tongue The characteristics of a pale red and lustrous tongue are often seen in healthy people. 2. Pale tongue In case the tongue is lighter in color than normal, the clinical significance is usually a deficiency of qi, blood, or yang. This diagnosis is similar to that in appearance of a pale thin tongue and if it is a pale, moist, and puffy tongue, this may suggest a yang deficiency, retention of fluids, deprivation of blood, and qi. 3. Red tongue Characteristic signs are redder than normal or even bright red. The clinical significance is noted by excess heat or internal

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Chinese and botanical medicines Chinese medicine map of the tongue Kidneys and urinary bladder

Stomach and spleen

Liver and gall bladder

Liver and gall bladder

Large and small intestines

Lungs

Heart

Figure 3.6 Different parts of the tongue correspond to different internal organs: the tip of the tongue relates to the heart and lungs; the middle part to the spleen and stomach; the root of the tongue to the kidneys, and both sides of the tongue relate to the liver and gallbladder.

heat from yin deficiency. The tip of the tongue or a slightly red tongue may suggest exterior heat syndrome at an early stage. If both edges of the tongue are red, this means an excess of heat in the liver and the gallbladder. 4. Crimson tongue A characteristic sign is a deep red color. The clinical significance indicates excessive heat or hyperactivity of fire from deficiency of yin. Further developments from the observed red tongue are caused by excessive heat that injures yin and


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condenses blood, or consumption of fluids due to yin deficiency and flaming of asthenic fire. It is a more severe situation than just the red tongue. 5. Blue/purple tongue In this case, the characteristics refer to the whole or part of the tongue being blue or purple or bluish purple. In this situation, the clinical significance indicates an impediment of blood flow. We now turn to the tongue’s characteristics 1. Tough: texture is coarse or crimpled, and the color is dark; may be indicative of an excess syndrome. 2. Delicate: fine texture and the color is light; might indicate a deficiency syndrome often by qi and blood. 3. Size—enlarged/swollen: larger and thicker than normal; indicates the retention of phlegm and fluid. 4. Size—small and thinner than normal: indicative of deficiency of qi and blood and exuberant fire from deficiency of yin. 5. Speckled and prickled: speckled, with red or purple spots on the tongue; and prickled, thornlike protrusions on the tongue’s surface, caused by retention of heat. 6. Cracked tongue: various cracks or fissures with no or very little tongue coating or very little indicating deficiency of blood and injury to body fluids due to exuberant heat or fire. The tongue pattern refers to the movement of the tongue body. In the normal case, the tongue moves flexibly, can freely stick out or draw back, indicating an abundance of qi and blood, normal function of channels, and the zang-fu organs. Two cases of abnormalities are the deviated tongue and the shortened tongue. 1. A deviated tongue In this case, the characteristic observation is that the tongue deviates to one side when extended. The clinical significance is seen in stroke patients or prodrome of apoplexy (see glossary). 2. A shortened tongue Characteristics of this tongue are that the tongue cannot fully extend from the mouth and appears to be contracted. In this

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scenario, the clinical significance is a condition of cold retained in the vessels or deficiency of qi and blood. 3. Coating of the tongue Usually on the tongue there is a light coating seen as a layer of moss-like spreading on the surface of the tongue produced by the upward steaming of stomach qi and upward flow of stomach fluid. In the case of a healthy tongue, the coating is seen as thin, even, white, and exhibits a moderately moist layer. The terms thin or thick reflect the condition of pathogenic factors and healthy qi and the site of the disease. The moist or dry tongue reflects the condition and distribution of body fluids, whereas the greasy or curd-like tongue reflects the condition of yang qi and dampness, indicating phlegm retention, damp existence, and indigestion. In the case of peeled or peel-like coating, this appearance suggests that the stomach qi is not sufficient, stomach yin dries up, and blood and qi are deficient too.

Palpation Palpation is a form of diagnosis made by feeling and tapping local areas of the body. It includes a pulse examination and examination of general palpation of different parts on the body surface (e.g., pressing the skin, hands, feet, chest, abdomen, etc.).

Pulse examination The pulse is differentiated in terms of depth, speed, strength, shape, and rhythm. Different conditions of the pulse indicate different syndromes. In the case of a normal pulse, it is smooth, even, and forceful with a frequency of four beats per breath (∼60/min). There will be variation due to age, sex, body constitution, emotional state, and climatic changes. The younger the person, the faster the pulse (infants 120–140/min), whereas with juveniles, the pulse tends to be stronger and forceful. In general, the elderly patients tend to exhibit a weaker pulse. Women tend to have a weaker but faster pulse than men. People who are slim tend to have a floating pulse, whereas those who are fat tend to have a deep pulse. After drinking/exercise/food/ motion, pulses are quicker and they are weaker when hungry. There are 28 different pulse types. The pulse is considered the “palace” of blood, and it is “governed” by the heart and


37

Figure 3.7 Examination of the pulse, indicating the location of pulses and three positions.

“commanded” by qi. Therefore, the pulse reflects the causes of disease, abnormalities, or pathological changes. Importantly, pulsetaking helps in judging the location and nature of a disease and the prosperity and decline of qi and pathogens to infer prognosis of the disease and form the basis for treatment (Figure 3.7).

Location of pulse One pulse is often known as cunkou and is located at the superficial part of the posterocarpal radial artery. The first three fingers are placed on the cun, guan, and chi regions and there is a correspondence to specific organs. It is generally acknowledged that the three regions of the left hand reflect, respectively, the conditions of the heart, liver, and kidney; and those of the right hand reflect the c onditions of the lung, spleen, and kidney.

An example of a diagnosis There may be two patients who both suffer from a common cold. Patient A has a cold for 2 days, coughs up yellow sputum, has a blocked nose, is running a fever, has a sore throat, feels thirsty, and

38


exhibits a red tip of tongue with yellow fur and a rapid pulse. Patient B has a cold, but coughs out clear sputum, has a runny nose with clear snivel, feels cold but has only a slight fever, no sweating, and exhibits a pale red tongue with white fur and a floating tight pulse. In these two examples, although both patients suffer from cold, their signs and symptoms are different from each other. Patient A has been diagnosed to have exterior heat syndrome and Patient B has exterior cold syndrome. Therefore, the treatment methods for Patient A are to release the exterior with pungent-cool. By contrast, the treatment for Patient B requires release of the exterior with pungent-warm herbal medicines (Figure 3.8). This simple example shows that Chinese medicine demands a doctor or practitioner to view the relationship between disease and syndrome dialectically. Both the diagnosis of a disease and

Cun

Heart

Guan

chi

Kidney

Liver

Left hand

Lung

Cun

Spleen

Guan

Kidney

chi

Right hand

Figure 3.8 Position of the pulses and references to their respective internal organs in the body.


39

differentiation of a syndrome are equally important. While one disease may present several different syndromes, a similar syndrome can exist in various and different types of diseases. Ultimately, it is the treatment of the syndrome that is important to the patient at any one stage. Determining which types of treatments are required is based on the syndrome, including reasoning, methodology, decoction, and medicine. In order to determine a syndrome and make the treatment analysis, the examination is based on syndrome differentiation. Syndrome differentiation requires four examination methods. These are (a) inspection, (b) auscultation and olfaction, (c) inquiry, and (d) palpation. Furthermore, the treatment determination includes reasoning, methodology, decoction, and medicine. There are several diagnostic methods available to the practitioner. One of the most important tests is to examine the tongue, its color, size, and shape and find out whether there are any cracks. The second is palpation to measure the pulse. To understand the symptoms presented by the patient, the practitioner looks at the appearance, listens to the patient’s breathing and voice, and takes note of the smell of the patient.

Further suggested reading Kong YC. 2005. The Cultural Fabric of Chinese Medicine. The Commercial Press, Hong Kong. Maciocia G. 1989. The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncture and Herbalists. Churchill Livingstone, Edinburgh, NY. Ni M. 1995. The Yellow Emperor’s Classic of Medicine: A New Translation of the Neijing Suwen with Commentary. Shambhala, Boston.

chapter four

Traditional Chinese medicinal herbs The Chinese culture has one of the world’s most extensive and elaborate systems of herbal medicines. Over the years, about 10,000 kinds of plants were found to possess medicinal properties, of which about a thousand are used nationwide. Among these medicinal herbs, some 400 kinds are commonly used, and of these, about 200 are considered essential, indispensable items in today’s TCM pharmacy stores. TCM medicinal herbs cover a broad span of over 200 plant families and several thousands of genera, ranging from the thallophytes (algae and fungi), pteridophytes (ferns), and gymnosperms to angiosperms. For each plant, specific plant part(s) is(are) utilized for medicinal purposes, including the underground parts (root and rhizome), bark, stem, leaf, flower, fruit, and seed. Plantderived substances, such as resins, juices, and fermented products, are also used. The term “herbal medicines” is a little misleading in the sense that, while substances originated from herbs are by far the most commonly used in prescriptions, animal and mineral products are also utilized, albeit less frequently. They include mollusks, crustaceans, insects, arachnids, fish, amphibians, reptiles, birds, and mammals of both aquatic and terrestrial habitats. Human body parts and fluids are also mentioned in traditional medicinal literature. Some items can be considered rather strange and unusual, such as pearl, scorpion, cow’s gallstone, bile of bear, rhinoceros horn, seahorse, and human placenta, just to mention a few. Another natural source of Chinese medicinal materials originates from the minerals, including metals and salts of many kinds, such as calcium sulfate, calcium oxide, and potassium aluminum sulfate. Some mineral drugs contain heavy metals such as mercury, arsenic, and lead. They are generally regarded as potentially toxic to humans in accord with modern biomedical knowledge and must be administered and monitored with great care when used. 41

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Herbal drug character and property From the point of view of Chinese medicine, diseases arise due to an imbalance between yin and yang elements in the human body; they are either in excess or in deficiency. For herbal drugs to correct the imbalance and thus reestablish an equilibrium state in the affected organs, they have a propensity to express their effects through their inherent properties. The Chinese herbs are thus classified in accord with their ability to affect any of the functional statuses of the organs (such as reinforcing the yang of the kidney or replenishing the qi of the liver) or to counteract the perceived pathological factors—the “evils”—such as “dispelling excessive coldness from the stomach” or “calming the fire in the heart.” Each herbal drug is characterized by inherent properties that are correlated with their ultimate clinical effects. The two most essential herbal drug properties are the so-called “Natures” and “Tastes.” They constitute the core of Chinese drug properties and serve as guiding principles in the clinical application of herbal drugs. There are four kinds of “natures”: cold, cool, warm, and hot; and five kinds of “tastes”: pungent, sweet, sour, bitter, and salty. a. The “four natures” system The concept of drug nature is evolved out of clinical practice over time by observing the outcome of treatment of diseases. All herbal drugs are characterized as having one of the four “natures,” mainly based on the principles of opposites shown in Figure 4.1. YIN

Cold

Cool

Drugs with cool or cold property usually have such effects as Clearing away heat and toxic substances Removing heat from blood Nourishing Yin Purging fire

YANG

Neutral

Warm

Hot

Drugs with warm or hot property usually have such effects as Warming the interior Dispelling coldness Supporting Yang Replenishing Qi

Figure 4.1 Relationship among the four natures.

Chapter four: Traditional Chinese medicinal herbs

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Thus, drugs that can cure diseases of hot nature or yang excess are of cool or cold nature. Similarly, those that can relieve cold syndromes or yin excess are of warm or hot nature. Thus, herbs with cool or cold nature are often used as febrifuges (a medicine used to reduce fever) to quench the “fire” and remove toxins from the body. On the other hand, drugs of warm or hot nature are useful for treating disorders of internal coldness and reinforcing the yang elements. Following the above principle, the Shen-Nong Materia Medica states, “Cure cold diseases with hot medications; and treat hot diseases with cold medications.” For example, the Chinese/Korean ginseng (Panax ginseng) root, which has a warm nature, is useful to nourish yang function, to dispel coldness, and to warm the body. On the other hand, the American ginseng (Panax quinquefolius) root has a cool nature; it is therefore suitable to nourish yin function and to remove excessive heat from the body. It should be noted that between the hot and cold categories, there is a category of “neutral” nature. It refers to a property of neither hot nor cold. Many drugs of neutral nature find applications in treating disorders that have little to do with the hot or cold disease states. b. The “five tastes” system The “five tastes” (pungent, sweet, sour, bitter, and salty) are the gustatory sensation when the drugs are put in the mouth. In addition, there is another category of “bland” taste (tasteless). Experiential evidence has shown that each of the five (or six, including bland) tastes of the herbal drugs indicates a generalized therapeutic effect. For examples, pungent drugs can promote movement of qi and body fluids, activate the blood circulation, and break up blood stasis. Many sweet drugs share the ability to vitalize the body and they are tonics (substances taken to gain vigor or well-being of the body). At the same time, they can be used to treat various symptoms of deficiency in qi, blood, yin, or yang. “Sour” drugs are astringents to reduce abnormal discharge or intestinal movement. “Bitter” drugs can remove excessive “wetness” from the body, strengthen the digestive functions, and dispel qi congestion. “Salty” drugs are mostly laxatives and they can soften concretions. Lastly, drugs with a “bland”

44


taste are often diuretics. In short, the taste of a drug will generalize its therapeutic application. c. The meridian-affinity system In Chinese medicine theory, the entire human body is perceived to be interconnected by a complex network of invisible (non-anatomical) meridian channels, through which nutrients are transported and qi flows to reach various parts of the body, including the internal organs. Drugs, after being digested, are thought to enter a meridian channel and finally reach a target organ to act on. Thus, through clinical experience, each drug item is generalized to have a special affinity to one or more meridians and visceral organs. For example, the Ephedra herb has affinity with the lung meridian and acts on symptoms related to, or arising from, pathological changes in the lungs. Thus, the notion of organ affinity serves to pinpoint the intimate relationship between a drug and an organ; and it becomes a guideline governing the specificity of drug action, although the modern concept of drug targets was not emplaced in TCM theories. Typical examples of Chinese medicinal herbs with different “natures,” “tastes,” and “organ affinity” are illustrated in Table 4.1.

Herbal formulas The Chinese herbal prescriptions probably started with the use of a single drug item for treating a specific symptom, the most well-known single-item prescription being the “Ginseng-Alone Decoction” which is used when all other drugs fail in a state of shock to restore yang and rescue from collapse. As the knowledge of physiology and pathology expanded, more drug items were included in a prescription and dealt simultaneously with different symptoms. The practice of using composite herbal formulas, also known as “poly-prescription” or “multi-item prescription” (Fu-Fang in Chinese), was subsequently adopted. In a modern view, the concept of a herbal formula may find resemblance to combination treatment (such as “cocktail therapy”) today. There are certain rules that a clinician must follow when composing a herbal formula, taking into consideration the roles of each herb and the possible interactions among them. Thus, each prescription is made up of one or more primary herbs (called the “Emperor”

Angelica sinensis Artemisia capillaris Astragalus membranaceus Atractylodes macrocephala Bupleurum chinense Chrysanthemum morifolium Cinnamomun cassia Citrus reticulata Codonopsis pilosula Coptis sinensis Crataegus pinnatifida Dioscorea opposita Ephedra sinica Fritillaria cirrhosa Glycyrrhiza uralensis

Botanical name

Nature Warm Cool Warm Warm Cool Cool Warm Warm Neutral Cold Warm Neutral Warm Cool Neutral

Medicinal part

Root Above-ground parts Root Root Root Flower head Young stem Fruit rind Root Rhizome Fruit Root Stem Corm Root

Acrid and sweet Acrid and bitter Sweet Sweet and bitter Bitter Sweet and bitter Acrid and sweet Acrid and bitter Sweet Bitter Sweet and sour Sweet Acrid Bitter and sweet Sweet

Taste

Major effect Blood tonic Diuretic and clear heat Tonify qi Tonic; diuretic Clear heat Clear heat Diaphoretic Regulate qi Tonify qi Clear heat Digestive; stomachic Stomachic Diaphoretic Antitussive; expectorant Tonify qi (Continued)

Table 4.1 Examples of commonly used Chinese medicinal herbs

Chapter four: Traditional Chinese medicinal herbs 45

Lonicera japonica Mentha arvensis Panax ginseng Panax notoginseng Poria cocos Pueraria lobata Prunella vulgaris Prunus armeniaca Rehmannia glutinosa Rehmannia glutinsa Rheum palmatum Salvia miltiorrhiza Scutellaria baicalensis Zingiber officinale Ziziphus jujuba

Botanical name

Flower Leaf Root Root Fungal body Root Inflorescence Kernel Root (raw) Root (steamed) Rhizome Root Root Rhizome Seed

Medicinal part Cold Cool Warm Warm Neutral Cool Cold Warm Cold Warm Cold Cool Cold Warm Warm

Nature Sweet Acrid Sweet; slightly bitter Sweet; slightly bitter Sweet Sweet and bitter Acrid and bitter Bitter Sweet Sweet Bitter Bitter Bitter Acrid Sweet and sour

Taste

Clear heat Diaphoretic; carminative Tonify qi Hemostatic Diuretic Clear heat Clear heat Antitussive Clear heat; cool blood Tonify yin; blood tonic Purgative; Laxative Promote circulation; tonify blood Clear heat Dispel cold Tonify qi; sedative

Major effect

Table 4.1 (Continued) Examples of commonly used Chinese medicinal herbs

46 Chinese and botanical medicines


47

drug), which provide the principal curative action. Other herbs are added for secondary purposes such as enhancing the effect of the primary herbs or treating the secondary symptoms (the “Minister” drug), reducing undesirable side effects or improving the palatability of the prescription (the “Assistant” drug), and harmonizing the properties of the ingredients or directing the action to the affected meridian or site (the “Servant” drug). A well-known example of a herbal formula is the Ma-Huang Tang (known as the Ephedra Decoction), which is composed of four herbal components: Ephedra herb, cinnamon twig, apricot kernel, and licorice. The recipe is recommended for the treatment of common cold caused by excessive coldness together with fever and cough, but without sweating. In the formula, Ephedra pairs with cinnamon twig as “Emperor and Minister” herbs, respectively. While Ephedra induces both sweating and disseminating of lung qi, cinnamon twig strengthens the diaphoretic function. Apricot kernel serves as the “Assistant” herb to relieve wheezing, and licorice serves as the “servant” herb to harmonize other ingredients. Examples of some Chinese herbal formulas are illustrated in Table 4.2. When herbs are used in combination, the effects can be complicated as various interactions may occur among the individual chemical components. The most desirable interactions are those which can result in additional therapeutic benefit. This is often the intended or expected outcome when using poly-prescriptions. However, owing to the presence of multiple components in the herbal products, the effects arising from herb–herb interactions are often unpredictable and complicated. The concept of herb–herb interaction appeared early in the history of Chinese medicine. It is based on the notions of positive (complementation) or negative (incompatibility) outcomes. There are two basic modes of complementation: synergism and potentiation. The synergistic effect refers to the situation in which the summation effect of two or more herbs is greater than the individual sums, whereas the potentiating effect refers to the situation in which an inactive herb will enhance the therapeutic effect of an active component. Complementary interaction has the benefit of attaining high potency with a low dose. Take, for example, the Decoction of Ephedra (Ma-Huang Decoction), which contains ephedra, cinnamon twig, bitter apricot seed, and licorice root. The prescription is used not only for its diaphoretic effect, but also for the

48

Chinese and botanical medicines Table 4.2 Examples of herbal formulas used in TCM (and further elaborated in Chapter 5)

Name of prescription Ephedra decoction

Four gentlemen decoction Six-item Rehmannia decoction

Four-item decoction

Care-free powder

Minor Bupleurum decoction

Component herbs Ephedra sinica above-ground part Cinnamomun cassia branch Prunus armeniaca seed Glycyrrhiza uralensis root Panax ginseng root Atractylodes macrocephala rhizome Poria cocos sclerotium Glycyrrhiza uralensis root Rehmannia glutinosa root (processed) Cornus officinalis fruit Paeonia suffruticosa bark Dioscorea opposite rhizome Poria cocos sclerotium Alisma orientalis root Angelica sinensis root Ligusticum chuanxiong rhizome Paeonia lactiflora root Rehmannia glutinosa root (processed) Bupleurum chinense root Angelica sinensis root Paeonia lactiflora root Atractylodes macrocephala rhizome Poria cocos sclerotium Glycyrrhiza uralensis root Mentha haplocalyx leaf Zingiber officinale rhizome (processed) Bupleurum chinense root Scutellariae baicalensis root Pinellia tenata rhizome Zingiber officinale rhizome (raw) Panax ginseng root Glycyrrhiza uralensis root Zizyphus jujuba fruit

Major therapeutic effect Releasing exterior wind-cold excess and promoting diaphoresis Fortifying the qi and improving spleen function Enhancing Yin element and improving liver and kidney function

Improving blood circulation and regulating menstruation Relieving depression of liver qi, invigorating the spleen, and nourishing the blood

Eradicating external heat and treating febrile disease


49

relief of cough and asthma, as well as for reducing headaches and general aches during common cold. These symptoms are given the interpretation by Chinese medicine theory to be caused by excessive “coldness” and “wind” in the body. The coadministration of multiple ingredients would result in complementary interactions to combat the symptoms of common cold. The scenario is comparable to the simultaneous prescription of an antipyretic, cough suppressant, and nasal decongestant for the treatment of common cold. Herbs should not be coadministered to the patients when they are incompatible. For example, herbs may counteract each other, resulting in diminished efficacy. In this case, it represents an antagonistic interaction, although the concept of physical, chemical, dispositional, or receptor antagonism is lacking in Chinese medicine. Another mutual incompatibility of herbs is the situation where a combination would result in toxic or severe adverse effects. In this scenario, the combined use of the herbs should be avoided. The concept and practice of herbal combination has been recognized in Chinese medicine for thousands of years. Their empirical effects are obvious, although the exact pharmacological mechanisms are not clearly understood. Pharmacokinetic, pharmacodynamic, and polyvalent effects are likely involved.

