by Bob Flaws

Eric Brand and Nigel Wiseman have recently published their Concise Chinese Materia Medica through Paradigm Publications and readers will see that I have written a very laudatory blurb on the back of the dust-cover. Taking a quick look at this book, some may wonder at my effusive praise. In some ways, this book seems to contain less material than Bensky et al.’s 3rd edition of Chinese Herbal Medicine: Materia Medica. So why do I think Eric and Nigel’s book is so good? First and foremost, it uses Wiseman and Feng Ye’s translational terminology. I’ve been saying for years that this translational terminology is the best we have and the closest one can currently get to the original Chinese in English. I understand that, if one doesn’t personally read Chinese, they have no way of knowing how good this terminology is. I also understand that some of the term choices use unfamiliar words. But I would stress that this is a professional technical terminology, and one should not expect familiar every-day English words. Until one has studied Western medical terminology, the professional technical words of Western medicine also are strange and unfamiliar. However, one of the arguments for not adopting this better, clinically more accurate Chinese medical terminology has been that all the schools use Bensky’s materia medica as a required text. Since Bensky’s text uses a different terminology, teachers did not want to confuse their students making them learn two different term sets. Now this is no longer necessary. In fact, now in 2009, a person can pretty much study all of Chinese medicine, soup to nuts, using Wiseman and Feng Ye’s single term set. In a way, Eric and Nigel’s new materia medica puts the capstone of that linguisitic edifice. This body of work has been built over the last 25 years by such authors and translators as Bob Damone, Marnae Ergil, Philippe Sionneau, Fred Jennes, Sabine Williams, Simon Becker, Dagmar Riley, Robert Helmer, Zhong Bai-song, Wei Li, David Frierman, Lynn Kuchinski, Jim Cleaver, Lorraine Wilcox, Craig Mitchell, Shelley Ochs, Lifang Liang, Shuai Xue-zhong, Andrew Ellis, Honora Lee Wolfe, Juliette Aiyana, Hoy Ping Lee Chan, Thomas Dey/Michael Helme, myself, and, of course, Eric Brand, Nigel Wiseman, and Feng Ye, all of whom have chosen to use this terminology as their standard. Now there is no need to learn two different term sets, since all the textbooks necessary for learning Chinese medicine in this linguisitically superior, more technically and clinically accurate terminology are available. Further, when it comes to this particular materia medica, Eric and Nigel have added definitions and explanations of all the critical technical terms, thus making this book all the more easy to use. So, not only will using this book help you understand Chinese herbal medicine in a more technically precise way, ultimately, the bottom line is that this increased clarity and precision will then result in better clinical results for you and your patients.

Copyright Blue Poppy Ent. Inc. 2009. All rights reserved.

by Honora Lee Wolfe

Yikes! As if email were not enough, now there is Facebook, Twitter, LinkedIn, and other social network phenoms like Yelp, CafeMoms, and Technorati. What's an overworked acupuncturist to do and what do we need to know about this new wave of online reality? I've been attending some classes, doing some reading, and trying to make heads or tails of these online opportunities this week.

Here are some statistics and a brief synopsis of what I've learned so far...and believe me I'm still a novice. I'll be blogging more on this subject in the coming weeks as I learn more.

Read more »

by Eric Brand

The legal situation regarding the use of xi xin (asarum) in the U.S. is somewhat complex. After the dangers of aristolochic acid (AA) surfaced, many governments worldwide banned the use of Chinese medicinals that contain AA. The U.S. is no exception, and there is an FDA ban on all substances that contain AA. Specifically included in this law are the Chinese medicinals guang fang ji (Aristolochiae Fangchi Radix), ma dou ling (Aristolochiae Fructus), guan mu tong (Aristolochiae Manshurensis Caulis), and xi xin (Asari Herba). Of these substances, the situation regarding xi xin is the most complicated. The situation with ma dou ling is quite simple, it contains AA by nature and is no longer legal for internal consumption.

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by Eric Brand

Chinese medicine enjoys broad coverage in the Taiwanese national insurance system, which covers all Taiwanese citizens as well as foreign students and workers. During my internship at Chang Gung Hospital in Taiwan, I was on a work-study visa that allowed me to have health insurance coverage for an astonishingly low $18/month (the insurance cost is related to one’s income). The insurance card itself is a smart card with a chip inside that can be read by computers in all hospitals and clinics, and the coverage includes biomedical care, dental care, and Chinese medical care. While there are naturally still some imperfections in the Taiwanese healthcare system, Taiwan nonetheless has one of the best healthcare systems in the world when it comes to comprehensive benefits, preventative care, and universal coverage.

