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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
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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
vi Contents

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
Contents vii

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
viii Contents

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 fear-
less 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 health-
care 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 con-
cepts into many other languages. In this day and age, it seems logi-
cal 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
x 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.

xi
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 indus-
try, 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 direc-
tor 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 profes-
sorship in the 150-year history of the College of Pharmacy. He is

xiii
xiv 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 postdoc-
toral 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 qual-
ity 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 peer-
reviewed 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 gynecol-
ogy 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 xv

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 char-
ity 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 ben-
efits of Chinese Medicine. She runs educational programs teach-
ing 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 remain-
ing 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 hus-
bandry, and minimal hygiene kept civilizations alive. The ability of
peoples to recognize and use the plants around them, which pos-
sessed 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 knowl-
edge 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 trea-
sure 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 pro-
mote an understanding of basic concepts on TCM, and its practice
using Chinese medicine.

1
2 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 pri-
vate enthusiasts, spiritual advisors, or folk healers. It has been insti-
tutionalized 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 regu-
late 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 pharma-
cies and clinics across the country resulted in the formation
of two separate and parallel government institutions for doc-
tors: one “Chinese” and the other “Western.” In 1935, a resolu-
tion 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 bil-
lion 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 hos-
pital and university.

During the period between the eighteenth and nineteenth centu-


ries, 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 3

and lack of quality parameters, skepticism began to take hold. As an


example, Edzard Ernst, emeritus professor of complementary medi-
cine 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 pub-
lished research.

However, two important aspects cannot be overlooked. First,


although botanicals or herbal medicines have been in use for thou-
sands of years, more recently, the use of botanicals and natural prod-
ucts 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 associ-
ated with the modern living style cannot be treated effectively with
conventional medicine. Examples include preparations and formu-
lae of TCM, Ayurvedic medicine, Kampo medicine, African tradi-
tional 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
4 Chinese and botanical medicines

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 sin-
gle 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 satisfac-
tory 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 prepara-
tions. There are opportunities for harmonizing standards, adapting
the latest research methodologies including “omics” and spectro-
scopic tools, now in use, to evaluate the actions of botanicals and
natural products for the development of better remedies. Yet with-
out 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 5

applied to strategies that provide scientific data and could substan-


tiate 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, qual-
ity, 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 collect-
ing 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.
6 Chinese and botanical medicines

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, quo-
tation 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 medi-
cine 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 medi-
cine: 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 medi-
cal 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, ani-
mals, 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 tra-
dition 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
8 Chinese and botanical medicines

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 stud-
ies 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 (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. 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-and-
error 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 Shen-
Nong 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 rec-
ommended 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 cate-
gory will cause strong reactions and have only narrow therapeutic
Chapter two:  The beginning of TCM in China and TCM herbalism 9

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
10 Chinese and botanical medicines

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 prac-
tical. 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.


Chapter two:  The beginning of TCM in China and TCM herbalism 11

Figure 2.3  A page from Bencao Gangmu, showing both the text and pic-
tures 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 dif-
ferent categories, which are closer to the more modern ideas of clas-
sification. 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
12 Chinese and botanical medicines

Table 2.2  Classification of medicinal herbs in the Compendium of


Materia Medica
Materia medica (medicinal materials)

Minerals Plants Animals Others

Water Glasses Small animals Clothing and


Fire Cereals Scaled animals utensils 16
Soil Vegetables Shelled animals Categories
Metals Fruits Birds
Trees Other animals (“Gang”)
Humans
Hillside grasses Turtle/Tortoise
Fragrant grasses shellfish
Wetland grasses
Poisonous grasses 60
Creepers subcategories
Aquatic grasses (“Mu”)
Grasses between rocks
Bryophyte
Weeds

called Mu. For example, under the class of grasses, there are hill-
side 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 fea-
tures, 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 sys-
tem of plant taxonomy (classification of plants) was not developed
until 1892, when Adolf Engler published a plant classification sys-
tem, 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) sys-
tem (2009). Nowadays, TCM plants are scientifically classified in
accord with these taxonomic groups and every plant is identified
Chapter two:  The beginning of TCM in China and TCM herbalism 13

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 First letter not capitalized Abbreviated for Carl
ltalized or underlined ltalized or underlined 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 com-
mon or vernacular names (Table 2.4). For example, Glycyrrhiza gla-
bra 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 com-
pound, shikimin, which cause severe inflammation of the kidney,
urinary tract, and digestive organs. Although the two kinds of
14 Chinese and botanical medicines

Table 2.4  Examples of the common names of medicinal herbs


Licorice
European and Middle Eastern Glycyrrhiza glabra
licorice
Chinese licorice Glycyrrhiza uralensis
or G. inflata
Ginseng
American ginseng Panax quinquefolius
Brazilian ginseng Pfaffia paniculata
Chinese and Korean ginseng Panax ginseng
Indian ginseng Withania somnifera
Japanese ginseng Panax japonicus
Peruvian ginseng Lepidium meyenii
Sanqi ginseng Panax notoginseng
Siberian ginseng Eleutherococcus
senticosus
Mistletoe
American mistletoe Phoradendron leucarpum
European mistletoe 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 identi-
fied 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 15

H H
O

O H O
O

O
H
O

O
H

Figure 2.5  Chemical structure of anisatin.

Identification of medicinal plants


It is indisputable that in support of any herbal medicinal prepara-
tion, 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 morpholog-
ical features such as the shape, size, color, texture, and arrange-
ment 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 tis-
sues 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 tech-
niques, have become available, and they have been successfully
16 Chinese and botanical medicines

applied to examine the plant taxonomic relationship. DNA data-


bases 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 inti-
mately related to traditional medicinal systems. The discipline doc-
uments, preserves, and studies plant species, which affect human
health, embracing studies on the morphology, classification, phar-
macology, 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 pho-
tosynthesis takes place, and the products are transported to other
parts of the plant, where further biotransformation may occur to pro-
duce other compounds. Accumulation and storage of these chemi-
cal 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 medici-
nal 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 con-
tent 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.
Chapter two:  The beginning of TCM in China and TCM herbalism 17

Table 2.5  Examples of TCM derived from different plant


parts
Organized drugs
Above-ground parts Ephedra sinica (ephedra); Artemisia
annua (Sweet wormwood herb);
Mentha haplocalyx (peppermint)
Stem/branch/vine Cinnamomum cassia (cassia twig);
Uncaria rhynchophylla
Stem bark Cinnamomum cassia (cinnamon);
Eucommia ulmoides
Wood Santalum album (sandalwood);
Caesalpinia sappan (sappan wood)
Leaf Ginkgo biloba (ginkgo); Cassia
angustifolia (senna)
Flower/inflorescence Datura metal (Datura flower);
Lonicera japonica (honeysuckle
flower)
Fruit Illicium vernum (star anise);
Ziziphus jujube (Chinese date)
Seed Nelumbo nucifera (lotus seed);
Myristica fragrans (nutmeg)
Root Panax ginseng (ginseng); Rheum
palmatum (rhubarb); Angelica
sinensis (Chinese angelica)
Root bark Paeonia suffructicosa (peony bark)
Rhizome Zingiber officinale (ginger);
Dioscorea opposite (yam)
Unorganized drugs
Fixed oil Castor oil; linseed oil
Volatile oil Menthol oil; cinnamon oil
Resin/oleoresin Myrrh; frankincense; turpentine
Dried juice Aloe
Latex 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
18 Chinese and botanical medicines

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 ingredi-
ents. Such herbal decoctions are taken orally.
Other traditional forms of TCM preparation include honey-
based tablets, powder, given orally, tincture, which can be used
either internally or externally (for the treatment of soft tissue inju-
ries), and poultices, used solely for topical applications to relieve
muscular soreness and dermal inflammation.
Other than the traditional preparations, modern pharmaceu-
tical 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 gran-
ules) 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 neighbor-
ing 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 medi-
cal 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 medic-
inal herbs with these countries. While the countries to which
TCM reached often already had their own indigenous medical
Chapter two:  The beginning of TCM in China and TCM herbalism 19

system, they were heavily influenced and enriched by such con-


tacts. 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, acu-
puncture 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 alterna-
tive medicine and natural products. Acupuncture and herbal rem-
edies have gained much attention and wider applications as part
of integrative health. Increasingly, patients turn to the use of non-
Western traditional healing modalities, particularly when mod-
ern 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 becom-
ing more aware and concerned about their wellness and quality
of life. To this end, TCM offers health benefits such as better self-
defense against, and thus, prevention of, diseases. Hence, the past
40 years have witnessed a global boom in the “health-food” mar-
ket. 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 energy-
enhancing effect of ginseng root (Panax ginseng), blood-nourishing
function of angelica root (Angelica sinensis), and the general health-
promoting action of Astragalus root (Astragalus membranaceus)
shown in Figure 2.6.
20 Chinese and botanical medicines

