Chinese herb may cause cancer

Scott Gottlieb , New York

Doctors in Belgium have discovered that a Chinese herb, Aristolochia fangchi, already linked to kidney failure, may cause cancer as well.

Patients at a Belgian weight loss clinic were given this herb in error. Staff at the clinic had prescribed the herb Stephania tetrandra, but the pills that patients received also included aristolochia, possibly because of a manufacturing error. On average, the patients took the two herbs for about a year.

Of the patients who accidentally received the herb, 18 developed cancers of the urinary system, according to the report. These 18 patients had already experienced severe kidney failure as a result of taking another combination of two Chinese herbs (S tetrandra and Magnolia officinalis) and needed kidney dialysis or kidney transplants (New England Journal of Medicine 2000;342:1686-92).

The Chinese name for A fangchis is similar to that for S tetrandra, and it is often substituted for stephania. "Since there is virtually no control over the quality of these products, it is not unusual not to know what is actually in herbal preparations and dietary supplements," wrote Dr David Kessler, the former commissioner of the US Food and Drug Administration, in an accompanying editorial.

Dr Joelle Nortier from Université Libre de Bruxelles in Brussels, Belgium, and associates first became aware of the extent of the cancer risk after discovering a urinary system cancer in one of their patients undergoing transplantation.

The researchers then offered preventive removal of the kidneys and ureters to 43 other patients being treated for kidney disease that was related to treatment with Chinese herbs. Thirty nine patients accepted the offer, and that is when the 18 cancers were discovered, representing a cancer rate of 46

In 19 of the 21 patients without cancer, mild to moderate precancerous abnormalities were found in the ureters or kidneys, according to the report.

All the affected kidneys showed evidence of exposure to aristolochic acid, the harmful ingredient in A fangchi, and lower levels were found in some of the ureters. Only four samples contained evidence of exposure to ochratoxin A, a possible carcinogen sometimes found in S tetrandra.

The risk of cancer was greater for patients who had taken larger amounts of A fangchi, the investigators note. Eight of 24 patients who took 200 g or less had urinary system cancer, compared with 10 of 15 patients who took 201 grams or more.

"Our findings reinforce the idea that the use of natural herbal medicine may not be without risk," said Dr Nortier.

Cases of kidney failure from aristolochia have been reported in France, Britain, Spain, Japan, Taiwan, and the United States. Last month, the US Food and Drug Administration sent warning letters about the herb to doctors and to the supplement industry.

Traditional medicine

Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.

Countries in Africa, Asia and Latin America use traditional medicine (TM) to help meet some of their primary health care needs. In Africa, up to 80% of the population uses traditional medicine for primary health care. In industralized countries, adaptations of traditional medicine are termed “Complementary“ or “Alternative” (CAM).

Increasing use and popularity
TM has maintained its popularity in all regions of the developing world and its use is rapidly spreading in industrialized countries.

* In China, traditional herbal preparations account for 30%-50% of the total medicinal consumption.
* In Ghana, Mali, Nigeria and Zambia, the first line of treatment for 60% of children with high fever resulting from malaria is the use of herbal medicines at home.
* WHO estimates that in several African countries traditional birth attendants assist in the majority of births.
* In Europe, North America and other industrialized regions, over 50% of the population have used complementary or alternative medicine at least once.
* In San Francisco, London and South Africa, 75% of people living with HIV/AIDS use TM/CAM.
* 70% of the population in Canada have used complementary medicine at least once.
* In Germany, 90% of the population have used a natural remedy at some point in their life. Between 1995 and 2000, the number of doctors who had undergone special training in natural remedy medicine had almost doubled to 10 800.
* In the United States, 158 million of the adult population use complementary medicines and according to the USA Commission for Alternative and Complementary medicines, US $17 billion was spent on traditional remedies in 2000.
* In the United Kingdom, annual expenditure on alternative medicine is US$ 230 million.
* The global market for herbal medicines currently stands at over US $ 60 billion annually and is growing steadily.

Safety and efficacy issues
Scientific evidence from randomized clinical trials is only strong for many uses of acupuncture, some herbal medicines and for some of the manual therapies. Further research is needed to ascertain the efficacy and safety of several other practices and medicinal plants.

Unregulated or inappropriate use of traditional medicines and practices can have negative or dangerous effects.

For instance, the herb “Ma Huang” (Ephedra) is traditionally used in China to treat respiratory congestion. In the United States, the herb was marketed as a dietary aid, whose over dosage led to at least a dozen deaths, heart attacks and strokes.

In Belgium, at least 70 people required renal transplant or dialysis for interstitial fibrosis of the kidney after taking a herbal preparation made from the wrong species of plant as slimming treatment.

Biodiversity and sustainability
In addition to patient safety issues, there is the risk that a growing herbal market and its great commercial benefit might pose a threat to biodiversity through the over harvesting of the raw material for herbal medicines and other natural health care products. These practices, if not controlled, may lead to the extinction of endangered species and the destruction of natural habitats and resources.

Another related issue is that at present, the requirements for protection provided under international standards for patent law and by most national conventional patent laws are inadequate to protect traditional knowledge and biodiversity.

Tried and tested methods and products
* 25% of modern medicines are made from plants first used traditionally.
* Acupuncture has been proven effective in relieving postoperative pain, nausea during pregnancy, nausea and vomiting resulting from chemotherapy, and dental pain with extremely low side effects. It can also alleviate anxiety, panic disorders and insomnia.
* Yoga can reduce asthma attacks while Tai Ji techniques can help the elderly reduce their fear of falls.
* TM can also have impact on infectious diseases. For example, the Chinese herbal remedy Artemisia annua, used in China for almost 2000 years has been found to be effective against resistant malaria and could create a breakthrough in preventing almost one million deaths annually, most of them children, from severe malaria.
* In South Africa, the Medical Research Council is conducting studies on the efficacy of the plant Sutherlandia Microphylla in treating AIDS patients. Traditionally used as a tonic, this plant may increase energy, appetite and body mass in people living with HIV.

WHO efforts in promoting safe, effective and affordable traditional medicine

The World Health Organization launched its first ever comprehensive traditional medicine strategy in 2002. The strategy is designed to assist countries to:

* Develop national policies on the evaluation and regulation of TM/CAM practices;
* Create a stronger evidence base on the safety, efficacy and quality of the TAM/CAM products and practices;
* Ensure availability and affordability of TM/CAM including essential herbal medicines;
* Promote therapeutically sound use of TM/CAM by providers and consumers;
* Document traditional medicines and remedies.

At present, WHO is supporting clinical studies on antimalarials in three African countries; the studies are revealing good potential for herbal antimalarials.

Other collaboration is taking place with Burkina Faso, the Democratic Republic of the Congo, Ghana, Mali, Nigeria, Kenya, Uganda, and Zimbabwe in the research and evaluation of herbal treatments for HIV/ AIDS, malaria, sickle cell anaemia and Diabetes Mellitus.

In Tanzania, WHO, in collaboration with China, is providing technical support to the government for the production of antimalarials derived from the Chinese herb Artemisia annua. Local production of the medicine will bring the price of one dose down from US $6 or $7 to a more affordable $2.

In 2003, WHO support has so far facilitated the development and introduction of traditional and alternative health care curricula in seven tertiary education institutions in the Philippines.

Training workshops on the use of traditional medicines for selected diseases and disorders have also been organized in China, Mongolia and Vietnam.

Priorities for promoting the use of traditional medicines
Over one-third of the population in developing countries lack access to essential medicines. The provision of safe and effective TM/CAM therapies could become a critical tool to increase access to health care.

While China, the Democratic People’s Republic of Korea, the Republic of Korea and Vietnam have fully integrated traditional medicine into their health care systems, many countries are yet to collect and integrate standardized evidence on this type of health care.

70 countries have a national regulation on herbal medicines but the legislative control of medicinal plants has not evolved around a structured model. This is because medicinal products or herbs are defined differently in different countries and diverse approaches have been adopted with regard to licensing, dispensing, manufacturing and trading.

The limited scientific evidence about TM/CAM’s safety and efficacy as well as other considerations make it important for governments to:

* Formulate national policy and regulation for the proper use of TM/CAM and its integration into national health care systems in line with the provisions of the WHO strategies on Traditional Medicines;
* Establish regulatory mechanisms to control the safety and quality of products and of TM/CAM practice;
* Create awareness about safe and effective TM/CAM therapies among the public and consumers;
* Cultivate and conserve medicinal plants to ensure their sustainable use.

Arabian Herbal

The history of herbal medicine in the lands of Arabia is as old as history itself, as it is in other herbal histories. Ancient Arabian medicine has also been influencing other traditional medicinal practices for almost as long. Since the earliest written history, there are records of the Arabs using herbal medicinal cures, and one of the oldest recorded histories of this was Hammurabi’s code, from the 18th Century BC. Apparently the ancient Babylonians were fairly proficient at healing people, and it was their custom to have the sick and suffering lay by the side of the street so that the passers by could have a go at healing them. In ancient Mesopotamia (which covers what are Arabia and the areas of Sham today) traditional medicine was advanced and effective. There are tablets that have been found that go back as far as 3000 BC about ancient medicinal practices. In ancient Egypt, the recorded healing tradition goes back to the most ancient Pharaohs, which is estimated to be around the 3rd millennium BC.

