Comparative Take on Bao He Wan

“保和丸,治一切食积。” (Bao He Wan, to treat all food stagnation.)

Bao He Wan is an herbal formula created by Zhu Dan Xi (朱丹溪). It is documented in his book 《丹溪心法》as treatment for what is termed food stagnation (食积). Especially useful if one feels a bloating sensation in the stomach after a meal, a sign of possible indigestion. We already have the TCM explanation for this formula make-up. It would hence be more useful for readers if we compare the ingredient of Bao He Wan with their biopharmaceutical peers.

The original formula is made up of three broad categories of herbs. The first are the digestives, akin to the enzymes e.g. protease, lipase, amylase that we use to aid digestion. Shan Zha (山楂), also known for helping weight loss and treating high blood lipids, is known traditionally to digest meats. Lai Fu Zi (莱菔子) is the seed of radish, and is known for breaking down wheat – remember, this is usually wheat in bread and noodles. Last of all, we have Shen Qu (神曲) which if simplified is a cocktail of enzymes.

In today’s formulations of Bao He Wan, we also see other herbs being included, most common of which is maiya (麦芽). Zhishi (枳实)and baishu (白术) are also wont to be thrown into the mix.

“人有食积,必生痰湿。” (He who is wrought with food stagnation, will produce phelgm and damp.)

In TCM, there is a saying that when there is food stagnation, phlegm-stagnation will appear. Which is why the second group of is erchen tang (二陈汤) but without licorice.

“食积日久则易生热。” (Food stagnation over time will generate heat.)

There is also another idea that the long-term result of food stagnation is heat generation. This is understandable, as in the case of chronic gastritis, where there is slight inflammation of the stomach lining. The original formula uses lian qiao (连翘) in response. These days, the solution would be the use of antacids like aluminium hydroxide and magnesium hydroxide.

That said, there is an obvious difference between the use of lian qiao as an anti-inflammatory and the use of antacids to neutralize excess acid production. One can read up on content by alternative medicine practitioners who believe that the problem is not excess acid production in the stomach; instead they believe it is the lack of acid production.

As mentioned above, qi regulators like houpu (厚朴) and zhishi (枳实) are thrown in to regulate qi and take away any bloating. While there is not clear connection, we can liken this to the use of anti-flatulent medications like simethicone (西甲硅油) or to gastroprokinetics like mosapride (莫沙必利) or cisapride (西沙必利).

Why Platycodon (桔梗) is a ship that carries the other herbs upward

“诸药舟楫,载药上行”

As a tradition, platycodon is used in many illnesses that are located at the chest and upward. For example: cough with alot of phlegm, a sore throat, or even lung abscesses. In many formulae, its role is as a carrier, to bring the other herbs to the chest area.

One modern explanation for this: Platycodon contains many saponins, which put simply are soap-like compounds. These saponins come in contact with a big part of the respiratory tract as well as the digestive tract (of course). And assuming (I don’t know yet) the action of saponins ends at the stomach area, then it is restricted to the chest and upward.

One example of its use at chest level: One particular type of saponin, platycodin (桔梗皂苷), can stimulate the mouth, throat and stomach lining upon contact, and this stimulus is passed on as a reflex, increasing bronchial mucus membrane secretions. This thins phlegm, explaning platycodon’s use as an expectorant.

Platycodon is also a natural aspirin: It is an anti-inflammatory pain-killer that also brings down your temperature. Small wonder its use in A Treatise on Warm Diseases (《温病条辨》). Go look at xing su san (杏苏散) and sang ju yin (桑菊饮) and the host of other cold, cough and flu formulas. It is seldom that platycodon is left out of the equation when treating pulmonary conditions.

Critique of a Medicine God

伤寒有五:有中风,有伤寒,有湿温,有热病,有温病。 – 难经

In the time of Mr. Zhang Zhongjing, all externally contracted diseases were classified Cold Damage (伤寒).