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by Eric Brand

The impact of Chinese medicine is easily seen in the food and drink of Taiwan. By nature, the prevailing local viewpoint regarding healthy diet emphasizes variety and suitability of food to the current climate. As far as the impact of Chinese medicine into the food in Taiwan, it is sometimes difficult to draw the line between foods and medicine. For example, a soy-milk style beverage is made out of yi yi ren, and shan yao is often seen as a vegetable on the dinner table. Can we say these are examples of the influence of herbal medicine? How about watermelon juice with aloe in the summertime, or a dish made of stir-fried si gua and ginger? Or a pesto-like sauce made from the aerial portions of the plant that yields chun pi?

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by Eric Brand

I am currently in Taiwan doing field research for my upcoming granule book, so I’m going to do a series of blogs on various local trends in Chinese medicine. Today’s blog will look at some of the trends in Chinese medical devices in Taiwan. A variety of interesting things fit into this category, such as customized granule packaging machines and decoction-steam delivery devices, which direct steam from a decoction to an affected site on the body.

Read more »

by Eric Brand

For the record, I've learned a few things recently that spur me to
correct a few things in my previous posts on granules.

It sounds like I had things a bit wrong with the issue of fillers, I
thought that most Taiwanese companies used pharmaceutical starch with
the proteins removed, but it may actually be that normal potato starch
and corn starch are used (for example, KPC uses only non-GMO potato
starch for its hypoallergenic nature, while Sun Ten uses corn starch).
I'm not positive about this, but after talking to some Taiwanese QC
experts the other day, it sounds like this is the case. Additionally,
it sounds like the minerals and gelatins, despite not being able to be
significantly concentrated, may also be cooked in water in Taiwan. I
visited one of the main companies recently and they said that there
was water boiling involved, but they wouldn't elaborate because the
precise technique was a trade secret.

Also, it seems that the main filler used to dilute Chinese granules in
the mainland is dextrin rather than starch. Sorry for the errors in
my previous posts, these issues are a bit tough to get to the bottom
of. I guess learning more requires us to constantly update our
knowledge as new information surfaces.

Copyright Blue Poppy Ent. Inc. 2009. All rights reserved.

by Eric Brand

During the few years that I taught at PCOM, I was always stricken by the fact that most students in America don’t really comprehend the vast scope of our fascinating field. I found that many students had never traveled to Asia, and tended to assume that the comparatively small world of little U.S. acupuncture clinics was representative of the general state of the field of Chinese medicine. New students often do not realize that Chinese medicine is a highly sophisticated field complete with large hospitals, incredible academic institutions, advanced scientific research centers, and an incredibly complex body of traditional and scientific literature covering virtually every subject imaginable.

The real treasure in Chinese medicine is the brilliant minds that power the cutting-edge developments in the field. In honor of these living legends, I am going to be writing an occasional blog series on some of the top people in the field today. I can think of no better place to begin than with an introduction to Dr. Zhao Zhong-Zhen, a researcher and instructor at Hong Kong Baptist University.

Dr. Zhao is originally from Beijing, but his current position at HKBU provides him with facilities that truly befit a scholar of his caliber. Dr. Zhao is one of the world’s top experts in herbal pharmacy. In fact, I suspect he is probably the top guy in the entire world within his area of expertise, but he is far too modest to actually affirm my suspicion upon a direct inquiry. While he is a world-class expert in the science of Chinese medicinal pharmacy, he also clearly has a profound knowledge of traditional medicine and extensive clinical experience. However, unlike many of China’s top doctors, Dr. Zhao is extremely modest and is not the least bit arrogant about his profound achievements. He practices taiji daily and he really fits the image of the classic self-aware, cultivated scholar-physician that newcomers to Chinese medicine (somewhat naively perhaps) expect to see all over the field.

Dr. Zhao essentially has an entire museum at HKBU dedicated to his private pharmacy collection. This collection includes true and counterfeit specimens of virtually every medicinal substance in common use. Many times these medicinals have actually been wild crafted by Dr. Zhao himself. He has traveled to all corners of China collecting samples, and he has an entire vaulted room full of pressed botanical specimens, complete with pages of collection data as well as pressed leaf, flower, stalk, and root tissue (the same as a normal botanical field sample but generally with the root intact because roots are commonly used in Chinese medicine). All of the medicinals with various adulterants are present in the main museum of dried pharmacy specimens, such as specimens of guang fang ji (Radix Aristolochia) next to han fang ji (Radix Stephania). In fact, all of the photographs in Dr. Zhao’s definitive book on common marketplace adulterants, Easily Confused Chinese Medicines in Hong Kong, were taken from his own specimens and are stored in the museum.