Evidence
There is evidence of this on the pyramids, particularly the older ones, and the papyri that have been discovered over the years. But, in fact, herbal medicinal tradition went back much, much farther than that. Back to far before recorded history. In fact, there was a burial site that was discovered in 1960 from the times of ancient Iraq that had clear evidence of herbal medicaments being used all the way back as far as the times of around 60,000 years ago! Later on, the Arabian herbal tradition was influenced by Islamic medicine as well, which came about in the beginning, through the traditions of the Prophet Mohammad (PBUH) himself, and later, was carried on by other great physicians, such as Ibn Sina (known in the west as Avicenna), Razi, Al-Tabbari, and more. This ancient medical tradition carried over into the subsequent years, and during the Dark and the Middle Ages, it is said that Europeans were using what amounts to barbaric methods to treat illness, and the Arabs were already using extremely sophisticated, time-tested methods to treat patients.

They would treat with herbal medicine with expertise and aplomb. In ancient Arabian medicine, the practitioner would first diagnose the illness by observing and examining the patient and asking him questions. In Arabian medicine, dietary recommendations are tantamount to cure, and the ancient Arabs said that disease begins in the stomach. There is also a prophetic tradition in this regard. The ancient Arabian healers had a huge herbal pharmacopea in their expertise. They knew how to use hundreds of local natural herbs in their cures, and were also aware of many herbal usages from other nearby locations as well. There were slight differences in the practices of the doctors from different parts of the Arabian world, with the Bedouin also having their own special version of Arabian medicine, which concentrated on the herbs that were available to them in the desert regions.

Expertise
The Arabian medicinal tradition was so strong and effective that later physicians from all over the world were influenced directly by it, and openly studied their cures and comments with regard to the vast variety of diseases that the information covered. In Arabian traditional medicine there is vast evidence of surgeries taking place, and they were also experts when it came to diseases of the eye. The ancient Egyptians (as well as the Mesopotamians) had expertise in the field of eye diseases, and knew about surgery, as well as gynecology, and internal medicine. They were aware of medicaments that are still used today by Arabian traditional practitioners. It is said that there are some herbal remedies that are made with herbs taken from the desert that are better than any modern chemical medication found in the world today, and cure much faster. In traditional Arabian medicine there is also plenty of use of animal derived cures, for example, using the fat of the sheep for a special salve to help rid the body of arthritic pain. Also, important in Arabian traditional medicine is cupping, branding, and blood letting. (Although the Prophet Mohammad (PBUH) didn’t allow branding, he recommended both cupping and blood letting).

This is still being carried out up to the present time, and is extremely successful in its cure. In fact, many of the modern essential oils used today were discovered and used since ancient times in ancient Arabia and ancient Egypt (and other places around the Arabian Peninsula). Herbs such as myrrh, frankincense, and licorice are still being used right up to the present time, in modern Arabian lands, as well as in western herbal medicine and aromatherapy. In fact, right here in Kuwait, there is a government sponsored herbal medical center based on the ancient Arabian healing tradition, and anyone can go there with a referral from any polyclinic. So, if you are suffering from an illness, go and try some of their expertise and cures. Some of the cures come from a time practically as old as the age of humankind.

The History of Herbal Medicine

The history of herbology is inextricably intertwined with that of modern medicine. Many drugs listed as conventional medications were originally derived from plants. Salicylic acid, a precursor of aspirin, was originally derived from white willow bark and the meadowsweet plant. Cinchona bark is the source of malaria-fighting quinine. Vincristine, used to treat certain types of cancer, comes from periwinkle. The opium poppy yields morphine, codeine, and paregoric, a treatment for diarrhea Laudanum, a tincture of the opium poppy, was the favored tranquilizer in Victorian times. Even today, morphine-the most important alkaloid of the opium poppy-remains the standard against which new synthetic pain relieves are measured.

Prior to the discovery and subsequent synthesis of antibiotics, the herb echinacea (which comes from the plant commonly known as purple coneflower) was one of the most widely prescribed medicines in the United States. For centuries, herbalists prescribed echinacea to fight infection. Today, research confirms that the herb boosts the immune system by stimulating the production of disease-fighting white blood cells.

The use of plants as medicine is older than recorded history. As mute witness to this fact, marshmallow root, hyacinth, and yarrow have been found carefully tucked around the bones of a Stone Age man in Iraq. These three medicinal herbs continue to be used today. Marshmallow root is a demulcent herb, soothing to inflamed or irritated mucous membranes, such as a sore throat or irritated digestive tract. Hyacinth is a diuretic that encourages tissues to give up excess water. Yarrow is a time-honored cold and fever remedy that may once have been used much as aspirin is today.

In 2735 B.C., the Chinese emperor Shen Nung wrote an authoritative treatise on herbs that is still in use today. Shen Nung recommended the use of ma huang (known as ephedra in the Western world), for example, against respiratory distress. Ephedrine, extracted from ephedra, is widely used as a decongestant. You'll find it in its synthetic form, pseudoephedrine, in many allergy, sinus, and cold-relief medications produced by large pharmaceutical companies.

The records of King Hammurabi of Babylon (c. 1800 B.C.) include instructions for using medicinal plants. Hammurabi prescribed the use of mint for digestive disorders. Modern research has confirmed that peppermint does indeed relieve nausea and vomiting by mildly anesthetizing the lining of the stomach.

The entire Middle East has a rich history of herbal healing. There are texts surviving from the ancient cultures of Mesopotamia, Egypt, and India that describe and illustrate the use of many medicinal plant products, including castor oil, linseed oil, and white poppies. In the scriptural book of Ezekiel, which dates from the sixth century B.C., we find this admonition regarding plant life: ". . . and the fruit thereof shall be for meat, and leaf thereof for medicine." Egyptian hieroglyphs show physicians of the first and second centuries A.D. treating constipation with senna pods, and using caraway and peppermint to relieve digestive upsets.

Throughout the Middle Ages, home-grown botanicals were the only medicines readily available, and for centuries, no self-respecting household would be without a carefully tended and extensively used herb garden. For the most part, herbal healing lore was passed from generation to generation by word of mouth. Mother taught daughter; the village herbalist taught a promising apprentice.

By the seventeenth century, the knowledge of herbal medicine was widely disseminated throughout Europe. In 1649, Nicholas Culpeper wrote A Physical Directory, and a few years later produced The English Physician. This respected herbal pharmacopeia was one of the first manuals that the layperson could use for health care, and it is still widely referred to and quoted today. Culpeper had studied at Cambridge University and was meant to become a great doctor, in the academic sense of the word. Instead, he chose to apprentice to an apothecary and eventually set up his own shop. He served the poor people of London and became known as their neighborhood doctor. The herbal he created was meant for the layperson.

The first U.S. Pharmacopeia was published in 1820. This volume included an authoritative listing of herbal drugs, with descriptions of their properties, uses, dosages, and tests of purity. It was periodically revised and became the legal standard for medical compounds in 1906. But as Western medicine evolved from an art to a science in the nineteenth century, information that had at one time been widely available became the domain of comparatively few. Once scientific methods were developed to extract and synthesize the active ingredients in plants, pharmaceutical laboratories took over from providers of medicinal herbs as the producers of drugs. The use of herbs, which for most of history had been mainstream medical practice, began to be considered unscientific, or at least unconventional, and to fall into relative obscurity.

Chinesse Medicine (The Basic Principles)

I. Yin and Yang
The theory of yin and yang is a kind of world outlook. It holds that all things have two opposite aspects, yin and yang, which are both opposite and at the same time interdependent. This is a universal law of the material world. These two aspects are in opposition to each other but because one end of the spectrum cannot exist without the other they are interdependent.

The ancient Chinese used water and fire to symbolize yin and yang; anything moving, hot, bright and hyperactive is yang, and anything quiescent, cold, dim and hypoactive is yin.

The yin and yang properties of things are not absolute but relative. As an object or person changes so the yin and yang components change at a gradual rate. Each of the yin and yang properties of the object is a condition for the existence of the other; neither can exist in isolation.

These two opposites are not stationary but in constant motion. If we imagine the circadian rhythm, night is yin and day is yang; as night (yin) fades it becomes day (yang), and as yang fades it becomes yin. Yin and yang are therefore changing into each other as well as balancing each other.

The Application of Yin and Yang to Chinese Medicine
Each organ has an element of yin and yang within it. The histological structures and nutrients are yin, and the functional activities are yang. Some organs are predominantly yang in their functions, such as the gan-liver, while others are predominantly yin, such as the shen-kidney. Even though one organ may be predominantly yin (or yang) in nature, the balance of yin and yang is maintained in the whole healthy body because the sum total of the yin and yang will be in a fluctuating balance.

If a condition of prolonged excess or deficiency of either yin or yang occurs then disease results. In an excess of yin the yang qi would be damaged, and a disease of cold of shi nature would develop. Excess of yang will consume yin and a disease of heat of shi nature would develop. In a deficiency of yin, diseases of heat of xu nature develop, while a deficiency of yang causes diseases of cold of xu nature.