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 non-
scientific and practiced solely based on experience. Chinese medi-
cine 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

21
22 Chinese and botanical medicines

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 his-
tory and was written by many medical experts. It expounds
the regularity of life and the integrity of man with his exter-
nal 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 elabo-
rated 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 practi-
tioners 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 23

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 primar-
ily affected by a given medicinal herb.
There is a categorization which is in accord with a specific func-
tion. These categories are grouped as follows:

1. Exterior-releasing or exterior-resolving, heat-clearing, down-


ward-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.
24 Chinese and botanical medicines

Sea of marrow
(brain)

Throat
Vertebral Pharynx
column
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
Anus orifice
Spermatic
Vital gate 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, con-
nected by Meridians, and restricted by synergistic actions. (Reproduced
with permission from https://clinic-tcm.com/.)
Chapter three:  TCM theory and practice 25

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 func-
tions 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, inter-
nal, 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 con-
dense, 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 coun-
terparts. Thus, these features are inseparable with restriction
26 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
Yang circle)
They are interconnected
Yin
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 cool-
ing effect, whereas too much yin results in a warming effect. A well-
known 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
Chapter three:  TCM theory and practice 27

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 Small Stomach Large Urinary


Bladder intestines Intestines 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 pos-
sess unique characteristic properties, but also to have an active and
28 Chinese and botanical medicines

Wood
liver

Water Fire
kidney heart

Metal Earth
lung spleen

Promation Restrain
(Generation) (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 pro-
moting 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 pos-
sess 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
Chapter three:  TCM theory and practice 29

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 sea-
son); 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 symp-
toms, 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.
30 Chinese and botanical medicines

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 symp-
toms 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 objec-
tively presented and is to be recognized by doctors and practi-
tioners 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 (defi-
ciency 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 gen-
eral belief is that blood represents the combination of nutritive qi
and the body fluids. Body fluid is a general term for all normal liq-
uids 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
Chapter three:  TCM theory and practice 31

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 ani-
mal products, which are also used, albeit less frequently, in medici-
nal prescriptions.

Acupuncture
This refers to a technique whereby fine needles are used to punc-
ture 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 develop-
ment in which an electric current is applied to the needles to pro-
vide 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 pass-
ing 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 com-
mon forms of mind–body therapy. The proper control of breath, a
peaceful mind, different postures, and body movements are benefi-
cial to promote the flow of qi and blood, calm the spirit, regulate the
emotion, and strengthen internal organs.
32 Chinese and botanical medicines

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 gener-
ally 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 indi-
cated if the tongue is healthy: bright red, moist, and moves freely.
Conversely, a “wizened” tongue will appear dark, or dull, and
moves with difficulty.
Chapter three:  TCM theory and practice 33

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
34 Chinese and botanical medicines

Chinese medicine map of the tongue

Kidneys and
urinary bladder

Large and small


intestines
Liver and gall bladder

Liver and gall bladder


Stomach
and
spleen

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 signifi-
cance 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
Chapter three:  TCM theory and practice 35

condenses blood, or consumption of fluids due to yin defi-


ciency 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 situa-
tion, 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; indi-
cates 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 func-
tion 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
36 Chinese and botanical medicines

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 stom-
ach 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 suffi-
cient, 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 examina-
tion 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 syn-
dromes. 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 cli-
matic 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 consid-
ered the “palace” of blood, and it is “governed” by the heart and
Chapter three:  TCM theory and practice 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 dis-


ease, abnormalities, or pathological changes. Importantly, pulse-
taking 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, respec-
tively, 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 Chinese and botanical medicines

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 pun-
gent-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

Guan chi
Cun

Heart Liver Kidney

Left hand

Lung Spleen
Kidney

Cun Guan chi

Right hand

Figure 3.8  Position of the pulses and references to their respective inter-
nal organs in the body.
Chapter three:  TCM theory and practice 39

differentiation of a syndrome are equally important. While one dis-


ease 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 dif-
ferentiation. Syndrome differentiation requires four examination
methods. These are (a) inspection, (b) auscultation and olfaction, (c)
inquiry, and (d) palpation. Furthermore, the treatment determina-
tion includes reasoning, methodology, decoction, and medicine.
There are several diagnostic methods available to the practitio-
ner. 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 phar-
macy 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 gymno-
sperms 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. Plant-
derived 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, crusta-
ceans, insects, arachnids, fish, amphibians, reptiles, birds, and mam-
mals 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 origi-
nates 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
42 Chinese and botanical medicines

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 rein-
forcing 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 proper-
ties 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 YANG

Cold Cool Neutral Warm Hot

Drugs with cool or cold Drugs with warm or hot


property usually have such property usually have such
effects as effects as
Clearing away heat and Warming the interior
toxic substances Dispelling coldness
Removing heat from blood Supporting Yang
Nourishing Yin Replenishing Qi
Purging fire

Figure 4.1  Relationship among the four natures.


Chapter four:  Traditional Chinese medicinal herbs 43

  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 febri-
fuges (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 inter-
nal 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 func-
tion, 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 appli-
cations 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 (taste-
less). Experiential evidence has shown that each of the five (or
six, including bland) tastes of the herbal drugs indicates a gen-
eralized 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 Chinese and botanical medicines

taste are often diuretics. In short, the taste of a drug will gen-
eralize its therapeutic application.
c. The meridian-affinity system
  In Chinese medicine theory, the entire human body is per-
ceived 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 relation-
ship 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 con-
cept of a herbal formula may find resemblance to combination treat-
ment (such as “cocktail therapy”) today.
There are certain rules that a clinician must follow when com-
posing a herbal formula, taking into consideration the roles of each
herb and the possible interactions among them. Thus, each prescrip-
tion is made up of one or more primary herbs (called the “Emperor”
Table 4.1  Examples of commonly used Chinese medicinal herbs
Botanical name Medicinal part Nature Taste Major effect
Angelica sinensis Root Warm Acrid and sweet Blood tonic
Artemisia capillaris Above-ground parts Cool Acrid and bitter Diuretic and clear heat
Astragalus membranaceus Root Warm Sweet Tonify qi
Atractylodes macrocephala Root Warm Sweet and bitter Tonic; diuretic
Bupleurum chinense Root Cool Bitter Clear heat
Chrysanthemum morifolium Flower head Cool Sweet and bitter Clear heat
Cinnamomun cassia Young stem Warm Acrid and sweet Diaphoretic
Citrus reticulata Fruit rind Warm Acrid and bitter Regulate qi
Codonopsis pilosula Root Neutral Sweet Tonify qi
Coptis sinensis Rhizome Cold Bitter Clear heat
Chapter four:  Traditional Chinese medicinal herbs

Crataegus pinnatifida Fruit Warm Sweet and sour Digestive; stomachic


Dioscorea opposita Root Neutral Sweet Stomachic
Ephedra sinica Stem Warm Acrid Diaphoretic
Fritillaria cirrhosa Corm Cool Bitter and sweet Antitussive; expectorant
Glycyrrhiza uralensis Root Neutral Sweet Tonify qi
(Continued)
45
46