Several of the items on display in Dr. Zhao’s museum are quite incredible. For example, Dr. Zhao is featured in the Guinness Book of World Records for finding the largest cistanches plant ever discovered; this massive wild crafted rou cong rong spike is displayed in an impressive glass case along with his Guinness Book certificate. Another amazing specimen is a larger-than-life statue of a Chinese god of longevity that is crafted purely from ginseng roots. Red and white roots give the appearance of robes while the god’s skin and huge forehead are made out of pressed ginseng cortex. A text description alone cannot hope to do all these specimens justice, but suffice to say that in all my adventures around the wholesale markets of China, I’ve never seen anything close to the incredible medicinal specimens that Dr. Zhao has assembled in this room.

Nearly as impressive is the laboratory that allows Dr. Zhao’s grad students to pursue their assignments. Within the lab of HKBU, one can see virtually every type of machine that is required for herbal analysis, including HPLC, TLC, heavy metal testing machines, and all manners of lab equipment that would typically be seen in a huge commercial granule factory rather than a private university. This technology is used to analyze specimens for a variety of purposes, for example, they often test Chinese prepared medicines to analyze their composition, active constituents, and contaminants. They also have a fascinating project where they test the same medicinal from 100 different markets throughout China and Hong Kong. Hundreds of boxes each contain 100 specimens of the same medicinal with detailed collection data, and they then test these items to assess the species used, contaminants, and active constituent levels. This is truly impressive, cutting edge scientific work.

All these things are but examples of the academic and scientific work that Dr. Zhao is involved with. I was fortunate to have him show me through his collection and facilities, but there was really more to see than I can describe in a simple blog entry. For example, their university library has an incredible book called the Ben Cao Da Quan. Actually, this “book” is really dozens and dozens of books that together form one complete set. Occupying several huge bookshelves, this set of books together contains the entire extant collection of materia medica literature. In other words, it is every materia medica text ever discovered in Chinese medicine, all assembled into one huge multivolume collected work. Amazing. Only about 100 copies exist in the world, as their high expense makes them virtually exclusively found in academic institutions such as HKBU.

I mentioned to Dr. Zhao that I’d like to feature him in an article, and he sent me a summary of his CV for reference. It is really almost too extreme to summarize. He lived in Japan for many years, where he completed his PhD, and he is currently the course director of the Bachelor of Pharmacy (Hons) in Chinese Medicine at Hong Kong Baptist University as well as a clinical supervisor. He is also a member of the Chinese Medicines Board of the Chinese Medicine Council of Hong Kong, a member of the HKSAR Department of Health Scientific Committee and International Advisory Board on Hong Kong Chinese Materia Medica Standards, an advisor of Traditional Medicines in the West Pacific Region of World Health Organization, and a member of the Steering Committee for Complementary and Alternative Medicine program at Harvard Medical School.

The publications section of Dr. Zhao’s CV really defies any simple summary. It lists “selected publications in the past five years,” and goes on to list 58 articles in scientific journals of all types. Entries range from “Development of high performance liquid chromatographic fingerprints for distinguishing Chinese Angelica from related Umbelliferae herbs” from the Journal of Chromatography to “Inhibition of DNA topoisomerase I by natural and synthetic mono- and dimeric protoberberine alkaloids” from Chemistry & Biodiversity, along with dozens of articles in the Chinese Journal of Chinese Medicine and his own special niche works such as “A systematic study on confused species of Chinese Materia Medica in the Hong Kong market” from the Annals Academy of Medicine. Add to this 13 books and a list of “selected presentations” ranging from Brazil to Japan, San Francisco to China, Australia, Korea, you get the picture.

Why do I mention all this? I feel that it is important for American practitioners of Chinese medicine to have perspective on what constitutes true expertise in the field of Chinese medicine. Doctors like Dr. Zhao Zhong-Zhen inspire me, they inspire all of us to set our sights high and pursue our education with diligence.

At Blue Poppy, we are committed to advancing the state of knowledge in the field of Chinese medicine. Our first and foremost goal is to promote education and growth in this field that we love so much. Currently, we are in the early stages of organizing elite study tours in East Asia. It will take a bit of time before we launch these tours formally because when we do it, we are going to do it right. But just to hint at our plans, we will probably aim to do a multicity tour that starts in Taipei and moves up towards Beijing, with stops in every major metropolitan center of Chinese medicine.

Our study tours will feature hospital rounds and tours of astounding herbal markets, and there will be private lectures with top practitioners from throughout China. All the translation will be high quality translation from a native speaker (yours truly) and the people that would do the lectures will be true experts in the field, the best of the best.