TCM dietary therapy For the Chinese, the principles of yin-yang balance apply not only to medicine but also to diets. Accordingly, food is taken not only for sustenance and survival but also for maintenance and regulation of internal balance. Many medicinal herbs become indistinguishable from foods: they are often selected as much for their therapeutic qualities as for nourishment. In TCM diets, the selection of foods does not emphasize on their nutrient content (e.g., total fat, carbohydrate, protein, vitamin, fiber) or on the nutritional value (e.g., calorie), but on the medicinal properties (e.g., the nature, taste, and organ-affinity). For example, red pepper is used not because it contains vitamins A and C, but because it can warm the body; yam is taken not because it is rich in proteins, carbohydrates, and vitamins, but because it can strengthen the “kidney functions.” When diet and medicines are merged into “medicinal diets” (sometimes referred to as dietary therapy), the paramount concern is achieving a physiological equilibrium in the body. It is believed

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Chinese and botanical medicines Table 4.3 Examples of herbs commonly used as dietary ingredients

Herb

Plant part used

Major effect

Yam Ginger

Rhizome Rhizome

Garlic

Bulb

Chilies

Fruit

Chinese wolfberry Lotus

Fruit

Chrysanthemum Mandarin orange Chinese date Foxnut

Flower Rind

Strengthening yin energy Warming the body and improving blood circulation Promoting energy circulation and warming the stomach Warming the body and removing dampness Tonic to kidney and liver and improving vision Reinforcing the spleen and stomach functions Clearing excessive heat Regulating qi, stopping coughing, and improving digestion General tonic to strengthen energy Tonic to kidney and spleen

Seed

Fruit Seed

that a combination of common foods and medicinal herbs in the diet would lead to specific benefits, produce certain physiological responses, and restore internal harmony. Thus, dietary therapy involves a careful selection of foods and herbs to treat mild visceral disorders, or address conditions of excess and deficiency. In addition, certain foods and herbs are applied during different seasons to provide counteracting effects to resist any undesirable impacts caused by climatic and environmental changes. Good dietary practice is considered essential to assure a healthy life and longevity. Table 4.3 provides examples of medicinal herbs commonly used as dietary ingredients.

Biologically active ingredients from TCM herbs The plant kingdom is a rich source of natural chemical substances, many of which have been found to be important natural pharmaceutical agents (such as caffeine, digitoxin, morphine, and paclitaxel). It is therefore not surprising that Chinese medicinal herbs contain a vast pool of pharmacologically active chemical compounds. Indeed, through pharmacognosy research, several active principles have been identified from Chinese medicinal herbs. These biologically active

Chapter four: Traditional Chinese medicinal herbs Artemisinin (Qing-Hao-Su), a sesquiterpene lactone containing an unusual peroxide bridge, is found in Artemisia annua (Qing-Hao).

CH3

H

It can kill the malaria parasite, Plasmodium falciparum. Discovery of this anti-malarial drug has led to the award of 2015 Nobel Prize in Physiology or Medicine to Dr. Youyou Tu of the China Academy of Chinese medical sciences.

O O

H3C O H

H H

O

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Analogs such as artemether, arteether and artesunate are also used in malarial therapy.

CH3 O

Artemisinin-based combination therapies are recommended by world health organization as the first-line treatment for uncomplicated P. falciparum malaria.

Artemisinin

O

N

Camptothecin is a cytotoxic alkaloid isolated from the bark and stem of Camptotheca acuminata (the Happy Tree).

N

HO

O

It is an enzyme inhibitor of topoisomerase I, preventing DNA replication and ultimately leading to cell death.

O

Two analogs, topotecan and irinotecan, are used in cancer chemotherapy.

Camptothecin

OH CH3 HN

Ephedrine is a sympathomimetic amine present in Ephedra sinica (Ma-Huang). It acts as a central nervous system stimulant and bronchodilator.

CH3

A stereoisomer, pseudoephedrine, is used as a nasal decongestant

Ephedrine

Figure 4.2 Examples of active compounds found in Chinese medicinal herbs.

natural products not only provide evidence, at least partially, for rational use of the medicinal herbs, but also serve as drugs or templates for chemical modification into useful drugs. Among others, ephedrine from Ephedra sinica is a sympathomimetic agent used as a central nervous system stimulant, artemisinin is an antimalarial drug obtained from the Artemisia annua herb, and camptothecin is an antitumor agent discovered from the tree Camptotheca acuminata (Figure 4.2).

Future prospects There is no doubt that the ancient science of Chinese medicine remains viable and is providing effective healthcare options to the modern world. Over the past few decades, we have witnessed the rapid and continuing growth of interest in Chinese medicine

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worldwide. The recognition that conventional medicine fails to offer satisfactory cure to many diseases (such as allergies, autoimmune diseases, chronic pains, and cancers) and that many drugs are ineffective and even have marked side effects has turned the attention of many to search for alternative therapies and herb-based supplements. The movement is expedited by the increasing awareness of health issues, consciousness in disease prevention, and preference in improvement of the quality of life. While TCM holds great promise to improve human health, there remains a clear and urgent need for a stronger evidence base to ensure the continuing development of this traditional medicine in modern societies. Some important issues are highlighted below. There is no doubt that a vast body of the literature is available on the clinical outcome of Chinese medicine, but it is less clear what level of evidence it represents and how it can be properly assessed. It is therefore important to develop reliable protocols to ensure the quality of clinical research on Chinese medicine so that the efficacy can be convincingly demonstrated. TCM is facing fierce challenges to demonstrate its safety, the mechanisms of action, and quality of the herbal products. In this respect, vigorous research is needed to confirm the evidence-based efficacy, to elucidate the mechanisms of action, to define pharmacological and toxicological profiles, to evaluate the safety, and to ensure the quality of the medicinal products. In the market, the quality of Chinese herbal products may vary. Problems include inconsistent composition, batch-to-batch variation, misleading labels, contamination, adulteration, and inclusion of undisclosed pharmaceutical ingredients. It is anticipated that many of these problems can be corrected under a well-planned regulatory framework. Consumers’ awareness of potential adverse reactions and herb– drug interactions associated with certain herbal products needs to be raised. The mainstream medical professionals also need to receive adequate e ducation on this kind of alternative therapy and to learn how to assess critically the validity of its claims.

Further suggested reading Hicks J. 2013. Principles of Chinese Herbal Medicine. Singing Dragon, London. Reid DP. 1987. Chinese Herbal Medicine. Shambhala, Boston. Tierra L. 1997. Healing with Chinese Herbs. Crossing Press, Freedom, CA.

chapter five

Examples of TCM formulas used in Chinese medicine Herbal medicine TCM appears complicated, since typically a batch of medicine is prepared as a decoction of about 9–18 substances, which constitute the prescription. A typical example of a mix of herbs is depicted in Figure 5.1. TCM is rarely prepared using single herb for treatment, although some examples are provided in Chapter 6. The practitioners almost always prescribe a TCM formula for the patients. As mentioned in Chapter 4, these formulas are based on, and designed in accord with, TCM theory. Each formula consists of the “Emperor or Monarch,” which contributes most of the therapeutic effect of the formula. The formula also contains a “Minister,” which strengthens the therapeutic effect of the formula. The “Assistant” helps the “Monarch” and the “Minister” to reach the position or meridian. Finally, the “Servant” reduces any adverse effects or may increase the potency of the whole formula. Thus, the combinations of the herbs in each formula have synergistic effects to deliver the therapeutic effects, in accord with ancient theories. An example is the treatment of cold, when the presenting symptoms are as follows: chills, fever, headache, generalized aching, panting, no sweat, thin and whitish coating on the tongue, and a floating and tense pulse. The syndrome is differentiated as follows: exterior syndrome due to exogenous wind-cold. Therapeutic strategies are as follows: exterior syndrome is relieved by diaphoretic therapy (promotes perspiration) and the wind-cold invasion can be removed by pungent and warm herbs. In this case, the matched classical formula is an Ephedra Decoction (Ma Huang Tang) that consists of ephedra (the “Monarch” or “Emperor” for dispelling the pathogens on the exterior and relieving most of the symptoms), cinnamon twigs (the “Minister,” which aids ephedra-inducing sweat and expelling the pathogens on the exterior), bitter apricot kernel (the ”Assistant,” 53

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Figure 5.1 Assorted dried plant and animal parts which are used in TCMs. Clockwise from top left corner: dried Lingzhi (“spirit mushroom”), ginseng, Luo Han Guo, turtle shell underbelly (plastron), and dried curled snakes. (Photograph of author DM.)

which helps the ephedra in enhancing the lung so to ease panting), and licorice root (the “Guide,” which modulates the harsh properties of the ephedra and cinnamon twigs). There are roughly 13,000 medicinal animal and plants used in China and over 100,000 medicinal recipes, or prescriptions, which are recorded in the ancient literature. Either whole plant parts or extracts are used. It should be noted that the use of some animal parts such as cow’s gallstones, hornet’s nest, leeches and antelope horns, deer antlers, testicles and penis bone of various animals, and snake and bear bile may be considered rather strange by those in the West. Controversy surrounds the use of animal parts and threatened animal species and there has been little research to justify the claimed clinical efficacy of many TCM animal products. For example, TCM uses bear bile as a medicinal, and there are many Asiatic black bears held captive in bear farms in China. The

Chapter five: Examples of TCM formulas used in Chinese medicine

55

bile is extracted through a permanent hole in the abdominal wall leading to the gallbladder, which can cause severe pain. As of 2012, approximately 10,000 bears are farmed in China for their bile. This unethical practice spurred public outcry across the country.

Efficacy of TCM The consensus in the West is that there are not sufficient good quality trials of herbal therapies to allow their effectiveness to be determined. Some data are incomplete; they may contain errors or are misleading. In fact, a 2012 Cochrane review found no difference in decreased mortality when Chinese herbs were used alongside Western medicine versus Western medicine exclusively. However, limits, notwithstanding, there are also many examples showing promising evidence for the use of Chinese medicines to treat various conditions and a small selection is presented below.

Some examples of complex formulas used in TCM Xiao-Chai-Hu-Tang (“Minor Bupleurum decoction”) Sheng-Mai-San containing ginseng, Ophiopogon, Schizandra, a general tonic for weak pulses including congestive heart failure. Liuwei-Dihuang preparations Buyang-Huanwu-Tang is indicated to be beneficial for yang deficiency. Many clinical studies have indicated the effects of Buyang-Huanwu-Tang on cardiovascular disorders including ischemic stroke. Danggui-Buxue-Tang Si Jun Zi Tang—Four Gentlemen decoction Suan Zao Ren Tang—Sour Jujube decoction Xiao-Chai-Hu-Tang (“Minor Bupleurum Decoction”) is indicated for “exterior Shao-Yang syndromes,” including common cold and very commonly used in Japan. Xiao-Chai-Hu-Tang, literally meaning “Minor Bupleurum Decoction,” is also known in Japanese traditional medicine as Sho-Saiko-To. It is one of the commonly used herbal formulas in Chinese medicine. The formula is made up by the following seven herbs: Bupleurum Chinese root (Bupleuri Radix) (Figure 5.2) Scutellaria baicalensis root (Scutellariae Radix)

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Figure 5.2 Bupleuri Radix. (From https://tcmwiki.com/wiki/radixbupleuri.)

Pinellia ternata rhizome (Pinelliae Rhizoma) Panax ginseng root (Panax Radix)—ginseng, or Codonopsis pilosula root (Codonopsis Radix) Zingiber officinale rhizome (Zingiberis Rhizoma Recens)—fresh ginger Ziziphus jujuba fruit (Jujubae Fructus)—Chinese date Glycyrrhiza uralensis (Glycyrrhizae Radix et Rhizoma)—licorice Traditionally, the prescription is used to treat fever and chills (particularly the Shao-Yang syndrome in accord with Chinese


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medicine theory) and related diseases. This herbal formula is indicated for common cold and fever together with symptoms such as congested chest, loss of appetite, and dry throat. It is also used to treat gastrointestinal disorders, chronic liver diseases, cancer, and malaria. The “Minor Bupleurum” Decoction is now available in several pharmaceutical forms, including tablets, powder, capsules, and granules. The raw herbs can also be boiled in water in a prescribed proportion of each herbal component to prepare a herbal tea. In accord with Chinese medicinal theories, the “Minor Bupleurum” Decoction can dispel heat from the body to relieve the liver and to bring harmonization between the liver and stomach. The “Emperor” (major) ingredient in the formula is Bupleuri Radix (Chai-Hu, root of Bupleurum chinense). It serves to lift and disperse qi stagnation, as well as to raise the qi of the yang element. Radix Scutellariae (Huang-Qin, root of Scutellaria baicalensis), a bitter and cold herb that enters the gallbladder channel, is good for clearing excessive heat. When used together, the Bupleurum root disperses the exterior while the Scutellaria root clears the interior to achieve the harmonizing effect. On the other hand, Pinelliae Rhizoma (Ban-Xia, rhizome of Pinellia tenata) works on the stomach to relieve nausea and vomiting as well as remove excessive dampness from the body. Zingiberis Rhizoma (fresh ginger, rhizome of Zingiber officinale) helps Pinellia harmonize the interior and reduces the toxicity of the latter. Ginseng Radix (ginseng, root of Panax ginseng), Glycyrrhizae Radix et Rhizoma (honey-fried licorice, root of Glycyrrhiza uralensis), and Jujubae Fructus (Chinese date, fruit of Ziziphus jujuba) all help tonify the stomach qi, nourish body fluids, and harmonize the yin element. Such a combination leads to the dismissal of external pathogens and strengthens bodily constitution. Cell-based and animal studies have revealed some pharmacological effects of the “Minor Bupleurum” Decoction. The formula and its components demonstrated marked antiproliferative effects on cancer cells such as hepatoma and ovarian cancer cell lines. Addition of the decoction to the cell culture inhibited cell growth and induced apoptosis (scheduled cell death). The decoction has been shown to prevent liver injury and promote liver regeneration in animal models. It improved hepatic inflammation and fibrosis as indicated by reduced liver hydroxyproline and a smaller increase in serum hyaluronic acid. Moreover, the treated rats developed

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fewer pre-neoplastic lesions. The formula has also been shown to prevent development or metastasis of carcinomas. It was reported to enhance various aspects of immune function, such as effects on killer cells, interleukins, interferons, and macrophages. Apart from traditional applications to treat the Shao-Yang syndrome, the “Minor Bupleurum” Decoction has found clinical applications nowadays for the treatment of hepatic and related disorders such as viral hepatitis, liver fibrosis, liver cancer, jaundice, cholecystitis, pancreatitis, and stomatitis. The formula has shown good activity in slowing down the progression of cirrhosis of the liver and development into cancer. The use of the formula in the treatment of cancers (such as lung, renal, and prostate cancers) has also been reported. The “Minor Bupleurum” Decoction has been evaluated in human studies. It was shown to be able to protect against the development of chronic hepatitis, hepatic fibrosis, and hepato-carcinoma. While the exact mechanism of action remains unclear, it may involve the production of cytokines, regulation of immune function, and suppression of lipid peroxidation. A clinical study shows that the “Minor Bupleurum” Decoction may improve liver pathology in hepatitis C patients who do not respond to interferon-based treatment. Adverse effects of the “Minor Bupleurum” Decoction have also been reported. A meta-analysis based on case reports has suggested that hepatitis B virus-infected patients who received “Minor Bupleurum” Decoction had an increased risk of liver injury. In Japan, cases of pneumonitis have been reported in patients who received “Minor Bupleurum” Decoction together with interferon treatment. The exact mechanism remains to be explained. The preparation also has upregulatory effects on cytochrome P450 enzymes (CYP2B, CYP3A1, and CYP4A1) and can alter the plasma concentration of the drugs metabolized by these enzymes. Sheng-Mai-San contains ginseng, Ophiopogon, Schizandra species and is a general tonic for weak pulses including congestive heart failure. Sheng-Mai-San, literally meaning “powder for generating pulses,” comprises three herbs, namely, Panax ginseng root (Ginseng Radix) Ophiopogon japonicus root (Radix Ophiopogonis) (Figure 5.3) Schisandra chinensis fruit (Schisandrae Fructus)


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Figure 5.3 Radix Ophiopogonis Ophiopogon root. (From http://traditionalherb.org/chinese-herbs/ophiopogon-root-mai-dong/.)

An important tonic formula that addresses deficiency of qi (the vital energy), San-Mai-San is well known for its ability to invigorate qi and promote body fluid production (nourishment of yin), especially for patients who have weak pulses. The formula is often indicated for symptoms of heat-induced depletion in qi and body fluid, or weakness in heart and lung functions due to deficiency of the yin and qi components. Traditionally, the Sheng-Mai-San preparation is used for treating yin- and qi-deficient conditions such as heat stroke, summer fever, and other feverish conditions. The original form of the prescription was a powder, but today it is available in several dosage forms including capsule, syrup, granule, ampoule liquid, and intravenous drip. In this formula, ginseng assumes the role of the “Emperor” ingredient. With its sweet taste and warm nature, ginseng can supplement the lungs with its actions of invigorating qi and promoting

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body fluid production. The Ophiopogon root, being the “Minister” ingredient, nourishes the lung and promotes body fluid production. With its sweet taste and cold nature, it nourishes yin and clears away excessive heat from the body. The combination of ginseng and the Ophiopogon root produces an additive effect of qi invigoration and yin nourishment. The inclusion of an “Assistant” ingredient, Schisandra fruit, which has a sour taste and warm nature, can exert an astringent action on the lungs and promote body fluid production. With regard to the pharmacology of the Sheng-Mai-San formula, a wealth of information is available in the literature, particularly on its effects on the cardiovascular system, such as protection from contractile heart failure (showing positive inotropic effect in pentobarbital-induced contractile heart failure in dogs), improvement of myocardial ischemia (as shown by the electrocardiograph and plasma creatine phosphokinase activity in isoproterenol-induced myocardial damage in rats), prevention of arrhythmia in animal models using electrical stimulation, chloroform or calcium chloride, as well as protection against hemorrhagic shock, endotoxin shock, and cardiogenic shock. Other studies have demonstrated that the Sheng-Mai-San preparation suppresses the formation of atherosclerosis and lowers the levels of blood lipids and cholesterol in a rabbit model of atherosclerosis. The herbal preparation was also found to elevate the levels of dopamine and serotonin in the corpus striatum of rats, as well as the noradrenaline level in the rat heart. In addition, the antioxidant activity of Sheng-Mai-San has been demonstrated both in animal and cell models. Modern applications of this prescription are based on its ability to regulate the heart rate, increase heart output, strengthen cardiac contractility, reduce oxygen consumption in the heart muscles, adjust blood pressure, exert actions against shock, expand the coronary arteries, and increase coronary arterial blood flow. It has found applications nowadays in the treatment of a wide range of cardiac diseases such as coronary heart disease, cardiac arrhythmia (tachycardia and bradycardia), viral myocarditis, cardiogenic shock, and cardiomyopathy. Modern TCM practice in China uses an intravenous drip made from the Sheng-Mai-San preparation for emergency treatment of heart attack, shock, and congestive heart failure. It has also been applied in patients suffering from chronic obstructive pulmonary disease and chronic bronchitis.


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The Liuwei-Dihuang preparation contains a six-ingredient decoction (or pill) with Rehmannia (Liuwei Dihuang Tang(wan)). It is mostly well known to restore yin deficiency of the kidney and is used as a tonic for general weakness. Liuwei-Dihuang is among the most highly regarded Chinese herbal formulas for nourishing the yin component of the kidney and liver. There are many dosage forms available for this formula, including decoction (Liuwei-Dihuang-Tang), pill (Liuwei-DihuangWan), and tablet (Liuwei-Dihuang-Pian). The formula is presented below: Rehmannia glutinosa root (Rehmanniae Radix Preparata) Cornus officinalis fruit (Corni Fructus) Paeonia suffruticosa rootbark (Moutan Cortex) Dioscorea opposita rhizome (Dioscoreae Rhizoma) Poria cocos sclerotium (Poria) Alisma orientalis rhizome (Alismatis Rhizoma) As the name of the formula implies, the Rehmannia root serves as the ‘Emperor” (major) ingredient in the combination. It warms and nourishes the kidney essence and replenishes the yin component. Other tonic ingredients are the Cornus fruit and Dioscorea rhizome, targeting the liver and spleen, respectively, to consolidate the essence of these organs. At the same time, the Alisma rhizome cools the kidney and remove excessive moisture from the body, the Moutan cortex cools the liver and promotes blood circulation, whereas the poria fungus helps drain excessive dampness from the body. The formula thus strikes a balance of tonifying and dispersing actions. The ultimate function is to replenish the yin component in the kidney. The Liuwei-Dihuang preparation is indicated for yin-deficient symptoms such as general weakness, dizziness, sweating, and low back pain. Today, the clinical application of the formula has expanded to a wide range of diseases including diabetes, asthma, menopausal syndrome, osteoporosis, hypertension, etc. Pharmacological studies of the Liuwei-Dihuang preparation have shown that it can increase the number of T lymphocytes and regulate the production of cytokines, thereby adjusting the immune function. Other studies have indicated an increase in the production of sex hormones and adrenal cortical hormones. Moreover, the Liuwei-Dihuang

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preparation can reduce blood sugar levels and increase the activity of superoxide dismutase in the diabetic rat mode. Buyang-Huanwu-Tang is good to promote yang deficiency. Many clinical studies have indicated the effects of Buyang-HuanwuTang on cardiovascular disorders including ischemic stroke. Buyang-Huanwu-Tang is a prescription renowned for its effects in invigorating the blood and clearing the meridians. It is made up of seven components: Astragalus membranaceus root (Astragali Radix) Angelica sinensis root (Angelicae Radix) Paeonia lactiflora root (Paeoniae Radix Rubra) Ligusticum chuanxiong rhizome (Chuanxiong Rhizoma) Carthamus tinctorius flower (Carthami Flos) Prunus persica seed (Persicae Semen)—apricot kernel Pheretima spp. (Pheretima)—earthworm The formula is best suited for conditions of deficiency of yang qi which results in blood stasis (stagnation of blood flow); it is recommended for stroke, paralysis, lower limb atrophy, facial paralysis, etc. In this formula, the Astragalus root aids qi movement, while the Angelica root promotes blood circulation, aided by Ligusticum and Paeonia. The inclusion of the Carthamus flower, apricot kernel, and earthworm further helps remove blood stasis and clear the blocked channels. Thus, the overall action of the formula is strong qi tonifying together with a blood-moving effect. The Buyang-Huanwu Decoction has been used extensively in the acute, recovery, and sequelae stages of patients with ischemic stroke in China. Various studies have reported that it has neuroprotective effects and is effective against cerebral ischemia-reperfusion injury in humans and animal models. Mechanistically, the mixture has been shown to protect neurons from ischemic injury, promote the regeneration of peripheral nerves and differentiation of neural progenitor cells, improve the recovery of neurological function, reduce infarction volume, stimulate neural proliferation, repair injured blood vessels and lesion tissues, inhibit apoptosis, repress inflammatory reactions, and reduce calcium overload and oxidative stress reaction. The broad range of action attributed to the prescription suggests that the neuroprotective effects on brain ischemia are through multiple mechanisms.