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


Botanical name Medicinal part Nature Taste Major effect
Lonicera japonica Flower Cold Sweet Clear heat
Mentha arvensis Leaf Cool Acrid Diaphoretic; carminative
Panax ginseng Root Warm Sweet; slightly bitter Tonify qi
Panax notoginseng Root Warm Sweet; slightly bitter Hemostatic
Poria cocos Fungal body Neutral Sweet Diuretic
Pueraria lobata Root Cool Sweet and bitter Clear heat
Prunella vulgaris Inflorescence Cold Acrid and bitter Clear heat
Prunus armeniaca Kernel Warm Bitter Antitussive
Rehmannia glutinosa Root (raw) Cold Sweet Clear heat; cool blood
Rehmannia glutinsa Root (steamed) Warm Sweet Tonify yin; blood tonic
Rheum palmatum Rhizome Cold Bitter Purgative; Laxative
Salvia miltiorrhiza Root Cool Bitter Promote circulation; tonify blood
Scutellaria baicalensis Root Cold Bitter Clear heat
Zingiber officinale Rhizome Warm Acrid Dispel cold
Ziziphus jujuba Seed Warm Sweet and sour Tonify qi; sedative
Chinese and botanical medicines
Chapter four:  Traditional Chinese medicinal herbs 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 palatabil-
ity 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 com-
mon 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 ker-
nel 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 compli-
cated as various interactions may occur among the individual chemi-
cal 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 indi-
vidual 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 ephe-
dra, cinnamon twig, bitter apricot seed, and licorice root. The pre-
scription 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 Major
prescription Component herbs therapeutic effect
Ephedra Ephedra sinica above-ground part Releasing exterior
decoction Cinnamomun cassia branch wind-cold excess
Prunus armeniaca seed and promoting
Glycyrrhiza uralensis root diaphoresis
Four Panax ginseng root Fortifying the qi
gentlemen Atractylodes macrocephala rhizome and improving
decoction Poria cocos sclerotium spleen function
Glycyrrhiza uralensis root
Six-item Rehmannia glutinosa root Enhancing Yin
Rehmannia (processed) element and
decoction Cornus officinalis fruit improving liver
Paeonia suffruticosa bark and kidney
Dioscorea opposite rhizome function
Poria cocos sclerotium
Alisma orientalis root
Four-item Angelica sinensis root Improving blood
decoction Ligusticum chuanxiong rhizome circulation and
Paeonia lactiflora root regulating
Rehmannia glutinosa root menstruation
(processed)
Care-free Bupleurum chinense root Relieving
powder Angelica sinensis root depression of
Paeonia lactiflora root liver qi,
Atractylodes macrocephala invigorating the
rhizome spleen, and
Poria cocos sclerotium nourishing the
Glycyrrhiza uralensis root blood
Mentha haplocalyx leaf
Zingiber officinale rhizome
(processed)
Minor Bupleurum chinense root Eradicating
Bupleurum Scutellariae baicalensis root external heat and
decoction Pinellia tenata rhizome treating febrile
Zingiber officinale rhizome (raw) disease
Panax ginseng root
Glycyrrhiza uralensis root
Zizyphus jujuba fruit
Chapter four:  Traditional Chinese medicinal herbs 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 exces-
sive “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 suppres-
sant, 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 antag-
onistic interaction, although the concept of physical, chemical, dis-
positional, 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 recog-
nized in Chinese medicine for thousands of years. Their empirical
effects are obvious, although the exact pharmacological mecha-
nisms are not clearly understood. Pharmacokinetic, pharmacody-
namic, 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, carbo-
hydrate, 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 con-
tains 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
50 Chinese and botanical medicines

Table 4.3  Examples of herbs commonly used as dietary ingredients


Herb Plant part used Major effect
Yam Rhizome Strengthening yin energy
Ginger Rhizome Warming the body and improving
blood circulation
Garlic Bulb Promoting energy circulation and
warming the stomach
Chilies Fruit Warming the body and removing
dampness
Chinese Fruit Tonic to kidney and liver and
wolfberry improving vision
Lotus Seed Reinforcing the spleen and
stomach functions
Chrysanthemum Flower Clearing excessive heat
Mandarin Rind Regulating qi, stopping coughing,
orange and improving digestion
Chinese date Fruit General tonic to strengthen energy
Foxnut Seed Tonic to kidney and spleen

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 differ-
ent seasons to provide counteracting effects to resist any undesir-
able 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 com-
monly 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 pharmaceu-
tical 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 51

CH3 Artemisinin (Qing-Hao-Su), a sesquiterpene lactone containing an


H unusual peroxide bridge, is found in Artemisia annua (Qing-Hao).
It can kill the malaria parasite, Plasmodium falciparum.
O O
H3C Discovery of this anti-malarial drug has led to the award of 2015 Nobel
O Prize in Physiology or Medicine to Dr. Youyou Tu of the China Academy
H of Chinese medical sciences.
H H
O Analogs such as artemether, arteether and artesunate are also used in
CH3 malarial therapy.
O Artemisinin-based combination therapies are recommended by world
Artemisinin health organization as the first-line treatment for uncomplicated
P. falciparum malaria.

O
N Camptothecin is a cytotoxic alkaloid isolated from the bark and stem of
Camptotheca acuminata (the Happy Tree).
N
O It is an enzyme inhibitor of topoisomerase I, preventing DNA replication
and ultimately leading to cell death.
HO O Two analogs, topotecan and irinotecan, are used in cancer
Camptothecin chemotherapy.

OH
Ephedrine is a sympathomimetic amine present in Ephedra sinica
CH3 (Ma-Huang).

It acts as a central nervous system stimulant and bronchodilator.


HN
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 ratio-
nal 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 ner-
vous 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
52 Chinese and botanical medicines

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 inef-
fective and even have marked side effects has turned the attention
of many to search for alternative therapies and herb-based supple-
ments. 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 pharma-
cological 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 varia-
tion, 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 practitio-
ners 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 strength-
ens 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 thera-
peutic effects, in accord with ancient theories.
An example is the treatment of cold, when the presenting symp-
toms 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 pun-
gent 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
54 Chinese and botanical medicines

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 proper-
ties 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 ani-
mal 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 qual-
ity trials of herbal therapies to allow their effectiveness to be deter-
mined. 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 vari-
ous 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 defi-
ciency. 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 indi-


cated 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)
56 Chinese and botanical medicines

Figure 5.2 Bupleuri Radix. (From https://tcmwiki.com/wiki/radix-


bupleuri.)

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
Chapter five:  Examples of TCM formulas used in Chinese medicine 57

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, pow-
der, 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 uralen-
sis), 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 pharmaco-
logical 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
58 Chinese and botanical medicines

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 syn-
drome, the “Minor Bupleurum” Decoction has found clinical appli-
cations nowadays for the treatment of hepatic and related disorders
such as viral hepatitis, liver fibrosis, liver cancer, jaundice, chole-
cystitis, 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 treat-
ment 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 devel-
opment of chronic hepatitis, hepatic fibrosis, and hepato-carci-
noma. While the exact mechanism of action remains unclear, it may
involve the production of cytokines, regulation of immune func-
tion, and suppression of lipid peroxidation. A clinical study shows
that the “Minor Bupleurum” Decoction may improve liver pathol-
ogy 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 sug-
gested 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 prep-
aration also has upregulatory effects on cytochrome P450 enzymes
(CYP2B, CYP3A1, and CYP4A1) and can alter the plasma concentra-
tion of the drugs metabolized by these enzymes.
Sheng-Mai-San contains ginseng, Ophiopogon, Schizandra spe-
cies and is a general tonic for weak pulses including congestive
heart failure. Sheng-Mai-San, literally meaning “powder for gener-
ating pulses,” comprises three herbs, namely,

Panax ginseng root (Ginseng Radix)


Ophiopogon japonicus root (Radix Ophiopogonis) (Figure 5.3)
Schisandra chinensis fruit (Schisandrae Fructus)
Chapter five:  Examples of TCM formulas used in Chinese medicine 59

Figure 5.3  Radix Ophiopogonis Ophiopogon root. (From http://tradition-


alherb.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), espe-
cially for patients who have weak pulses. The formula is often indi-
cated 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 sup-
plement the lungs with its actions of invigorating qi and promoting
60 Chinese and botanical medicines

body fluid production. The Ophiopogon root, being the “Minister”


ingredient, nourishes the lung and promotes body fluid produc-
tion. 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 invigora-
tion and yin nourishment. The inclusion of an “Assistant” ingredi-
ent, 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 pen-
tobarbital-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 atheroscle-
rosis 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 stria-
tum of rats, as well as the noradrenaline level in the rat heart. In
addition, the antioxidant activity of Sheng-Mai-San has been dem-
onstrated both in animal and cell models.
Modern applications of this prescription are based on its abil-
ity to regulate the heart rate, increase heart output, strengthen car-
diac 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 arrhyth-
mia (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.
Chapter five:  Examples of TCM formulas used in Chinese medicine 61

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-Dihuang-
Wan), 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 com-
ponent. 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 dispers-
ing 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 hor-
mones and adrenal cortical hormones. Moreover, the Liuwei-Dihuang
62 Chinese and botanical medicines

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-Huanwu-
Tang 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 recom-
mended 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 pro-
genitor cells, improve the recovery of neurological function, reduce
infarction volume, stimulate neural proliferation, repair injured
blood vessels and lesion tissues, inhibit apoptosis, repress inflam-
matory 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.
Chapter five:  Examples of TCM formulas used in Chinese medicine 63

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 abun-
dant 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 in-
depth studies are certainly needed to fully comprehend the interac-
tions 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 exten-
sively. 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.
64 Chinese and botanical medicines

In ancient times, people washed the Angelicae Radix with alco-


hol 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 prac-
titioners 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 for-
mula 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.
Chapter five:  Examples of TCM formulas used in Chinese medicine 65

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 accumula-
tion, 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 full-
ness 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 resti-
tution and protect against indomethacin-induced damage of intes-
tinal 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)
66 Chinese and botanical medicines

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 feel-
ings 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 vari-
ous specific conditions for its efficacy in reducing sleeping distur-
bances. 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 day-
time dysfunction. Also, Suan Zao Ren Tang improves the sleep qual-
ity 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.
Chapter five:  Examples of TCM formulas used in Chinese medicine 67

Bibliography
Chan YY, Chen YH, Yang SN, Lo WY, Lin JG. 2015. Clinical efficacy of tra-
ditional Chinese medicine, Suan Zao Ren Tang, for sleep disturbance
during Methadone Maintenance: A randomized, double-blind, pla-
cebo-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 pro-
spective 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 glob-
ally. In this chapter, several examples of TCM plants that are gain-
ing widespread interest in the wellness and medical arena have
been chosen and are now being sold as dietary or nutritional sup-
plements 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 eventu-
ally 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
70 Chinese and botanical medicines

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 eval-
uation 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 effec-
tive 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 71

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 artemis-
inin 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
72 Chinese and botanical medicines

to reduce the risk of the parasites developing resistance. Thus, arte-


misinin 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 for-
mer 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).