I wrote this mini-bio of Dr. Zhao primarily to make sure that people hear about this man’s incredible achievements. But I also wanted to paint a picture of what the phrase “true expert” means to me. I’ve been fortunate to meet many of China’s best doctors and I have a good ability to recognize what constitutes a real world-class expert. Western students need to see these true experts in action so that we go home with the inspiration to become the best doctors we can be. I feel lucky to have such a strong network in China, and I’d really like to bring students over to see how truly advanced and inspiring our field really is. As Bruce at Blue Poppy likes to say, no wine is opened before its time, and it will likely take us another year at least before we start arranging elite study tours in Asia. But you can rest assured that when the tours begin, we are setting our sights high.

Copyright Blue Poppy Ent. Inc. 2009. All rights reserved.

by Bob Flaws

Continuing to think about legal issues, be careful treating patients with cancer. Some states, such as my own, Colorado, have laws specifically stating that only licensed MDs can "diagnose, treat, or prescribe for the treatment of cancer." The law in Colorado is called the Cancer Cure Control Act. You can find it in the Colorado Revised Statutes under Title 12 Professions & Occupations, Article 30 Cancer Cure Control, Subsection 107 Unlawful Acts:

"It is a misdemeanor for an individual, person, firm, association, or other entity, other than a licensed physician, licensed osteopath, or licensed dentist to diagnose, treat, or prescribe for the treatment of cancer or to hold himself out to any person as being able to cure, diagnose, treat, or prescribe for the treatment of the disease of cancer."

While the first time or two you run afoul of this statute, it's a misdemeanor, if you persist, it becomes a felony with jail time in Canon City with all the other homeboys.

Those acupuncturists who do see persons suffering from cancer (notice I did not say "cancer patients") do so in an attempt to specifically alleviate the side effects of Western medical cancer therapy, for instance the nausea of chemo. This is all right, but I'd be sure to get a signed statement from the patient that he or she understands that this is all they are being treated for and not for the treatment of their malignancy itself.

In California, the CALIFORNIA CODES, HEALTH AND SAFETY CODE, SECTION 109300 states:

"The sale, offering for sale, holding for sale, delivering,
giving away, prescribing or administering of any drug, medicine,
compound, or device to be used in the diagnosis, treatment,
alleviation, or cure of cancer is unlawful and prohibited unless (1)
an application with respect thereto has been approved under Section
505 of the federal Food, Drug and Cosmetic Act, or (2) there has been
approved an application filed with the board setting forth:

"(a) Full reports of investigations that have been made to show
whether or not the drug, medicine, compound, or device is safe for
the use, and whether the drug, medicine, compound, or device is
effective in the use;

"(b) A full list of the articles used as components of the drug,
medicine, compound, or device;

"(c) A full statement of the composition of the drug, medicine,
compound, or device;

"(d) A full description of the methods used in, and the facilities
and controls used for, the manufacture, processing, and packing of
the drug, medicine, or compound or in the case of a device, a full
statement of its composition, properties, and construction and the
principle or principles of its operation;

"(e) Such samples of the drug, medicine, compound, or device and of
the articles used as components of the drug, medicine, compound, or
device as the board may require; and

"(f) Specimens of the labeling and advertising proposed to be used
for the drug, medicine, compound, or device."

I read the word "compound" to include Chinese herbal medicine, and I read the word "device" to include acupuncture needles, moxibustion, etc. In other words, before you treat someone for cancer per se, you need to prove to the State of California that the treatment you intend to give/are giving does effectively treat cancer. That's a pretty tall order for most of us.

In New York, the New York Consolidated Laws have a section on the duty to report. It reads:

"§2401. Cancer; duty to report.

"1. Every physician, dentist and other health care provider shall give notice immediately but not later than one hundred eighty days of every case of cancer or other malignant disease coming under his or her care, to the department, except as otherwise provided."

"Other health care provider" would include licensed acupuncturists. It's not clear to me what repercussions such a report by an acupuncturist would elicit from the authorities charged with administering this statute. So I'd be sure to check this out before treating anyone for or even with cancer who asked me to treat them.

My point here is that, if you take cancer patients into your practice, regardless of whether you are specifically treating their cancer, you need to check with your state's laws (if any) concerning your limitations and obligations. You can research your state's laws on-line. So this is no onerous project, nor do you need to spend money hiring a lawyer. Nevertheless, typically, the treatment of cancer by non-MDs is like waving a flag in front of a bull. While the state may overlook the illegal (as in unlicensed treatment) of other conditions, this is the one they tend to come down on with both feet.

Be aware and take care.

Copyright Blue Poppy Ent.Inc. 2009. All rights reserved.

by Bob Flaws

There's an interesting article in the Feb/Mar 2009 issue of The Townsend Letter about what we can expect from Washington in terms of alternative/complementary (CAM) health care. In the author's opinion: some good and some bad -- about what one would expect.