II. The Channels and Collaterals
The channels and collaterals are the representation of the organs of the body. They are also a functional system in their own right and they are responsible for conducting the flow of qi and blood through the body. The flow of qi can be disrupted by direct damage to the channels, such as trauma, or by an internal imbalance of yin and yang within the body.

The central principle of traditional Chinese medicine is to diagnose the cause of the internal disease, or yin yang imbalance within the body, and, by using the relevant acupuncture points, to correct the flow of qi in the channels and thus correct the internal disease. The acupuncture points that are on the channels have a direct influence on the flow of qi through the channels, and also on the internal organs. The zang channels are yin in nature and the fu channels are yang in nature.

Qi circulates through the channels of the body in a well defined circadian rhythm.

III. Zang and Fu Organs
The zang and fu organs are the internal visible organs of the body. The xin-heart, gan-liver, pi-spleen, fei-lung, shen-kidney and pericardium are the zang organs. The small intestine, large intestine, stomach, gall-bladder, urinary bladder and sanjiao are the fu organs.

The zang organs have a Chinese prefix because a direct translation from the Chinese might be misleading. The Chinese xin has functions rather different from the concept of the heart in Western medicine, so if we call the heart 'xin-heart', or the liver 'gan-liver', we are able to understand that we are referring to the organ of the heart or the liver, but it is really rather different from our concept of those organs.

The zang organs are of paramount importance in the body. They co-ordinate with the fu organs and connect with the five tissues (channels, jin¹ muscles, skin-hair, bones), and the nine openings (eyes, nose, ears, mouth, tongue, anus and external genitalia), to form the system of the Five Zang. The pericardium is not considered to be an important zang organ.

The Functions of the Zang Organs
The xin-heart
The xin-heart dominates the circulation of blood. When it functions properly the tissues and organs are well perfused and nourished, but when it malfunctions there is precordial pain, cyanosis and ischaemia. This disease is due to 'stagnation of the blood of xin-heart'.

The xin-heart 'keeps' the mind. Normally there is a clear mind, normal mentality, normal sleep and a good memory. When this fails there is coma, insomnia or somnolence, amnesia and mental derangement, because the xin-heart is failing to 'keep' the mind.

The xin-heart takes the tongue as its orifice and opens through it. Normally the tongue is reddish, moist, and moves freely. When the tongue has ulcers, is swollen or becomes purplish-red, there is 'upward blazing of the fire in xin-heart'. When the tongue is rigid and curled up (this may be accompanied by mental symptoms) 'phlegm and heat are covering the orifice of the xin-heart'.

The gan-liver
The gan-liver is the main yang organ of the body.

The gan-liver stores blood. Normally there is sufficient blood supply to all tissues. When this fails there is ischaemia, dizziness, malaise, abnormal menstruation and hemorrhage.

The gan-liver takes charge of freeing. Freeing really means the free flow of blood and qi through the body, especially digestion and the discharge of bile. When this is impaired there is irritability, mental depression, anorexia, abdominal distension and jaundice.

The gan-liver controls the jin which governs the muscle tone. When this function is disturbed there is muscle spasm, twitching, opisthotonos and convulsions. This is due to an 'insufficiency of yin and blood of the gan-liver, resulting in the malnutrition of the jin'.

The gan-liver takes the eye as its orifice and opens through it. Usually there is normal vision and normal eye movement. When this function is disturbed there is poor vision, night blindness, nystagmus and abnormal eye movements. This is due to an 'insufficiency of yin and blood in the gan-liver causing malnutrition of the eyes and stirring of the inner wind of the gan-liver.'

The pi-spleen
The pi-spleen governs the transportation and transformation of food, i.e. digestion. When digestion is abnormal there is anorexia, distension of the abdomen, diarrhea, emaciation, lassitude and oedema. This is due to 'a deficiency of the qi of pi-spleen'.

The pi-spleen commands the blood. Normally the blood circulates within the blood vessels but when this function fails there is extravasation of blood, chronic recurrent hemorrhage and bruising.

The pi-spleen dominates the muscles. This really means controlling the muscle bulk. Normally there is no muscle wasting, but when there is malnutrition of the muscles they are weak and wasted.

The pi-spleen takes the mouth as its orifice and opens through it. Normal people have a good appetite, a sense of smell and taste and red and moist lips. Abnormally there is anorexia, tastelessness or a sweetish, greasy taste, and pale sore lips. This is due to 'heat and damp in the pi-spleen'.

In addition the qi of pi-spleen lifts and fixes the internal organs in their normal position.

The fei-lung
The fei-lung takes charge of respiration. Normally respiration is even and the tissues are well oxygenated. When this function fails breathing is uneven, there is a cough, dyspnoea, shallow respiration and anoxia. This is due to 'a deficiency of qi of fei-lung which causes an impairment of dissipation and descent of clean qi (oxygen).

The fei-lung frees and regulates the water passage. This function covers the transportation and distribution of nutrients and water, the secretion of sweat and the excretion of urine. Abnormally there will be hyperhydrosis or hypohydrosis, oedema and difficulty in urination due to 'obstruction of the water passage'.

The fei-lung dominates the hair and skin. Normally the skin is lubricious, the hair lustrous, and sweating is normal. Abnormally the skin is rough, the hair dry and withered and the skin is 'loose'. This looseness opens the pores and increases the susceptibility to invasion by pathogenic factors.

The fei-lung takes the nose as its orifice and opens through it. Normally the nose is open and there is an acute sense of smell. Abnormally it may be obstructed, there may be anosmia, epistaxis and flaring of the alae nasi (usually accompanied by fever). This is due to 'invasion of the fei-lung by wind and cold or wind and heat'.

The shen-kidney
The shen-kidney is the main yin organ of the body. The shen-kidney dominates growth, reproduction and development. When this function fails there is a loss of reproductive function, retardation of growth, failure to thrive, and premature senility due to 'an insufficiency of the qi of shen-kidney'.

The shen-kidney produces marrow, filling the brain with marrow, dominating the bones and producing blood. Normally the spinal cord and the brain are fully developed, the bones are strong and the blood sufficient. Abnormally there will be dizziness, tinnitus, insomnia, poor memory and lassitude. The bones will be weak and brittle and the blood will be insufficient. This is due to 'an insufficiency of the essence of shen-kidney'.

The shen-kidney controls body water. This entails normal urine production and micturition. Abnormally there will be oliguria or anuria, oedema, difficult or dribbling micturition, polyuria, enuresis and incontinence. This is due to 'an insufficiency of yang of the shen-kidney failing to control body water'.

The shen-kidney controls the intake of clean qi (air). Abnormally there will be wheezing due to 'the failure of the shen-kidney to control the intake of clean air'.

The shen-kidney takes the ear as its orifice, opening through it. Normally there is sharp hearing, abnormally there is tinnitus, hearing loss, and even total deafness.

The pericardium
This may be called the organ of circulation in some texts. It is the least important of the zang organs.

It encloses and protects the xin-heart and the diseases of the pericardium result in dysfunction of the xin-heart.

The Functions of the Fu Organs
In general the traditional functions of the fu organs are very similar to their functions in Western medicine. Each fu organ channel connects internally and externally with a zang organ channel. This can have therapeutic importance in that a point on the fu channel may be used to treat a problem on its connected zang channel, and vice versa.

The small intestine
The small intestine connects with the xin-heart. The small intestine receives and digests food from the stomach. It absorbs the pure part and distributes it to the whole body, the impure part going on to the large intestine. This function of the small intestine belongs to the transforming and transporting function of the pi-spleen.

The gall-bladder
The gall-bladder connects with the gan-liver. It stores and discharges bile. The expulsion of bile from the gall-bladder is closely related to the freeing function of the gan-liver. The gan-liver and the gall-bladder take charge of freeing together, and jaundice results when this function is deranged.

The stomach
The stomach connects with the pi-spleen. The stomach stores and digests food, passing it on to the small intestine. A deficiency of qi of the stomach causes indigestion, epigastric pain and sour regurgitation When the qi of the stomach ascends then nausea, heartburn, vomiting, hiccoughs and flatulence occur.

The large intestine
The large intestine connects with the fei-lung. The large intestine absorbs the residue of water and turns the rest of the food into feces. Disturbance of this function results in diarrhea or constipation due to the 'descent of qi'.

The urinary bladder
The urinary bladder connects with the shen-kidney. The bladder stores and then discharges urine from the body.

The sanjiao
In Chinese the sanjiao means the three cavities. The xin-heart and the fei-lung are in the upper jiao (the chest), and they transport qi and blood to all parts of the body in order to nourish the body. The pi-spleen and stomach are in the middle jiao (the epiastrium) and they digest and absorb food. The shen-kidney and bladder are in the lower jiao (the hypogastrium) and they control water metabolism and the storage and excretion of water. The sanjiao is also sometimes called the triple warmer organ. This is because the three body cavities are intended to control the body temperature.