Chapter six:  Examples of single Chinese and botanical medicines 73

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, arte-
misinin 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 sci-
entist Tu for her scientific contributions.

The chemical structure of artemisinin possesses an unusual


peroxide linkage, which is believed to be involved in the antimalar-
ial 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 treat-
ment, 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 medic-
inal 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
74 Chinese and botanical medicines

Figure 6.3  Ginkgo leaves.

6% terpene lactones (with removal of the ginkgolic acids from any


ginkgo preparations). The flavone glycosides neutralize free radi-
cals 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,
Chapter six:  Examples of single Chinese and botanical medicines 75

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 con-
centration, especially in the elderly and those recovering from ill-
ness. 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 vari-
ation exists in both the types and ratios of ginsenosides. The most
abundant ginsenosides in P. ginseng are Rb1 and Rg1 which gener-
ally 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, equiva-
lent 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
76 Chinese and botanical medicines

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
Chapter six:  Examples of single Chinese and botanical medicines 77

OR3

OH
20
12

3
6
R1O

R2

Ginsenosides R1 R1 R3 PD or PT

Rb1 -Glc2-Glc -H -Glc8-Glc PD


Rb2 -Glc2-Glc -H -Glc8-Ara(pyr) PD
Rc -Glc2-Glc -H -Glc8-Ara(fur) PD
Rd -Glc2-Glc -H -Glc PD
Re -H -O-Glc2-Rha -Glc PT
Rf -H -O-Glc2-Glc -H PT
Rg1 -H -O-Glc -Glc PT
Rg2 -H -O-Glc2-Rha -H PT

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 gin-
seng 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.
78 Chinese and botanical medicines

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 antioxi-
dant 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).


Chapter six:  Examples of single Chinese and botanical medicines 79

OH

OH

H
OH O
OH

O
H
OH OH
O

OH

OH

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

epicatechin (EC), gallocatechol (GC), gallocatechol gallate (GCG),


epigallocatechin (EGC), and epicatechin gallate (ECG). These poly-
phenols 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 experi-
ments and animal studies, many potential mechanisms have been
proposed for the chemopreventive effect of green tea and/or epi-
gallocatechin 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
80 Chinese and botanical medicines

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 war-
rants 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 admin-
istered 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 rang-
ing 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
Chapter six:  Examples of single Chinese and botanical medicines 81

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 fun-
gus 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 trans-
formed 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 para-
sitic 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 mummi-
fying 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).
82 Chinese and botanical medicines

Figure 6.8 Fruiting body of Cordyceps sinensis grown on the Tibetan


Plateau. “Winter Worm, Summer Grass”—the remarkable natural trans-
formation 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 per-
formance, 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
Chapter six:  Examples of single Chinese and botanical medicines 83

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 ath-
letes’ 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 con-
sumption 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”).
84 Chinese and botanical medicines

Figure 6.10 An athlete on an ergometer where VO2max levels are mea-


sured 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
Chapter six:  Examples of single Chinese and botanical medicines 85

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 com-
pleted 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
86 Chinese and botanical medicines

(Panax notoginseng; known as sanchi or tien-chi ginseng), and the


chemical borneol.
An antioxidant called salvianolic acid (or salvianolic acid B), iso-
lated from Danshen, is under study for protection against cerebro-
vascular 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-inflam-
matory 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 isch-
emia 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 devel-
opment of liver fibrosis, the formation of scar-like fibers in the
liver. Since the nonfunctioning fibers crowd out active liver tis-
sue, liver function decreases gradually as the amount of fibrous
tissue increases. Having chronic hepatitis and habitually drink-
ing 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 dia-
betes. In China, Danshen has also been studied for treating acute
Chapter six:  Examples of single Chinese and botanical medicines 87

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 color-
ing 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 gastro-
intestinal distress, prevent diarrhea, and improve blood circu-
lation. 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.
88 Chinese and botanical medicines

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 func-
tion 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 concentra-
tions 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 gynecologi-
cal ailments, fatigue, mild anemia, and high blood pressure. The
plant’s phytochemicals consist of coumarins, phytosterols, polysac-
charides, 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 dur-
ing pregnancy due to possible hormonal, anticoagulant, and anti-
platelet 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 clot-
ting. 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 multi-
ingredient 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.
Chapter six:  Examples of single Chinese and botanical medicines 89

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, ajo-
ene, and other organosulfur constituents such as S-allyl-l-cysteine.
90 Chinese and botanical medicines

A wide variation exists in the chemical composition of garlic prod-


ucts, reflecting differences in processing. The constituent profile of
garlic is unique and complex, being particularly rich in sulfur-con-
taining compounds. The main constituents of garlic include cys-
teine 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 fruc-
tosans, 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 choles-
terol-lowering agent, and several as an immune-stimulating agent.
Other activities such as anti-atherosclerotic, antithrombotic, antican-
cer, 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, atheroscle-
rosis, 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
Chapter six:  Examples of single Chinese and botanical medicines 91

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 glu-
cose, cholesterol, and triglycerides, whereas boiled garlic has little
effect on these parameters.
In two separate studies, solvent-extracted garlic and sul-
fur compounds given to patients with hyperlipidemia low-
ered 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
92 Chinese and botanical medicines

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 chro-
matography in cultured hepatoma cells treated with fresh gar-
lic 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 sulf-
hydryl 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 activ-
ity including S-allyl cysteine, S-allyl mercaptocysteine, alliin,
allixin, and N-acetyl-S-allyl cysteine, a metabolite of S-allyl cys-
teine. For hypertension, garlic is thought to reduce blood pres-
sure by two mechanisms: (a) causing smooth muscle relaxation
and vaso­dilation by activating the production of an endothe-
lium-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 clini-
cally 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
Chapter six:  Examples of single Chinese and botanical medicines 93

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.
94 Chinese and botanical medicines

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.
Chapter six:  Examples of single Chinese and botanical medicines 95

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, ana-
lytical, 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 indi-
cated 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 toxic-
ity 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 neighbor-
hoods; 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 reac-
tions 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 medi-
cines 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 exam-
ple, to avoid the toxic and adverse effects in Xanthium sibiricum, this
plant must be processed very carefully. Furthermore, hepatotoxicity

97
98 Chinese and botanical medicines

has been reported with products containing Polygonum multiflorum,


glycyrrhizin, Senecio, and Symphytum. Other herbs indicated as
being hepatotoxic include Dictamnus dasycarpus, Astragalus membra-
naceous, 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 cardiomyopa-
thy. Products adulterated with pharmaceuticals for weight loss or erec-
tile 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 veri-
fied 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 com-
pounds, some of which are used in TCM. However, the ancient wis-
dom 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 99

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 pro-
motes the movement of qi and resolves stagnation and abdom-
inal distention. They are not used for weight loss, and nor are
they recommended for prolonged use, in accord with TCM prac-
tices. 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 under-
went 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 tet-
randra radix to make the product, another herb Aristolochia fang-
chi was used. This may have occurred because the Chinese name

O
OH

NO2
O

OCH3

Figure 7.1  Structure of aristolochic acid.