Cold Damage was the umbrella term for all classifiable infectious diseases then. The Classic of Difficulties gives us the five sub-categories: Wind Strike (中风), Cold Damage (伤寒), Damp-Warmth (湿温), Hot Diseases (热病) and Warm Diseases (温病).

Zhang’s classic tome On Cold Damage is revolutionary. Why? Because it unveils a theoretical framework for classifying disease based on the signs and symptoms exhibited. Mr. Zhang used a six-channel theretical framework, which later people have come to understand as a mapping out of the diseases process – from the 3 yang channels into the 3 yin channels. During the disease process, the sick person would manifest heat and cold symptoms. This language of heat and cold is the bedrock upon which herbs (also classified thus) were chosen to deal with the illness.

In fact, after Zhang’s time, later scholars spent much time writing and interpreting his work, which was a theoretical masterpiece, then as it is today.

A copious half of the book focuses on the Greater Yang (太阳) channel, which later scholars have understood as the first pass, the initial encounter with disease. Whether or not this has any basis, we will find a heavy documentation with regards to Wind Strike (中风) and Cold Damage (伤寒), both of which see the disease etiology as Wind or Cold entering the body. Both these ‘external pathogens’ then begin a process that moves inward from the outside, and when it reaches the innermost parts, the person dies.

In China today, within the sub-culture of Chinese Medicine, there are the people who still hold steadfast to such an understanding of diseases; they use this theory to treat disease. Even though the Cold Damage sect are a minority today, and many practitioners see it as one of many systems, there are those who swear by this one framework only.

In the earlier time notwithstanding, from the late Han up till the early Song dynasty, almost everyone used Mr. Zhang’s framework to treat diseases.

法不离伤寒,方必遵仲景。

There was a running phrase: The method should not depart from On Cold Damage; the method should abide by Zhang Zhongjing’s.

论伤寒不读仲景书,犹如为儒者不知有孔子《六经》也。

We can see here how he had become a medicine god that some had come to follow without too much critical thought. In fact, the herd who saw Zhongjing as the one and only also came up with other self-uplifting aphorisms, like this one in particular: If one discusses Cold Damage but does not read Zhang Zhongjing’s books, it’s like saying you are Confucian but not know the Six Classics of Confucius.

Many of the doctors before the Song era would be using herbs in a formulaic manner as dictated in On Cold Damage. While likely that such manner of practice works sometimes, it may not be the most effective method if used blindly.

Two formulas and their variants were used and stuck to for goodness knows how long, only because they were created by the much-revered Zhang Zhongjing. Cinnamon Twig Decoction (Gui Zhi Tang) was the solution for Wind Strike, while Ephedra Decoction (Ma Huang Tang) was used to treat Cold Damage. On hindsight, these are formulas with herb components more suitable for diseases linked to Wind and Cold. Are these formulas suitable for other sub-categories like Damp-Warmth, Hot Disease and Warm Disease? Perhaps yes? Perhaps not too.

An aside: Herbs are classified into the framework accorded in the Chinese Medicine framework, by flavor and by the channels they enter. This was a theoretical framework borne of an ancient past, and while they no longer sound scientific to the intellectuals of today, this framework was discussed and improved upon by the intellects of many a foregone era.

Zhugong (朱肱) in his book Living Scroll of Cold Damage-type Patterns (伤寒类证活人书) was vocal about the need to use herbs more flexibly.

“桂枝汤自西北二方居人,四时行之无不应验。自江淮间,唯冬及初春可行,自春末及夏至以前,桂枝证可加黄芩半两,夏至后有桂枝证,可加知母一两、石膏二两,或加升麻半两。若病人素虚寒者,正用古方,不再加减也。” – Zhugong

Zhugong voices a very reasonable suggestion regarding the use of Cinnamon Twig Decoction, which is warm in nature. He says that the people in the north can use it to good effect at any time of year, but for the people in the south, only in the the winter and early spring should it be used. From the end of spring to the peak of summer, we should add Skullcap (黄芩). After the peak of summer, consider adding Anemarrhena (知母) and Gypsum (石膏), or Cimicifuga (升麻). If the person is of deficient-Cold constitution, use the original formula.