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Danggui-Buxue-Tang Danggui-Buxue-Tang literally means “Angelica Radix Blood Tonics.” It was first documented in a medical text Nei Wai Shang Bian Huo Lun published during the Jin dynasty (1115-1234 AD) of China and has been very popular among the Chinese population. It is a simple formula which consists of two herbs: Astragalus membranaceus root (Astragali Radix) Angelica sinensis root (Angelicae Radix) To examine the potential synergistic effects of the formula, a detailed chemical analysis of Danggui-Buxue Tang was carried out which indicated that it is not a simple mixture of the hot water extracts of the two individual herbs. By putting the two herbs together in boiling water, a component asparagine is more abundant in the decoction than in the simple mixture of the hot water extracts of the two herbs. Also, experimental results suggested that by removing some chemical components from the decoction, the remainder is much less effective. All these suggested that the ancient wisdom of using formula does have reasons, but more indepth studies are certainly needed to fully comprehend the interactions of the herbs in a modern scientific framework. According to the TCM theory, qi and blood are closely related. Blood is said to be a denser form of qi, and more yin in nature. Qi plays a crucial role in the production and circulation of blood inside the human body. The design of this formula is essentially a qi tonic, which nourishes the blood. Astragali Radix is considered as a qi tonic and the amount in this formula is fivefold over that of Angelicae Radix, which is a blood tonic. Thus, the formula is a renowned blood tonic designed to help women to enrich the blood and activate the blood circulation. It is good for anemia, menstrual disorders, and osteoporosis. Pharmacology studies on rat models suggested that this tonic strengthens hematopoietic function, stimulates cardiovascular circulation, and prevents osteoporosis. The chemical composition and biological activities of the formula have been studied extensively. By using cell models to assess the estrogenic and osteogenic activities, it has been shown that the decoction with Astragali Radix and Angelicae Radix in the ratio of 5:1 exhibits the best biological activity.

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In ancient times, people washed the Angelicae Radix with alcohol before boiling with Astragali Radix to prepare the decoction, although this approach is not commonly used anymore. Research studies suggest that this alcoholic wash step does produce a better decoction that shows strong biological activity in cell models. The alcoholic wash step reduced the volatile content of Angelicae Radix and increased the solubility of the ingredients of Astragali Radix in water.

Four Gentlemen Decoction (Si Jun Zi Tang) Four Gentlemen Decoction (Si Jun Zi Tang) is recorded in the Taipin Huimin Hejiju Fang during the Song Dynasty. It has been recognized for its qi-replenishing effects. This is often the first formula TCM practitioners consider whenever they encounter a qi-deficiency syndrome. The formula is made up of the following four herbs: Radix Ginseng Radix Glycyrrhizae/Radix Glycyrrhizae Preparata (Licorice) Rhizoma Atractylodis Macrocephalae/White Atractylodis Poria/Sclerotum Poriae Cocos The name of this formula is unique and one of the implications of terming it “four gentlemen” is that the four ingredients have an equal status in the formula, in contrast to many formulas, which have a “Ruler (Emperor),” a “Minister,” an “Assistant,” and an “Aid.” The four ingredients in Si Jun Zi Tang play an equally important role in the formula and work harmoniously together, without any inequality. By contrast, the role of licorice, which in many formulas is seen very much as an aid, is as important as that of Ginseng, Atractylodis, or Poria in this formula. Jun Zi is a term that comes from Confucianism, which is used to describe men who are authoritative by earning their status with their manners and not by their position or power. Thus, this formula is termed Jun Zi to reflect the inherent character of the four herbs. They are considered mild, supporting each other, and their qualities are well suited to the organ system (stomach-spleen), which they aim to treat. This formula is given to those who lack qi, who are fatigued and pale, with poor appetite, and a tendency toward loose stools.


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Causes of such problems involve the weakened central qi, in the stomach-spleen region, due to stress, anxiety, irregular and poor eating habits, and exposure to extreme weather. The formula aims to improve the function of the spleen. Ginseng and licorice are the two ingredients to enliven the spleen; they help to transform food into qi, then transport the essences to the spleen and help the spleen to transport the fluids. The use of the atractylodes is similar to that of Ginseng and licorice for tonifying the spleen and stomach, and it has an additional role to help dry excess fluids that generally make the spleen perform sluggishly. Poria has the same function too in removing excess fluids which impair the yang qi of the spleen to function normally and efficiently. This formula can be modified by adding pinellia and citrus to Liu Junzi Tang (now named as the “Six Gentlemen” Decoction). Adding these two herbs can help to resolve the phlegm accumulation, a by-product of stagnancy of food in the stomach. The formula is used for the same principles as the four gentlemen decoction, but benefits further those patients presenting with excess expectoration in cough, chest fullness, and nausea. In case of further additions of Saussurea plant species and cardamom into the herbal mix, it is called Xiang Sha Liu Junzi Tang, which can alleviate abdominal fullness and pain. In modern research, the polysaccharides in the Si JunZi Decoction have been shown to improve gastrointestinal functions and the immune response, as well as to enhance the intestinal restitution and protect against indomethacin-induced damage of intestinal epithelial cells.

Suan Zao Ren Tang (Sour Jujube Decoction) Suan Zao Ren Tang (Sour Jujube Decoction) is a well-known remedy for treating insomnia. The mixture consists of a combination of five medicinal herbs as follows: Semen Zizyphi spinosae (Suan zoa ren) Sclerotinum poriae Cocos (Fu Ling) Radix Ligustici Chuanxiong (Chuan Xiong) Rhizoma Anemarrhena (Zhi Mu) Radix Glycyrrhizae (Gan Cao)

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This formula originates from Jin Gui Yao Lue (Synopsis of Golden Chamber) that governs patterns of insomnia caused by the consumptive disease and deficient dysphoria. This formula later inspired many other remedies in the treatment of insomnia. As the name of the formula indicates, Suan Zao Ren or the jujube seed plays a key role in the formula. The formula treats sleeplessness and feelings of unease, due to liver deficiency accompanied with heat. It can be taken in different forms, such as Suan Zao Ren Wen (pills), Pian (tablets), Jao Nang (capsule), and ke Li (granules). Suan Zao Ren, the “Monarch” drug, working along with the two minister drugs, Fu Ling and Zhi Mu, effectively calms the shen and nourishes the heart and liver. Fu Ling tonifies the stomach and spleen while Zhi Mu helps the yin and also clears the heat and moistens the internal dryness from Chuan Xiong. The assistant, Chaun Xiong, and the guide, Gan Cao, then help to regulate the liver qi and harmonize the properties of all the herbs in the formula. In modern research, this formula has been tested under various specific conditions for its efficacy in reducing sleeping disturbances. The efficacy and safety of Suan Zao Ren Tang was evaluated in reducing the impact of sleep disturbance on climacteric women and after 4 weeks, the clinical trial subjects noticed an improvement in terms of quality of sleep and in improving any noticeable daytime dysfunction. Also, Suan Zao Ren Tang improves the sleep quality of subjects on a methadone-maintained regimen when assessed by the Pittsburgh Sleep Quality Index questionnaire. Although Suan Zao Ren Tang shows good efficacy in improving the sleep quality, this formula can aggravate pathogenic heat and therefore should not be used in patients with heat-related diseases. Further, Suan Zao Ren is a seed crop, which means it undoubtedly has the effect of lubricating the intestinal tract, thus, caution must be exercised when using this formula in patients who exhibit spleen-qi deficiency.

Further suggested reading Foster S, Yue C. 1992. Herbal Emissaries: Bringing Chinese Herbs to the West. Healing Arts Press, Rochester, VT. Hesketh T, Zhu WX. 1997. Health in China traditional Chinese medicine: One country two systems. British Medical Journal 315: 115–117. Yang Y. 2010. Chinese Herbal Formulas: Treatment Principles and Composition Strategies. Churchill Livingstone, London.


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Bibliography Chan YY, Chen YH, Yang SN, Lo WY, Lin JG. 2015. Clinical efficacy of traditional Chinese medicine, Suan Zao Ren Tang, for sleep disturbance during Methadone Maintenance: A randomized, double-blind, placebo-controlled trial. Evidence based Complementary and Alternative Medicine 2015: 710895. Leonti M, Casu L. 2013. Traditional medicines and globalization. Current and future perspectives in ethnopharmacology. Frontiers in Pharmacology 4: 92. Liu L, Han L, Wong DY, Yue PY, Ha WY, Hu YH, Wang PX, Wong RN. 2005. Effects of Si-Jun-Zi decoction polysaccharides on cell migration and gene expression in wounded rat intestinal epithelial cells. British Journal of Nutrition 93(1): 21–9. Liu X, Zhang M, He L, Li Y. 2012. Chinese herbs combined with Western medicine for severe acute respiratory syndrome (SARS). Cochrane Database of Systematic Reviews 10. DOI: 10.1002/14651858.CD004882. pub3. Shaw D. 2012. Toxicological risks of Chinese herbs. Planta Medica 76(17): 2012–8. Yeh CH, Arnold CK, Chen YH, Lai JN. 2011. Suan Zao Ren Tang as an original treatment for sleep difficulty in climacteric women: A prospective clinical observation. Evidence Based Complementary and Alternative Medicine 2011: 673813.

chapter six

Examples of single Chinese and botanical medicines derived from TCM Introduction Owing to the rich folklore and continual use over many centuries, TCM has not only been thoroughly embraced by Chinese and many Asiatic cultures but also more TCM plants are being accepted globally. In this chapter, several examples of TCM plants that are gaining widespread interest in the wellness and medical arena have been chosen and are now being sold as dietary or nutritional supplements worldwide. Examples of active compounds found in Chinese medicinal herbs were introduced in Chapter 4 and artemisinin and ephedrine will be reviewed in detail. Furthermore, some Chinese medicines have been adapted by the West in the form of dietary supplements. At least two of the top 10 selling botanical products are derived from TCM, including Ginkgo, Ginkgo biloba Ginseng, Panax ginseng Green tea, Camellia sinensis Cordyceps, Cordyceps sinensis Salvia (Danshen), Salvia miltiorrhiza Red yeast rice, Monascus purpureus Dong quai, Angelica sinensis Garlic, Allium sativum Several studies describing new mechanisms of action applied to each one of these botanicals are reviewed, which may eventually lead to a positive clinical outcome or the potential for a better understanding of their respective modes of action. In this chapter, using select examples, the importance of linking such chemical 69

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signals to biological effects leading to a therapeutic use is given. This approach, in turn, may lead to better crafted, well-defined herbal extracts that demonstrate efficacy in clinical studies. These plants require different model systems to evaluate their therapeutic potential and are represented herein. Although each one has been well studied, there have been conflicting clinical data, suggesting a lack of specific activity or inappropriate preparation. Various in vitro/in vivo bioassays have been employed for the evaluation of botanicals to determine the mechanism of their action and thereby to fix parameters of pharmacological, microbiological, and other standardization methodologies, leading to a more effective role in health care. These bioassays may include whole animal models, as well as organs, tissues, cells, receptors, enzymes, and cell parts. Botanical extracts can only be declared pharmacologically active if a reliable correlation can be made between a measurable active principle and its declared medicinal effect. Clinical confirmation of pharmacological activity can only be ascertained when unequivocal effects of standardized extracts are demonstrated in clinical trials.

Evidence-based approach In many cases, the exact amount of chemical constituents in the plant needed to give a defined and specific biological effect has yet to be verified. Thus, these results are limited to a biological effect, which in turn is relevant to a therapeutic or nutritional target. This approach may be achieved by determining the structural analyses of natural compounds present in the selected botanical, followed by pharmacological testing, to identify biological fingerprints of the plant extracts and their effective concentration.

Artemisinin: A Chinese miracle drug In more recent times, A new antimalarial drug artemisinin, derived from nature, is another botanical miracle success story beginning with its secret development in China.

Malaria Malaria is a vector-borne disease transmitted by the bite of a female mosquito infected with a single-celled (protozoan) parasite

Chapter six: Examples of single Chinese and botanical medicines

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Figure 6.1 Parts of the world where malaria is endemic are shown in red on the map. (From 2013 Global Malaria Mapper, Courtesy of WHO, http://www.who.int/malaria/publications/world_malaria_report/ global_malaria_mapper/en/. This free platform is accessible to interested individuals and organizations from all over the world.)

(known as plasmodium). The tiny parasites pass through the bloodstream of the human victim and travel to the liver where they mature and reproduce before affecting the whole body by attacking the red blood cells. Symptoms of malaria typically include headache, fever, and fatigue. If not treated, malaria can cause death. The areas in the world most associated with malaria are shown in red in Figure 6.1. Two major drugs are employed in the fight against malaria and both originate directly from natural products: quinine from the bark of the cinchona tree found in South America and artemisinin from the leaves of Artemisia annua native to China. The latter discovery is particularly important as the effectiveness of drugs based solely on quinine has gradually diminished as the infecting parasites have developed resistance to the quinine-based drugs. Subsequently, artemisinin has become the treatment of choice for malaria. However, the World Health Organization (WHO) called for cessation of the single use of artemisinin preparations in 2006 in favor of combinations of artemisinin with another malarial drug

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to reduce the risk of the parasites developing resistance. Thus, artemisinin is usually combined with a synthetic derivative of quinine, known as chloroquine. This dual dose of the drugs reinforces one another in addressing malaria and has complementary roles; the former is fast acting while the latter reduces inflammation. However, it remains to be seen whether the strategy of combination therapy will be entirely successful in the management of malaria. More recently, this new and completely different antimalarial miracle drug, artemisinin, has been extracted from the leaves of Artemisia annua grown in China (Figure 6.2).

Figure 6.2 Artemisia annua (annual wormwood).


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Historical note: The plant, Artemisia annua, has been used by Chinese herbalists for over two millennia. An extract was believed to have been used in the treatment of skin diseases and malaria. The antimalarial property of the extract was first specifically described in the fourth century within the Classic Chinese Text, “The Handbook of Prescriptions for Emergencies.” In the 1960s, a research program was set up by the Chinese army to find an adequate treatment for malaria. By 1972, artemisinin had been discovered in the leaves of Artemisia annua. Screening of over 5000 traditional Chinese medicines revealed that artemisinin was the most effective drug in dealing with malaria parasites in a patient. Owing to the secret nature of the research program, however, the work was never given the full international recognition it deserved until 2015 when the Nobel Prize in Medicine was awarded to the lead Chinese scientist Tu for her scientific contributions.

The chemical structure of artemisinin possesses an unusual peroxide linkage, which is believed to be involved in the antimalarial effectiveness of the drug and may also account for its relatively rapid medical action compared to quinine. The WHO recognizes that artemisinin is very effective in the prevention and treatment of malaria even in cases where the parasite responsible is resistant to quinine. However, to avoid resistance during any artemisinin treatment, the WHO recommends a combination therapy of artemisinin and quinine derivatives, respectively.

Ginkgo Ginkgo, the oldest fossil tree known, plays an important role in Chinese medicine. Generally, the leaves (Figure 6.3) provide medicinal benefit, whereas the ginkgo nut after soaking or boiling in hot water is a nutritious food. The constituents of the ginkgo leaf of primary interest are the phenolic and terpenoid compounds. For effectiveness, Ginkgo biloba extracts are standardized to 24% ginkgo flavone glycosides and

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Figure 6.3 Ginkgo leaves.

6% terpene lactones (with removal of the ginkgolic acids from any ginkgo preparations). The flavone glycosides neutralize free radicals and improve circulation by dilating small blood vessels and thereby are believed to protect brain cells from damage through oxygen deprivation. The diterpene ginkgolides are believed to antagonize activities of inflammation and blood clotting associated with a platelet-activating factor. A combination of these chemical compounds and their actions is believed to be responsible for this plant’s efficacy in improving blood circulation in the brain and application for use in slowing age-related cognitive decline. In a recent meta-analysis, researchers reviewed the efficacy and safety of Ginkgo biloba in the treatment of patients with dementia or cognitive decline. Overall, 33 relevant clinical trials were selected for review and all were randomized,


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double-blind controlled studies. The daily dose of ginkgo extract used in these studies varied from 80 to 600 mg. Treatment periods also varied from 3 to 52 weeks, with the majority being of 12 weeks’ duration. Most studies indicated positive results compared with placebo. Several rating scales or tests were used to assess ginkgo’s effect on cognition and included memory impairment, attention, concentration of mind, and speed of learning.

Ginseng Introduction Ginseng (Panax ginseng) is considered a tonic or adaptogen that enhances physical performance, relieves fatigue, promotes vitality, and increases resistance to stress. TCM considers ginseng to have beneficial effects on physical capacity, alertness, and power of concentration, especially in the elderly and those recovering from illness. Athletes also use it to enhance their “energy level.” (Figure 6.4) The ginsenosides are the major active compounds present in ginseng (P. ginseng). In the various Panax species, more than 30 ginsenosides have been identified. The type, number, and site of attachment of the sugars impart structural and functional variation among the ginsenosides. Among the Panax species, significant variation exists in both the types and ratios of ginsenosides. The most abundant ginsenosides in P. ginseng are Rb1 and Rg1 which generally occur in a ratio from 1 to 3. For example, in P. quinquefolius, the Rb1:Rg1 ratio is approximately 6:1; and Rb1 and Rb2 ginsenosides have been well documented to be higher and lower in concentration than those in P. ginseng. Figure 6.5 shows the structures of Rb1 and Rb2 and other ginsenosides. Several of their biological mechanisms are reviewed in detail.

Ginsenoside variation and standardization Ginsenoside content is standardized to 1.5%–7%. Dosages used in clinical studies are typically around 200 mg/day of extract, equivalent to 0.5–2 g of dried root per day administered for 2–4 months.

Ratio of Rg1 and Rb1 and the yin and the yang Ginsenosides are associated with the pharmacological activity of Panax species, yet the two key ginsenosides, Rb1 and Rg1, may

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Figure 6.4 Distinctive features of ginseng root.

mechanistically exert opposing activity: Rg1 is a weak stimulant of the central nervous system and considered to be “yang,” that is, more stimulating and energizing, whereas Rb1 is a depressant of the central nervous system and considered to be more “yin,” that is, more balanced, calming, and less stimulating. The extract from


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OR3 OH 20 12

3 R1O

6 R2

Ginsenosides

R1

R1

R3

PD or PT

Rb1

-Glc2-Glc

-H

-Glc8-Glc

PD

Rb2 Rc Rd Re Rf Rg1

-Glc2-Glc -Glc2-Glc -Glc2-Glc -H -H -H

-H -H

-Glc8-Ara(pyr) -Glc8-Ara(fur) -Glc -Glc -H -Glc

PD PD PD PT PT PT

Rg2

-H

-H

PT

-H -O-Glc2-Rha -O-Glc2-Glc -O-Glc -O-Glc2-Rha

Figure 6.5 Ginseng compounds.

P. ginseng, which has a predominance of Rb1, exerted a preventive effect in multiple cancer models. For example, American ginseng has a lower ratio of ginsenoside Rg1 to Rb1 than Asian ginseng, and is thus considered to be more “yin” (i.e., more balanced and less stimulating) than Asian ginseng.

Adaptogen and effects on exercise performance Although the mechanism underlying the alleged strength of ginseng on physical performance has not been defined, theories include stimulation of the hypothalamic–pituitary–adrenal cortex axis and increased resistance to the stress of exercise, enhanced myocardial metabolism, increased hemoglobin levels, vasodilation, increased oxygen extraction by muscles, reduced oxidative stress, and improved mitochondrial metabolism in the muscles, all of which theoretically could enhance aerobic exercise performance.