100 Chinese and botanical medicines

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 tes-
tis 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 lower-
ing 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 manshu-
riensis, 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 inci-
dent 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 medici-
nal materials due to its harmful effects.
Table 7.1 summarizes the major herbs belonging to the
Aristolochiaceae family.
Table 7.1  Plants with medicinal functions in the aristolochiaceae family
Contains
aristolochic
Chinese name Species Function in TCM acids
Madouling Fruits of Aristolochia debilis Siebold & Zucc.Clearing lung and lowering adverse qi, +
or A. contorta Bunge 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, +
Chapter seven:  TCM safety and regulations

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
101

(Continued)
102

Table 7.1 (Continued)  Plants with medicinal functions in the aristolochiaceae family
Contains
aristolochic
Chinese name Species Function in TCM acids
Duheng Whole herb of Asarum forbesii Maxim. Expelling wind, dispelling cold, relieving +
pain. Slightly toxic
Xixin Roots and rhizome of Asarum heterotropoides Expelling wind and dispelling cold, +
Fr. Schmidt var. mandshuricum (Maxim.) dispelling wind and relieving pain,
Kitag., Asarum sieboldii Miq. var. seoulense stimulating meridians, warming lungs,
Nakai or Asarum sieboldii Miq. and dissipating phlegm
Jinerhuan Roots and rhizome of Asarum insigne Diels Expelling wind and dispelling cold, +
reducing swelling and easing pain,
dissipating phlegm. Mildly toxic
Chinese and botanical medicines
Chapter seven:  TCM safety and regulations 103

The toxic Aconitum plants


Aconitum, also known as aconite, is a genus of herbaceous peren-
nial 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 yuna-
conitines 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 kusnezof-
fii 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

OH
O
O
O N
O
OH
HO O
O
O

Figure 7.2  Structure of aconitine.


104 Chinese and botanical medicines

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 poten-
tial 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 tox-
icity 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 low-
ers 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 cen-
ter 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 pro-
cessed 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 poi-
soning cases. A study examining the reports of Aconitum poison-
ing 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
Chapter seven:  TCM safety and regulations 105

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 govern-
ment and information from the Chinese Pharmacopeia now rec-
ommend 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 symp-
toms, 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
106 Chinese and botanical medicines

1 2
7
8
N 3
6
5 4
7

6
3 1
2
5 N
4
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 gly-
cosides 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 hepa-
totoxic compounds.
Chapter seven:  TCM safety and regulations 107

O
O O
S Na+
O S O O
Na+ O–
O
OH
O H
O
O
O

OH
H
HO 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 decoc-
tions. Owing to the confusion created by common names or con-
tamination, 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 poison-
ing. 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 con-
taining 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
108 Chinese and botanical medicines

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 sibutra-
mine 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 manufac-
turing 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 pow-
ders 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 pow-
der size of the herbal materials for the capsule. It was this out-
sourced 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 sug-
gested that none of the traditional pills were found to be contami-
nated 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, manufactur-
ers have taken shortcuts and not followed the advice of the quality
control experts and professional knowledge to prepare safe prod-
ucts. 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 can-
cer cells taken from prostate cancer patients.
Chapter seven:  TCM safety and regulations 109

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 inter-
nationally, 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 rubes-
cens), 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, cli-
nicians 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 fur-
ther study of the formula.
PSA is a glycoprotein enzyme which is needed for the ejacula-
tion of sperm in males. It is also detected in serum of healthy indi-
viduals; 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 ther-
apy is usually used to treat these androgen-dependent (AD) pros-
tate 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 fol-
low-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 ingre-
dients are distinct from some well-known estrogens including
110 Chinese and botanical medicines

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 recom-
mended 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 prin-
ciples 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, respec-
tively, 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 endo-
crine 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 moni-
toring 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,
Chapter seven:  TCM safety and regulations 111

suggesting that PC-SPES is superior to the latter. However, the inci-


dent has generated a very negative impact on the use of herbal sup-
plements in North America.
Herbs are natural and many of them are safe. However, the inci-
dents 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 consum-
ers 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 pro-
gressive 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 prod-
ucts 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 corre-
sponding 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 reg-
ulations 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

113
114 Chinese and botanical medicines

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 regula-
tions has evolved, partly because of the learning from the experi-
ences 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 devel-
opment, whereby China could support a higher standard of regu-
lations and the incremental costs resulting from regulations can
reasonably be passed on to the community.
The Chinese Food and Drug Administration (CFDA) is respon-
sible 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 eth-
nomedicines for China. For products to be available on the market
in mainland China, they must be registered by the CFDA. The cur-
rent drug registration policy was released in 2007. China is one of
the few countries where TCM is regulated as drugs which have dis-
ease 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 stan-
dards, 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 cat-
egories, 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 require-
ments for at least one of the following categories:
Chapter eight:  The current use of TCM 115

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 mar-
keted 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 mar-
keted 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 administra-
tion route. For products developed based on classic formulations or
TCM prescriptions formulated under the TCM theory (whose indica-
tions 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
116 Chinese and botanical medicines

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 med-
ical 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 prod-
ucts 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 veri-
fication 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 break-
fast; 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 tradi-
tional and complementary medicine practitioners, including TCM
practitioners as well as other traditional and complementary medi-
cine practitioners such as those in traditional Malay medicine and
traditional Indian medicine.
Chapter eight:  The current use of TCM 117

Singapore
The TCM Practitioners Act was passed by Parliament in 2000 and
the TCM Practitioners Board was established in 2001 as a statu-
tory board under the Ministry of Health, to register and regu-
late TCM practitioners. The requirements for registration include
possession of a diploma or degree from a TCM educational insti-
tution/university on a gazette list, either structured TCM clini-
cal training at an approved local TCM educational institution or
foreign TCM registration together with supervised TCM clini-
cal 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 medi-
cines, 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 ben-
efits. 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 juris-
diction outside of China to regulate Chinese m ­ edicine practitio-
ners. Chinese medicine is offered as an ­i ndependent course in the
universities (along with Western medicine), thus, it is now a regis-
tered 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).
118 Chinese and botanical medicines

Chinese dietary and lifestyle advice was also almost always or fre-
quently 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 doc-
tors. 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 nine-


teenth century. (From http://www.skyscrapercity.com/showthread.
php?t=338983.)
Chapter eight:  The current use of TCM 119

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 main-
stream in the Hong Kong medical system. However, it is impor-
tant 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 devel-
opment of “evidence-based” Chinese medicine practice through
120 Chinese and botanical medicines

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 regula-
tions (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.)
Chapter eight:  The current use of TCM 121

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 medi-
cine 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).)
122 Chinese and botanical medicines

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 conve-
nient. 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 train-
ing 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
Chapter eight:  The current use of TCM 123

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 reg-
ulates TCM. The Chinese Medicine Council was established for
implementing regulatory measures for Chinese medicine practitio-
ners and Chinese medicines. This includes the licensing of Chinese
medicine practitioners (to ensure their professional practice, con-
duct, 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 identifica-
tion 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 collabora-
tions together with tertiary institutions and the Government are
124 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 particu-
lar 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 attract-
ing 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 grow-
ing 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 differ-
ences in Eastern and Western medical systems. This is a significant
development since, to date, the international pharmaceutical com-
panies have been reluctant to invest in traditional medicine.
While Western medicine is focused on treating specific dis-
eases, 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 treat-
ments 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,

125
126 Chinese and botanical medicines

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 conver-
gence 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 ail-
ment. One example of this is the experimental use of bioinformat-
ics, which attempts to employ advanced computer systems to gain
an understanding of TCM mechanisms.
Meanwhile, Western medicine is increasingly being used along-
side traditional medicine in China. Many hospitals in Asia including
Singapore, Malaysia, and Thailand offer traditional Chinese medi-
cine, while the WHO has established collaborative centers for tradi-
tional 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
Chapter nine:  Global acceptance of TCM 127

clots, and trigger heart attack (Chest Bi) and cerebral vascular acci-
dent (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 pio-
neer 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 with-
out 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 his-
tory 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 substanti-
ate 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.
128 Chinese and botanical medicines

Resurgence of consumer interest: A need for


better science in botanical preparations
The majority of the world’s population still relies heavily on natu-
ral 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 move-
ment of their respective traditional medicines. There is the move-
ment 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 con-
ducting 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 natu-
ral 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 preclini-
cal 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 usu-
ally contain complex chemical mixtures and their interaction in
the human body may be much more complicated. The reduction-
ist approach—to isolate compounds and evaluate their individual
activities—has not been sufficient to fully elucidate the biologi-
cal interactions of the botanicals in the body. The recent advances
in systems biology, metabolomics, and chemometrics offer new
Chapter nine:  Global acceptance of TCM 129

technological platforms to study complex mixtures and to evalu-


ate 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 botani-
cals 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 dif-
ficult 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 clini-
cal studies leading to a “total quality system”—the integration of
these various technical platforms and strategies that could con-
tribute 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 tech-
niques 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 botani-
cals 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
130 Chinese and botanical medicines

region. Yet, despite these efforts, we have not developed efficient


research platforms capable of untangling the chemical composi-
tions 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 evalu-
ate the actions of botanicals and natural products for the devel-
opment of better remedies and
3. Developing research strategies to provide scientific data that
could substantiate the health claims to support a wider accep-
tance of botanicals and herbs in the world