Extra Organs

The brain
The brain is a sea of marrow, i.e. it is an enlarged part of the spinal cord. The shen-kidney produces the marrow that fills the brain. If the essence of shen-kidney is absent then there is inadequate marrow for the brain. In traditional Chinese medicine the function of the mind is included in that of the xin-heart.

The uterus
The function of the uterus is to control the menstrual cycle, develop the embryo and nourish the foetus. The qi and blood of the channels pass into the uterus through the chong and the ren channels, so that the qi of the body is able to influence the flow and regularity of the menstrual cycle.

IV. Qi, Blood And Body Fluid
Qi, blood and body fluid are important substances and structures in the body. They sustain the vital activities and they nourish the body, thereby keeping the functions of the tissues, organs and channels in good order. The production and circulation of qi and blood also depends on the health of the tissues and organs that are nourished by these substances.

Qi
Qi is a complex concept; it relates to both substance and function. Clean qi (oxygen), waste qi (carbon dioxide) and qi (nutrients) are generally known as material qi, and the existence of material qi is shown by the functional activity of various organs. The function of an organ depends on the functional qi of that organ; for instance, qi of xin-heart or qi of pi-spleen is the vital energy and functional activity of the xin-heart or pi-spleen. The function of an organ, or its functional qi, cannot exist without material qi, and vice versa.

Zhong qi
Zhong qi is found mainly in the chest. It nourishes the structures and functions of the xin-heart and fei-lung.

Nourishing qi
Nourishing qi circulates in the channels and collaterals, mainly in the viscera

Defensive qi
Defensive qi is in the muscles and skin. It circulates outside the channels, in the subcutaneous tissues, and it defends the body against invasion by pathogens.

The original qi is nourished and maintained by qi derived after birth. These combine to form genuine qi, i.e. the total sum of qi in the healthy body. This contrasts with pathogenic factors that are known as pathogenic qi.

Blood
The nutrients from food are digested by the pi-spleen and stomach and they are then transported to the xin-heart and fei-lung and turned into red (oxygenated) blood by qi. The essence of shen-kidney produces bone marrow, and bone marrow uses the digested food to produce blood.
Qi of shen-kidney promotes digestion by pi-spleen, which in turn strengthens the xin-heart and fei-lung. This interaction therefore promotes haemopoesis.

There is a close relationship between qi and blood. The formation and circulation of blood depends on qi, whereas the formation and distribution of qi, as well as the health of the various organs of the body, is dependent on adequate nourishment from the blood. If the flow of blood 'stagnates' the circulation of qi is 'retarded' and, conversely, if the circulation of qi is 'retarded' then the blood flow 'stagnates'.

Body Fluid
Body fluid is formed from food and drink. It exists in the blood, the tissues, and all the body openings and cavities.

V. The Pathogenesis of Disease
In traditional Chinese Medicine various elements and other factors cause disease. These are known as pathogenic factors or pathogens. Normally the human body is able to resist pathogens and maintain a healthy balance between the body and the environment. This ability is a function of normal qi, especially the defensive qi.

Disease develops because normal qi is unable to resist the onslaught of the pathogenic qi; if pathogenic qi overwhelms normal qi then a functional disturbance of the body results. The major principle of treating a disease in Chinese medicine is to strengthen and protect normal qi and maintain a healthy body. In ancient China a physician was only paid while his patient was healthy, not while his patient was ill!

Pathogenic Factors
These are divided into three main groups, exogenous pathogens, mental pathogens and various miscellaneous pathogens. 'Phlegm and humour' and 'stagnant blood' are pathological products; once they are formed new pathological changes will ensue so they are considered to be secondary pathogens.

Pathological factors serve as a generalization of clinical symptoms and signs, reflecting the struggle of normal qi and pathogenic qi. By differentiating the clinical symptoms and signs the cause of the disease can be traced, and then treatment can be determined. In order to do this the diseased organs must be defined and the pathogen causing that disease must also be diagnosed. This is called the 'determination of treatment on the basis of the differentiation of a syndrome', and it is the basis of diagnosis and treatment in Chinese medicine.

The Exogenous Pathogens
These refer to six relatively abnormal meteorological conditions; wind, cold, summer heat, damp, dryness and heat (fire, warmth). The diseases caused by these pathogens include most viral, bacterial and protozoal diseases and some 'allergic' conditions such as urticaria.

 cold and damp    normal qi of
 invade pi spleen   pi-spleen is
 impairing its function          overpowered

 
    
 symptoms of disease—   impairment of the
 anorexia. abdominal distention,  function of pi-spleen
 pain, diarrhoca, cold extremities,
 greasy white tongue, deep thready  pulse

Wind
This pathogen is characterized by movability (of symptoms) and changeability. The clinical manifestations are abnormal limb motion, such as spasm or twitching, and a wandering symptomatic site as in urticaria or arthralgia. The symptoms may vary in intensity and they usually include a dislike of wind, fever, sweating, headache and an itchy throat.

Cold
Invasion of cold will consume the yang causing a contraction of the channels and the blood vessels, and therefore a poor circulation of qi and blood. The symptoms are those of a slight fever, a dislike of cold, hypohydrosis, headache, muscular pain and spasm, and occasionally a dark blue and painful area in the local muscles and skin; a frozen shoulder is a good example of the pathogen cold.

Summer heat
This only occurs in the summer; it damages the yin and may progress to affect the level of consciousness. The symptoms are excessive body heat, profuse sweating, thirst, a dry mouth, dry red skin and, in severe cases, delirium (this is known as heat exhaustion in Chinese medicine). Summer heat may combine with wind and cause convulsions. Summer heat often combines with damp to produce dizziness, nausea, a stuffy sensation in the chest and general malaise.

Damp
Diseases caused by damp are sticky, muddy, greasy and stagnant. Damp causes a generalized heavy feeling associated with distension, dizziness and a heavy head, general malaise and a stuffy sensation in the chest. The patient may also complain of abdominal swelling and an exudative and prolonged skin disease.

Dryness
Dryness consumes yin fluid. There may be a dry sore feeling in the nose, mouth and throat, a coarseness of the skin, or a cough with scanty sputum and possibly haemoptysis. Tuberculosis is an example of the pathogen dryness.

Heat (fire, warmth)
All these represent the same pathogen, but at different intensities. Fire is the most severe and warmth the mildest. As with summer heat the yin may be damaged and this will affect the level of consciousness. The main difference is that summer heat only occurs in the summer and is generally less severe than fire. Diseases that are caused by heat are generally of abrupt onset and rapid change, they are nearly always acute infections. Initially the patient may complain of a high fever, chill, thirst, restlessness, irritability and profuse sweating. In severe cases the patient may be in coma with convulsions.

Mental Pathogens
These are overjoy, anger, anxiety, overthinking, grief, fear and fright.

Excessive fear and fright, or overjoy, injures the xin-heart. This causes palpitations, insomnia, irritability, anxiety and mental abnormality.

Excessive anger causes dysfunction of the gan-liver. This impairs the function of freeing, and causes pain and distention in the costal and hypochondriac region, abnormal menstruation, depression and irritability. If the function of storing blood is disturbed then menorrhagia and hemorrhage can result.

Excessive grief, anxiety and overthinking cause dysfunction of the pi-spleen and stomach. This causes anorexia and a feeling of fullness or distension after meals.

Excessive grief, anxiety and anger cause poor circulation of qi and blood. If there is retardation of qi and stagnation of blood then this can cause a tumor.

Miscellaneous Pathogens
Irregular feeding
Overeating, or eating too much uncooked or cold food, impairs the function of pi-spleen and stomach and causes nausea, vomiting, heartburn, sour regurgitation and diarrhea, for example dyspepsia, gastritis and enteritis.

Over-indulgence in alcohol and an excess of fatty or hot, pungent food produces damp and heat, or phlegm and heat, in the pi-spleen and stomach. Initially dyspepsia results but in more severe cases hypertension, enteritis, gastritis, cirrhosis, cancer or ischaemic heart disease can result. All these are related to nutritional habits.

Too little food intake, or lack of some essential material in food may cause malnutrition. This results in a deficiency of qi and blood which causes emaciation, lassitude, palpitations and sometimes coma.

The intake of contaminated food may impair the function of pi-spleen and stomach, and cause intestinal infections and various parasitic diseases.

Too little or excessive physical labor
Excessive physical labor results in feebleness, emaciation, palpitations and dizziness.

Too little physical exercise causes a poor circulation, limp muscles, soft bones and obesity. This lowers the resistance of the body to disease.

Traumatic injuries
These are the same as in Western medicine.

Appendix
Stagnant blood and phlegm and humour are pathogenic products that may cause further pathological change if they are not eliminated. They have substantive and non-substantive meanings. Substantively they could be described as a blood clot or sputum, the non-substantive meaning is a generalization of a clinical syndrome, for instance, the stertorous breathing that may occur after a severe stroke is described as 'phlegm covering the orifice of the xin-heart'.

Stagnant blood
Stagnant blood can cause pain. The painful area is fixed and has a stabbing, boring or colicky nature.

Stagnant blood causes hemorrhage. This produces deep purple blood, often with clots.