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Green tea Introduction The anticancer effects of tea are indicated both in animal in vivo studies and in human epidemiological observations. Numerous studies show an inverse association between tea consumption and cancer of the colon, urinary bladder, stomach, esophagus, lungs, and pancreas. Studies have attempted to link green tea to antioxidant benefits including protection against the damage caused by cigarette smoke, pollution, stress, and other toxins (Figure 6.6). The major polyphenol, belonging to the family of catechins and found in green tea, is (_)-Egg, with lesser amounts of catechin (C),

Figure 6.6 Leaves of Camellia sinensis (green tea).


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OH OH H O

OH

OH

H

O

OH

OH

O

OH OH

Figure 6.7 Chemical structure of the major green tea catechin, epigallocatechin gallate (EGCg).

epicatechin (EC), gallocatechol (GC), gallocatechol gallate (GCG), epigallocatechin (EGC), and epicatechin gallate (ECG). These polyphenols are among the dietary factors that may play a role in cancer protection, and have recently been shown to have potent antioxidant and antitumor effects. Green tea polyphenols have been reported to protect in varying degrees against certain cancers, including colon, rectal, bladder, breast, stomach, pancreatic, lung, esophageal, and prostate (Figure 6.7).

Anticancer mechanisms of action Various responses of specific cellular targets relating to cancer and Egg have been reviewed. Through in vitro cell culture experiments and animal studies, many potential mechanisms have been proposed for the chemopreventive effect of green tea and/or epigallocatechin gallate (EGCg). However, the exact mechanism(s) of anticarcinogenic activity remains to be found.

Inhibition of NADH oxidase activity A cell surface protein with NADH oxidase activity (ENOX2), which exhibits protein disulfide-thiol interchange activity, has been

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identified as the potential target for the anticancer action of green tea catechins and especially EGCg. Several studies in animals have shown promise of tea catechins as an adjunct cancer therapy. The use as an adjunct with conventional cancer treatment was indicative of survival benefits both for cancer protection and for slowing the growth and metastatic spread of established cancers. This study suggests a role of green tea as an aid for the prevention and control of cancer growth, metastasis and/or recurrence, and clearly warrants more clinical studies to determine a definitive role in cancer treatment.

Chinese Cordyceps: Winter Worm, Summer Grass Introduction The fruiting body of the Cordyceps sinensis has become the source of one of the most sought after herbal extracts in the world and has been collected almost to the point of extinction on the Tibetan plateau. The cordyceps has enjoyed immense popularity in the highly populated eastern China coming from areas of Tibet and Western China to the international market. It is hailed as one of China’s medical treasures. In China, the wild fungus is sold as medicine or food. It can be found packaged in small bundles, tied with thread, and often attached to the naturally myceliated larvae of the caterpillars. The fungus is eaten in soups or cooked with meats and is often administered to elderly patients recovering from illness. This seasonal, ancient Chinese extract has now become a popular fungal-based tonic reputed to address many illnesses and conditions. It is claimed that extracts of the fungus have been prescribed for illnesses ranging from headache to Asian flu to cancer. Historical note: The cordyceps grows on the Tibetan Plateau which would have been traversed by Marco Polo in following the trail of the Silk Road to the East. He wrote that on resting the yaks, which drew the caravan train, his animals became very frisky. The male yaks began mounting the female yaks in


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the pack. The yaks had been grazing on the hillsides but he did not realize that they had been eating the plentiful cordyceps. There are many tales in folklore about the fungus acting as an invigorating tonic. Reports suggest that the cordyceps was collected and made into medicinal teas by China’s early rulers. Other stories relate that only emperors were given the cordyceps at supper, when it was added to their duck soup, to give them the energy for nightly pleasures with concubines. In more recent times, its reputation gained even more prominence when the story broke that the national Chinese coach announced to the world the secret of the caterpillar fungus amid claims of a performance-enhancing nutrient taken by the Olympic Chinese athletes who broke world records at the 1993 China National Games in Beijing. However, today, this mushroom has been collected almost to extinction, yet through Chinese ingenuity it has been transformed into a health-giving, energy-boosting food available to the world.

Life cycle of Cordyceps sinensis In summer, the fruiting body appears as brownish-black “blades” that are about 3–6 cm long and found among grass growing at an altitude of 3,000 m on the Tibetan plateau (Figure 6.8). Apart from provinces of Sichuan and Yunnan in China, the mushroom is also found in Japan, Canada, and Russia. The cordyceps are fungi parasitic upon insect and arthropod larvae. The spores, which are present in the fungus infect the larva. Then the spores develop into a thin, thread-like “body” of the fungus which is called the mycelium. The mycelium consumes the host larva, eventually killing and mummifying it. Fungi feed by absorption of nutrients, which the filaments of mycelium find in their hosts. They are nongreen plants without chlorophyll and cannot photosynthesize their own food. One form of the mushroom, Cordyceps sinensis, is parasitic on the caterpillars of a moth which are colonized by the fungus underground. When the host dies, the mycelium of the fungus produces a fruiting body above ground which releases more spores to continue the life cycle (Figure 6.9).

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Figure 6.8 Fruiting body of Cordyceps sinensis grown on the Tibetan Plateau. “Winter Worm, Summer Grass”—the remarkable natural transformation of the mushroom, Cordyceps sinensis, which evolves from the caterpillar of a moth.

Perceived health benefits To examine if ancient medicines possess any therapeutic effects, it is often necessary to employ modern technology. In the case of Cordyceps, since it is believed to enhance energy and improve performance, athletes can be tested using an ergometer (Figure 6.10). Using the ergometer, it is possible to measure increases in VO2max (oxygen uptake). The idea is to measure the heart rate, pulse, and work output as measured by speed and distance on a stationary bicycle and the athlete is hooked up to a breathing apparatus which measures oxygen intake. Measurements indeed showed that the


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Figure 6.9 The fruiting body of Cordyceps sinensis (dark brown) protrudes from the earth and grows from the caterpillar of the moth a Paecilomyces hepialis (orange) (R Cooper collection).

oxygen intake increased when taking the cordyceps and the athletes’ capacity increased too. Most of the world’s supply of naturally produced fungus comes from China where an important industry has arisen providing income generation to relieve rural poverty. However, human consumption has been limited due to high price and short supply. Intensive research is being undertaken to generate sustainable supplies and meet the spiraling demand. As an alternative, fungal strains from natural Cordyceps sinensis were isolated and used to achieve large-scale production by fermentation. The fungus is grown in fermentation cultures as pure mycelia in the liquid phase in China and in the solid state on grains in the Western world.

Salvia (Danshen) Salvia is the largest genus of plants in the mint family. The name Salvia derives from the Latin salvere (“to feel well and healthy, health, heal”).

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Figure 6.10 An athlete on an ergometer where VO2max levels are measured after taking cordyceps. (From http://www.northeastcycling.com/ ne_mail.htm. Permission granted by D. Jansen.)

The outside of the taproot of Danshen, which is the part used in medicine, is red. Danshen is widely used in traditional Chinese medicine for treating chronic renal failure. The root (Radix Salvia miltiorrhiza) is used with the kudzu root (Radix Puerariae lobata) for the treatment of coronary heart disease in Chinese medicine. Danshen is one of five ingredients in tangzhiqing (TZQ) used in traditional Chinese medicine for treating diabetes. In studies with mice and in vitro studies, TZQ and a modified formula known as TZQ-F have shown positive results. The other ingredients of TZQ are red peony root, mulberry leaf, lotus leaf, and hawthorn leaf (Figure 6.11). Salvia miltiorrhiza (also known as red sage, Chinese sage, tanshen, or danshen, is a perennial plant in the genus Salvia highly valued for its roots in TCM. Native to China and Japan, it grows at an elevation of 90—1,200 m (300–3,900 ft.), preferring grassy places in forests, hillsides, and along stream banks. The specific epithet miltiorrhiza


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Figure 6.11 Salvia miltiorrhiza. (With permission from S. Foster.)

means “red juice extracted from a root.” Salvia miltiorrhiza has been widely used in China and, to a lesser extent, in Japan, the United States, and European countries for the treatment of cardiovascular and cerebrovascular diseases. In China, the specific clinical use is angina pectoris, hyperlipidemia, and acute ischemic stroke. A patented Chinese herbal medicine has successfully completed Phase II clinical trials in the United States and will soon begin Phase III, raising the possibility that it could become the first TCM product to obtain drug approval from the U.S. Food and Drug Administration (FDA). The product, Compound Danshen Dripping Pill (also referred to as “Cardiotonic Pill”), is produced by the Tianjin Tasly Pharmaceutical Co. Ltd. China. It contains the extract of the root of Danshen, as well as the extract of the root of notoginseng

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(Panax notoginseng; known as sanchi or tien-chi ginseng), and the chemical borneol. An antioxidant called salvianolic acid (or salvianolic acid B), isolated from Danshen, is under study for protection against cerebrovascular disorders. Dihydrotanshinone, tanshinone I and IIA are also under study for anticancer effects. Tanshinone IIA is one of the most abundant constituents of the root of Salvia miltiorrhiza which exerts antioxidant and anti-inflammatory actions in many experimental disease models. Tanshinone IIA (Tan IIA) has been widely used for various cardiovascular and cerebrovascular disorders in Asian countries. Tanshinone IIA might be a novel promising therapeutic agent for oxidative stress injury in neurodegenerative diseases. It may improve renal dysfunction associated with chronic kidney disease. Tan IIA was effective for attenuating the extent of brain edema formation in response to ischemia injury in rats. Results from animal and human studies support the use of Danshen for circulatory disorders to some extent because it is known to decrease the blood’s ability to clot in at least two ways. First, it limits the stickiness of blood platelets. It also decreases the production of fibrin, the threads of protein that trap blood cells to form clots. Both these effects help to improve blood circulation. In addition, chemicals in Danshen may relax and widen blood vessels, especially those around the heart. In animal studies, chemicals in Danshen may also have protected the inner linings of arteries from damage. Some other research suggests that it may increase the force of heartbeats and slow the heart rate slightly. In animal studies, Danshen appears to interfere with the development of liver fibrosis, the formation of scar-like fibers in the liver. Since the nonfunctioning fibers crowd out active liver tissue, liver function decreases gradually as the amount of fibrous tissue increases. Having chronic hepatitis and habitually drinking large amounts of alcoholic beverages are the major causes of liver fibrosis, which could also result from exposure to chemicals or certain drugs. Danshen may also increase blood flow into the liver, so the length of time that potentially damaging substances stay in the liver may be reduced, also reducing the possible injury they may cause. Results from a few animal studies showed that it may also protect kidney tissues from damage caused by diabetes. In China, Danshen has also been studied for treating acute


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O O

O

Figure 6.12 Structure of Tanshinone IIA.

pancreatitis, a painful and possibly dangerous inflammation of the pancreas (Figure 6.12).

Red yeast rice, Monascus purpureus Red yeast rice is a bright reddish purple fermented rice, which acquires its color from being cultivated with the fungus Monascus purpureus. White rice is fermented with Monascus purpureus. The process requires the sterilization of washed rice adjusted to pH 3–5 with vinegar and the rice to be washed to remove excess acid; then the moist rice is partially cooked (steamed) for several days in the presence of the fungus with turning and aeration leading to the final product.

Historical note: Traditionally from both the Tang and Song Dynasties, RYR has been used as a preservative and as a coloring and flavoring agent in fish and meat. In the Ben Cao Gang Mu, Li Shi-zhen (1590), a detailed medical usage is described as mild, slightly pungent, and sweet. The functions include an increase of vitality, promote good indigestion, relieve gastrointestinal distress, prevent diarrhea, and improve blood circulation. One traditional formula to improve digestion requires the grinding of equal amounts of RYR together with Cyperus rotundus and Boswellia carteri into a powder, mixing with rice wine, and drinking it after heating.

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In modern times, chemical analysis of RYR reveals the presence of natural chemicals known as monacolins, particularly monacolin K (chemically identical to lovastatin). Their pharmacological function is to inhibit cholesterol production in the liver. These results were supported further by the clinical trials performed on the red yeast rice product. In a double-blind, placebo-controlled clinical trial (Heber et al., 1999) over a 12-week period, with participants presenting with hyperlipidemia, the total cholesterol concentrations of the RYR-treated group decreased greatly compared with the placebo-treated group (Figure 6.13).

Dong quai, Angelica sinensis Angelica sinensis, commonly known as dong quai or “female ginseng,” is a herb from the family Apiaceae, indigenous to China. The dried root of Angelica sinensis is commonly known as Chinese angelica and is widely used in Chinese traditional medicine for gynecological ailments, fatigue, mild anemia, and high blood pressure. The plant’s phytochemicals consist of coumarins, phytosterols, polysaccharides, ferulic acid derivatives, and flavonoids. It has antioxidant activity. It is often used in premenstrual syndrome formulas as well as menopausal formulas. However, this herb is not recommended during pregnancy due to possible hormonal, anticoagulant, and antiplatelet properties. Animal research has noted conflicting effects on the uterus, with reports of both stimulation and relaxation. Dong quai is traditionally viewed as increasing the risk of miscarriage. More evidence is needed to rate the effectiveness of dong quai for these uses. How does it work? The Dong quai root has been shown to affect estrogen and other hormones in animals. It is not known if these same effects happen in humans. Dong quai might slow blood clotting. However, it has been shown that taking Dong quai along with medications that also slow clotting might increase the chances of bruising and bleeding. For early orgasm in men (premature ejaculation), a multiingredient cream preparation containing P. ginseng root, Dong quai, Cistanches deserticola, Zanthoxyl species, Torlidis seed, clove flower, Asiasari root, cinnamon bark, and toad venom was applied to the glans penis 1 h before sex and washed off immediately before sex.


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Figure 6.13 Structures of statins.

Garlic The applicable part of garlic Allium sativum L. (Alliaceae) is the bulb and the pharmacological effects of garlic are attributed to allicin, ajoene, and other organosulfur constituents such as S-allyl-l-cysteine.

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A wide variation exists in the chemical composition of garlic products, reflecting differences in processing. The constituent profile of garlic is unique and complex, being particularly rich in sulfur-containing compounds. The main constituents of garlic include cysteine sulfoxides (0.6%–1.9%) of which the most abundant is alliin (S-allylcysteine sulfoxide), representing up to 14 mg/g fresh weight of cloves, followed by the S-methyl analog (methiin), which occurs in quantities of up to 2 mg/g, followed by S-trans-1-propenylcysteine sulfoxide (isoalliin) at about 0.5 mg/g. The glutamylcysteines (0.5%– 1.6%) are represented by S-allyl and the S-trans-1-propenyl analogs, which are the most abundant. Other organosulfur components include the scordinins, a family of structurally related compounds to the thioglyco-phosphopeptides. Garlic is also noted for its very high content of fructans or fructosans, which account for up to 65% of its dry weight, and the total carbohydrate content can reach 77%. Free amino acids, of which arginine is the most prevalent, constitute 10–15 mg/g fresh weight in the garlic cloves. Numerous research papers describe the use of garlic as a cholesterol-lowering agent, and several as an immune-stimulating agent. Other activities such as anti-atherosclerotic, antithrombotic, anticancer, and antioxidant, as well as the antimicrobial and detoxifying effects of garlic, are well documented in the literature and beyond the scope of the present review.

Use of garlic in cardiovascular disease models Garlic (Figure 6.14) possesses pharmacological conditions, which include hypertension, hyperlipidemia, prevention of coronary heart disease, as well as age-related vascular changes, atherosclerosis, reducing re-infarction and mortality rate post-myocardial infarction. A recent focus of attention has been on the mechanism of action of how garlic lowers total cholesterol, low-density lipoproteins and triglycerides, and increases high-density lipoprotein cholesterol. There is substantial clinical evidence that shows that consumption of the equivalent of one-half to one clove of garlic daily leads to a decrease of 9%–12% in serum cholesterol and average decrease in serum triglycerides of about 13%. Over 50 clinical studies have been conducted on the lipid lowering effects of garlic, of which at least 19


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Figure 6.14 Garlic. (With permission from collection of Steven Foster.)

(including 1275 patients) have been included in two meta-analyses. Clearly, various garlic preparations exhibit different antilipidemic effects. In rodents, oral and intraperitoneal administration of raw garlic (50–500 mg/kg) has a very significant effect in reducing glucose, cholesterol, and triglycerides, whereas boiled garlic has little effect on these parameters. In two separate studies, solvent-extracted garlic and sulfur compounds given to patients with hyperlipidemia lowered cholesterol levels and the researchers suggested that the effects resembled those of HMG-CoA reductase inhibitors. One of the constituents in fresh garlic and in solvent extracts

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is S-allyl-l-cysteine, which is also present in a large amount in aged garlic extract. This material typically contains 19% of the S-allyl cysteine found in the original cloves. This compound is a potent inhibitor of hepatic cholesterol synthesis. Recent research suggests that the site of inhibition is downstream of lanosterol synthesis, as HMG CoA reductase does not appear to be affected. The accumulation of methyl sterols was detected using gas chromatography in cultured hepatoma cells treated with fresh garlic macerates, suggesting that 4a-methyl oxidase is the principal enzyme inhibited in cholesterol synthesis. It has been concluded that all garlic compounds sharing an allyl-disulfide or allyl sulfhydryl group appear to be inhibitors of the enzyme. An additional benefit of allyl sulfides in garlic preparations is LDL oxidative prevention. Many compounds share this activity including S-allyl cysteine, S-allyl mercaptocysteine, alliin, allixin, and N-acetyl-S-allyl cysteine, a metabolite of S-allyl cysteine. For hypertension, garlic is thought to reduce blood pressure by two mechanisms: (a) causing smooth muscle relaxation and vasodilation by activating the production of an endothelium-derived relaxation factor and (b) inhibition of angiotensin- converting enzyme, although the latter effects have not been demonstrated conclusively in vivo and are not observed with all garlic preparations.

Ephedra, Ephedra sinica Ephedra comes from the plant Ephedra sinica, known in Chinese as Ma Huang (Figure 6.15) and have been used in TCM for 5,000 years for the treatment of asthma and hay fever as well as for common cold. In TCM, the leaves rather than the stem are used and clinically the dose is between 3 and 10 g. The main purpose of using this drug clinically is to expel the exogenous cold pathogens by promoting perspiration. The stem, on the other hand, stops the sweat. However, TCM practitioners have observed that for some people their heart beats become faster after taking ephedra. This is an important observation and should be regarded as an adverse reaction. Furthermore, in the West, ephedra, in a concentrated pill form, was offered as part of a weight loss program. It was believed that by increasing the body’s metabolism, there were fat-burning


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Figure 6.15 Ephedra sinica.

effects. However, the medical community questioned the safety of ephedra as a result of reports of serious side effects and ephedra-related deaths. As a direct consequence, FDA banned the sale of ephedra-containing supplements in 2004. The sale of ephedra-containing dietary supplements is currently illegal in the United States.

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Further suggested reading Blumenthal M. 1998. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. German Federal Institute for Drugs and Medical Devices. Commission E. American Botanical Council, Austin, TX. Blumenthal M. 2001. The ABC Clinical Guide to Herbs. American Botanical Council, Austin, TX, pp. 335–349. Wang LK, Itokawa H, Morris-Natschke SL. 2000. Current perspective on Chinese medicines and dietary supplements in China, Japan, and the United States. Journal of Food and Drug Analysis 8: 219–228. Weisburger JH. 1997. Tea and health: A historical perspective. Cancer Letters 114: 315–317. World Health Organization. 1999. WHO Monographs on Selected Medicinal Plants. World Health Organization, Geneva, Switzerland.

Suggested reading on Ginkgo Birks J, Grimley EJ. 2004. Ginkgo biloba for cognitive impairment and dementia (Cochrane Review). In: The Cochrane Library, Issue 1. John Wiley & Sons, Ltd. Mix JA, Crew WD. 2002. A double-blind, placebo-controlled, randomized trial of Ginkgo biloba extract EGb761 in a sample of cognitively intact older adults: neuropsychological findings. Human Psychopharmacology 17: 267–277. Stromgaard K, Vogensen SB, Nakanishi K. 2005. Ginkgo biloba. In: Encyclopedia of Dietary Supplements, Eds. PM Coates, MR Blackman, and GM Cragg. Marcel Dekker Inc., New York. pp. 249–257.

Suggested reading on Ginseng Fulder SJ. 1990. The Book of Ginseng. Healing Arts Press, Rochester, VT. Hobbs C. 1996. Ginseng, the Energy Herb. Interweave Press, Inc, Loveland, CO. Sengupta S, Toh SA, Sellers LA et al. 2004. Modulating angiogenesis: the yin and the yang in ginseng. Circulation 110: 1219–1225. Tang W, Eisenbrand G. 1992. Panax ginseng. In: Chinese Drugs of Plant Origin, Ed. CA Myer. Springer, Berlin, pp. 711–737.

Suggested reading on Green tea Cooper R, Morré DJ, Morré DM. 2005. Medicinal benefits of green tea. Part I: Review of non-cancer health benefits. Journal of Alternative and Complementary Medicine 11: 521–528.


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Cooper R, Morré DJ, Morré DM. 2005. Medicinal benefits of green tea. Part II: Review of anti-cancer properties. Journal of Alternative and Complementary Medicine 11: 639–652. Hara Y. 2001. Green Tea: Health Benefits and Applications. Marcel Dekker Inc., New York. Mitscher LA. 1998. The Green Tea Book. Avery Publishing Group, New York.

Suggested reading on Cordyceps Ophiocordyceps sinensis in China. 2010. Edited by the Grassland Monitoring and Management Center, Ministry of Agriculture. ISBN:9877501192144.