The longtime use of these herbal remedies suggests some mea-


sure of pharmaceutical activity. Despite these ongoing efforts, we
have not yet developed efficient research platforms capable of assur-
ing 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 authori-
ties in China, Hong Kong, and elsewhere seek better and harmo-
nized approaches to maintain safety and the highest standards of
botanical preparations. There are opportunities for harmonizing
standards, adapting the latest research methodologies including
Chapter nine:  Global acceptance of TCM 131

“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
134 Appendix: Plant names

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 135

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)
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. Electro-
acupuncture 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 proper-
ties; 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 prescrip-
tion 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 car-
michaeli 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
138 Glossary of terms

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 mac-
rocephala 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 diges-
tion 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 for-
mula on the target meridian or area of the body; and to har-
monize 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 anes-
thesia 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 tech-
niques applied to the soft tissues and joints to remove
obstructions in the superficial tissues, improve circula-
tion, and relax muscles. In general, pressure is applied to
Glossary of terms 139

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 for-
mula 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 medi-
cine, 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 prodro-
mos 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 prep-
aration 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.
140 Glossary of terms

Zang viscera (臟):  A collective term for five internal organs includ-
ing 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 consist-
ing 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 com-
prehensive 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 Apricot kernel, 47
Aristolochiaceae family, 100–102
AAN, see Aristolochic acid nephropathy Aristolochia species, 97–100
Aconite, see Aconitum A. debilis, 100, 133
Aconitine, 103 A. fangchi, 133
Aconitum, 97–98 A. manshuriensis, 100, 133
A. carmichaeli, 103, 133 Aristolochic acid, 99, 100
A. kusnezoffii, 103, 133 Aristolochic acid nephropathy (AAN), 100
toxic Aconitum plants, 103–105 Artemisia annua, see Artemisinin
Acupoints, 31 Artemisia capillaris (A. capillaris), 45
Acupuncture, 19, 31, 117–118 Artemisia vulgaris (A. vulgaris), 31
Acute pancreatitis, 87 Artemisinin (Artemisia annua), 51, 70, 72, 133
Acute renal failure, 106 Malaria, 70–73
AD prostate cancer, see Androgen- Asarum species, 97–100
dependent prostate cancer A. heterotropoides, 100, 133
AI prostate cancer, see Androgen A. sieboldii, 100, 133
independent prostate cancer “Assistant” drug, 47
Akebia quinata (A. quinata), 100, 133 Astragalus membranaceus, see Astragalus root
Akebia trifoliata (A. trifoliata), 100, 133 Astragalus root (Astragalus membranaceus),
Alisma orientalis (A. orientalis), 133 19, 20, 45, 62, 133
Alkaloids, 99–100 Atherosclerosis, 60
Allium sativum L, see Garlic Atractylodes macrocephala (A. macrocephala), 45
Alzheimer disease, 125 Atractyloside, 106, 107
American ginseng (Panax quinquefolius), Aucklandia lappa (A. lappa), 133
43, 135 Australia, TCM in, 117–118
Androgen-dependent prostate cancer (AD
Ayurvedic medicine, 3
prostate cancer), 109
Aztecs, 1
Androgen independent prostate cancer (AI
prostate cancer), 109
Angelica Radix Blood Tonics, see B
Danggui-Buxue-Tang
Baifupian, 104
Angelica root (Angelica sinensis), 19, 62, 88, 133
Baikal Skullcap, see Skullcap (Scutellaria
Angelica sinensis, see Angelica root
radix)
Angiosperm Phylogeny Group system
“Bencao”, 7
(APG III system), 12 “Bencao Gang-Mu”, 11
Anisatin, 13, 15 Bioassays, 70
Antipyretic-like medicines, 126 Biologically active ingredients from TCM
APG III system, see Angiosperm Phylogeny herbs, 50–51
Group system “Bitter” drugs, 43

143
144 Index

“Bland” taste, 43, 44 Chinese angelica, see Angelica root


Blood, 30 (Angelica sinensis)
blood-nourishing function of angelica Chinese Cordyceps, 80
root, 19 life cycle of C. sinensis, 81
Blue/purple tongue, 35 perceived health benefits, 82–83
Body fluids, 30 Chinese/Korean ginseng, see Ginseng
Bone setting, 32 (Panax ginseng)
Botanical authentication, 15 Chinese Materia Medica (CMM), 97, 98, 116,
Botanical classification of TCM herbs, 12; 117–118, 121
see also Classical TCM herbal Chinese medicine, 21
literature cardinal characteristics, 23–25
binomial system of botanical herbs, 45–46, 50
nomenclature, 13 initiation of theoretical system, 21–22
Engler system, 12 products, 107
examples of TCM derived from theories, 19
different plant parts, 17 Yin and yang theory and application
internationalization, 18–20 to, 25
medicinal botany, 16–17 Chinese Medicine Council, 118, 123
medicinal plant identification, 15–16 Chinese Pharmacopeia, 103, 116
Star anise, 13 Chinese sage, see Salvia miltiorrhiza (S.
TCM preparations, 17–18 miltiorrhiza)
Buddhist monks, 18 Chinese star anise (Illicium verum), 13,
Bupleuri Radix (Bupleurum chinense), 45, 56, 14 134
57, 133 Chinese State Drug Administration, 114
Buyang-Huanwu-Tang, 62 Chloroquine, 72
Chrysanthemum morifolium (C. morifolium), 45
C Chuanwu, 103
Cinnamomun cassia (C. cassia), 45
Calculus bovis (C. bovis), 121 Cistanches deserticola (C. deserticola), 133
Camellia sinensis, see Green tea Citrus reticulata (C. reticulata), 45
Campsis grandiflora (C. grandiflora), 133 Classical TCM herbal literature, 7; see also
Camptotheca acuminata, see Camptothecin Botanical classification of
Camptothecin (Camptotheca acuminata), TCM herbs
51, 133 “Bencao”, 7
Cangerzi, see Fructus xanthii (F. xanthii) “Bencao Gang-Mu”, 11
Caowu, 103 classification of medicinal materials,
Cardinal characteristics of Chinese 9, 12
medicine, 23–25 Gang, 11–12
Cardiotonic Pill, see Danshen Dripping Pill Shen-Nong Materia Medica, 8, 10
Carthamus tinctorius (C. tinctorius), 133 Tang Bencao, 10
Catechin (C), 78 CMM, see Chinese Materia Medica
CFDA, see China Food and Drug Coating of tongue, 36
Administration Cocktail therapy, 44
Chai-Hu, see Bupleuri Radix (Bupleurum Codonopsis pilosula (C. pilosula), 45, 133
chinense) Combination preparation, 115
Chaun Xiong, 66 Compendium of Materia Medica, medicinal
Chemical biosynthesis, 16 herbs classification in, 12
China, 113 Complementary interaction, 47
class 1 to class 9 drugs in, 114–116 Complementation modes, 47
reform policy of, 113–114 Consumer interest, resurgence of,
TCM regulation in, 114 128–129
China Food and Drug Administration Contamination, 108
(CFDA), 114, 116 Coptis sinensis (C. sinensis), 45
Index 145