Beautiful. Zhugong is suggesting that we add herbs of a cold nature to an essentially warm-natured decoction. In a nutshell, he encourages the act of modifying the original decoction depending on geography, season and personal constitution.

During the Jin-Yuan era, discussion was rife and tempers flared. One man who emerged within this pre-revolutionary mess as a man named Liu Wansu (刘完素) who later came to be known as the founder of the ‘cold sect’ (寒凉派). His focus was on the use of ‘cold’ herbs to remove the ‘heat’ characteristics of most externally contracted disease. An analogous phrase using today’s medical jargon would be “inflammation is the substance of all infectious disease.”

Mr. Liu was most famous for getting patients to ‘shit out’ the pathogen, although he also applied vomiting and perspiration to his repertoire of treatment methods. While the form of his methods is congruous with that used during the medicine god’s era – vomit, sweat, shit – the substance of his core herbs couldn’t be more different from Mr. Zhang’s.

Would Zhang have have declared war on this different manner of treatment? We don’t know, but being of open mind and ingenious spirit, Zhang might have found resonance with Liu’s ideas. But why did those who made him a medicine god raise such a ruckus?

Wang Hao Gu

Spleen-Stomach Guy?

Wang Haogu (王好古) is often lumped together with Ligao (李杲), both having been disciples of Zhang Yuansu in Hebei, North China. Wang Haogu later put himself under the discipleship of Li Gao. We will naturally see him as a Spleen-Stomach kind of guy. But in fact, he was never affixed to any one idea, using cold herbs as and when necessary.

His most oft-used formulas included siwu tang (四物汤), lizhong tang (理中汤) and pingwei san (平胃散), each of which he had manifold modifications of — 60 for siwu tang alone. He would also use “colder” formulas like baihu tang (白虎汤), xijiao dihuang tang (犀角地黄汤), ganlu yinzi (甘露饮子) and xie bai san (泻白散), so readers see the broad nature of his herb usage. The important thing to him was to have the herb combination fit the disease situation at hand.

On Yin Patterns?

阴证毒为尤惨,阳证易辨易治,阴证难辨难治。

Wang Haogu is known for his views on Yin patterns. One of his views (the quote above) is that “Yang patterns are easy to diagnose and treat;Yin patterns are difficult to diagnose and treat.”

Who gets Yin patterns (阴证)? Not the hardy person riding on horseback. The hardy person will likely show Yang patterns (阳证) however mild the pathogenic attack. But the bloke with constitutional deficiency will exhibit Yin patterns, even if it is caused by a heat pathogen (热邪).

This, to me, concerns the inflammatory process. Imagine a kid with fever – this kid has alot of yang qi (阳气) and so the fever is high. Compare the kid against a grown man with weak immunity – it could be because he has a weak constituion (体质弱) or because of a chronic disease (慢性病). He will exhibit low fever or none at all.

Greater Yin Disease (太阴病) in the Shang Han Lun (伤寒论)?

When discussing the treatment of cold patterns (寒证) in the Shanghanlun, Wang Haogu says that a person who gets Greater Yin disease (太阴病) is ill not so much because of pathogen invasion, but rather because this person already has deficiency in Spleen yang. If you think about it, it is a very enlightened statement for his time.

This Spleen yang deficiency manifests as diarrhea and occasional abdominal pain. We can push it further and conclude that lizhong wan (理中丸) is not for treating Cold Damage (伤寒). Rather, it is for treating diseases of miscellaneous internal damage (内伤杂病).Y

In a similar vein, he views the person with Shao Yin disease as having Kidney Yang Deficiency. As for Jue Yin Disease, tongmai sini tang (通脉四逆汤) is used to rebalance a Liver yang deficiency (肝阳不足). The formula danggui sini tang (当归四逆汤) is also used.

Regarding the three yin diseases (三阴证):

The issue here is that the person is already deficient (病人体质), and yin pathogen is thought to be hiding inside the body (内已伏阴). The treatment principle is first to strengthen the Right Qi (扶正).