Stagnant blood causes ecchymosis or petechia.

Stagnant blood can cause a mass. This can be any sort of mass, tumor, splenomegaly or hepatomegaly.

Phlegm and humour
Phlegm and humour are formed when water metabolism is disordered; an accumulation of excess water then turns into phlegm or humour. Phlegm and humour in the lung causes cough, dyspnoca and excessive sputum.

Phlegm and humour in the stomach causes abdominal distension and a succussion sound.

Phlegm covering the heart orifice causes coma and a rattling sound from the sputum in the throat, such as in a stroke.

Phlegm blocking the channels and collaterals causes hemiplegia, numbness of the extremities and difficulty in speech, such as in a stroke.

Phlegm accumulating subcutaneously occurs when there is a subcutaneous lymph node.

VI. Differentiation of Disease According to the Eight Principles
This is the diagnostic system of Chinese traditional medicine. The notes in the ensuing section explain the broad principles of diagnosis, using the history and examination of the patient as a basis.

Diseases are either exterior or interior. If a pathogen such as cold invades the body then it may be superficial or exterior in its damaging effect, such as the common cold, or it may be deep or interior, such as septicaemia. Usually diseases of the exterior show mild fever, headache, generalized aches and pains, and a superficial pulse. Diseases of the interior are characterized by a high fever, thirst, restlessness, delirium, vomiting, diarrhea, a purplish-red tongue proper, with a white or yellow coating and a deep pulse.

Disease may be hot or cold. This means they may be due to the pathogen factors cold or heat. Diseases of heat show the signs of an acute infection or intestinal obstruction, whereas diseases of cold are more chronic in nature. Diseases of cold are characterized by a dislike of cold, pallor, loose stool, polyuria, a large flabby white tongue with a white coating, and a slow or deep and thready pulse. Diseases of heat show fever, dislike of heat, thirst, a red face, constipation, red scanty urine, and a red tongue proper with a yellow coating, associated with a rapid pulse.

Diseases may be xu or shi: Diseases of xu are usually more chronic in nature and are due to a deficiency of either the yin or the yang within the body. The patient is in low spirits, pale, emaciated, has palpitations and the tongue proper is light or red with a white or yellow coating, and there is a xu pulse. A shi disease is often more acute and is due to an excess of the yin or the yang within the body. This presents with irritability, distension and fullness of the chest and abdomen, scanty urine and dysuria, a red or white tongue proper with a yellow or white coating, and a shi or forceful pulse. There is a great deal of reference to xu and shi and it is important to realize that xu really means a deficiency, and shi really means an excess.

The last two principles are yin and yang. They are the generalization of the above ideas, which have already been discussed in Part I of this section.

VII. Methods Of Diagnosis

Inspection
Mental condition
See mental pathogens.

Facial complexion
A red face occurs with febrile diseases, a pale wizened face is due to anaemia or xu diseases, a yellow face occurs in jaundice and a purple face occurs in anoxia, severe pain or stagnation of blood.

Body build, posture and motion
In an obese person there is a chronic deficiency of qi with invasion of phlegm and damp, while in an emaciated person there is hyperactivity of fire due to a deficiency of yin. Paralysis of the limbs indicates insufficiency of qi and blood with blocked channels and collaterals. Convulsions and muscle spasm are often due to an invasion of the channels by wind, due to an insufficiency of yin.

Examination of the tongue
This is a most important diagnostic tool; the tongue is divided into the tongue proper and the tongue coating. A normal tongue has a pink tongue proper with a white clear coating over the tongue.

The tongue proper
A light coloured tongue proper: A light tongue proper indicates insufficiency of qi and blood, invasion of cold, and xu of yang.

A red tongue proper: A red tongue proper indicates diseases due to heat, or internal diseases of heat due to xu of yin.

A purplish-red tongue proper: This occurs in acute diseases of heat when heat has been transmitted from the exterior of the body to the interior, for instance septicaemia. It can also be seen in diseases that exhaust the body fluid, causing hyperactivity of yang due to an insufficiency of yin, for instance terminal carcinoma.

A purplish tongue proper: A purple or bluish-purple tongue proper indicates retardation of qi and stagnation of blood, causing internal cold due to xu of yang, for instance ischaemic heart disease or heart failure.

A large flabby tongue proper: A large and flabby tongue proper with teeth marks indicates xu of qi and xu of yang, for instance chronic enteritis. If there are purplish-red spots on the tongue then this means that there is an invasion of heat.

A streaked tongue proper: Some people have a congenital streaked tongue (this is called a geographical tongue in Western medicine) and it must be ignored. Streaks or red prickles on the tongue normally indicate hyperactivity of fire causing consumption of the body fluid and this is often found after infectious diseases.

Stiff and tremulous tongue proper: The tongue shows fasciculation and it may curl up. This is often accompanied by indistinct speech and mental disorders and indicates disturbance of the mind by phlegm and heat, or deficiency of yin of the gan-liver.

The tongue coating
A white coating: A thick white coating indicates stagnation of food, for instance dyspepsia.

A white greasy coating indicates invasion by the pathogen cold and damp, or phlegm, for instance chronic bronchitis.

A white powder-like coating indicates invasion by plague, for instance typhoid.

A yellow coating: A thick yellow coating indicates chronic indigestion.

A thin yellow coating indicates invasion of fei-lung by wind and heat, for instance a cold.

A greasy yellow coating indicates internal damp and heat, or phlegm and heat, for instance bacillary dysentry or a lung abscess.

A charring yellow coating indicates the accumulation of heat in the intestines which damages the yin, for instance infectious diseases of the intestine.

A yellow tongue coating may also be caused by smoking.

A greyish- black coating: A grayish-black slippery coating indicates excessive cold due to xu of yang, and this occurs in certain types of dyspepsia.

A grayish-black dry coating indicates exhaustion of the body fluids due to excessive heat, for instance dehydration.

A peeling coating: When the tongue coating is partially or completely peeled off the tongue proper can be seen. This indicates severe damage of the normal qi and an extreme deficiency of yin, for instance the late stages of terminal cancer.

Auscultation
Listening to the speech
Speaking in a low feeble voice indicates diseases of xu nature and sonorous speech indicates shi diseases. A partial loss of consciousness means that heat and phlegm are covering the heart orifice. Talking to oneself means that there is a derangement of the mind, and indistinct speech often means that the channels are blocked by wind and phlegm.

Listening to the respiration
Feeble respiration with dyspnoea and excessive sweating indicates xu of qi of the xin-heart and fei-lung. Heavy respiration, with a productive cough, indicates a shi disease of fei-lung due to an accumulation of phlegm and heat, or phlegm and humour, in fei-lung.

Listening to the cough
A heavy unclear cough is caused by invasion of fei-lung with wind and cold, or accumulation of cold and humour in fei-lung. A loud clear cough often indicates wind and heat, or phlegm and heat, in fei-lung. A dry cough with minimal sputum is often caused by a chronic xu of yin of fei-lung, for instance tuberculosis.

Smell
A rank foul smell of any discharge or secretion indicates a disease of shi nature (infection). A light smell indicates a disease of xu nature, for instance scanty red urine with a foul smell indicates a hot shi-disease, like cystitis, while clear profuse urine indicates a cold xu disease, like diabetes insipidus.

Interrogation
This is best summed up by the translation of an old Chinese text called the ten askings:

One ask chill and fever, two perspiration, three ask head and trunk, four stool and urine, five food intake and six chest. Deafness and thirst are seven and eight, nine past history and ten causes. Besides this you should ask about the drugs taken, and for women patients you should ask their menstrual and obstetric history. Finally, for infants, ask about the normal childhood diseases.

This section is included purely for interest as the method of taking a history so clearly corresponds with that used in Western medicine.

Palpation
Palpation of the pulse
The pulse provides a great deal of the information gained from palpation, although a mass or trauma will obviously have to be examined on a more Westernized basis. In classical Chinese medicine there are six pulses at each wrist. These pulses occupy three positions at each wrist over the radial artery, and each position has a deep and superficial pulse. Each of these pulses represents a different organ and in this way all twelve of the zang fu organs are represented by a wrist pulse. The character of the pulse indicates the state of health of each organ and also the balance between each organ. Although traditional pulse diagnosis is still used in China we were taught a much simpler form of pulse 'generalization' rather than the traditional pulse diagnosis, and it is this purse 'generalization' that will be discussed in the following section.

A superficial pulse: This pulse responds to the finger when pressed lightly and becomes weak on heavy pressure. It is often seen in the early stages of diseases caused by exogenous pathogens, such as infections.

A deep pulse: This pulse is not clear on superficial palpation but it is felt on deep pressure. It is often seen in interior diseases such as glomerulonephritis.

A slow pulse: This pulse is less than sixty beats per minute; it may be normal or it may be seen in atrio-venticular block, i. e. diseases of cold.

A rapid pulse: This pulse is greater than sixty beats per minute; it is often seen in diseases of heat.

A xu pulse: The pulse is weak and forceless and goes on heavy pressure. This is seen in diseases of xu nature, such as malnutrition or diseases of pi-spleen.