Cordyceps sinensis (C. sinensis), 81, 133 Electro-acupuncture, 31


athlete on ergometer, 84 “Emperor” drug, 44, 47
fruiting body, 82, 83 “Emperor” ingredient, 57, 59
life cycle of, 81 “Emperor and Minister” herbs, 47
Cornus fruit, 61 Energy-enhancing effect of ginseng
Cornus officinalis (C. officinalis), 133 root, 19
Cracked tongue, 35 Engler system, 12
Crataegus pinnatifida (C. pinnatifida), 45 ENOX2, see NADH oxidase activity
Crimson tongue, 34–35 Ephedra (Ephedra sinica), 92–93
Crude drug, 115 Ephedra Decoction (Ma Huang Tang),
Cunkou, 37 47, 53
Cupping, 31 Ephedra herb, 44
Ephedra sinica, see Ephedra; Ephedrine
Ephedrine (Ephedra sinica), 45, 51, 134
D
Epicatechin (EC), 79
Da Hui Xiang, 126 Epicatechin gallate (ECG), 79
Danfupian, 104 Epigallocatechin (EGC), 79
Danggui-Buxue-Tang, 63–64 Epigallocatechin gallate (EGCg), 79
Danshen, see Salvia Essence, 30
Danshen Dripping Pill, 85 “Evidence-based” Chinese medicine
Daturae flos (D. flos), 105 practice, 119–120
Datura metel (D. metel), 105–106, 134 Evidence-based approach, 70
Decoction, 17–18 Exercise therapy, 31
Dendranthema folium Chrysanthemum “Exterior Shao-Yang syndromes”, 55
indicum or Chrysanthemum
morifolium, 134 F
Dendrantherma folium, see Mum
Deviated tongue, 35 FDA, see U.S. Food and Drug
Diaphoretic effect, 47–48 Administration
Dictamnus dasycarpus (D. dasycarpus), 134 Female ginseng, see Angelica root (Angelica
Dietary therapy, 32, 49–50 sinensis)
Diethylstilbestrol, 110 FHH, see Forum of Harmonization of
Dihon Pharmaceutical Group, 125 Herbal Medicine
Dihydrotanshinone, 86 Fire, 26–29
Dioscorea opposita (D. opposita), 45, 134 Five elements, 26
Dioscorea rhizome, 61 dynamic relationships, 28
Disease, 30 relationship to five major visceral
Diterpene ginkgolides, 74 organs, 27
DNA databases, 16 “Five tastes” system, 43–44
Dong quai, see Angelica root (Angelica Flavone glycosides, 74
sinensis) Floating tight pulse, 38
Dyer’s Woad (Isatis Radix), 109 Foamy narcotic powder, see Mafeisan
Forum of Harmonization of Herbal
Medicine (FHH), 129–130
E
Four Gentlemen Decoction (Si Jun Zi Tang),
Earth, 26–29 64–65
Eastern and Western medical systems, 125 “Four natures” system, 42–43
EC, see Epicatechin Fritillaria cirrhosa (F. cirrhosa), 45
ECG, see Epicatechin gallate Fructus xanthii (F. xanthii), 106
Efficacy of TCM, 55 Fu Ling, 66
EGC, see Epigallocatechin Fu viscera, 23, 27
EGCg, see Epigallocatechin gallate Fuzi, 103, 104
Eighty-One Medical Problems, 22 Fuzi Lizhong decoctions, 104
146 Index

G H
Gallbladder, 55 “Half-processed Fuzi”, 104
Gallocatechol (GC), 79 Han Fang Ji, 100
Gallocatechol gallate (GCG), 79 “Health-food” market, 19
Gan Cao, 66 Hepatotoxicity, 97–98, 106
Gang, 11–12 “Herb”, 31
Ganoderma lucidum, see Mushroom Reishi Herbal drugs, 16
Garlic (Allium sativum L.), 89, 91, 133 Herbalism, TCM, 7, 11
in cardiovascular disease models, Herbal medicines, 41, 53–55
90–92 Herbal remedies, 19
constituents, 90 Herb–herb interactions, 47
GC, see Gallocatechol Herbology, 31
GCG, see Gallocatechol gallate Herbs, TCM, 41
General health-promoting action of active compounds, 51
Astragalus root, 19 biologically active ingredients from,
Ginkgo, 73–75 50–51
Ginkgo biloba (G. biloba), 134 Chinese medicinal herbs, 45–46
extracts, 73–75 Chinese medicinal materials, 41
“Ginseng-Alone Decoction”, 44 dietary ingredients, 50
Ginseng (Panax ginseng), 13, 19, 45, 75, 134 future prospects, 51–52
adaptogen and effects on exercise herbal drug character and property,
performance, 77 42–44
compounds, 77 herbal formulas, 44–49
distinctive features, 76 TCM dietary therapy, 49–50
ginsenoside variation and HKCMMS, see Hong Kong Chinese Materia
standardization, 75 Medica Standards
ratio of Rg1 and Rb1 and yin and yang, HMG-CoA reductase inhibitors, 91
75–77 Holism, 23
Ginsenoside, 75 Hong Kong, 118
Global acceptance of TCM; see also Aconitum poisoning, 104–105
Traditional Chinese Medicine ancient TCM pharmacy, 120
(TCM) as fishing village, 118
resurgence of consumer interest, herb wholesalers, 120
128–129 Hospital Authority, 119–120
TCM needs TQM, 129–131 old Tung Wah Hospital, 119
in world, 125–127 TCM in, 119–124
Glutamylcysteines, 90 Hong Kong Chinese Materia Medica
Glycoprotein enzyme, 109 Standards (HKCMMS), 123, 129
Glycyrrhizae radix (G. radix), 104, 109, 110 Huang-Qin, see Radix Scutellariae (Scutellaria
Glycyrrhiza glabra, see Licorice baicalensis)
Glycyrrhiza uralensis (G. uralensis), 45, 134 Huangdi’s inner classic of medicine, 22
Green tea (Camellia sinensis), 78, 133 Human body, 23, 24, 41, 44, 128
anticancer effects, 78
anticancer mechanisms of action, 79 I
chemical structure, 79
leaves, 78 ICU, see Intensive care unit
NADH inhibition oxidase activity, Illicium anisatum, see Japanese star anise
79–80 Illicium verum, see Chinese star anise
Guangfangji, 100 Immune function, 58
Guang Fang Ji, 100 Incas, 1
Guanmutong, 100 Indomethacin, 110
“Guide”, 54 Indonesian Ministry of Health, 117
Index 147

Indonesia, TCM in, 117 Modern pharmaceutical formulations, 18


Intensive care unit (ICU), 105 Modern Western medicine aspects, 2
Internationalization of TCM, 18–20 Monacolins, 88
Isatis indigotica (I. indigotica), 134 “Monarch” drug, 53, 66
Isatis Radix, see Dyer’s Woad Monascus purpureus, see Red yeast rice
Moxibustion, 31
Mu, 12
J
Multi-item prescription, see
Japanese star anise (Illicium anisatum), 13, Poly-prescription
14, 134 Mum (Dendrantherma folium), 109
Jin Gui Yao Lue, 66 Mushroom Reishi (Ganoderma lucidum),
Jun Zi, 64 109, 134
Mutong, 100
Mycelium, 81
K
Kampo Medicine, 3, 125 N
Kidney functions, 29, 49
Kudzu root (Radix Puerariae lobata), 84 NADH inhibition oxidase activity, 79–80
NADH oxidase activity (ENOX2), 79–80
“Nam Pak Hong”, see Hong Kong herb
L wholesalers
LDL oxidative prevention, 92 Natural medicinal products, 115
Licorice (Glycyrrhiza glabra), 13, 47, 64, 109, 134 “Natures”, 42
Ligusticum chuanxiong (L. chuanxiong), 134 Nonfunctioning fibers, 86
Liuwei-Dihuang preparation, 61–62 Nonspecific anti-inflammatory, 126
Liver fibrosis, 86 Notoginseng (Panax notoginseng), 46,
Lonicera japonica (L. japonica), 46 85–86, 135
Lower Class drugs, 8
O
M Ophiopogon japonicus (O. japonicus), 134
Ophiopogon root, see Radix Ophiopogonis
Ma-Huang Tang, 47 Organoleptic approach, 15
Madouling, see Aristolochia debilis (A. debilis) Orthodox drug treatments, 125
Mafeisan, 105 Over-the-counter (OTC), 113
Magnolia officinalis (M. officinalis), 99, 134
Ma Huang Tang, see Ephedra Decoction P
Malaria, 70–73
Malaysia, TCM in, 116 Paeonia lactiflora (P. lactiflora), 62, 98, 134
Medical massage and manipulation, 32 Paeonia suffruticosa (P. suffruticosa), 61, 134
Medicinal Pale red tongue, 33
botany, 16–17 Pale tongue, 33
diets, 49 Palpation, 36
herbs, 14 Panax ginseng, see Ginseng
plant identification, 15–16 Panax notoginseng, see Notoginseng
recipes, 54 Panax quinquefolius, see American ginseng
Mentha arvensis (M. arvensis), 46 PC-SPES, 108–111
Meridian-affinity system, 44 Phenolphthalein, 107–108
Meridian, 23 Pheretima spp., 135
Metal, 26–29 Pinellia ternata (P. ternata), 56, 135
Middle Class drugs, 8 Plant kingdom, 50
“Minister” drug, 47 Plant species, 16
Minor Bupleurum Decoction (Xiao-Chai- Plasmodium, 71
Hu-Tang), 55–58 Po Chai Pills, 107–108
148 Index