Nevertheless, this article got me thinking about our two major parties vis a vis our profession. When I was President of the Acupuncture Association of Colorado during our bid in the early 1990s to expand our scope of practice to include Chinese herbal medicine, one of the things I learned was that, paradoxically (parodoxically for an independent who nevertheless typically votes Democrat), on this issue, the Democrats were our enemies and the Republicans were our friends. While my experience is that more Democrats in general use CAM, Democrats in positions of power are often pro-regulation and tend to act in loco parentis. In other words, they want to protect the public from itself (as if they know better what's right and wrong). Henry Waxman, D from Hollywood, CA is a case in point. He wants to put more restrictions on the Dietary Supplement Health Education Act (DSHEA) under which we are allowed to buy and sell (but not "prescribe") Chinese herbal "supplements." On the other hand, Republicans believe in freedom of choice and free trade. While they probably don't use CAM in as large numbers, they are also less likely to want more restrictions on choice in health care and choice at the market (or health food store). In addition, Orin Hatch, R from Utah, is a staunch ally of the nutraceutical industry since something like half of the major nutraceutical manufacturers are located in his state.

As a case in point, when we were trying to get our second law passed in Colorado to include Chinese herbal medicine in our L.Ac. scope, I had to get a Republican from Colorado Springs (bastion of the religious right) to sponsor our bill. Then we had to fight the Democrats on the Health, Education & Welfare (HEW) Committee to get our bill out of their committee. The Dems were deeply aligned with the Colorado branch of the AMA, while some Republicans admitted to me that the Medical Practices Act which gives MDs a state-mandated monopoly on professional health care should never have been enacted.

I guess what I'm getting at here is that we need to be very pro-active in our oversight and communications with the new administration in Washington to protect our rights. While I am overjoyed that Obama won and that both houses of Congress are in the hands of the Dems, I am worried that, as a profession, we may become complacent in thinking, "These are the good guys. What's to worry?" In The Townsend Letter article mentioned above, the Vitamin Lawyer Blogger is quoted as identifying Waxman and Ted Kennedy, venerable D from Massachussets, as the "Kenedy-Waxman Axis of Control" for opposing health claims under DSHEA. In other words, under DSHEA and the FDA which oversees and implements DSHEA, we are not allowed to say that Huang Qi boosts immunity or Dan Shen dilates the coronary arteries. That would be a health claim regardless of the many valid pieces of research supporting these claims. Although some of the health freedom bloggers and advocates are a little too Cassandra-ish for my taste, past experience here in Colorado suggests that we need to be careful about our assumptions of who're our friends and who're our enemies.

Oh dear, welcome to the world of realpolitik.

Copyright Blue Poppy Ent. Inc. 2009. All rights reserved.

by Eric Brand, L.Ac.

Recently, I’ve been hearing some conversations between friends about schools and endowments in Chinese medicine, and it made me think that I should really blog about the inspiring potential that increased resources can bring to Chinese medical education.

I recently had the pleasure to do a few guest lectures at the New York Chiropractic College (NYCC) in upstate New York. I have visited many Chinese medicine schools across the U.S., and I’ve never been more impressed with the resources that NYCC has available. While NYCC is primarily a chiropractic school, they have a Chinese medicine program that benefits from the nicest facilities that I’ve ever seen in a Western TCM school. Despite the fact that they only have 100 TCM students and a correspondingly modest number of Chinese medicine faculty members, they are fortunate to have some of the country’s finest teachers and academic resources that would make most other TCM schools turn green with envy.

The thing that makes NYCC so special is their non-profit structure and wealth of endowments. Unlike most U.S. Chinese medicine schools that can fit into urban office space, NYCC boasts a 300 acre campus, making it feel more like a proper college than a trade school. They have a $70,000 Chinese medicinal herb garden that was designed by Jason Wright, one of the outstanding herbalists on their faculty. This garden is a beautiful ba gua-shaped landscape, a true artistic masterpiece that allows students to see hundreds of growing medicinal plants that were lovingly planted by Jason. Looking across the campus, one cannot help but notice that they have a proper library and anatomy lab, not just a room of books but a stand-alone building like one sees in a Chinese TCM university or a normal mainstream U.S. university. Bookworm heaven!

I found it truly inspiring to see a Chinese medicine school in the U.S. that is backed by $30 million in endowments; it is astounding how much potential is opened up when a school is funded by endowments instead of simple tuition funds. Furthermore, the non-profit nature of NYCC allows them to funnel all of the tuition funds back into the faculty and facilities. Consequently, they have real, full-time faculty with offices and proper salaries, which is a rarity in most U.S. acupuncture schools. This allows them to retain some of the finest faculty in the country, which is a far more valuable asset than the 300 acres, nice clinical settings and beautiful classrooms.