A shi pulse. The pulse is forceful and will not go on deep palpation; it is seen in shi diseases.

A large pulse: This is an abundant pulse; it is like a surging wave and is seen in diseases of shi nature and heat.

A thready pulse: This is like a thready flow of water and it is often seen in xu diseases

A bowstring pulse. The pulse is hard and forceful and gives the sensation of pressing on the string of a bent bow. It may be normal or it may be seen in diseases where there is hyperactivity of the yang of the gan-liver.

A gliding pulse: This is round and forceful, like beads rolling on a plate. It is often seen in cases of indigestion or obstruction of phlegm. Sometimes a gliding pulse may be seen in a healthy person, especially in pregnancy.

An intermittent pulse. The pulse is irregular. This occurs in retardation of qi and stagnation of blood, causing a deficiency of qi in the xin-heart, such as atrial fibrillation.

Palpation for all other pathology, such as mass or trauma, follows the same rules as in Western medicine.

VIII. The Differentiation Of Syndromes
The Chinese described symptom pictures which allow the differentiation of specific Zang Fu syndromes. The major syndromes are described below and provide further useful information which will enable the acupuncturist to reach a clear Zang Fu diagnosis.

Syndromes of the Xin-heart

1. Weakness of the qi of the xin-heart
Clinical Manifestations: Palpitations, dyspnoea aggravated by exertion, a pale tongue and a thready xu or irregular pulse. If there is evidence of a deficiency of the yang of the xin-heart then cold limbs, pallor, and purplish lips can be found. Exhaustion of the yang of the xin-heart may manifest itself as profuse sweating, mental confusion and a fading, thready pulse.

Aetiology and pathology: This syndrome is usually caused by general malaise after anxiety or a long illness, which injures the qi of the xin-heart. When the qi of the xin-heart is weak it fails to pump blood normally resulting in palpitations, dyspnoea and a thready irregular or xu pulse. Alternatively, a prolonged weakness of the qi of the xin-heart may lead to weakness of the yang of the xin-heart. When the body lacks yang it lacks energy and heat, therefore symptoms such as chills, cold limbs and pallor occur. If the yang of the xin-heart is exhausted, the defensive qi of the body surface can no longer protect the essential qi and lets it dissipate, this results in profuse sweating and a fading, thready pulse.

2. Insufficiency of the yin of the xin-heart

Clinical Manifestations: Palpitations, insomnia, dream disturbed sleep, anxiety and possible malar flush with a low grade fever. A red tongue proper and a thready and rapid pulse will also be found.

Aetiology and pathology: This syndrome is usually due to damage of the yin by a febrile disease or anxiety, which consumes the yin of the xin-heart. Insufficiency of the yin of the xin-heart often leads to hyperactivity of the fibber of the xin-heart, resulting in the above symptoms. Insufficiency of the yin of the xin-heart may also cause insufficiency of the blood of the xin-heart. If this happens then there is not enough yin and blood to nourish the xin-heart, and the xin-heart fails in its function of keeping the mind. The symptoms of insomnia, poor memory and dream-disturbed sleep will therefore appear.

3. Stagnation of the blood of the heart

Clinical Manifestations: Palpitations, cardiac retardation and pain (paroxysms of pricking pain, or in more severe cases colicky pain often referred to the shoulders and the back), peripheral and central cyanosis and a thready or irregular pulse.

Aetiology and pathology: This syndrome is due to anxiety leading to stagnation of qi and stagnation of blood. It may also be due to insufficiency of the qi of the xin-heart after a chronic illness; if the qi of the xin-heart is too weak to sustain the cardiac circulation then stagnation of blood of the xin-heart and obstruction of the blood vessels results. Stagnation of the blood often impedes the distribution of yang qi in the chest causing discomfort in the chest (angina) and peripheral cyanosis. A dark purplish tongue proper, or purple spots on the tongue, and a thready or irregular pulse are manifestations of stagnation of blood and confinement of the yang qi.

4. Hyperactivity of the fire of the xin-heart
Clinical Manifestations: Ulceration, swelling and pain in the mouth and tongue, insomnia accompanied by fever, a flushed face, a bitter taste in the mouth, hot, dark and yellow urine, a red tongue proper and a rapid pulse.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The depressed qi may turn into endogenous fire and disturb the mind, causing the symptoms of insomnia and fever to appear. As the xin-heart has the tongue as its orifice, and its function is reflected in the face, a disorder of the fire of the xin-heart may cause many of the above symptoms.

5. Derangement of the mind

Clinical Manifestations: Depression, dullness, muttering to oneself, anxiety, incoherent speech, mania and in severe cases coma.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The body fluid stagnates to form damp and/or phlegm which causes blurring of the xin-heart and mind, resulting in dullness and depression. If the depressed qi turns into fire and the phlegm and fire disturb the xin-heart, anxiety, incoherent speech and mania result. Blurring of the mind by phlegm and/or damp, or phlegm and/or fire causes coma. A high fever, coma and delirium resulting from invasion of the pericardium by heat, are due to pathogenic heat invading deep into the interior of the body and disturbing the mind.

Syndromes of the Gan-liver

1. Depression of the qi of the gan-liver
Clinical manifestations: Hypochondrial and lower-abdominal pain and distension, a distended sensation in the breasts, discomfort in the chest and belching, sighing, or a sensation of a foreign body in the throat. Women may experience irregular periods.

Aetiology and pathology: This syndrome is usually due to mental irritation causing depression of the qi of the gan-liver and stagnation of the qi in the liver channel. This leads to hypochondrial and lower abdominal pain and distension, a distended sensation in the breasts and discomfort in the chest. Stagnation of the qi of the gan-liver may affect the stomach, causing failure of the qi of the stomach to descend and resulting in belching. The sensation of a foreign body in the throat is due to stagnation of the qi of the liver channel, which with the phlegm forms a lump in the throat. Depression of the qi of the gan-liver and the subsequent lack of freeing may further impair the gan-liver's function of blood storage. Stagnation of qi leads to stagnation of blood, the cause of irregular periods.

2. Flare-up of the fire of the gan-liver
Clinical manifestations: Dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth, a flushed face, irritability and sometimes haematemesis and epistaxis can occur. The tongue proper is red with a yellow coating and the pulse is wiry and rapid.

Aetiology and pathology: This syndrome is often due to a longstanding depression of the qi of the gan-liver which can turn into fire. It may also be due to over-indulgence in alcohol and tobacco causing an accumulation of heat which turns into fire. The upward disturbance of the fire of the gan-liver causes dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth and a flushed face. Fire injures the gan-liver, causing impairment of its function in promoting the free flow of qi and this causes irritability. When the fire of the gan-liver injures the blood vessels it causes extravasation of blood and haematemesis and epistaxis can occur.

3. Stagnation of cold in the liver channel
Clinical manifestations: Lower-abdominal pain, swelling and distension in the testis with tenesmus. The scrotum may be cold and contracted and these symptoms can be alleviated by warmth. The tongue proper is pale with a white coating and the pulse deep and wiry or slow.

Aetiology and pathology: The liver channel curves around the external genitalia and passes through the lower abdomen. When cold, which is characterized by contraction and stagnation, stays in the liver channel, stagnation of the qi and blood may occur and cause lower-abdominal pain, swelling and distension of the testis with tenemus. Cold and contraction of the scrotum are also due to the pathogen cold.

4. Insufficiency of the blood of the gan-liver

Clinical manifestations: Dizziness, blurred vision, dry eyes, pallor, spasm of the tendons and muscles, numb limbs and a scanty light coloured menstrual flow with a prolonged cycle.

Aetiology and pathology: This syndrome often occurs after a hemorrhage or another chronic disease in which blood is destroyed, and the reserves of the gan-liver are depleted, thereby resulting in a failure of the gan-liver to nourish the channels. A xu (deficiency) of blood may cause endogenous wind so that the symptoms of muscle spasticity and numb limbs appear. An upward disturbance of endogenous wind (xu type) can cause dizziness and blurred vision. Insufficiency of the blood of the gan-liver and disruption of its blood storage function results in emptiness of the chong channel which will cause menstrual abnormalities.

5. Stirring of the wind of the gan-liver by heat
Clinical manifestations: High fever, convulsions, neck rigidity (Opisthotonos) and coma. A deep-red tongue proper and a wiry, rapid pulse are also found.

Aetiology and pathology: This syndrome is due to transmission of the pathogen heat from the exterior to the interior, which burns the yin of the gan-liver and deprives the tendons and blood vessels of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pi-spleen

1. Weakness of the qi of the pi-spleen
Clinical manifestations: Sallow complexion, anorexia, loose stools, oedema, and lassitude. There may be distension and a bearing-down sensation in the abdomen, a prolapse of the rectum and/or uterus, or a chronic blood disorder such as purpura, bloody stools or uterine bleeding. A pale tongue proper and a thready xu pulse will be found on examination. If there is evidence of xu (deficiency) of the yang of the pi-spleen, symptoms of cold such as cold limbs will occur.