Note too that Zhang Zhongjing was already accounting for deficiency in people with the three yang patterns (三阳证). For example, when using baihu tang (白虎汤), ginseng (人参) is being added for the deficient types. He also made it very clear that mahuang tang (麻黄汤) is not suitable for people who sweat easily (汗家). Similar considerations are made in the case of guizhi jia fuzi tang (桂枝加附子汤).

Prescribing using Han Dynasty measures of quantity

Mastering the quantity of each herb used is very important in clinical practice. This is especially so when we want to practice prescribing 经方 i.e. those created by Mr. Zhang Zhongjing.

桂枝汤 as an example:

In 桂枝汤, 3 liang each of 桂枝 and 芍药 are used, and the function of 桂枝 is to 解肌祛风、调和营卫.

  • If we increase the quantity of 桂枝 – as in 桂枝加桂汤 where 5 liang of 桂枝 is used – its purpose is to 温补心阳、降逆平冲 as treatment for the running piglet pattern.
  • If we increase the quantity of 芍药 instead – as in 桂枝加芍药汤 – the decoction’s purpose is to treat intrusion on the taiyin spleen channel that causes 气血不和-type of abdominal pain(腹满时痛).

Yes, you say, in the latter decoction, the key herb is no longer 桂枝 but 芍药, and it’s 芍药 that helps to take away the pain. One can even infer further that treatment of such pain is limited to the 桂枝-type person. As for the former decoction, the additional 桂枝 just turns up the heat on the lower jiao in addition to helping the heart, all in all eliminating further activity by the piglet.

麻黄汤 as an example:

Again, the ratio of 麻黄:桂枝:甘草 should be 3:2:1, otherwise you’ll probably spend all day trying to get the patient to perspire.

五苓散 as an example:

The herb used in the largest quantity here is 泽泻, while 桂枝 just plays a minor role. If used as presribed in the ancient texts, this formula has a diuretic effect. Interestingly, when all five component herbs are used in equal portion, the diurectic effect is no significant. Obviously, that’s because we now know 泽泻 to be a diuretic, and of course it has to be the main player here.

We’ve only covered ratios above, which most people won’t have a problem with. The more important question becomes “how many grams of each herb do I put in?” We have to understand that Mr. Zhang was living in the Han era, and the Han era didn’t measure in grams or units we use today. If the chinese measurements of qian and jin could have been different in that era.

And it was.

Checking out the Han era books:

Checking up 《汉书·律历志》, which reflects measurement norms in the Han era, we see the following phrase:

“千二百黍(shu3),重十二铢,两之一两”

meaning 1200 grains of rice is 12 zhu (unit of measurement)  and two 12 zhu is one liang. Hence 24 zhu is 1 liang. Which tells us that the most fundamental unit was zhu and we used rice grains to determine that. Which also tells us that the unit of measurement liang is 24 zhu.

The book continues…

“十六两为斤,三十斤为钧,四钧为石。”

informing us that 16 liang is one jin, and 30 jin is one jun, and 4 jun is one shi.

Overall, we’re set, we just need to find those grains of rice and count 1200 of them. But from where? Beijing, Changsha, from the sack, fresh from harvest? So there’s an issue here. But luckily, we needn’t go through all that trouble, because in the museums are heavy bronze pieces of different units of measure, and that includes one that says 1 jin and when we weigh that something, we realize that it’s 250g. So easy.

And so, using the original text once again, we can deduce that if 1 jin is 250g, then 1 liang is 250/16 = 15.625g. Let’s approximate 1 liang at 15g then.

Let’s now move on to volume measurements:

“千二百黍实其龠(yue4),合龠之为合(ge2),十合为升,十升为斗(dou3),十斗为斛(hu2)”

If you put 1200 grains into a container, that container contains one yue. So the smallest volume measurement is called yue. Two yue is one ge. And so on.

We go back to the museums and find out that One ge is 20ml. One sheng is 200ml. One dou is 2,000ml. One hu is 20,000ml (you can actually find a big hu in the Shandong Museum).