Chief among these outstanding faculty members are Marnae Ergil and Kevin Ergil, two of the best Chinese medicine instructors in the nation. It was an honor to teach to Kevin’s class, because Kevin is really one of the greatest Western minds in Chinese medicine. Kevin Ergil is not a household name like some of the celebrity authors that dominate the state board reading list, but in reality he is far more knowledgeable and heavyweight than virtually any of the celebrities. Marnae is also one of the top minds in our field; she is a fantastic translator, experienced clinician, and all-around great practitioner. In addition, there is the aforementioned Jason Wright, who is a very knowledgeable herbalist and a wizard in the pharmacy and the garden. Jason gave me some incredibly pure gold moxa that he had casually whipped up from simple Spring Wind crude ai ye, along with some homemade burn cream and other little treats that his students make in their herbal medicine processing class. I’d love to sit in for a semester in his class, and I wish that some of my former students could spend more time studying with some of these great folks (and their additional colleagues on the faculty).

In addition to the faculty and the campus, I was very impressed by the hospitality of the school. They unveiled a student appreciation party for the day of my lecture, and had great food, a huge room full of attentive students to attend the lecture, and fantastic faculty support. The president and the dean both attended the entire lecture on EBM trends in TCM, and there was a fantastic faculty turnout. I’ve never experienced such hospitality and organization at any of the other school lectures that I’ve delivered in the U.S. The whole experience was akin to the type of hospitality that I’ve experienced when lecturing at Chinese medicine universities in Taiwan and China, which is a far cry from the average U.S. acupuncture school where one is lucky to get a posting on a bulletin board and an empty room to lecture in.

Anyway, I’ll cut the praises short for the sake of brevity, but I couldn’t help but blog about the experience. It was truly inspirational to see the potential that can be achieved as our profession grows and enters into more mainstream academic environments. The presence of endowments instead of simple tuition revenues opens many doors, and it is fantastic to see that the future of our field will take us beyond the little office parks that most of us are currently trained in. I cannot imagine how many new doors would open for practitioners if more of our schools had endowments and all the resources that endowments can bring. It is truly a whole new world.

Copyright Blue Poppy Ent., Inc. 2009. All rights reserved.

by Bob Flaws

Wow! Eric Brand has posted some killer blogs the last few days. I learned a lot from these on a variety of subjects. I hope you all found them as useful as I did.

On a more mundane level, acupuncture students applying to the NCCAOM exams typically need stuff notarized. For those of you that live in the Boulder, CO area, I'd like you all to know that we have a licensed Notary Public at Blue Poppy. She's Joann, our Sales Manager. So if you need anything notarized, there's no need to pay some other Notary to do it. Just call Joann and make sure she's going to be in when you want to come. Then stop by and she'll notarize whatever you need for free. This is just another way we at Blue Poppy want to help you in any way possible be a successful acupuncturist and professional practitioner of Chinese medicine.

One other thing, our General Manager, Bruce Staff, is currently in China visiting our new herbal extract manufacturing facility making sure it meets all of our standards and to get ready for the certification of the FDA's cGMPs (current Good Manufacturing Procedures). Bruce left here with a large stack of very detailed specification sheets for the manufacture of every Blue Poppy internal formula. Bruce spent weeks preparing these. This site visit and the implementation of these detailed manufacturing specifications are just more ways we are trying to make absolutely sure our products are the absolutely highest quality in the industry. We'll have more to say about all this in the up-coming months.

Copyright Blue Poppy Ent., Inc. 2009. All rights reserved.

by Eric Brand, L.Ac.

The question of weights and measurements in Chinese medicine is complicated, and I never cease to be amazed at how few people are even aware of this complex issue. Most practitioners generally equate one Chinese qian to three grams, and we express the dose range of many common medicinals as 3-9 grams. (This dose range is based on the traditional 1-3 qian). However, the weight of one qian has varied throughout history, and most people are stunned to hear that the 3-9 gram dose ranges that we take for granted are more closely rounded to 4-11 grams in places that still use qian measurements, such as pharmacies in Hong Kong, Taiwan, Singapore, and Western Chinatowns.

Why all the confusion?

As many people know, Qin Shi-huang (the first Chinese Emperor) united Chinese culture by systematizing weights, measures, and written Chinese characters during his reign from 221-206 BCE. The existence of a common written language and a common system of weights and measures allowed Chinese people of different regions to communicate and trade with each other, which was an unprecedented historical advantage. Even up to the present day, Chinese people that speak different dialects communicate through their use of the same common written language. (For example, Mandarin and Cantonese are mutually unintelligible when spoken, but they are written the same.) At present, the entire world outside the U.S. uses the common metric system of weights and measures, but the metric equivalent of the traditional Chinese weights is still not completely standardized.