Aetiology and pathology: This syndrome is often caused by irregular food intake, excessive mental strain or chronic disease. These problems result in weakness of the qi of the pi-spleen and impair its function of transportation and transformation, which consequently results in a poor appetite and loose stools. Accumulation of fluid in the interior is the cause of the oedema. The general malaise is due to a lack of food failing to provide a nourishing basis for blood formation. When the qi of the pi-spleen is weak, it loses its ability to uplift tissues so that there is distension, a bearing-down sensation in the abdomen and a prolapse of the rectum and/or uterus. Weakness of the qi of the pi-spleen also causes the blood disorders. Xu (deficiency) of the yen of the pi-spleen causes cold limbs.

2. Invasion of the pi-spleen by cold and damp
Clinical manifestations: Fullness and distension in the chest and epigastrium, a poor appetite, a heavy feeling in the head, malaise, borborygmii, abdominal pain and loose stools. A white sticky tongue coating and a thready pulse will be found.

Aetiology and pathology: This syndrome usually occurs after rain, or it may be due to over-indulgence of raw or cold food. In both cases the pathogen cold and damp injure the pi-spleen impairing its function of transportation and transformation and resulting in a poor appetite, borborygmii, abdominal pain and loose stools. As pathogenic damp is sticky and stagnant, it is liable to block the flow of qi causing a sensation of epigastric fullness and distension.

Syndromes of the fei-lung

1. Invasion of the fei-lung by the pathogen wind
Clinical manifestations: An itchy throat and cough associated with fever and chills. If the wind is accompanied by cold then the patient usually feels cold and presents with nasal obstruction, a watery nasal discharge and mucoid sputum. The tongue coating is thin and white. If the wind is associated with heat, fever will be the most prominent symptom and will be associated with a red, swollen throat, a purulent nasal discharge and purulent sputum. The tongue coating will be yellow.

Aetiology and pathology: Invasion of the fei-lung by the pathogen wind disturbs its function of dispersal and descent. Normal respiration is affected producing the symptoms of cough and nasal obstruction. Cold is a yin pathogen and therefore liable to damage the yang qi. Consequently when wind is associated with cold, the sensation of cold will be more severe than that of fever and will be accompanied by a watery nasal discharge and white mucoid sputum. Heat is a yang pathogen, and if wind is accompanied by heat, fever will become the most prominent symptom and will be associated with a purulent nasal discharge and purulent sputum.

2. Retention of damp and/or phlegm in the fei-lung
Clinical manifestations: Cough, dyspnoea and white frothy Sputum The onset is generally precipitated by cold, and the tongue coating is white and sometimes sticky.

Aetiology and pathology: This syndrome is due to the disturbance of the normal circulation of body fluid, the body fluid accumulates and precipitates the formation of damp/or phlegm. When damp and phlegm remain in the fei-lung the passage of qi is blocked and the functions of the fei-lung are impaired, this results in the above symptoms.

3. Retention of phlegm and/or heat in the fei-lung

Clinical manifestations: Cough, dyspnoea, wheezing and thick yellow and/or green sputum (occasionally pus). This can be associated with rigors and a fever; the tongue proper is red with a yellow coating and there is a rapid pulse.

Aetiology and pathology: This syndrome is caused by invasion of exogenous wind and/or heat, or wind and/or cold, which later develops into heat. The heat mixes with phlegm, which remains in the fei-lung and blocks the circulation of qi; this impairs the functions of the fei-lung and causes cough, dyspnoea and wheeze. Heat exhausts body fluid causing purulent sputum. When phlegm and heat are found in the fei-lung, stagnation of blood results which in turn leads to purulent, bloody sputum.

4. Insufficiency of the yin of the fei-lung
Clinical manifestations: A dry, unproductive cough associated with sticky, scant, blood-stained sputum, fever, a malar flush, a feverish sensation in the palms and soles, a dry mouth and night sweats. A red tongue proper and a thready and rapid pulse will be found.

Aetiology and pathology: Such symptoms are usually caused by chronic disease of the fei-lung, which consumes the yin and results in insufficiency of body fluid. The fei-lung is deprived of nourishment, its functions are impaired and this produces a dry mouth. Xu (deficiency) of yin causes endogenous heat which drives out body fluid and injures blood vessels, this results in a fever, a malar flush, a feverish sensation in the palms and soles, night sweats and bloody sputum.

Syndromes of the Shen-kidney

1. Weakness of the qi of the shen-kidney
Clinical manifestations: A sore and weak sensation in the lumbar region and knee joints, urinary frequency, polyuria, dribbling, enuresis, urinary incontinence, dyspnoea, wheezing, and occasionally infertility. The pulse will be thready.

Aetiology and pathology: This syndrome is often caused by malaise after a prolonged chronic illness, or may be the result of senility or congenital deficiency. Weakness of the qi of the shen-kidney results in an inability of the urinary bladder to control urination; this causes enuresis, incontinence, frequency and urgency. Shen-kidney stores essence (shen), but when the qi of the shen-kidney is deficient, infertility can result. When the qi of the shen-kidney is weak, it fails to help the fei-lung perform its function of descent, qi therefore attacks the fei-lung resulting in dyspnoca and wheezing.

2. Insufficiency of the yang of the shen-kidney
Clinical manifestations: These are broadly similar to the syndrome described as 'Weakness of qi of the shen-kidney'. The major symptoms are a dull ache in the lumbar region and knee joints, cold, pallor, impotence, oliguria and oedema of the lower limbs. A pale, tooth-marked tongue and a deep thready pulse will be found.

Aetiology and pathology: This syndrome usually occurs after a prolonged chronic illness in which the yang of the shen-kidney is injured, it may occasionally be due to an excess of sexual activity which also injures the yang of the shen-kidney. In either instance, the yang of the shen-kidney fails to warm the body which results in cold aching sensations in the low back and knee joints, and impotence. Then shen-kidney controls water metabolism, and an insufficiency of the yang of the shen-kidney results in oliguria; the subsequent fluid excess presents with the symptom of oedema.

3. Insufficiency of the yin of the shen-kidney
Clinical manifestations: Blurred vision, tinnitus, amnesia, feverish sensation in the palms and soles, a malar flush, night sweats, hot yellow urine and constipation. The tongue proper will be red and the pulse thready and rapid.

Aetiology and pathology: This usually occurs after a prolonged chronic illness in which the yin of the shen-kidney is impaired, it may also be due to an over-indulgence in sexual activity, which consumes the shen-kidney. Either of these factors can result in the shen-kidney failing to produce marrow and maintaining normal cerebral function. The symptoms that result are dizziness, blurred of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pericardium
The syndromes of the pericardium are seen clinically as the invasion of the pericardium by heat. The symptoms are a high fever, coma and delirium, these result from heat invading the interior of the belly, which in turn disturbs the mind.

Syndromes of the Small Intestine
Disturbance of the function of the small intestine is included in the syndromes of the pi-spleen, particularly with respect to its main function (transformation and transportation).

Syndromes of the Gall Bladder

Damp and heat in the gall bladder Clinical manifestations: Yellow sclera and skin, pain in the costal and hypochondrial region, pain in the right upper abdominal quadrant and a bitter taste in the mouth. Some patients may vomit sour and/or bitter fluid. The tongue coating is yellow and sticky.

Aetiology and pathology: The function of the gall bladder is to store and excrete bile, and this depends on the normal function of the gan-liver. Exogenous damp and/or heat (heat caused by depression of the gan-liver, damp and heat caused by overindulgence in alcohol and rich food) may accumulate in the gan-liver and gall bladder, thereby impairing the free flow of qi. Bile cannot therefore be secreted and freely excreted, and the subsequent biliary overflow causes jaundice, a bitter taste in the mouth and vomiting. Stagnation of the qi of the gan-liver and gall bladder also leads to stagnation of blood, causing right hypochondria! pain. This syndrome is closely related to the gan-liver, and is also known as 'damp and heat in the gan-liver and gall bladder'. Syndromes of the Stomach

1. Retention of food in the stomach
Clinical manifestations: Distension and pain in the epigastric region, anorexia, belching, heartburn and vomiting. The tongue has a thick sticky coating.

Aetiology and pathology: This syndrome is usually caused by over-eating, which leads to the retention of undigested food in the stomach; the qi of the stomach ascends rather than descending.

2. Retention of fluid in the stomach due to cold
Clinical manifestations: The sensation of fullness associated with a dull epigastric pain, aggravated by cold and alleviated by warmth. The tongue coating will be white and sticky and the pulse thready or slow.

Aetiology and pathology: This syndrome usually follows a cold after rain, or may be precipitated by the excessive ingestion of raw or cold food. Either of these factors result in cold in the stomach which causes stagnation of qi and pain. Prolonged damage injures the yang qi of the pi-spleen and stomach so that body fluid is retained in the stomach instead of being transported and transformed, this results in vomiting.

3. Hyperactivity of the fire of the stomach
Clinical manifestations: A burning in the epigastrium, thirst, a preference for cold drinks, vomiting of undigested food or sour fluid, gingival swelling pain and ulceration, halitosis. The tongue proper will be red with a dry yellow coating.