Suggested reading on Salvia Clebsch B, Barner CD. 2003. The New Book of Salvias. Timber Press, Portland. Wu B, Liu M, Zhang S. 2007. Dan Shen agents for acute ischaemic stroke. Cochrane Database of Systematic Reviews 2004(4). Zhou L, Zuo Z, Chow MS. 2005. Danshen: An overview of its chemistry, pharmacology, pharmacokinetics, and clinical use. Journal of Clinical Pharmacology 45(12): 1345–1359.

Suggested reading on Garlic Agarwal KC. 1998. Therapeutic actions of garlic constituents. Medical Research Reviews 16: 111–124. Lawson LD, Upton R, Graff A et al. 2005. Garlic bulb, Allium sativum, analytical, quality control, and therapeutic monograph. In: American Herbal Pharmacopoeia and Therapeutic Compendium, Eds. R Upton, A Graff, and D Swisher. Santa Cruz, Philadelphia, PA. Lawson LD. 1998. Garlic: A review of its medicinal effects and indicated active compounds. In: Phytomedicines of Europe: Chemistry and Biological Activity, Eds. LD Lawson and R Bauer. American Chemical Society Books, Washington, DC, pp. 176–209. Rahman K, Lowe GM. 2006. Garlic and cardiovascular disease: A critical review. Journal of Nutrition 136: 736S–740S.

chapter seven

TCM safety and regulations TCM safety concerns Although rich in folklore and used over many centuries, TCM has not been thoroughly examined using Western-developed biological criteria, nor has it been clinically evaluated in much detail outside of China and Asia. Furthermore, by looking at the earliest records regarding the use of medicinal herbs to the present day, the toxicity of certain substances has been described in all Chinese Materia Medica. Since TCM has become more popular in the Western world, there are increasing concerns about the potential toxicity of many traditional Chinese medicinal plants including plants, animal parts, and minerals. Traditional Chinese herbal remedies are conveniently available from food and health outlets in most Chinese neighborhoods; yet some of these items may contain toxic ingredients; they are sometimes imported into the United States illegally, and are associated with claims of therapeutic benefits without evidence. For most Chinese medicinal plants, efficacy and toxicity testing are based on traditional knowledge rather than laboratory analysis. Traditional herbal medicines can contain extremely toxic chemicals and heavy metals, and naturally occurring toxins, which can cause illness, exacerbate preexisting poor health conditions, or result in death. Botanical misidentification of plants can cause toxic reactions in humans. The description of some plants used in TCM has changed, leading to unintended intoxication of the wrong plants. A further concern is also the possibility of contaminated herbal medicines with microorganisms and fungal toxins, including aflatoxin. Traditional herbal medicines are sometimes contaminated with toxic heavy metals, including lead, arsenic, mercury, and cadmium, which inflict serious health risks to consumers. Substances known to be potentially dangerous include Aconitum, certain fungi, and Aristolochia and Asarum species. In another example, to avoid the toxic and adverse effects in Xanthium sibiricum, this plant must be processed very carefully. Furthermore, hepatotoxicity 97

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has been reported with products containing Polygonum multiflorum, glycyrrhizin, Senecio, and Symphytum. Other herbs indicated as being hepatotoxic include Dictamnus dasycarpus, Astragalus membranaceous, and Paeonia lactiflora. However, many adverse reactions are due to the misuse or abuse of Chinese medicine. For example, the misuse of the dietary supplement Ephedra (containing ephedrine) can lead to adverse events including gastrointestinal problems as well as sudden death from cardiomyopathy. Products adulterated with pharmaceuticals for weight loss or erectile dysfunction are one of the main concerns. Chinese herbal medicine has been a major cause of acute liver failure in China.

Toxic compounds and contaminants in TCM herbs TCM has been used extensively in Chinese communities for a very long time, and is generally believed to be safe, because most of the materials used are natural and their safety has been verified through a long history of use. However, despite the popularity, adverse events have been related to the consumption of TCM herbs. Owing to good record keeping in Hong Kong, these adverse events have been documented in the Chinese communities every year. In fact, it should be noted that many plants contain toxic compounds, some of which are used in TCM. However, the ancient wisdom described the use of various processing methods to remove these toxic compounds before designing a final formula or the dose amounts were limited so that the herbs could be used safely. Thus, if these herbs are used without proper processing or without the guide of TCM knowledge as outlined in the Chinese Materia Medica or in modern monographs, then poisoning may occur, resulting in reported adverse events. In this chapter, some well-known toxic herbs used in TCM are chosen to highlight the potential hazards involved. Also, there have been some case reports where TCM products have been found to be contaminated with Western drugs, resulting in a health risk for certain TCM-based health products.

Aristolochia and Asarum species The plants Aristolochia and Asarum were inadvertently used as part of a slimming treatment in the 1990s. The plants had been used effectively and safely for about 15 years without any problems.

Chapter seven: TCM safety and regulations

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The slimming program included regular intake of a weight loss pill, which included these herbal components. For some reason in the summer of 1990, the formulation was changed with the introduction of two more Chinese herbs, Stephania tetrandra radix and Magnolia officinalis cortex. Traditionally, Stephania tetrandra radix is used as a “diuretic” while Magnolia officinalis cortex promotes the movement of qi and resolves stagnation and abdominal distention. They are not used for weight loss, and nor are they recommended for prolonged use, in accord with TCM practices. It was perhaps thought that adding these two herbs would reduce the retention of fluid and excess nutrition, and hence lead to weight loss. However, these new preparations led to a surge of incidents of patients being diagnosed with interstitial nephritis of unknown origin. Some patients were hospitalized and underwent dialysis. The coincidence of the introduction of these new herbs to the weight loss pill and the unusual increase in incidence of kidney damage strongly pointed to the introduction of these Chinese herbs into the formulation. Analytical and chemical analysis of the formulation and the individual Chinese herbs contained in the products revealed the presence of chemicals known as alkaloids. The alkaloid profiles were different from the original formula used before 1990. It was determined that the toxin aristolochic acid (Figure 7.1) was found in the weight loss product. Instead of using Stephania tetrandra radix to make the product, another herb Aristolochia fangchi was used. This may have occurred because the Chinese name O O

O

OH NO2

OCH3

Figure 7.1 Structure of aristolochic acid.

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of Stephania tetrandra (Han Fang Ji) is very similar to that of A. fangchi, which is known as Guang Fang Ji. The similarity in these Chinese names may have caused one herb to be accidentally replaced by the other one, due to a confusion in pronunciation and this remains a critical issue when the herbs are being traded outside China. The compound has been found in some of the plant species in the Aristolochia and Asarum genus in the family of Aristolochiaceae and may cause rapid interstitial nephritic fibrosis, cancer, and testis toxicity. A number of Aristolochiaceae plants have been used in TCM, for example, Aristolochia debilis (also known as Madouling). The Chinese name refers to the shape of the fruit which looks like a horse bell, and the fruit is used for clearing the lung and lowering adverse qi and relieving cough and asthma. The aerial part of Aristolochia debilis is called Tianxianteng, which it can promote qi and blood circulation, removing obstruction in channels and relieving pain, while the root is called Qingmuxiang, which can promote qi circulation and alleviate edema. In the case of Aristolochia manshuriensis, the vine of the plant is called Guanmutong, and A. fangchi, the root is called Guangfangji. The kidney damage due to the intake of excessive aristolochic acid is known as aristolochic acid nephropathy (AAN). An incident similar to the case reports described above was reported in Belgium. Many of the AAN cases were due to the confusion in the nomenclature of these Aristolochia species with other herbs. For example, A. manshuriensis is known as Guanmutong in Chinese and there is another herb known as Mutong which is the stem of Akebia quinata or Akebia trifoliate. A. fangji (Guangfangji) may be confused as Fangji (root of Stephania tetrandra). With the known toxicity of aristolochic acid, since 2005 herbs containing aristolochic acid, except Madouling, Tianxianteng, and Xixin (root and rhizome of Asarum heterotropoides, Asarum sieboldii spp.), are no longer listed in the Chinese Pharmacopeia. It should be noted that in Hong Kong, the Department of Health has banned all sales of herbs from the genus Aristolochia or products containing these herbs. Since 2004, a further restriction has been announced, whereby only the root and rhizome of Xixin can be used as medicinal materials due to its harmful effects. Table 7.1 summarizes the major herbs belonging to the Aristolochiaceae family.

Fruits of Aristolochia debilis Siebold & Zucc. or A. contorta Bunge

Species

Function in TCM

Madouling

Clearing lung and lowering adverse qi, relieving cough and asthma, relieving hemorrhoids Tianxianteng Aerial parts of Aristolochia debilis Siebold & Promoting qi and blood circulation, Zucc. or A. contorta Bunge removing obstruction in channels and relieving pain Qingmuxiang Roots of Aristolochia debilis Siebold & Zucc. Suppressing hyperactive liver and or A. contorta Bunge relieving pain, detoxifying, and promoting the subsidence of swelling Guangfangji Roots of A. fangchi Y.C.Wu ex L.D. Chou et Expelling wind and relieving pain, S.M. Hwang clearing heat and diuresis Hanzhongfangji Roots of Aristolochia heterophylla Hemsl. Expelling wind and relieving pain, clearing heat and diuresis Guanmutong Vine of A. manshuriensis Kom. Clearing heart fire, promoting diuresis, clearing meridians, and promoting lactation Xungufeng Whole herb of Aristolochia mollissima Hance Expelling wind, activating the circulation of channels, relieving pain Nanmuxiang Vine of Aristolochia calcicola C. Y. Wu or Regulating qi and relieving pain, Aristolochia yunnanensis Franch. expelling wind and promoting blood circulation

Chinese name

Table 7.1 Plants with medicinal functions in the aristolochiaceae family

(Continued)

−

+

+

+

+

+

+

+

Contains aristolochic acids

Chapter seven: TCM safety and regulations 101

Jinerhuan

Xixin

Duheng

Chinese name

Function in TCM

Expelling wind, dispelling cold, relieving pain. Slightly toxic Roots and rhizome of Asarum heterotropoides Expelling wind and dispelling cold, dispelling wind and relieving pain, Fr. Schmidt var. mandshuricum (Maxim.) stimulating meridians, warming lungs, Kitag., Asarum sieboldii Miq. var. seoulense and dissipating phlegm Nakai or Asarum sieboldii Miq. Roots and rhizome of Asarum insigne Diels Expelling wind and dispelling cold, reducing swelling and easing pain, dissipating phlegm. Mildly toxic

Whole herb of Asarum forbesii Maxim.

Species

Table 7.1 (Continued) Plants with medicinal functions in the aristolochiaceae family

+

+

+

Contains aristolochic acids

102 Chinese and botanical medicines


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The toxic Aconitum plants Aconitum, also known as aconite, is a genus of herbaceous perennial plants under the family of Ranunculaceae. Most of these plants grow in the mountainous area of the northern hemisphere. They are highly toxic as they contain aconitum alkaloids which affect the functions of the cardiovascular and nervous systems. Ingestion of excessive amount of these plants could be fatal. Aconitine (Figure 7.2) and related alkaloids, mesaconitine, hypaconitine, and yunaconitines are some of the well-known aconitum diester diterpene alkaloids responsible for the toxicity. Despite the toxicity of Aconitum plants, they have been used as traditional medicines for long periods. In the Chinese Pharmacopeia of 2015, the root tubers of two plant species, Aconitum kusnezoffii and Aconitum carmichaeli, are included. The root of Aconitum kusnezoffii is known as Caowu in Chinese. The other main root of Aconitum carmichaeli is known as Chuanwu in Chinese, which means the plant is grown in Sichuan Province while the lateral root or the side root is known as Fuzi. In fact, many ancient Chinese medicine formulas include Fuzi. Some Chinese practitioners even consider Fuzi as the Four pillars of Chinese herbs or Chief of the Herbs, suggesting the unique therapeutic effects of Fuzi in helping the body to store the yang qi and restoring the energy of the patients. Depending on the dosage of Fuzi, the herb can be used to supplement fire, assist the yang and warm the meridian, dispel the cold and dampness, and relieve pain. Today, it is estimated from both historical literature and modern clinical reports that the number of TCM formulations comprising O O O

OH O

N O

HO

Figure 7.2 Structure of aconitine.

OH O

O

O

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Aconitum is about 600. The most commonly used herbal products containing Aconitum in the market, particularly in China, are Fuzi Lizhong decoctions and the Jingui Shenqi Pill. The toxicity of these Aconitum herbs has been known for a long time. For example, Fuzi has been classified in the “low” category in the “Shen Nong’s Classic of Medicinal Herbs” in the Western Han Dynasty (about 200–250 AD) indicating the absence of potential hazards of the material and prolonged use. However, through systematic observations of their effects inside the body, the ancient wisdoms found ways to process the herbs to reduce further the toxicity to safe levels. Thus, the raw herb needs to be soaked for a long period in water, later with salt, and heated to dryness, which lowers the toxic effect before use. Different processing methods include soaking in concentrated mineral salt liquid for several days, then boiling and rinsing with water to make the “half-processed Fuzi.” Further processes to achieve different types of decoction pieces like Baifupian are achieved when the “half-processed Fuzi” is cut into slices, soaked in water and rinsed, steamed and dried. In another approach, Danfupian is accomplished by boiling the “half-processed Fuzi” with Glycyrrhizae radix, black beans, and water until the center is thoroughly cooked and there are no numbness-like feelings on the tongue when tasted. This treatment can significantly lower the aconitum alkaloid content in the herb. Traditionally, when processed Fuzi is used in a formula, it is boiled for 2 h before other herbs are added. The prolonged boiling in the processing and in the preparation of a decoction turns the major toxic components, the diester diterpene alkaloids, into monoester diterpene alkaloids, with significant reduction in overall toxicity. Unfortunately, poisoning cases have been reported in Asia, as well as China and Hong Kong, even with detailed information about the proper processing of these Aconitum herbs. In China, intake or overdose of tincture is the major cause of Aconitum poisoning cases. A study examining the reports of Aconitum poisoning in Mainland China during the period 1989–2008 showed that the tincture accounted for 55.5% of the cases while consumption of decoctions accounts for only ∼11% of the poisoning cases. However, by focusing only on hospital-based studies, the tinctures account for ∼80% of the poisoning cases. In Hong Kong, the poisoning usually arises from the intake of the decoction containing the herb. There were about 25 incidents of


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Aconitum poisoning reported per year during the period 1989–1991. The number decreased significantly after public education on this issue by late 1991. However, the number increased again to about 19 incidents per year reported during the period 2008–2010. The details on pre-decoction boiling of the root of Aconitum herbs are not known, but it is quite clear that overdoses and use of inadequately processed herbs were the main causes of the more recent cases. Other emerging causes of poisoning cases due to the aconitum herbs are due to mixing with other Chinese herbs. In May 2010, a woman was admitted to the intensive care unit (ICU) in Hong Kong after taking a Chinese medicine decoction. The formulation did not contain any aconitum herbs; however, experts recognized the presence of some aconitum herbs in the prescribed formula that remained after preparing the decoction, confirmed by further chemical analysis, identifying the presence of aconitum alkaloids in the formulation. Thus, it was declared that one of the herbs was contaminated with aconitum herbs. Owing to the potential danger of the aconitum herbs, in Hong Kong, guidelines from the Department of Health, HKSAR government and information from the Chinese Pharmacopeia now recommend the intake to be limited to small amounts (1.5–3 g), the critical inclusion of prolonged boiling, to avoid the intake or use of tincture, and to avoid any intake of unprocessed Fuzi (same as in Caowu and Chuanwu).

Datura metel L. Daturae flos is the dried flower of Datura metel L. (Solanaceae). In TCM, the use of Daturae flos was first recorded in the Compendium of Materia Medica. It is described as a herb that tastes pungent, is warm in nature, and toxic. Its function is to reduces cough symptoms, alleviate pain, and relieve spasms and twitching. Daturae flos is believed to be the main ingredient of the famous Mafeisan or foamy narcotic powder, which was the first anesthesia invented by the Chinese Medicine doctor Hwa Tuo in the Eastern Han Dynasty (25–220 AD). Except in the use of TCM, different parts of Datura metel, for example, the leaves, are being used in other parts of the world such as India and Africa as traditional medicine. Since Datura contains tropane alkaloids (Figure 7.3), it may cause anticholinergic poisoning symptoms, including visual

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Chinese and botanical medicines 2

1 7 N

8

3

6 5

4 7

6

3

1 2 4

5

N 8

Figure 7.3 Chemical structure of tropane.

hallucination, confusion, disorientation and slurring of speech, clumsy movements, and weakness in the limbs. Tropane alkaloids are classified as bicyclic [3.2.1] alkaloids. They are secondary metabolites. Tropane alkaloids occur naturally in many members of the Solanaceae family and act as anticholinergics or stimulants. In Hong Kong or in China, the reported toxicity incidents caused by Daturae flos were due to the misidentification of Daturae flos as Campsis grandiflora.

Xanthium sibiricum poisoning Fructus xanthii or Cangerzi is the dried ripe fruit and involucre of Xanthium sibiricum Patrin ex Widder (Asteraceae). It had been used in Chinese Medicine to expel wind-cold, clear the nasal passage, and expel wind and dampness. Hepatotoxicity and acute renal failure have been reported due to an overdose and prolonged usage of Cangerzi. Two hepatotoxic compounds of diterpenoid glycosides in Cangerzi have been identified as atractyloside (Figure 7.4) and carboxy-atractyloside. In the health guidelines issued by the Department of Health, HKSAR government and Chinese Pharmacopeia, it is recommended that Cangerzi should be properly processed to reduce the toxicity. This procedure requires stir-frying until yellow-brown on the surface. Studies have shown that using this process leads to a significant reduction in the amount of hepatotoxic compounds.

Chapter seven: TCM safety and regulations O

O Na+

O

S

O

O

S

O

Na+

O–

O

107

OH H

O

O O

O

H HO

OH

O

Figure 7.4 Structure of atractyloside.

Chinese medicinal products As shown in the above examples, most of the adverse effects reported arise when the Chinese medicines are consumed as decoctions. Owing to the confusion created by common names or contamination, the potentially toxic herbal materials are introduced into the formula. Inappropriate quality controls during processing, even if unintentional, may lead to cases of overdosing and poisoning. For the Chinese medicinal products, also known as proprietary Chinese medicine, coming from licensed manufacturers, confusion or contamination due to potentially toxic herbs is rare. However, other safety issues arise and are illustrated in the following two cases.

Po Chai Pills This is a very famous proprietary Chinese medicine that is well accepted for use in Hong Kong. It was produced by a renowned Chinese Medicine manufacturer, Lu Chung Shing Tong, producing medicines for more than a century. Po Chai Pills is a formula containing over 10 herbs and used to promote gastrointestinal health. It was first manufactured in Foshan in 1896 and the operation moved to Hong Kong after the Chinese Civil war. This product has been well received by the Chinese communities in Hong Kong and other parts of the world. However, upon inspection, the product was found to contain trace amounts of two Western drugs, namely phenolphthalein and

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sibutramine. The product was recalled from the market in Singapore and later from Hong Kong by March 2010. Phenolphthalein is a drug used for treating constipation which had been banned from the market in 2001, as it is carcinogenic. The presence of sibutramine was even more surprising, as it is an appetite suppressant drug and does not relate to the indication of the product at all. The manufacturer called for a thorough investigation of the manufacturing process and it was discovered that only the more recently developed dosage form, the capsule form, was contaminated. The capsule form required the herbs to be ground into fine powders for small pill dose preparations in contrast to the traditional forms. The new pills could not be prepared in the manufacturer’s own facilities and were outsourced to achieve the desired powder size of the herbal materials for the capsule. It was this outsourced material that was contaminated. Contamination must have entered at this stage and all production and development of the capsule form ceased because of these incidents. Only after safety and quality controls were introduced was production of the traditional pills allowed to resume in May 2010. All evidence suggested that none of the traditional pills were found to be contaminated by the Western drug.

PC-SPES Safety incidents related to herbs are more common when quality procedures are not in place or not followed. In the past, manufacturers have taken shortcuts and not followed the advice of the quality control experts and professional knowledge to prepare safe products. It might appear that safety incidents related to herbal products only appear in Asia, but as the popularity of using herbs increases, quality issues may appear in other regions. A case which occurred in the United States is discussed below. A herbal product called PC-SPES was circulated in the market between 1996 and 2001. PC in PC-SPES refers to prostate cancer while SPES means hope in Latin. It was developed by Dr. Sophie Chen and her brother, Dr. Allan Wang, who was the director of TCM at Shanghai Medical University, based on an existing TCM formula for the treatment of urologic problems. The researchers modified the ingredients and developed a formula, which kills cancer cells taken from prostate cancer patients.