It seems that there’s no problem at all when there are artifacts to tell us exactly what was. We can then re-measure them using contemporary units of measure.

Now, we understand what eight ge means, we realize the book is exhorting us to drink 8 times 20ml of Ephedra Decoction, which is a total of 160ml. Great! And for Cinnamon Twig Decoction, it would be one sheng which equals 200ml. Eureka! Same with 麻杏石甘汤,which is one sheng, and the text adds “温服一升,本云黄耳杯” meaning that the yellow-earred cup(黄耳杯)approximates one sheng. And when if we go to the museum and check, voila, it is!

Before and after the Song dynasty:

Up till the Song dynasty, most practitioner would use the units of measure delineated above. There were changes, especially between the Jin and Song dynasty (a period of about 800 years), however the units of measure remained the same. After the Song dynasty, because the government brought about many changes, you’ll see the following units of measure: 斤、两、钱、分、厘、毫. So that’s a way to recognize whether the manuscript you’re reading is before or after the advent of the Song dynasty.

Later on though, in the modern era, the Chinese converted 1斤=500g, but this didn’t affect how chinese practitioners calculated herbal quantity. 1钱 was still about 3g, and so 3钱 was  about 9g. And since 9g is close to 10g, that’s why we see so many 10g herbs in prescriptions these days. A typical quantity at that time was 3钱, which is approximate 10g today.

Counter-stimulation, Acupuncture & Pain Relief

[See video above] New technologies for Virtual Reality, as evidenced by Snow World, add fuller dimension to the evolving idea of pain relief.

The idea of counter stimulation – where sensory stimulation reduces our perception of pain, either locally or distally – is not new. We do it all the time, clenching our faces in pain or wriggling our toes when the masseur presses down hard at one spot. It’s instinctive for most of us to rub our bruises as if that act of rubbing takes the pain away. But it does – most of the time – until we stop rubbing or putting pressure on the spot. And remember how you would slap that itch away.

Today, we understand it as a crowding out of pain, where we interfere with the sensation of pain by creating other sensations that our sensory nerves detect and send to the brain. These sensations may include different types of touch (rubbing, pressing, slapping) or different temperatures (hot, cold). That’s how it works, but let’s move on to review some approaches developed through the centuries.

Traditional approaches: Massage and Acupuncture as Counter-stimulation

One would postulate that massage and acupuncture probably came about as described above, when parts of the body that were painful were rubbed to ease the pain. These points – called A-shi points – are still indicated in massage or acupuncture treatment, and we understand intuitively that most times it makes sense to stimulate the spot that is painful. The pricking of the skin with a needle is understood to give this effect.

But I think it’s often more than this. Rubbing your bruised arm is not just counter-stimulation – it may also relax the muscles by creating warmth, or help disperse chemical mediators in the area. In a similar way, the effect of acupuncture is much more. Some say it causes the brain to release enkaphalins (endorphins) or regulates the release of neurotransmitters as serotonin, dopamine et al. Some points certainly have more marked endocrine effect, and may cause a variety of changes in our body chemistry, dilating vessels and bringing in the healing salvation of blood to the area, or boosting the production of hormones that the body is in need of but not making. It runs a large gamut, and may not be as easy to pin down as we’d like.

Gate theories are also used to explain the effect of acupuncture on pain perception and on motor function.

  • Gate control theory sees pain perception as controlled by a gate between the place you’ve been pricked (locatin of impulse generation) and the brain. We know that pain travels via sensory nerve fibers to be relayed to the brain. But this gate closes up and blocks off the transmission of pain IF the pain impulses are getting through too much too quickly. The thin C fibers have been found to exhibit such a “gate” function.
  • Gates may not just exist in sensory fibers. When implicated in motor fibers, stimulation of the fibers – whether by massage, acupuncture or exercise – reopens a closed gate, hence enabling motor impulses from the brain to reach muscles or internal organs. This is not just useful for treating impaired muscle function, but may also be helpful when we think that nerves leading to certain organs are “blocked.”