The weight of one qian has changed numerous times throughout Chinese history. There are 10 qian in one liang, and 16 liang in one jin. From the Tang dynasty (starting in 618 CE) to the present day, the weight of one jin has been about 600 grams, making one liang about 37.3 grams and one qian about 3.73 grams. With the notable exception of classical texts such as the Jin Gui Yao Lue and the Shang Han Lun, most traditional Chinese medical texts were written during eras that used this 3.73 gram/qian measurement. Thus, if a medicinal formula from the comparatively recent Qing dynasty specified three qian of Huang Qin (Radix Scutellariae), the amount of Huang Qin that was historically used was around 11 grams, rather than the nine gram weight that most practitioners today associate with three qian.

The reason that this discrepancy exists is because mainland China made a decision to adopt the metric system about 50 years ago, and the traditional weight units of jin-liang-qian were rounded to make the transition to the metric system smoother. Thus, the traditional 600-gram jin was rounded down to an even ½ kilogram or 500 grams. In Chinese medicine, one jin is divided into 16 liang, and each liang is divided into 10 qian. Thus, in the rounded 500 grams/jin calculation method, one liang weighs approximately 31.25 grams, and one qian weights 3.125 grams. This is the calculation method used in textbooks produced in mainland China. So the 3.125-gram qian is rounded down to three.

In mainland China, jin-liang-qian measurements are no longer commonly used for Chinese medicine. Medicinals are dosed in grams and are sold wholesale by the kilogram. Therefore, there is little practical impact of the discrepancy because the entire field is based on the metric system there. However, in Chinese communities outside of the mainland, traditional medicine practitioners often use jin-liang-qian measurements for Chinese medicine, and these overseas markets all use the 600-gram jin, 37.3-gram liang, and the 3.73-gram qian. Thus, when a doctor in Hong Kong, Taiwan, California, Amsterdam, or Singapore writes a prescription with three qian of Ren Shen (Radix Ginseng), 11 grams are dispensed, not nine grams.

The truly interesting thing is that remarkably few people are aware of this issue. Practitioners in mainland China are often amazed to hear that people still use the traditional measurements elsewhere, and people elsewhere often do not know that the 600-gram jin was rounded down to 500 grams in mainland China, creating a domino effect on all the other traditional weight units. Thus, many Western students always think of dosing medicinals in multiples of three grams, despite the fact that a multiple of four grams would be more accurate to tradition.

Making matters even more confusing, some products in China unrelated to Chinese medicine (such as tea) are still sold by the jin and liang, but based upon a different calculation method. In this calculation scheme, one jin is still an even ½ kilogram, but there are 10 liang in one jin rather than 16 liang per jin. Thus, one liang of tea or peanuts in China weighs 50 grams instead of 31.25 grams.

To summarize, one liang of tea in mainland China weighs 50 grams, and one liang of Ren Shen in China weighs 31.25 grams. In Hong Kong, Taipei, Seoul, or LA Chinatown, one liang weighs 37.3 grams, regardless of whether one is measuring tea or Ren Shen.

As complicated as this is, it is really just the tip of the iceberg in terms of measurements in Chinese medicine. Volume measurements such as the sheng are even more variable from dynasty to dynasty, and some ancient measurements are disputed up to the present day. For example, the metric equivalent of the dosages recorded in the Shang Han Lun is not definitively known.

The Shang Han Lun was written during the later half of the Han dynasty. At this time, the qian measurement was not used, but the jin and liang were both used. Thus, the precise metric weight of the Shang Han Lun liang is disputed. Some authorities suggest that the weight of one liang was close to three grams, or the modern day mainland one qian, while other authorities suggest that one liang in the Shang Han Lun times weighed about 15.68 grams, roughly equivalent to the modern day four qian (as used outside of mainland China).

This huge variation in metric equivalents makes modern day scholars uncertain as to whether Zhang Zhong-jing used heroic or moderate doses of medicinals. I recently had the pleasure of translating a workshop for Dr. Huang Huang, a modern master of classical formulas who was flown in from China to teach a workshop last weekend in San Francisco. There was a great turnout of experienced practitioners, and Dr. Huang delivered a fascinating four-day lecture on the Shang Han Lun and constitutional types. Dr. Huang reiterated the scholarly dispute on Zhong Zhong-jing’s dose ranges, and he tends to use a five gram per liang rule of thumb when calculating the dose of Shang Han Lun formulas. With a range of 3g-15.68 grams/liang, he feels that a five gram/liang estimate provides a conservative middle ground for estimating Shang Han Lun dose equivalents. A very interesting approach by a very thought-provoking practitioner, and it was interesting to see that even someone with decades of experience has still not been able to find a definitive answer to this fundamental question.