Poly-prescription, 44 Rehmannia glutinosa (R. glutinosa), 46, 135


Polygonum multiflorum (P. multiflorum), 98, 135 Rehmannia root, 61–62
Polyphenols, 79 Restraining cycle, 28
Poria cocos (P. cocos), 46, 61, 135 Rg1, 75–77
Potentiating effect, 47 Rheum palmatum (R. palmatum), 17, 46
Potentiation, 47 RYR, see Red yeast rice (Monascus purpureus)
Prescriptions, 54
Prickled tongue, 35 S
Prodrome of apoplexy, 35
Promoting cycle, 28 Safety and regulations, TCM
Proprietary Chinese medicine, see Chinese Aristolochiaceae family, 101–102
medicinal products Aristolochia species, 98–100
Prostate-specific antigen (PSA), 109 Asarum species, 98–100
Prostate cancer, 109 Chinese medicinal products, 107
Prunella vulgaris (P. vulgaris), 46 Datura metel L., 105–106
Prunus armeniaca (P. armeniaca), 46 PC-SPES, 108–111
Prunus persica (P. persica), 135 Po Chai Pills, 107–108
PSA, see Prostate-specific antigen TCM safety, 97–98
Pseudoginseng Radix, see San-Qi Ginseng toxic Aconitum plants, 103–105
Pueraria lobata (P. lobata), 46, 135 toxic compounds and contaminants in
Pulse examination, 36, 37 TCM herbs, 98
example of diagnosis, 37–38 X. sibiricum poisoning, 106
location of pulse, 37 S-allyl-l-cysteine, 89, 92
position of pulses and references, 38 S-allyl analogs, 90
syndrome differentiation, 39 “Salty” drugs, 43
types, 36 Salvia (Danshen), 83
Pungent-cool, 38 FDA, 85
Pungent-warm herbal medicines, 38 TZQ, 84
Pungent drugs, 43 Salvia miltiorrhiza (S. miltiorrhiza), 46, 84,
85, 135
Q San-Mai San, 59
San-Qi Ginseng (Pseudoginseng Radix), 109
Qi, 21, 25, 30, 63, 65 Sanchi, 86
function, 30 Saw Palmetto, 109
Qi-Gong, 31 Schisandra chinensis (S. chinensis), 58, 135
Qingmuxiang, 100 Schisandra fruit, 60
Scutellaria baicalensis, 46, 57, 135
Scutellaria radix, see Skullcap
R
Seasonal variation, 16
Rabdosia (Rabdosia rubescens), 109, 135 “Selling TCM” theory, 5
Rabdosia rubescens, see Rabdosia “Servant” drug, 47
Radix Ophiopogonis (Ophiopogon root), 59 SFDA, see State Food and Drug
Radix Puerariae lobata, see Kudzu root Administration
Radix Salvia miltiorrhiza, 84 Shao-Yang syndrome, 56–57
Radix Scutellariae, 46, 57, 135 Sheng-Mai-San, 58–60
Ranunculaceae, 103 Shen-Nong, 8, 9
Rb1, 75–77 classic of medical herbs, 22
Red sage, see Salvia miltiorrhiza Shen-Nong Bencaojing, see Shen-Nong
(S. miltiorrhiza) Materia Medica
Red tongue, 33–34 Shen-Nong Materia Medica, 8, 9, 10
Reductionist approach, 4, 128 Shikimin, 13
Red yeast rice (Monascus purpureus), Shortened tongue, 35–36
87–88, 134 Sibutramine, 107–108
Index 149

Si Jun Zi Tang, see Four Gentlemen Tang Bencao, 10


Decoction Tangzhiqing (TZQ), 84
Singapore, TCM in, 117 Tan IIA, see Tanshinone IIA
Singapore TCM Physicians Registration Tanshen, see Salvia miltiorrhiza (S. miltiorrhiza)
Examination (STRE), 117 Tanshinone I, 86
Single Chinese and botanical medicines, 69 Tanshinone IIA (Tan IIA), 86, 87
artemisinin, 70–73 “Tastes”, 42
bioassays, 70 TCM, see Traditional Chinese Medicine
Chinese Cordyceps, 80–83 TGA, see Therapeutic Goods
Dong quai, 88 Administration
Ephedra, 92–93 Thai traditional medicine, 125
evidence-based approach, 70 Theory and practice, TCM, 21; see also
Garlic, 89–92 Traditional Chinese Medicine
Ginkgo, 73–75 (TCM)
Ginseng, 75–77 cardinal characteristics of Chinese
Green tea, 78–80 medicine, 23–25
Red yeast rice, 87–88 characteristics of yin and yang, 25–26
Salvia, 83–87 Chinese medicine, 21
statins, 89 close relation of human being with
Six-ingredient decoction (or pill) with surroundings in nature, 29
Rehmannia (Liuwei Dihuang diagnosis, 32–36
Tang(wan)), 61 five elements, 26–29
Skullcap (Scutellaria radix), 109, 100 function of qi, 30
Slimming program, 99 initiation of theoretical system of
SMZ, 126 Chinese medicine, 21–22
“Sour” drugs, 43 palpation, 36
Speckled tongue, 35 pulse examination, 36–39
Spores, 81 qi, blood, body fluids, and essence, 30
Star anise, 13 simple expression of yin–yang
State Food and Drug Administration relationship, 26
(SFDA), 114 therapeutic modalities, 30–32
State–Private Joint Ownership traditional categorization, 22–23
Campaign, 113 wax and wane and transformation of
Statins, 89 yin–yang, 26
Stephania tetrandra (S. tetrandra), 99, 100, 135 Yin and yang theory and application to
S-trans-1-propenyl analogs, 90 Chinese medicine, 25
STRE, see Singapore TCM Physicians Therapeutic Goods Administration
Registration Examination (TGA), 117
Suan Zao Ren, 66 Therapeutic modalities, 30–32
Suan Zao Ren Tang (Sour Jujube Decoction), Therapeutic strategies, 53
65–66 Tianxianteng, 100
Substances, 23 Tien-chi ginseng, 86
Sweet drugs, 43 Tincture, 18
Symptom, 30 Tongue, 32
Syndrome, 30 abnormalities, 35–36
differentiation, 39 characteristics, 35
Synergism, 47 colors, 33–35
Synergistic effect, 47 normal, 33
parts, 32, 34
Total quality system, 129
T
Toxic Aconitum plants, 103–105
Tai-Chi, 31 Toxic compounds and contaminants in
Tamiflu, 126 TCM herbs, 98
150 Index

TQM, TCM needs, 129–131 V


Traditional and Complementary Medicine
Bill, 116 Visceral organs, 27, 28
Traditional and Complementary Medicine Vitality, 32
Council, 116
Traditional categorization, 22–23 W
Traditional Chinese Medicine (TCM), 1, 7;
see also Theory and practice, TCM Warfarin, 110
assorted dried plant and animal parts, 54 Water, 26–29
in Australia, 117–118 Water-soluble granules, 18
botanical classification of TCM herbs, Wax and wane and transformation of
12–20 yin–yang, 26
in China, 113–116 Western drugs, 107–108
classical TCM herbal literature, 7–12 Western medicine, 118, 119, 125, 126, 128
efficacy of TCM, 55 “Wizened” tongue, 32
examples, 55–66 Wood, 26–29
formulas, 3, 53 World Health Organization (WHO), 71
herbalism, 7, 11
herbal medicine, 53–55 X
herbs, 19
in Hong Kong, 118–124 Xanthium sibiricum (X. sibiricum), 97–98, 135
in Indonesia, 117 poisoning, 106
internationalization of, 18–20 Xiang Sha Liu Junzi Tang, 65
in Malaysia, 116 Xiao-Chai-Hu-Tang, see Minor Bupleurum
modern Western medicine aspects, 2 Decoction
Practitioners Act, 117
Practitioners Board, 117 Y
preparations, 3, 17–18
reductionist approach, 4 Yaks, 80–81
in Singapore, 117 Yin and Yang, 21, 26, 27, 42, 43, 75–77,
Traditional Herbal Medicinal Products 103, 116
Directive, 125–126 characteristics of, 25–26
Traditional Medicine License, 117 theory and application to Chinese
Tropane alkaloids, 105–106 medicine, 25
Tui-Na, 32 wax and wane and transformation
TZQ, see Tangzhiqing of, 26
TZQ-F, 84
Z
U
Zang-fu functions, 32, 35
United Nations Educational, Scientific Zàng organ, 23
and Cultural Organization Zang viscera, 23, 24, 27
(UNESCO), 11 Zhi Mu, 66
Unusual peroxide linkage, 73 Zingiberis Rhizoma, 57
Upper Class drugs, 8 Zingiber officinale (Z. officinale), 17, 46, 56,
U. S. Food and Drug Administration 57, 135
(FDA), 85 Ziziphus jujuba (Z. jujuba), 46, 135