Traditional Approaches: Counter-irritants

I put counter-irritants in a different category, because whether correct or otherwise, I think of counter-irritants as liniments or ointment that are rubbed on painful parts of the body.

In general, application of a counter-irritant will not only crowd out the primary course of pain (e.g. arthritis) but will also induce inflammation. Inflammation involves vasodilation, blood moving in with oxygen to nurture the local area and with neutrophils and macrophages to get rid of any byproducts, and perhaps other chemical mediators that will assist in healing.

So, the idea here is that inflammation inadequate with chronic pain. We may thus need to induce inflammation – in moderation – to aid healing.

This may be over-simplifying it, but counter-irritants are:

  • analgesic: by crowding out the primary source of pain.
  • vasodilating: by inducing benevolent inflammation.

This would be a good explanation for why moxibustion, baguan and gusha are TCM treatments that may be both analgesic and beneficial to the healing process.

Can natural statins damage your liver?

Some time back, over a dinner conversation, someone brought up the topic of Hongqu (红曲), also known as Red Yeast Rice Extract. Hongqu has now been popularized as a natural statin, useful for the prevention or treatment of high blood cholesterol (高血胆固醇). Almost immediately, the topic moved on to the danger of using Chinese medicinal herbs, citing the case where someone suffered liver damage eating Hongqu. So what really went wrong? Is Hongqu really that harmful?

The enzyme, high blood cholesterol and LDL:

In the liver exists this enzyme called HMG-CoA reductase. If left on its own, this enzyme is able to create cholesterol from HMG-CoA. In many older people, there is a tendency to see excess cholesterol clogging up the blood vessels.

High blood cholesterol levels is related to high blood LDL levels. LDLs carry cholesterol from the liver (where it is mainly produced) into the blood vessels for use in other parts of the body. Therefore, when there is high blood cholesterol, there is usually high blood LDL. Usually this is a sign that your blood vessels are clogged up by cholesterol.

Statins, their effect and side effects:

Different statins include fluvastatin, atorvastatin, lovastatin and simvastatin. Available commercially, pharmaceutical statins work by inhibiting the action of the enzyme HMG-CoA reductase. When the enzyme is inhibited, HMG-CoA can no longer become cholesterol. This reduces the amount of cholesterol produced by the body. LDL is also reduced as a result.

That said, statins are broken down in the liver, hence increasing its workload. Liver damage is a possible side effect.

Important Information:

 

  • Side effects include dizziness, heartburn and muscle weakness.

 

 

 

  • Statins increase the risk of heart attack, unstable angina, and stroke is you stop taking it suddenly.

 

 

 

  • Studies have found that grapefruit juice enhances level blood levels of these statins, with the associated side effects. Therefore, you should be careful when taking grapefruit juice with statins.

 

 

 

  • Statins may lower the production of Coenzyme Q10 in the body. Coenzyme Q10 provides energy for every cell, and is crucial especially for helping our heart beat. Therefore, levels of Coenzyme Q10 are usually supplemented when using statins.

 

 

Hongqu as a natural statin:

Hongqu contains monacolins, compounds that are similar in structure to statins. Monacolins inhibit the same enzyme inhibited by statins. Hongqu is also called a natural statin. You may ask, how could it have caused liver damage if it is a natural herb?

It could have been used together with prescription statins like simvastatin and lovastatin. It could also have been due to misuse by the patient. More likely, the patient was not aware that even Hongqu overworks the liver despite being a natural product.

The lesson to be learned:
Yes, even natural statins are able to damage your liver. This is because of the way statins work.

是药三分毒.

The person who blamed Hongqu for causing liver damage must be aware that prescription statins are just as harmful. In the end, it is more a matter of how you use the medicines you have. Medicine (药) is synonymous to poison (毒) in Chinese Medicine. The lesson to be learned is to respect medicine and to use it with care.

By the way, there is an ongoing debate now in the States on whether or not to give Hongqu the status of a prescription drug. Of course the drug companies don’t want that to happen, since synthetic drugs like lovastatin are already making them alot of money.