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The first patient to use PC-SPES was Chen’s brother-in-law, a physician in Taiwan who had advanced prostate cancer but was alive and well 10 years later. News of the apparent success of the formulation spread by word of mouth, first in Taiwan, then internationally, leading Chen to license the patent to BotanicLab for commercialization. PC-SPES is a formula consisting of seven Chinese Materia Medica and a foreign herb, Saw Palmetto, which is a well-known botanical plant in the West and used to improve prostate health. The seven Chinese Materia Medica are Rabdosia (Rabdosia rubescens), Skullcap (Baikal Skullcap) (Scutellaria radix), Dyer’s Woad (Isatis Radix), San-Qi Ginseng (Pseudoginseng Radix), Mum (Dendrantherma folium), the mushroom Reishi (Ganoderma lucidum), and Licorice (Glycyrrhizae radix). The first three herbs are used in TCM and have anticancer activities. Ganoderma lucidum and Notoginseng are believed to improve the immune system. Clinical studies in the United States were first conducted in 1996 using PC-SPES samples provided by BotanicLab. For patients who had failed in conventional hormone treatment, there was little effective treatment available but with treatment using PC-SPES, clinicians were amazed that 50% of these patients had reduction in pain as well as prostate-specific antigen (PSA) levels after taking the product. These preliminary results stimulated interest in further study of the formula. PSA is a glycoprotein enzyme which is needed for the ejaculation of sperm in males. It is also detected in serum of healthy individuals; however, higher serum levels are detected in individuals with prostate cancer or other prostate disorders. Prostate cancer cells may have androgen receptors for its survival. Hormone therapy is usually used to treat these androgen-dependent (AD) prostate cancers. However, the AD prostate cancer may become resistant to the hormone therapy (androgen independent, AI) and resume growth after a few years of treatment. The treatment options for AI prostate cancer are scarce. Several reports suggested that PC-SPES might be helpful to treat AI prostate cancer. However, in the follow-up clinical studies, some of the patients receiving PC-SPES began to experience breast enlargement and tenderness, and loss of libido, responses usually associated with an estrogen treatment. An analysis of the PC-SPES in 1998 suggested that the active ingredients are distinct from some well-known estrogens including

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diethylstilbestrol, estrone, and estradiol. This stimulated further studies to isolate and identify the active compounds and some researchers at first considered that the compounds such as baicalin or licochalcone A were responsible for the biological activity. In 2001, a patient became unconscious due to profound bleeding after unsupervised use of PC-SPES at a dosage double the recommended amount over a 1-month period. Warfarin was found in the serum of the patient collected at the time the patient was admitted to hospital. This immediately led to a more in-depth study of the chemical compositions of the product, and in 2002 the active principles in the product were identified and quantified in eight lots of PC-SPES, manufactured from 1996 through mid-2001. Licochalcone A and baicalin from Glycyrrhizae radix and Scutellaria radix, respectively, were quantified. However, three pharmaceutical agents in the market were also detected in these samples from different lots. The agents were identified as diethylstilbestrol, indomethacin, and warfarin. Diethylstilbestrol is a synthetic estrogen, thus an endocrine disruptor. It has been used for various medical purposes and one major indication is against prostate cancer. The content was found to be higher in earlier lots and progressively became lower in later lots. Indomethacin is a nonsteroidal anti-inflammatory drug reported to enhance chemotherapeutic drug efficacy. The amount of indomethacin also decreased in later batches. Warfarin is the most widely prescribed oral anticoagulant drug in the United States, yet it requires careful supervision by medical professionals because of the possible interactions with many commonly used drugs and certain foodstuffs that might enhance or reduce its anticoagulation effect. In particular, the dosage of warfarin requires careful monitoring to make sure that the anticoagulation is sufficient but not too much. PC-SPES was circulated as a health product, but the adulteration of Western drugs, particularly warfarin, resulted in a press release from the Health authority asking people to stop using PC-SPES. BotanicLab recalled their products in February 2002 and ceased operation later that year. Studies on PC-SPES are still ongoing as results suggest that although it contains diethylstilbestrol, a drug for prostate cancer, the amount is much lower than the recommended dose, particularly in batches produced in 2000 and 2001. A comparison between the effects of PC-SPES and diethylstilbestrol has also been conducted,


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suggesting that PC-SPES is superior to the latter. However, the incident has generated a very negative impact on the use of herbal supplements in North America. Herbs are natural and many of them are safe. However, the incidents introduced in this chapter are a reminder that there are some hazardous components present in herbs. It is important that TCM should be consumed after consultation with qualified personnel as there are precautions recorded in the literature which consumers should be aware of. It is also important for manufacturers to establish quality control standards to make sure that the products are safe and consistent. This is certainly a necessary cornerstone to secure the validity of the conclusions of a systematic scientific study devoted to them.

Further suggested reading Li S, Luo X. 2003. Compendium of Materia Medica (Bencao Gangmu). Bencao Gangmu. Foreign Languages Press, Beijing. Commission CP. 2015. Pharmacopoeia of the People’s Republic of China. English Edition. China Medical Science Press, Beijing.

Bibliography Kim EJY, Chen Y, Huang JQ, Li KM, Li GQ. 2013. Evidence-based toxicity evaluation and scheduling of Chinese herbal medicines. Journal of Ethnopharmacology 146(1): 40–61. Vanherweghem L, Tielemans C, Abramowicz D et al. 1993. Rapidly progressive interstitial renal fibrosis in young women: Association with slimming regimen including Chinese herbs. The Lancet 341(8842): 387–391. Chan TYK. 2009. Aconite poisoning. Clinical Toxicology 47(4): 279–285. Singhuber J, Zhu M, Prinz S, Kopp B. 2009. Aconitum in traditional Chinese medicine: A valuable drug or an unpredictable risk? Journal of Ethnopharmacology 126(1): 18–30.

chapter eight

The current use of TCM in China, Hong Kong, and Southeast Asia China The practice of TCM in China has a long history. The medicine has been very well received in the Chinese community, and has been one of the major healthcare options in mainland China. The medicine is dispensed by the practitioner in the form of a prescription, and there are also many over-the-counter (OTC) products derived from the TCM available in the market. Owing to the wide acceptance and long history of TCM practice as well as the extensive range of products available, the regulations of TCM products in mainland China are also the most comprehensive around the world. China used to adopt a planned economy that affects every aspect of production, including the pharmaceutical industry and the corresponding regulatory agency. In 1956, there were about 500 privately owned pharmaceutical factories and more than 100,000 merchants of TCM. The State–Private Joint Ownership Campaign eventually converted most of the privately owned enterprises into State-owned enterprises including many renowned TCM manufacturers. Thus, the relationship between the regulator and the one being regulated was very close, as the State controlled both entities. The reform policy of China began in 1978, which gradually changed from a planned economy to a market economy. As the market forces came into existence and after about two decades of experiences, the State became more aware of the importance of regulations to provide an efficient market. Thus, the regulatory agency became more independent of the manufacturers who were being regulated. The analogy in the West is the responsibility of the US FDA for regulation of drugs on the market and no participation by

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FDA in the development of the pharmaceutical industries as well as any other profit-making activities.

TCM regulation in China The operations of the Chinese State Drug Administration are all supported by Government funding and an independent drug regulatory system was established for the first time in mainland China. The name changed to State Food and Drug Administration (SFDA) and was more recently renamed China Food and Drug Administration (CFDA). Although this independent regulatory system has only been in place for a short time, a rather comprehensive set of drug regulations has evolved, partly because of the learning from the experiences of the Western regulatory agencies, and partly because of the unique demands in China, particularly in the regulation of TCM. This situation has also benefited from the rapid economic development, whereby China could support a higher standard of regulations and the incremental costs resulting from regulations can reasonably be passed on to the community. The Chinese Food and Drug Administration (CFDA) is responsible for drafting laws, regulations and rules, and policy plans on the administration and supervision of food (including food additives and health food) safety, and drugs, which include TCMs and ethnomedicines for China. For products to be available on the market in mainland China, they must be registered by the CFDA. The current drug registration policy was released in 2007. China is one of the few countries where TCM is regulated as drugs which have disease claims and indications, and share similar status and regulation concepts with other chemical drug and biological products. Thus, to register a TCM drug, data are required to specify and support the quality of the herbs used, the production processes, all quality standards, safety (toxicological data), and efficacy (clinical data) of the product. TCM products can be registered under different categories depending on the design principles and history of use. In some categories, the requirement of clinical data can be exempted.

Class 1 to class 9 drugs in China The provisions for drug class registration must meet the requirements for at least one of the following categories:

Chapter eight: The current use of TCM

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Category 1: An active ingredient (a chemical compound) obtained from plant, animal, or mineral materials and its preparations that have not been marketed in China. Category 2: A newly discovered Chinese crude drug (e.g., new herbs) and its preparations. Category 3: A new substitute for a Chinese crude drug. Category 4: A new part for medicinal use from currently used Chinese crude drugs and their preparations. Category 5: Active fraction(s) extracted from plant, animal, or mineral materials and its preparations that have not been marketed in China. Category 6: A combination preparation of TCM or a natural medicinal product that has not been marketed in China. Category 7: A preparation with a changed administration route of a marketed TCM or natural medicinal product. Category 8: A preparation with a changed dosage form of a marketed TCM or natural medicinal product. Category 9: Generic TCMs or natural medicinal products. Importantly, the following terms are elaborated in detail as follows: A crude drug refers to the medicinal material from raw herbs or parts derived from plants, animals, or minerals. TCM refers to medicinal materials and their preparations developed based on TCM theories and practices. Natural medicinal products refer to the medicinal materials and their respective preparations, which are developed based on modern medical theory. This is similar to the concept of botanical drugs (if the raw material is obtained from the plant). A combination preparation describes a TCM combination whereby preparations may consist of extracts, active fractions, and/or active ingredients besides the products developed from crude drugs. In the case of categories 7–9, these are designed for existing TCM products with a different manufacturer, dosage forms, or administration route. For products developed based on classic formulations or TCM prescriptions formulated under the TCM theory (whose indications are a combination of TCM syndrome or diseases), these could be registered under category 6. All the TCM crude drugs used in the products (and in the prescriptions) must satisfy the quality standards described in the

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Chinese Pharmacopeia, which are revised every five years. However, not all TCM crude drugs are included in the Chinese Pharmacopeia, and in these cases, standards from lower level authorities can be adopted including the specification approved by CFDA and Monographs of the Chinese Materia Medica (CMM) and the process of TCM decoctions approved by local provinces. China gradually upgrades the quality standard during the regular revision of the Chinese Pharmacopeia to provide more stringent standards for the crude drugs (raw herbs) and decoctions by including the testing of more chemical components in the herbs and enhance the specificity of the testing methods. The CFDA is also responsible for the organization, formulation, and publication of the national pharmacopeia, other drug and medical device standards and classification system, and supervising their implementation. This responsibility includes the development of good practices in research, production, distribution, and use of drugs and to establish monitoring systems for adverse events. The CFDA issues notices of approval for clinical trials including products from Hong Kong, Macao, and Taiwan, which are Traditional Chinese Medicine and Natural Medicinal Products. The CFDA will review the content of licensing and issue verification of registration certificates for imported TCM and natural medicine (from Hong Kong, Macao, and Taiwan). It should be noted that TCM has a base also in Chinese food therapy. The traditional Chinese characters 陰 and 陽 for the words yin and yang denote different classes of foods, and it is important to consume them in a balanced fashion. The meal sequence should also observe these classes: In the Orient, it is traditional to eat yang before yin: Miso soup (yang—fermented soybean protein) for breakfast; raw fish (more yang protein); and then vegetables which are yin.

Malaysia The Malaysian Parliament in 2012 passed the Traditional and Comple mentary Medicine Bill, establishing the Traditional and Complementary Medicine Council to register and regulate traditional and complementary medicine practitioners, including TCM practitioners as well as other traditional and complementary medicine practitioners such as those in traditional Malay medicine and traditional Indian medicine.


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Singapore The TCM Practitioners Act was passed by Parliament in 2000 and the TCM Practitioners Board was established in 2001 as a statutory board under the Ministry of Health, to register and regulate TCM practitioners. The requirements for registration include possession of a diploma or degree from a TCM educational institution/university on a gazette list, either structured TCM clinical training at an approved local TCM educational institution or foreign TCM registration together with supervised TCM clinical attachment/practice at an approved local TCM clinic, and, upon meeting these requirements, passing the Singapore TCM Physicians Registration Examination (STRE) conducted by the TCM Practitioners Board.

Indonesia The Indonesian Ministry of Health regulates all traditional medicines, including TCM. Practitioners are granted a Traditional Medicine License if they can demonstrate that (a) the methods are scientifically recognized as safe and (b) there are health benefits. TCM clinics must be registered. However, it should be noted that the only TCM method that is accepted by medical logic is acupuncture.

Australia It is reported that in Australia, more than 20% of the population uses some form of Chinese medicine. Since more people wish to become practitioners, in 2000, the state of Victoria became the first jurisdiction outside of China to regulate Chinese m edicine practitioners. Chinese medicine is offered as an i ndependent course in the universities (along with Western medicine), thus, it is now a registered healthcare profession in Australia. Chinese medicine herbal products are regulated, and proprietary manufactured items are regulated by the Therapeutic Goods Administration (TGA), whereas raw herbs are controlled by the Australian Customs and Australian Quarantine and Inspection Services. TGA requires registration of the herbal formulas. The Chinese medicine practitioners practice acupuncture or combine acupuncture and Chinese herbal medicine (CHM).

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Chinese dietary and lifestyle advice was also almost always or frequently used.

Hong Kong The Chinese Medicine Council of Hong Kong was established in 1999. It regulates the medicinal and professional standards for TCM practitioners. All TCM practitioners in Hong Kong are required to register with the Council. The eligibility for registration includes a recognized 5-year university degree of TCM, a 30-week minimum supervised clinical internship, and passing the licensing exam. In the early part of the nineteenth century in Hong Kong, then only recognized as a fishing port (Figure 8.1) it was apparent that Western medicine was used only by the rich and upper classes. Yet TCM played an important role in primary health care as the local Chinese citizens relied on herbs or Chinese medicine doctors. In fact, in the area known today as Sheung Wan, the Tung Wah Hospital was established in 1872 (Figure 8.2).

Figure 8.1 Photo of Hong Kong as a fishing village in the early nineteenth century. (From http://www.skyscrapercity.com/showthread. php?t=338983.)


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Figure 8.2 Photograph of the entrance to the old Tung Wah Hospital, Hong Kong.

TCM as part of the medical system in Hong Kong Hong Kong underwent turmoil during World War II and was occupied by Japan, which did not encourage TCM. After World War II, Western medicine became even more popular and mainstream in the Hong Kong medical system. However, it is important to note that Hong Kong citizens still used TCM even though the laws did not regulate them, at that time. The Hong Kong Government did not impose any regulations or include TCM in the Hong Kong medical system until a TCM working group was set up in 1989. The outcome was that TCM became one of the main medical systems and is regulated under Chinese Medicine Ordinance (Cap. 549). Since 1999, the Hong Kong Hospital Authority was tasked to set up one Chinese Medicine Center for Training and Research in each of the 18 districts in Hong Kong. Their aim is to promote the development of “evidence-based” Chinese medicine practice through

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clinical research, as well as to integrate Chinese medicine into the whole of the public healthcare system leading to modernization of TCM clinics. Thus, many TCM private clinics and clinical branches have opened since then.

TCM trading in Hong Kong Since the time that Hong Kong opened for trade in the nineteenth century, it has remained an entry point for imported goods from mainland China and exports all over the world and this includes Chinese herbs. In Hong Kong, herb wholesalers are called “Nam Pak Hong,” meaning transporting the goods (herbs/food) from North (mainland China) to/from South (Southeast Asia). These traders are mainly located in the reclaimed area of Sheung Wan in Hong Kong and they have traditionally followed their own rules and regulations (Figure 8.3).

Figure 8.3 Photograph of an ancient TCM pharmacy. (With permission of the author (DM) from his private collection: name: 20160526_Shanghai TCM museum_TCM pharm01.)


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The wholesalers mainly trade valuable or imported Chinese Materia Medica (CMM), including ginseng, American ginseng, bird’s nest, cervi cornu pantotrichum (young deer’s antlers, lu rong), Chinese cinnamon, Saffron, and Calculus bovis (Niuhuang). Many renowned TCM brands with a long history of use are preserved in Hong Kong. However, owing to reforms in mainland China and the opening up of China beginning in the late 1980s, the role of Hong Kong as an entry port for Chinese medicines has declined. There is now a shift to an entry port for proprietary Chinese medicines and health products. Large companies with brands of modern Chinese medicine have now appeared (Figure 8.4). One example is turtle jelly. Taking a herbal tea or turtle jelly is a common practice for good health and many herb shops in the Lingnan area of Hong Kong provide such a tea. In the past, ready-to-serve herbal teas or turtle jelly was taken in small shops,

Figure 8.4 Photograph of a shop selling fresh herbs and dried medicinal herbs in Hong Kong. (With permission from the author (DM).)

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Figure 8.5 Photograph showing various TCM products in different forms. (With permission of the author (DM): name: 20120903_BU museum_TCM forms.)

each with their own secret recipes. Today, these teas are available through chain stores, in bottles or cans, so they are more convenient. They are found not only in liquid form but also in powders and snacks. Other common forms of TCM products are shown in Figure 8.5.

TCM education in Hong Kong A serious commitment to raise the formal standard of TCM training began in Hong Kong in 1998. The Hong Kong Baptist University began offering a Bachelor of Chinese Medicine and Bachelor of Science (Hons) in biomedical science and the first Bachelor of Pharmacy (Hons) in Chinese Medicine. Later, the University of Hong Kong and Chinese University also started a bachelor’s degree course in Chinese medicine. Prior to 1998, TCM education was mainly by apprenticeship, whereby a TCM master taught the apprentice in his traditional


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TCM shop or the apprentice registered for TCM courses offered by some TCM associations.

TCM regulations in Hong Kong In 1999, the Hong Kong Government passed the Chinese Medicine Ordinance (Cap. 549). This is the first law in Hong Kong that regulates TCM. The Chinese Medicine Council was established for implementing regulatory measures for Chinese medicine practitioners and Chinese medicines. This includes the licensing of Chinese medicine practitioners (to ensure their professional practice, conduct, and education), proper use of CHMs, and ensuring the safety, quality, and efficacy of proprietary Chinese medicines. To regulate CHMs and proprietary Chinese medicines, a license to practice was imposed. Everyone with a business in the following field is required to apply and this includes the retailing of CHMs, wholesaling of Chinese herbal and proprietary Chinese medicines, and the manufacturing of proprietary Chinese medicines. In this way, all Chinese medicine practitioners are required to register and pass the license examination before they can practice TCM in Hong Kong. By 2002, the Department of Health established The Hong Kong Chinese Materia Medica (HKCMM) Standards to establish the safety and quality standard of HKCMM. It was anticipated that by the end of 2014, monographs describing 200 herbs would be completed, with each monograph containing specific information on a TCM formula.

TCM monographs In the TCM monograph, the following information for identification is included: outer appearance, microscopic identity; description of a physical chemical test, for example, thin-layer chromatography; an assay test to ensure safety, for example, absence of any heavy metals, aflatoxins, sulfur dioxide, etc.

TCM in Hong Kong: Present and future With improvements in the technology, the TCM industry in Hong Kong is not just focusing on trade. More science collaborations together with tertiary institutions and the Government are

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Chinese and botanical medicines TCM processing

TCM manufacturers Herbs wholesaler

TCM herbal stores

Figure 8.6 Constituents of the TCM industry in Hong Kong in the year 2016.

continuing and Chinese medicine hubs are being established. These hubs provide trading, testing, and certification, in particular to test and certify the quality of the herbs or products and to support new product development. In turn, this may lead to ever greater acceptance and understanding of the use of TCM in China and in the West. For the near future, the number of constituents related to TCM is expanding (see Figure 8.6).