Aetiology and pathology: This syndrome is usually due to overeating rich food, which causes heat to accumulate in the stomach. The heat consumes body fluid and causes the qi of the stomach to ascend. This results in a burning epigastric pain, thirst, a preference for cold drinks and vomiting. Halitosis and gingival ulceration are due to the fire element in the stomach.

Syndromes of the Large Intestine

1. Damp and heat in the large intestine
Clinical manifestations: Fever, abdominal pain, loose dark smelly stools, frequent bowel movements. White or red mucus may be present in the stool, and can be associated with perineal pain and tenesmus. The tongue proper is red with a yellow coating, and the pulse rolling and rapid.

Aetiology and pathology: This syndrome is usually caused by eating too much raw, cold or contaminated food. It may also be due to invasion of summer heat and damp. Damp and heat accumulate in the large intestine, blocking the passage of qi and disturbing its function of transmission and transformation; this produces diarrhea, abdominal pain and dark smelly stool. Damp and heat may also injure the blood vessels of the large intestine producing bloody mucus in the stool. The downward pressure of the damp and heat causes perineal pain and tenesmus.

2. Stasis of the large intestine
Clinical manifestations: A distended full abdomen, abdominal pain (intensified with pressure), constipation, nausea and vomiting. The tongue coating is white and sticky and the pulse shi and deep.

Aetiology and pathology: This syndrome may be due to food retention, gastro-intestinal parasites, or blood stagnation; all these factors cause obstruction of the qi and functional derangement of the large intestine. This results in constipation, abdominal distension and pain. The nausea and vomiting are caused by the qi of the large intestine impeding the des

Jamu, Indonesian traditional Medicines

Writings about Javanese herbal medicines (jamu) in Indonesia often emphasise their ancient origins and their status as traditional medicine. But the world of jamu has undergone many changes, and the market in jamujamu are currently made, distributed, marketed and used provides a window into some of these issues. today reflects the complexities of contemporary life. An examination of how

Traditionally, jamu was prepared at home. But while few people today have the time, or the skills, for the lengthy process of preparing the various ingredients, traditional-style jamu are still readily available. In the early morning hours in almost any kampung in the cities and towns of Java, women peddle jamu door to door. Carrying a deep round basket heavy with bottles of reddish-brown or golden coloured liquid tied to her back, the jamu seller walks the narrow lanes of the kampung. These itinerate jamu sellers also service offices and factories, offering a pick-me-up for tired workers. Any traditional market, too, has permanent stalls selling jamu of various sorts that can be combined on the spot by the vendor depending on the client’s needs.

However, the majority of jamu sold today come in packaged form (jamu bungkus). These are most often in the form of small, brightly-coloured foil or plastic sachets of powder to brew with hot water or mix with other drinks. Jamu is also increasingly available in the form of tablets or capsules that look like conventional medicine.

Traditionally, jamu preparations were as much used to maintain good health and proper bodily functioning as for treating specific illnesses. Today, the taking of jamu as opposed to conventional pharmaceuticals, is still common for the many categories of ailments that don’t precisely correspond to biomedical categories of sickness. These are ailments such as masuk angin, similar to a cold or flu, and pegel linu, a term which refers to joint and muscular stiffness and rheumatic-type pain. Jamu­are also frequently used for women’s problems such as vaginal discharge, regulating the menses, and for conditions associated with pregnancy, birth, and postnatal health.

Today at least 50 per cent of all traditional medicines sold are for the enhancement of manliness, sexual performance, and sexual health. Increasingly common also is the marketing of jamu for problems such as high cholesterol, diabetes, and high blood pressure, as well as for conditions such as acne. Customers wanting to lose weight, enlarge their busts and so on, also turn to jamu.

The business of Jamu

The number of smaller businesses involved in the manufacture of jamu exploded in the late 1980s and through the 1990s. By 1998, nearly 700 firms making traditional medicines were registered with the Department of Health. Seventy nine of these were classed as industries proper, the remainder as small (often home) industries. This number does not include the many tiny household enterprises that operate without formal approval.

However, the commercial production of jamu is dominated by a few large companies. These firms generally began as family businesses but over time expanded into modern industries manufacturing jamu for both domestic and export markets. The earliest companies were Jamu Cap Jago founded in 1918 and Jamu Cap Potret Nyonya Meneer founded in 1919. Other main players in the jamu business have been Sido Muncul (1951), Air Mancur (1963), and more recent firms such as Mustika Ratu (1975), Sari Ayu (1979), as well as Deltomed and Borobodur.

In the 1960s and 1970s, the big jamu brands were still widely advertised at markets and fairs by teams of travelling salesmen. By the early 1980s, when the network of local distributors and agents was already well developed and the main brands were well known, the marketing strategies of the four biggest firms shifted to kiosks. Tens of thousands of kiosks were opened throughout Java and jamu companies ran training courses for their agents and sellers. The brand kiosks still exist, many in somewhat changed form, but many more kiosks of different sorts have opened over the last few years in both urban and rural areas. Kiosk owners often function as ‘consultant pharmacists’ giving advice on what jamu to take for specified ailments or needs. Local healers may write ‘prescriptions’ suggesting what jamu should be purchased at a brand kiosk.

Expanded markets

Jamu sales of all types have increased greatly since the beginning of the economic crisis in 1997. The price of conventional pharmaceuticals is very high, because even pharmaceuticals made in Indonesia use a high percentage of imported raw materials.

Part of this market expansion is demand, but the distribution and sale of packaged jamuxhas also provided income opportunities for many people. This has led to an ever expanding marketing chain for packaged jamu in rural and urban communities. Packaged jamu has moved into the supermarkets, pharmacies, beauty salons, and department stores, as well as the hundreds of thousands of small shops that sell tea, sugar or cigarettes. They are also available in a myriad of food stalls and small restaurants.

Some big jamu firms have moved toward products aimed at the middle class and wealthy, especially in the areas of natural skin care and cosmetics. More expensive brands are heavily promoted at special counters in exclusive shops or salons and upmarket jamu bars have joined Starbucks cafes opening in malls across the country. Middle and lower-priced brands are often marketed from temporary kiosks set up in market complexes or malls. Small, permanent shops also abound within shopping plazas or districts adjacent to bus terminals or other busy places. Even the old jamu gendong seller now usually carries packets of a selection of ready-made jamu, and women providing mixed jamu from their stalls in the markets, also have available a range of jamu bungkus.

Customer beware

Consumers of packaged jamu need to be both informed and cautious. They should buy from a reliable manufacturer and take note of warnings issued by government and non-governmental bodies that operate as watchdogs over the traditional medicine market as well as the food, cosmetic, and pharmaceutical industries.

Authenticity is also frequently a problem. The popularity of a jamu from a small firm, for example, may lead to counterfeiting. The name and packaging are duplicated almost exactly — but not necessarily its contents.

New ailments, new needs

There are other factors involved in the growing popularity of jamu. The profound economic crisis and growing political and social disorder, and the stresses these factors bring about in peoples’ everyday lives, has engendered a growing concern with health, stamina and wellbeing. In the context of these changing conditions, new demands for different sorts of medicines and tonics have emerged. The growth in demand for jamu has been accompanied by increased use of pharmaceuticals such as anti-depressants and anti-anxiety drugs, and an increase in prevalence of alcohol and illicit drug use.

Some of the most popular jamu today are those that meet the new demand for renewed energy, stamina, and alertness. Most of these energy drinks, tonics and supplements are manufactured by large drug or food manufacturers. Although they are considered jamu, they are not jamu proper, because they are not primarily herbal.

Best-selling bottled tonics like ‘Kratingdaeng’, ‘Fit-Up’, and ‘Hemaviton’ contain ingredients such as vitamin B, caffeine, and other substances associated with quick energy. One of the most successful energy drinks is ‘Extra-Joss’, manufactured by the firm Bintang Toedjoe. Though not a herbal preparation (except that it contains some ginseng), like some jamu it comes in the form of a small sachet of instant powder, and costs much less than the bottled energy drinks. Another product made by Bintang Toedjoe is a jamu for male potency, ‘Irex’. Extra-Joss and Irex, both already extremely popular, achieved even greater prominence when they were the featured advertised products during Indonesian TV broadcasts of World Cup Soccer. The images used to promote these and other energy drinks were ones of strength and anliness.

The promotion of manly qualities has always been an important function of jamu. Consequently, the category of energy drinks overlaps with the traditional category of obat kuat (literally medicine to make one strong, powerful). Obat kuat include medicines for enhancing male potency and aphrodisiacs, an increasing number of which are marketed as jamu in markets.

Obat kuat is primarily produced by small local manufacturers or imported from China. Few are actually purely herbal preparations; many contain testosterone or other steroids, and are marketed as the equivalent of Viagra at a fraction of the cost.

These new products, including new types of traditional medicines, sell a chemical sense of ‘power’. For their users, energy drinks and other stimulants create a sense of enhanced physical resources. Whatever their actual ingredients, they offer a sense of ready energy, of potential action, in the face of the daily grind of poorly-paid work or continuing poverty. But this strength is an illusion. It merely masks the effects of poor life conditions — lack of sleep, inadequate food intake, poor nutrition, pollution, chronic disease and parasites.