Further suggested reading Kennelly EJ, Lau, CBS. 2017. A Snapshot of the Modernization of Traditional Chinese Medicines in Hong Kong. ABC Herbal Gram 114, 46–51. Moore A, Komesaroff PA, O’Brien K, Xu H, Bensoussan A. 2016. Chinese medicine in Australia. Journal of Alternative and Complementary Medicine 22(7): 515–525.

chapter nine

Global acceptance of TCM Acceptance of TCM in the world TCM is growing commercially at a rate of about 12% a year, and is expected to reach US$88 billion by 2017. While Asians are still the biggest consumers, TCM and botanical medicines are attracting a growing following in the West. Outside of China, the biggest overseas customers are Japan (Kampo Medicine), Hong Kong, the United States, and South Korea which together account for over 70% of the export market. Treatments such as meditation and holistic approaches to maintaining health have entered the mainstream and are included in the arsenal for fighting a variety of conditions, from mental health problems to Alzheimer disease. One sign of the growing acceptance of TCM is that the German pharmaceutical giant Bayer agreed to buy the privately held Chinese traditional herbal medicine maker, Dihon Pharmaceutical Group—a deal rumored to be worth over $500 million. Bayer said its goals were to strengthen its life sciences portfolio, grow its business in China, and gain a foothold in the TCM market, even though there are marked differences in Eastern and Western medical systems. This is a significant development since, to date, the international pharmaceutical companies have been reluctant to invest in traditional medicine. While Western medicine is focused on treating specific diseases, Eastern systems, including Thai traditional medicine, are more inclined to look at the body as a connected whole and often use a range of treatments and herbal concoctions. This can make it difficult to measure the efficacy of any specific treatment. Another problem is regulation. While orthodox drug treatments must pass rigorous testing before being approved for human application, in the past herbs used in traditional medicine were often classified as foods rather than medicines and so avoided such rigorous testing. This is changing, and in 2011 the European Union introduced the Traditional Herbal Medicinal Products Directive,

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prohibiting the sale of unlicensed herbal medicinal products, with a 2-year grace period to conform to appropriate standards. Despite such challenges, it is interesting to see some convergence in the two approaches. There is a trend in the West toward integrated medicine and life sciences that takes a much broader approach toward medicine than merely treating an isolated ailment. One example of this is the experimental use of bioinformatics, which attempts to employ advanced computer systems to gain an understanding of TCM mechanisms. Meanwhile, Western medicine is increasingly being used alongside traditional medicine in China. Many hospitals in Asia including Singapore, Malaysia, and Thailand offer traditional Chinese medicine, while the WHO has established collaborative centers for traditional medicine in the United States, Asia, Europe, and Africa. With the rapid aging of populations around the world and the increasing interest in healthy lifestyles, these efforts may lead to successfully combining the best of the Western and Eastern approaches. First, TCM is a holistic natural medicine, rooted in a philosophy of keeping harmony with the natural environment, and a harmony inside the body (both mentally and physically). TCM has been used for over 5000 years of medical practice on billions of people in China and outside China, and believed by many to be a natural, safe, and effective treatment. Several laboratory and clinical studies demonstrated antibiotic-like properties of “clearing the heat.” There are herbs, such as Jin Yin Hua, Lian Qiao, Da Qing Ye, Huang Qin, Huang Lian, and Zhi Zi, Qing Dai, which act as antiviral medicines, or possess bacteriostatic or bactericidal properties. Most of these herbs can relieve toxicity by promoting the body’s immunity to clear the endotoxin. Also, there are nonspecific anti-inflammatory, antipyretic-like medicines, which are used in combination, and no drug resistance has been observed to date. There may be synergistic effects when they are used together with chemical antibiotics. Several antibiotics have their origin in botanical sources. A good example is SMZ, Tamiflu (the active ingredient from the star anise, Chinese herbal medicine Da Hui Xiang). More recently, Chinese herbs have been found to be very effective on H1N1 patients, bird flu patients, and on flu viruses. TCM has been used as a preventative medicine for more than 2000 years. TCM practitioners realized that oily and fatty sweet foods may cause phlegm (Fat), block heart vessels resulting in blood

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clots, and trigger heart attack (Chest Bi) and cerebral vascular accident (Wind stroke). There is an ancient Chinese saying, “Death starts from the mouth”; thus, watching the intake of food, maintaining movement, and consuming a small amount of alcohol to improve blood circulation are considered beneficial. Using “blood mover” materials, for example, Tao Ren, Hong Hua, Shui Zi, or earthworms, are considered core products of prevention, such that death from cardiovascular diseases has dropped by 40%–60%. TCM is the pioneer of anticoagulation, much earlier than the application of aspirin. TCM practitioners have used herbs and acupuncture to treat tumors for a long time. Some anticancer medicines are derived from Chinese herbs. There have been some favorable results without undesired side effects, and it may be worthwhile to continue this avenue of research. There are hundreds of Chinese medicinal formulas used for emotional disorders, which appear to be effective. A safe and effective method is acupuncture, a traditional method of inserting needles at special points in the body, which may help the body to produce opium-like chemical endorphins, and produce serotonin, to help the body regulate moods. TCM has contributed greatly to China, Japan, Korea, and Vietnam, benefitting a huge population in those regions. Even though TCM is very popular in China as a conventional therapy, and is spreading to the United States, Canada, Europe, and even Africa, there is an urgent need to promote a scientific inquiry into the study and use of botanicals, natural products, and Chinese medicine to secure global understanding and acceptance. Although there is an enormous history of use of Chinese medicines, a road map forward is needed to better understand and gain acceptance of these preparations and formulae within the scientific and international community. Some specific areas include (a) harmonizing standards and international collaborations, (b) further improving the research methodologies required to understand the actions of the botanicals and natural products for the development of better remedies, and (c) developing the research strategies to provide scientific data that could substantiate the health claims. This chapter offers some commentary on the role of traditional Chinese medicine in global health care; the role of traditional Chinese medicine in the management of major diseases (or one major disease, such as diabetes, cancer, etc.); progress toward total quality management of herbal medicines.

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Resurgence of consumer interest: A need for better science in botanical preparations The majority of the world’s population still relies heavily on natural products as herbal remedies for their primary health care. In fact, over the past several decades, the literature, both scientific and popular, reflects an increased interest in natural products by the public that has helped fuel a greater scientific awareness of drugs from nature and botanical medicine. The increasing migration of people across different countries has been accompanied by movement of their respective traditional medicines. There is the movement of Western medicine to developing countries, and a flow of traditional medicines from China, for example, and from other countries. This renewed interest in traditional herbal medicines has also contributed to a resurgence of interest in Western herbal medicine (and natural products), particularly in the United States and Europe, as well as a desire for more chemical information and information about safety and efficacy. There are challenges in conducting sound scientific studies of botanicals—from the sourcing of appropriate products to details on the preparation of the products and understanding the types of scientific inquiry that will advance this field. Many challenges to the dietary supplement industry exist to improve the quality of botanical products and to increase the industry’s commitment to facilitating the collection of data that will provide an evidence base for the safety and effectiveness of the products being produced. Thus, the training and role of natural products chemists (whether from marine or plant sciences) in furthering the quality of botanical preparations and the quality of clinical research is critical. Scientific leadership and high-quality scientific research are required to achieve higher-quality preclinical and clinical studies of herbal preparations and better-quality herbal products. Despite the worldwide efforts in the past century, scientific inquiry of botanicals remains a very challenging task. They usually contain complex chemical mixtures and their interaction in the human body may be much more complicated. The reductionist approach—to isolate compounds and evaluate their individual activities—has not been sufficient to fully elucidate the biological interactions of the botanicals in the body. The recent advances in systems biology, metabolomics, and chemometrics offer new


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technological platforms to study complex mixtures and to evaluate corresponding biological responses more effectively. These approaches are holistic, more integrated, and can provide a new tool to advance our understanding of the complex actions of botanicals and natural products in our body at an unprecedented level.

TCM needs TQM There is clearly a need to examine, explore, and design acceptable means in the scientific studies of botanicals and natural products, which include TCM, to link both a suitable chemical marker to a biological signal that can be linked to the therapeutic use. However, the idea of applying rigorous evidence-based methods may be difficult and unacceptable. Among TCM researchers, many are not accepting the “Western norm of science” in their lab results and may correctly consider that this approach is entirely “unsuitable” for TCM. So, if that is the case, what is the best path forward? The systematic studies of the health effects of botanicals and natural products require the collaboration of experts from many different disciplines including the proper collection or cultivation of source materials, botanical identification and authentication, chemical analysis, evaluation of the biological response, and clinical studies leading to a “total quality system”—the integration of these various technical platforms and strategies that could contribute to a more robust and effective evaluation of the therapeutic potential of botanicals that current evidence-based clinical studies have not been able to achieve to date. These are important techniques to authenticate the herbal samples, which are crucial for all scientific investigation of botanicals. Significant research efforts in different parts of the world have been applied to examine the efficacy and chemical compositions of botanicals and herbs. Specifically, Hong Kong, the traditional hub for the international trading of Traditional Chinese herbal medicine, has played an important role in advancing the scientific knowledge and the establishment of quality standards of botanicals and herbs. The Hong Kong Chinese Materia Medica Standards (HKCMMS) project is but one example of these efforts. In addition, Hong Kong is in the process of developing itself into a testing and certification center for TCM, and is an active member of the Forum of Harmonization of Herbal Medicine (FHH) of the West Pacific

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region. Yet, despite these efforts, we have not developed efficient research platforms capable of untangling the chemical compositions and linking them to the biological effects of the botanicals and herbs. If more effective research platforms can be established in Hong Kong, this certainly will leverage Hong Kong as an important research center for scientific studies of herbs and will assist in the development of the local TCM trading and testing industries. New approaches and opportunities of scientific inquiry can be integrated and applied to further the study and use of botanicals and natural products for 1. Harmonizing standards and international collaborations of botanicals, health products, and Chinese medicines 2. Adapting the latest research methodologies required to evaluate the actions of botanicals and natural products for the development of better remedies and 3. Developing research strategies to provide scientific data that could substantiate the health claims to support a wider acceptance of botanicals and herbs in the world The longtime use of these herbal remedies suggests some measure of pharmaceutical activity. Despite these ongoing efforts, we have not yet developed efficient research platforms capable of assuring our international colleagues (both clinicians and in respective foreign governments) that Chinese medicine is evidence based. More advanced techniques will be required to examine the actions of these complex mixtures in the human body. Presentations were made to highlight state-of-the-art concepts and address ways to improve the modernization of Chinese medicine and recommend possible pathways forward that future research should take. However, this is not an isolated task for academics and there will always be a need to integrate the challenges of government, regulation, safety, and culture, and help industry find the path to successful commercialization. We believe that the key scientific aspects presented herein are important and timely, as both the industry and regulatory authorities in China, Hong Kong, and elsewhere seek better and harmonized approaches to maintain safety and the highest standards of botanical preparations. There are opportunities for harmonizing standards, adapting the latest research methodologies including


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“omics” and spectroscopy tools now in use to evaluate the actions of botanicals and natural products for the development of better remedies. In this way, we hope to contribute new research strategies to provide scientific data that could substantiate the health claims to support a wider acceptance of botanicals and herbs in the world.

Further suggested reading Cooper R. 2017. TCM Needs TQM! J Complement Med Alt Healthcare 2(3), DOI: 10.19080/JCMAH.2017.02.555586. Cooper R, Chang J. 2001. Asian herbals: Opportunities for marketing traditional Chinese medicines in the West. Journal of Nutraceuticals, Functional & Medical Foods 3, 25–37. Cooper R, Cooper S. 2006. Science-based business model for the dietary supplement industry. Nutrition Business Journal 12: 26–28. Cooper R, Cooper S. 2007. A scientific and organizational quality system for the botanical & dietary supplement industry. Nutraceuticals World, July/August: 60–66.

Appendix: Plant names A Aconitum carmichaeli (Chuanwu) (川烏) Aconitum kusnezoffii (Caowu) (草烏) Akebia quinata or Akebia trifoliata (Mutong) (木通) Alisma orientalis (Zexie) (澤瀉) Allium sativum (Garlic) (大蒜) Angelica sinensis (Dongquai) (當歸) Aristolochia debilis (Madouling) (馬兜鈴) Aristolochia debilis (Aerial part, Tianianteng) (天仙藤) Aristolochia fangchi (Guangfangji) (廣防己) Aristolochia manshuriensis (Guanmutong) (關木通) Artemisia annua (Qinghao) (青蒿) Asarum sieboldii or Asarum heterotropoides (Xixin) (細辛) Astragalus membranaceus (Huangqi) (黃蓍) Aucklandia lappa (Muxiang) (木香)

B Bupleurum chinense (Chaihu) (柴胡)

C Camellia sinensis (Cha) (茶) Camptotheca acuminata (Xishu) (喜樹) Campsis grandiflora (Lingxiaohua) (凌霄花) Carthamus tinctorius (Honghua) (紅花) Cistanches deserticola (Roucongrong) (肉蓯蓉) Codonopsis pilosula (Dangshen) (黨參) Cordyceps sinensis (Dongchongxiacao) (冬蟲夏草) Cornus officinalis (Shanzhuyu) (山茱萸) 133

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D Datura metel (Yangjinhua) (洋金花) Dendranthema folium Chrysanthemum indicum or Chrysanthemum morifolium (Juhua) (菊花) Dictamnus dasycarpus (Baixianpi) (白鮮皮) Dioscorea opposita (Shanyao) (山藥)

E Ephedra sinica (Mahuang) (麻黃)

G Ganoderma lucidum (Lingzhi) (靈芝) Ginkgo biloba (Yinxing) (銀杏) Glycyrrhiza uralensis or Glycyrrhiza glabra (Ganzao) (甘草)

I Illicium verum (Bajiao) (八角) Illicium anisatum (Japanese star anise) (日本八角) Isatis indigotica (Banlangen) (板藍根)

L Ligusticum chuanxiong (Chuanxiong) (川芎)

M Magnolia officinalis (Houpo) (厚朴) Monascus purpureus (Red yeast rice) (紅麴霉)

O Ophiopogon japonicus (Maidong) (麥冬)

P Paeonia lactiflora (Baishao) (白芍) Paeonia suffruticosa (Mudanpi) (牡丹皮) Panax ginseng (Renseng) (人參)

Appendix: Plant names

Panax notoginseng (Sanqi) (三七) Panax quinquefolius (Xiyangseng) (西洋參) Pheretima spp. (Earthworm) (地龍) Pinellia ternata (Banxia) (半夏) Polygonum multiflorum (Heshouwu) (何首烏) Poria cocos (Fuling) (伏苓) Prunus persica (Taoren) (桃仁) Pueraria lobata (Gegen) (葛根)

R Rabdosia rubescens (Donglingcao) (冬凌草) Rehmannia glutinosa (Dihuang) (地黃)

S Salvia miltiorrhiza (Danshen) (丹參) Schisandra chinensis (Wuweizi) (五味子) Scutellaria baicalensis (Huangqin) (黃芩) Stephania tetrandra (Fangi) (防己)

X Xanthium sibiricum (Cangerzi) (蒼耳子)

Z Zingiber officinale (Jiang) (薑) Ziziphus jujuba (Dazao) (大棗)

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Glossary of terms Acupuncture: A therapeutic technique that uses fine needles to puncture the surface of the skin at specific positions known as acupoints along the energy pathways of meridians. Either local or distal effects, or both, can be achieved through the stimulation of qi along the meridian channel. Electroacupuncture is a modern development in which an electric current is applied to the needles to provide mild electrical stimulation to the acupoint. Assistant (助): Three different roles: to reinforce the effects of the monarch or minister drug or to treat the less important coexisting patterns; to eliminate the toxicity of the monarch and minister ingredients, or modulate their harsh properties; and to provide paradoxical assistance. Baifupian: A commercial product of processed side roots of Aconitum carmichaeli, the “white aconite slices,” after being cooked, steamed, and fumigated with sulfur. Bone-setting: A special manipulation to correct dislocated joins and bone fracture. Bu-yang Huan-wu: This decoction is a multi-item herbal prescription used to tonify yang. Cupping: A form of therapy in which a cup is placed on the body surface after a negative pressure is created inside the cup by passing a flame into it. Cupping warms the meridians, dispels coldness, and stimulates the flow of qi and blood. Danfupian: A commercial product of processed Aconitum carmichaeli side roots that is made by cooking “salty aconite” together with licorice and black beans. Dietary therapy: Adding medicinal herbs to the diet in order to treat acute or chronic disorders. Some medicated diets 137

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tonify the qi, others supplement yin and yang and nourish blood, and yet others may clear the heat or warm up the cold conditions of the body. Exercise therapy: Represented by Tai-Chi and Qi-Gong as common forms of mind–body therapy. The proper control of breath, a peaceful mind, different postures, and body movements are beneficial to promote the flow of Qi and blood, calm the spirit, regulate the emotion, and strengthen internal organs. Four-Gentlemen decoction (Si Jun Zi Tang): A renowned tonic herbal formula consisting of ginseng root, Atractylodes macrocephala rhizome, poria, and licorice. Fu viscera (腑): Represent the six internal “hollow” organs, namely, the gallbladder, stomach, small intestine, large intestine, bladder, and triple energizer. They are involved in the digestion of food, absorption of nutrients and water, transporting waste and undigested materials, and discharge of feces and urine. The triple energizer may refer to the body cavities in charge of water and qi metabolism. Fuzi Lizhong decoction: A herbal formula consisting of ginseng root, Atractylodes macrocephala rhizome, Aconitum carmichaeli side root, dry ginger, and licorice. It has strong effects to warm the kidney, liver, and stomach. Gang: TCM materials are classified into groups called a Gang. Guide (使): Two different functions: to force the actions of the formula on the target meridian or area of the body; and to harmonize and integrate the effects on other drugs. Herbology: Use of herbs to treat diseases. In this case, the term “herb” is used in a wider context to include minerals and animal products that are also used, albeit less frequently, in medicinal prescriptions. Mafeisan (or foamy narcotic powder) (麻沸散): A powder for anesthesia during ancient days invented by the famous surgeon Hua Tuo. The exact composition of the powder remains unclear. Medical massage (Tui-Na) and manipulation: A variety of techniques applied to the soft tissues and joints to remove obstructions in the superficial tissues, improve circulation, and relax muscles. In general, pressure is applied to

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the acupoints along the meridians by a special kneading motion. It has not only a local effect by promoting blood circulation and relaxing muscular stress but also one that regulates the function of the meridians and internal organs. Minister (臣): Also known as the associate ingredient, it refers to two different functions: (1) to support the monarch drug and (2) to improve and treat the accompanying symptoms. Minor Bupleurum decoction (Xiao Chai Hu Tang): A herbal formula consisting of seven herbs for the treatment of fever and chills, in particular the “Shao-Yang syndrome.” Monarch (君): Exerts the major and leading effects in a formula. It constitutes the largest proportion of a formula; a competent formula usually only contains one to two principal herbs so that the therapeutic effects can be focused on. Moxibustion: A therapeutic technique in which a burning stick (the moxa) made from the leaves of Artemisia vulgaris is placed on top of the acupoints to warm the meridians and promote the flow of qi and blood. Prodrome of apoplexy (unconsciousness or incapacity): In medicine, a prodrome is an early symptom (or set of symptoms) that might indicate the start of a disease before specific symptoms occur. It is derived from the Greek word prodromos meaning “precursor.” Pulse cunkou (寸口) and positions cun, guan, and chi regions (寸關尺): Three locations on the wrist from where pulse patterns are taken by the herbal doctor by touching and pressing with his fingers. Sanmai San: A herbal formula consisting of ginseng root, Ophiopogon root, and Schizandra fruit used for “generating pulses.” Modern TCM practice uses the Shengmai-San preparation for emergency treatment of heart attack, shock, and congestive heart failure. Six-ingredient decoction (or pill) with Rehmannia (Liuwei Dihuang Tang(wan)): A herbal formula containing the Rehmannia root and other five ingredient herbs. It is one of the best known prescriptions for nourishing the yin of the kidney and liver. Sour Jujube decoction (Suan Zao Ren Tang): A herbal formula used as a tranquilizer by reducing irritability or excitement.

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Zang viscera (臟): A collective term for five internal organs including the heart, lungs, spleen, liver, and the kidney. They are major organs to transform, produce, and store the essential substances for nourishing the body. Zang-fu (臟腑): The collective term for all internal organs consisting of five Zang, six Fu, and other so-called extraordinary organs (such as the brain, bone, marrow, vessels, and uterus).

Bibliography Additional Reading: Texts and Books Written in Chinese Shen-Nong Materia Medica (Shen-Nong Bencaojing), which describes the usage of 365 kinds of drugs, of which 252 are of plant origin, 67 of animal origin, and 46 of mineral origin. Bencao Gang-Mu (“Compendium of Materia Medica”), written by Li Shizhen in the Ming Dynasty, which is regarded as the most comprehensive medicinal book ever written in the history of traditional Chinese medicine. It lists all the plants, animals, minerals, and other items that were believed to have medicinal properties known at the time. Huangdi’s Inner Classic of Medicine (Yellow Emporer’s Cannon of Internal Medicine”), which is the most important text in Chinese medicine. It sets the foundation for the theories and practices of Chinese medicine. Eighty-One Medical Problems, written by Zhang Zhongjing, which adopts the question-and-answer model to illustrate the contents of viscera, meridians, pulse lore, pathology, and acupuncture technique. Nei Wai Shang Bian Huo Lun, published in the Jin dynasty (1115– 1234 AD). Chinese Materia Medica. Li S, Luo X. 2003. Compendium of Materia Medica (Bencao Gangmu). Bencao Gangmu. Foreign Languages Press, Beijing. Pharmacopoeia of the People’s Republic of China. English edition. 2015, China Medical Science Press, Beijing. The Hong Kong Chinese Materia Medica Standards (HKCMMS). 2005–2017. Department of Health, The Government of the Hong Kong Special Administrative Region, China. Vol 1:2005, Vol 2:2008, Vol 3:2010, Vol 4:2011, Vol 5:2012, Vol 6:2013, Vol 7:2015, Vol 8:2017 (in print). 141

Index A AAN, see Aristolochic acid nephropathy Aconite, see Aconitum Aconitine, 103 Aconitum, 97–98 A. carmichaeli, 103, 133 A. kusnezoffii, 103, 133 toxic Aconitum plants, 103–105 Acupoints, 31 Acupuncture, 19, 31, 117–118 Acute pancreatitis, 87 Acute renal failure, 106 AD prostate cancer, see Androgendependent prostate cancer AI prostate cancer, see Androgen independent prostate cancer Akebia quinata (A. quinata), 100, 133 Akebia trifoliata (A. trifoliata), 100, 133 Alisma orientalis (A. orientalis), 133 Alkaloids, 99–100 Allium sativum L, see Garlic Alzheimer disease, 125 American ginseng (Panax quinquefolius), 43, 135 Androgen-dependent prostate cancer (AD prostate cancer), 109 Androgen independent prostate cancer (AI prostate cancer), 109 Angelica Radix Blood Tonics, see Danggui-Buxue-Tang Angelica root (Angelica sinensis), 19, 62, 88, 133 Angelica sinensis, see Angelica root Angiosperm Phylogeny Group system (APG III system), 12 Anisatin, 13, 15 Antipyretic-like medicines, 126 APG III system, see Angiosperm Phylogeny Group system

Apricot kernel, 47 Aristolochiaceae family, 100–102 Aristolochia species, 97–100 A. debilis, 100, 133 A. fangchi, 133 A. manshuriensis, 100, 133 Aristolochic acid, 99, 100 Aristolochic acid nephropathy (AAN), 100 Artemisia annua, see Artemisinin Artemisia capillaris (A. capillaris), 45 Artemisia vulgaris (A. vulgaris), 31 Artemisinin (Artemisia annua), 51, 70, 72, 133 Malaria, 70–73 Asarum species, 97–100 A. heterotropoides, 100, 133 A. sieboldii, 100, 133 “Assistant” drug, 47 Astragalus membranaceus, see Astragalus root Astragalus root (Astragalus membranaceus), 19, 20, 45, 62, 133 Atherosclerosis, 60 Atractylodes macrocephala (A. macrocephala), 45 Atractyloside, 106, 107 Aucklandia lappa (A. lappa), 133 Australia, TCM in, 117–118 Ayurvedic medicine, 3 Aztecs, 1

B Baifupian, 104 Baikal Skullcap, see Skullcap (Scutellaria radix) “Bencao”, 7 “Bencao Gang-Mu”, 11 Bioassays, 70 Biologically active ingredients from TCM herbs, 50–51 “Bitter” drugs, 43

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144 “Bland” taste, 43, 44 Blood, 30 blood-nourishing function of angelica root, 19 Blue/purple tongue, 35 Body fluids, 30 Bone setting, 32 Botanical authentication, 15 Botanical classification of TCM herbs, 12; see also Classical TCM herbal literature binomial system of botanical nomenclature, 13 Engler system, 12 examples of TCM derived from different plant parts, 17 internationalization, 18–20 medicinal botany, 16–17 medicinal plant identification, 15–16 Star anise, 13 TCM preparations, 17–18 Buddhist monks, 18 Bupleuri Radix (Bupleurum chinense), 45, 56, 57, 133 Buyang-Huanwu-Tang, 62

C Calculus bovis (C. bovis), 121 Camellia sinensis, see Green tea Campsis grandiflora (C. grandiflora), 133 Camptotheca acuminata, see Camptothecin Camptothecin (Camptotheca acuminata), 51, 133 Cangerzi, see Fructus xanthii (F. xanthii) Caowu, 103 Cardinal characteristics of Chinese medicine, 23–25 Cardiotonic Pill, see Danshen Dripping Pill Carthamus tinctorius (C. tinctorius), 133 Catechin (C), 78 CFDA, see China Food and Drug Administration Chai-Hu, see Bupleuri Radix (Bupleurum chinense) Chaun Xiong, 66 Chemical biosynthesis, 16 China, 113 class 1 to class 9 drugs in, 114–116 reform policy of, 113–114 TCM regulation in, 114 China Food and Drug Administration (CFDA), 114, 116

Index Chinese angelica, see Angelica root (Angelica sinensis) Chinese Cordyceps, 80 life cycle of C. sinensis, 81 perceived health benefits, 82–83 Chinese/Korean ginseng, see Ginseng (Panax ginseng) Chinese Materia Medica (CMM), 97, 98, 116, 117–118, 121 Chinese medicine, 21 cardinal characteristics, 23–25 herbs, 45–46, 50 initiation of theoretical system, 21–22 products, 107 theories, 19 Yin and yang theory and application to, 25 Chinese Medicine Council, 118, 123 Chinese Pharmacopeia, 103, 116 Chinese sage, see Salvia miltiorrhiza (S. miltiorrhiza) Chinese star anise (Illicium verum), 13, 14 134 Chinese State Drug Administration, 114 Chloroquine, 72 Chrysanthemum morifolium (C. morifolium), 45 Chuanwu, 103 Cinnamomun cassia (C. cassia), 45 Cistanches deserticola (C. deserticola), 133 Citrus reticulata (C. reticulata), 45 Classical TCM herbal literature, 7; see also Botanical classification of TCM herbs “Bencao”, 7 “Bencao Gang-Mu”, 11 classification of medicinal materials, 9, 12 Gang, 11–12 Shen-Nong Materia Medica, 8, 10 Tang Bencao, 10 CMM, see Chinese Materia Medica Coating of tongue, 36 Cocktail therapy, 44 Codonopsis pilosula (C. pilosula), 45, 133 Combination preparation, 115 Compendium of Materia Medica, medicinal herbs classification in, 12 Complementary interaction, 47 Complementation modes, 47 Consumer interest, resurgence of, 128–129 Contamination, 108 Coptis sinensis (C. sinensis), 45

Index Cordyceps sinensis (C. sinensis), 81, 133 athlete on ergometer, 84 fruiting body, 82, 83 life cycle of, 81 Cornus fruit, 61 Cornus officinalis (C. officinalis), 133 Cracked tongue, 35 Crataegus pinnatifida (C. pinnatifida), 45 Crimson tongue, 34–35 Crude drug, 115 Cunkou, 37 Cupping, 31

D Da Hui Xiang, 126 Danfupian, 104 Danggui-Buxue-Tang, 63–64 Danshen, see Salvia Danshen Dripping Pill, 85 Daturae flos (D. flos), 105 Datura metel (D. metel), 105–106, 134 Decoction, 17–18 Dendranthema folium Chrysanthemum indicum or Chrysanthemum morifolium, 134 Dendrantherma folium, see Mum Deviated tongue, 35 Diaphoretic effect, 47–48 Dictamnus dasycarpus (D. dasycarpus), 134 Dietary therapy, 32, 49–50 Diethylstilbestrol, 110 Dihon Pharmaceutical Group, 125 Dihydrotanshinone, 86 Dioscorea opposita (D. opposita), 45, 134 Dioscorea rhizome, 61 Disease, 30 Diterpene ginkgolides, 74 DNA databases, 16 Dong quai, see Angelica root (Angelica sinensis) Dyer’s Woad (Isatis Radix), 109

E Earth, 26–29 Eastern and Western medical systems, 125 EC, see Epicatechin ECG, see Epicatechin gallate Efficacy of TCM, 55 EGC, see Epigallocatechin EGCg, see Epigallocatechin gallate Eighty-One Medical Problems, 22

145 Electro-acupuncture, 31 “Emperor” drug, 44, 47 “Emperor” ingredient, 57, 59 “Emperor and Minister” herbs, 47 Energy-enhancing effect of ginseng root, 19 Engler system, 12 ENOX2, see NADH oxidase activity Ephedra (Ephedra sinica), 92–93 Ephedra Decoction (Ma Huang Tang), 47, 53 Ephedra herb, 44 Ephedra sinica, see Ephedra; Ephedrine Ephedrine (Ephedra sinica), 45, 51, 134 Epicatechin (EC), 79 Epicatechin gallate (ECG), 79 Epigallocatechin (EGC), 79 Epigallocatechin gallate (EGCg), 79 Essence, 30 “Evidence-based” Chinese medicine practice, 119–120 Evidence-based approach, 70 Exercise therapy, 31 “Exterior Shao-Yang syndromes”, 55

F FDA, see U.S. Food and Drug Administration Female ginseng, see Angelica root (Angelica sinensis) FHH, see Forum of Harmonization of Herbal Medicine Fire, 26–29 Five elements, 26 dynamic relationships, 28 relationship to five major visceral organs, 27 “Five tastes” system, 43–44 Flavone glycosides, 74 Floating tight pulse, 38 Foamy narcotic powder, see Mafeisan Forum of Harmonization of Herbal Medicine (FHH), 129–130 Four Gentlemen Decoction (Si Jun Zi Tang), 64–65 “Four natures” system, 42–43 Fritillaria cirrhosa (F. cirrhosa), 45 Fructus xanthii (F. xanthii), 106 Fu Ling, 66 Fu viscera, 23, 27 Fuzi, 103, 104 Fuzi Lizhong decoctions, 104

146

Index

G

H

Gallbladder, 55 Gallocatechol (GC), 79 Gallocatechol gallate (GCG), 79 Gan Cao, 66 Gang, 11–12 Ganoderma lucidum, see Mushroom Reishi Garlic (Allium sativum L.), 89, 91, 133 in cardiovascular disease models, 90–92 constituents, 90 GC, see Gallocatechol GCG, see Gallocatechol gallate General health-promoting action of Astragalus root, 19 Ginkgo, 73–75 Ginkgo biloba (G. biloba), 134 extracts, 73–75 “Ginseng-Alone Decoction”, 44 Ginseng (Panax ginseng), 13, 19, 45, 75, 134 adaptogen and effects on exercise performance, 77 compounds, 77 distinctive features, 76 ginsenoside variation and standardization, 75 ratio of Rg1 and Rb1 and yin and yang, 75–77 Ginsenoside, 75 Global acceptance of TCM; see also Traditional Chinese Medicine (TCM) resurgence of consumer interest, 128–129 TCM needs TQM, 129–131 in world, 125–127 Glutamylcysteines, 90 Glycoprotein enzyme, 109 Glycyrrhizae radix (G. radix), 104, 109, 110 Glycyrrhiza glabra, see Licorice Glycyrrhiza uralensis (G. uralensis), 45, 134 Green tea (Camellia sinensis), 78, 133 anticancer effects, 78 anticancer mechanisms of action, 79 chemical structure, 79 leaves, 78 NADH inhibition oxidase activity, 79–80 Guangfangji, 100 Guang Fang Ji, 100 Guanmutong, 100 “Guide”, 54

“Half-processed Fuzi”, 104 Han Fang Ji, 100 “Health-food” market, 19 Hepatotoxicity, 97–98, 106 “Herb”, 31 Herbal drugs, 16 Herbalism, TCM, 7, 11 Herbal medicines, 41, 53–55 Herbal remedies, 19 Herb–herb interactions, 47 Herbology, 31 Herbs, TCM, 41 active compounds, 51 biologically active ingredients from, 50–51 Chinese medicinal herbs, 45–46 Chinese medicinal materials, 41 dietary ingredients, 50 future prospects, 51–52 herbal drug character and property, 42–44 herbal formulas, 44–49 TCM dietary therapy, 49–50 HKCMMS, see Hong Kong Chinese Materia Medica Standards HMG-CoA reductase inhibitors, 91 Holism, 23 Hong Kong, 118 Aconitum poisoning, 104–105 ancient TCM pharmacy, 120 as fishing village, 118 herb wholesalers, 120 Hospital Authority, 119–120 old Tung Wah Hospital, 119 TCM in, 119–124 Hong Kong Chinese Materia Medica Standards (HKCMMS), 123, 129 Huang-Qin, see Radix Scutellariae (Scutellaria baicalensis) Huangdi’s inner classic of medicine, 22 Human body, 23, 24, 41, 44, 128

I ICU, see Intensive care unit Illicium anisatum, see Japanese star anise Illicium verum, see Chinese star anise Immune function, 58 Incas, 1 Indomethacin, 110 Indonesian Ministry of Health, 117

Index Indonesia, TCM in, 117 Intensive care unit (ICU), 105 Internationalization of TCM, 18–20 Isatis indigotica (I. indigotica), 134 Isatis Radix, see Dyer’s Woad

J Japanese star anise (Illicium anisatum), 13, 14, 134 Jin Gui Yao Lue, 66 Jun Zi, 64

K Kampo Medicine, 3, 125 Kidney functions, 29, 49 Kudzu root (Radix Puerariae lobata), 84

L LDL oxidative prevention, 92 Licorice (Glycyrrhiza glabra), 13, 47, 64, 109, 134 Ligusticum chuanxiong (L. chuanxiong), 134 Liuwei-Dihuang preparation, 61–62 Liver fibrosis, 86 Lonicera japonica (L. japonica), 46 Lower Class drugs, 8

M Ma-Huang Tang, 47 Madouling, see Aristolochia debilis (A. debilis) Mafeisan, 105 Magnolia officinalis (M. officinalis), 99, 134 Ma Huang Tang, see Ephedra Decoction Malaria, 70–73 Malaysia, TCM in, 116 Medical massage and manipulation, 32 Medicinal botany, 16–17 diets, 49 herbs, 14 plant identification, 15–16 recipes, 54 Mentha arvensis (M. arvensis), 46 Meridian-affinity system, 44 Meridian, 23 Metal, 26–29 Middle Class drugs, 8 “Minister” drug, 47 Minor Bupleurum Decoction (Xiao-ChaiHu-Tang), 55–58

147 Modern pharmaceutical formulations, 18 Modern Western medicine aspects, 2 Monacolins, 88 “Monarch” drug, 53, 66 Monascus purpureus, see Red yeast rice Moxibustion, 31 Mu, 12 Multi-item prescription, see Poly-prescription Mum (Dendrantherma folium), 109 Mushroom Reishi (Ganoderma lucidum), 109, 134 Mutong, 100 Mycelium, 81

N NADH inhibition oxidase activity, 79–80 NADH oxidase activity (ENOX2), 79–80 “Nam Pak Hong”, see Hong Kong herb wholesalers Natural medicinal products, 115 “Natures”, 42 Nonfunctioning fibers, 86 Nonspecific anti-inflammatory, 126 Notoginseng (Panax notoginseng), 46, 85–86, 135

O Ophiopogon japonicus (O. japonicus), 134 Ophiopogon root, see Radix Ophiopogonis Organoleptic approach, 15 Orthodox drug treatments, 125 Over-the-counter (OTC), 113

P Paeonia lactiflora (P. lactiflora), 62, 98, 134 Paeonia suffruticosa (P. suffruticosa), 61, 134 Pale red tongue, 33 Pale tongue, 33 Palpation, 36 Panax ginseng, see Ginseng Panax notoginseng, see Notoginseng Panax quinquefolius, see American ginseng PC-SPES, 108–111 Phenolphthalein, 107–108 Pheretima spp., 135 Pinellia ternata (P. ternata), 56, 135 Plant kingdom, 50 Plant species, 16 Plasmodium, 71 Po Chai Pills, 107–108

148 Poly-prescription, 44 Polygonum multiflorum (P. multiflorum), 98, 135 Polyphenols, 79 Poria cocos (P. cocos), 46, 61, 135 Potentiating effect, 47 Potentiation, 47 Prescriptions, 54 Prickled tongue, 35 Prodrome of apoplexy, 35 Promoting cycle, 28 Proprietary Chinese medicine, see Chinese medicinal products Prostate-specific antigen (PSA), 109 Prostate cancer, 109 Prunella vulgaris (P. vulgaris), 46 Prunus armeniaca (P. armeniaca), 46 Prunus persica (P. persica), 135 PSA, see Prostate-specific antigen Pseudoginseng Radix, see San-Qi Ginseng Pueraria lobata (P. lobata), 46, 135 Pulse examination, 36, 37 example of diagnosis, 37–38 location of pulse, 37 position of pulses and references, 38 syndrome differentiation, 39 types, 36 Pungent-cool, 38 Pungent-warm herbal medicines, 38 Pungent drugs, 43

Q Qi, 21, 25, 30, 63, 65 function, 30 Qi-Gong, 31 Qingmuxiang, 100

R Rabdosia (Rabdosia rubescens), 109, 135 Rabdosia rubescens, see Rabdosia Radix Ophiopogonis (Ophiopogon root), 59 Radix Puerariae lobata, see Kudzu root Radix Salvia miltiorrhiza, 84 Radix Scutellariae, 46, 57, 135 Ranunculaceae, 103 Rb1, 75–77 Red sage, see Salvia miltiorrhiza (S. miltiorrhiza) Red tongue, 33–34 Reductionist approach, 4, 128 Red yeast rice (Monascus purpureus), 87–88, 134

Index Rehmannia glutinosa (R. glutinosa), 46, 135 Rehmannia root, 61–62 Restraining cycle, 28 Rg1, 75–77 Rheum palmatum (R. palmatum), 17, 46 RYR, see Red yeast rice (Monascus purpureus)

S Safety and regulations, TCM Aristolochiaceae family, 101–102 Aristolochia species, 98–100 Asarum species, 98–100 Chinese medicinal products, 107 Datura metel L., 105–106 PC-SPES, 108–111 Po Chai Pills, 107–108 TCM safety, 97–98 toxic Aconitum plants, 103–105 toxic compounds and contaminants in TCM herbs, 98 X. sibiricum poisoning, 106 S-allyl-l-cysteine, 89, 92 S-allyl analogs, 90 “Salty” drugs, 43 Salvia (Danshen), 83 FDA, 85 TZQ, 84 Salvia miltiorrhiza (S. miltiorrhiza), 46, 84, 85, 135 San-Mai San, 59 San-Qi Ginseng (Pseudoginseng Radix), 109 Sanchi, 86 Saw Palmetto, 109 Schisandra chinensis (S. chinensis), 58, 135 Schisandra fruit, 60 Scutellaria baicalensis, 46, 57, 135 Scutellaria radix, see Skullcap Seasonal variation, 16 “Selling TCM” theory, 5 “Servant” drug, 47 SFDA, see State Food and Drug Administration Shao-Yang syndrome, 56–57 Sheng-Mai-San, 58–60 Shen-Nong, 8, 9 classic of medical herbs, 22 Shen-Nong Bencaojing, see Shen-Nong Materia Medica Shen-Nong Materia Medica, 8, 9, 10 Shikimin, 13 Shortened tongue, 35–36 Sibutramine, 107–108

Index Si Jun Zi Tang, see Four Gentlemen Decoction Singapore, TCM in, 117 Singapore TCM Physicians Registration Examination (STRE), 117 Single Chinese and botanical medicines, 69 artemisinin, 70–73 bioassays, 70 Chinese Cordyceps, 80–83 Dong quai, 88 Ephedra, 92–93 evidence-based approach, 70 Garlic, 89–92 Ginkgo, 73–75 Ginseng, 75–77 Green tea, 78–80 Red yeast rice, 87–88 Salvia, 83–87 statins, 89 Six-ingredient decoction (or pill) with Rehmannia (Liuwei Dihuang Tang(wan)), 61 Skullcap (Scutellaria radix), 109, 100 Slimming program, 99 SMZ, 126 “Sour” drugs, 43 Speckled tongue, 35 Spores, 81 Star anise, 13 State Food and Drug Administration (SFDA), 114 State–Private Joint Ownership Campaign, 113 Statins, 89 Stephania tetrandra (S. tetrandra), 99, 100, 135 S-trans-1-propenyl analogs, 90 STRE, see Singapore TCM Physicians Registration Examination Suan Zao Ren, 66 Suan Zao Ren Tang (Sour Jujube Decoction), 65–66 Substances, 23 Sweet drugs, 43 Symptom, 30 Syndrome, 30 differentiation, 39 Synergism, 47 Synergistic effect, 47

T Tai-Chi, 31 Tamiflu, 126

149 Tang Bencao, 10 Tangzhiqing (TZQ), 84 Tan IIA, see Tanshinone IIA Tanshen, see Salvia miltiorrhiza (S. miltiorrhiza) Tanshinone I, 86 Tanshinone IIA (Tan IIA), 86, 87 “Tastes”, 42 TCM, see Traditional Chinese Medicine TGA, see Therapeutic Goods Administration Thai traditional medicine, 125 Theory and practice, TCM, 21; see also Traditional Chinese Medicine (TCM) cardinal characteristics of Chinese medicine, 23–25 characteristics of yin and yang, 25–26 Chinese medicine, 21 close relation of human being with surroundings in nature, 29 diagnosis, 32–36 five elements, 26–29 function of qi, 30 initiation of theoretical system of Chinese medicine, 21–22 palpation, 36 pulse examination, 36–39 qi, blood, body fluids, and essence, 30 simple expression of yin–yang relationship, 26 therapeutic modalities, 30–32 traditional categorization, 22–23 wax and wane and transformation of yin–yang, 26 Yin and yang theory and application to Chinese medicine, 25 Therapeutic Goods Administration (TGA), 117 Therapeutic modalities, 30–32 Therapeutic strategies, 53 Tianxianteng, 100 Tien-chi ginseng, 86 Tincture, 18 Tongue, 32 abnormalities, 35–36 characteristics, 35 colors, 33–35 normal, 33 parts, 32, 34 Total quality system, 129 Toxic Aconitum plants, 103–105 Toxic compounds and contaminants in TCM herbs, 98

150 TQM, TCM needs, 129–131 Traditional and Complementary Medicine Bill, 116 Traditional and Complementary Medicine Council, 116 Traditional categorization, 22–23 Traditional Chinese Medicine (TCM), 1, 7; see also Theory and practice, TCM assorted dried plant and animal parts, 54 in Australia, 117–118 botanical classification of TCM herbs, 12–20 in China, 113–116 classical TCM herbal literature, 7–12 efficacy of TCM, 55 examples, 55–66 formulas, 3, 53 herbalism, 7, 11 herbal medicine, 53–55 herbs, 19 in Hong Kong, 118–124 in Indonesia, 117 internationalization of, 18–20 in Malaysia, 116 modern Western medicine aspects, 2 Practitioners Act, 117 Practitioners Board, 117 preparations, 3, 17–18 reductionist approach, 4 in Singapore, 117 Traditional Herbal Medicinal Products Directive, 125–126 Traditional Medicine License, 117 Tropane alkaloids, 105–106 Tui-Na, 32 TZQ, see Tangzhiqing TZQ-F, 84

U United Nations Educational, Scientific and Cultural Organization (UNESCO), 11 Unusual peroxide linkage, 73 Upper Class drugs, 8 U. S. Food and Drug Administration (FDA), 85

Index V Visceral organs, 27, 28 Vitality, 32

W Warfarin, 110 Water, 26–29 Water-soluble granules, 18 Wax and wane and transformation of yin–yang, 26 Western drugs, 107–108 Western medicine, 118, 119, 125, 126, 128 “Wizened” tongue, 32 Wood, 26–29 World Health Organization (WHO), 71

X Xanthium sibiricum (X. sibiricum), 97–98, 135 poisoning, 106 Xiang Sha Liu Junzi Tang, 65 Xiao-Chai-Hu-Tang, see Minor Bupleurum Decoction

Y Yaks, 80–81 Yin and Yang, 21, 26, 27, 42, 43, 75–77, 103, 116 characteristics of, 25–26 theory and application to Chinese medicine, 25 wax and wane and transformation of, 26

Z Zang-fu functions, 32, 35 Zàng organ, 23 Zang viscera, 23, 24, 27 Zhi Mu, 66 Zingiberis Rhizoma, 57 Zingiber officinale (Z. officinale), 17, 46, 56, 57, 135 Ziziphus jujuba (Z. jujuba), 46, 135

Chinese and Botanical Medicines - Traditional Uses and Modern Scientific Approaches - Chun-Tao Che and Charmaine Tsang

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