At Blue Poppy, dosage is always regarded as a key issue. Practitioners should always be able to easily calculate dosages for maximum clinical effect. To this end, Blue Poppy is one of the only companies to openly label all of their products with precise information on ingredient quantities and concentration ratios. Despite the variance in the metric expression of traditional weights and measures in Chinese medicine, there is widespread consensus that adequate dosage is an issue of critical clinical importance. At Blue Poppy, all of our products are designed to be transparent with regards to dosage and concentration. We believe that this transparency greatly benefits practitioners and patients alike, and we are proud to openly display the potency of our products on clear, informative labels.

Copyright Blue Poppy Ent., Inc. 2009. All rights reserved.

by Eric Brand, L.Ac.

It is hard to accurately assess how long ago sexual transmission was recognized as a vector of disease in Chinese medicine. Many diseases that are now known to be caused by particular organisms or other vectors of disease were traditionally believed to be caused by the invasion of evil qì contracted from environmental factors. For example, malaria was not known to be caused by mosquitoes; it was classically attributed to contraction of summerheat during the hot season, contact with mountain forest miasma, or contraction of cold-damp. Similarly, many sexually transmitted diseases were long thought to be due to contraction of external environmental evils, possibly related to constitutional weakness or unclean hygiene habits.

In ancient times, many sexually transmitted diseases would be difficult to conclusively link to sexual transmission. For example, gonorrhea and similar diseases that manifest with urinary symptoms were grouped under the traditional category of strangury (lin) disorders. In fact, the modern Chinese name of gonorrhea in Western medicine is lin bing, which reflects term borrowing from the traditional Chinese disease category known as lin zheng. Both sexually transmitted and non-sexually transmitted cases of urinary tract infections were traditionally grouped together, so some cases would be linked to sexual history while others would not be.

Traditional Chinese cultural tendencies towards privacy about sexual life may also be a factor in the lack of extensive literature on sexual transmission in early texts. Furthermore, other sexually transmitted diseases such as human papilloma virus(HPV) and herpes simplex virus (HSV) would be particularly difficult to conclusively link with sex due to their latency, potential transmission from asymptomatic carriers, and recurrences unrelated to sexual intercourse.

In fact, the first strong evidence that sexual transmission was well-known in Chinese medicine is not clearly seen until the Ming dynasty, after the discovery of the New World and the introduction of syphilis into China. It is generally accepted that syphilis reached the Old World via European New World explorers. The historical use of the name “Cantonese Sores” (guangdong chuang) to describe syphilis supports the theory that the spread of syphilis through China followed the trade routes that linked early European traders with Canton province. Following the arrival of syphilis, it is easy to conclusively say that sexual transmission was known in Chinese medicine.

Zhāng Zhòng-Jǐng’s Han dynasty Shāng Hán Zá Bìng Lùn (On Cold Damage and Miscellaneous Diseases) is the first text to describe disease transmission by sexual means, but it does not obviously refer to sexually transmitted disease per se. Rather, it documents the observation that one could contract disease of the six excesses without environmental exposure, if one is in close contact with an individual afflicted by disease from the six excesses. In other words, it shows knowledge of the transmission of contagious disease, but not necessarily sexually transmitted diseases.

We can see more clear evidence that the Chinese knew of sexual transmission by 1264 CE, in the Southern Song dynasty text Rén Zhāi Zhí Zhǐ Fāng Lùn. This text states: “[After] great licentiousness, sores are formed on the penis...women also have sores at the jade gate, which are called genital erosion sores.” Although this text goes on to describe a disease that is more severe than a condition such as genital herpes, it nonetheless suggests knowledge of sexual transmission.

By the Ming dynasty, sexual transmission was indisputably recognized as a causative factor in syphilis (梅毒 méi dú). In 1624 CE, Zhāng Jiè-bīn (also known as Zhāng Jǐng-yuè) described the pathomechanisms of syphilis in his text, the Jǐng Yuè Quán Shū (Jǐng-Yuè’s Complete Compendium). He states: “…most of these pathoconditions are engendered following the transmission of licentious (sexual) toxins. Following the discharge of essence, the qì of this foul licentious toxin follows the essence pathway, exploiting vacuity to penetrate directly into the life-gate before pouring into the controlling (rèn) vessel. It goes to all the places that the controlling (rèn) vessel reaches, the skin and body hair in the outer body, and the bones and marrow in the inner body; there is no place that it does not reach.”

Yin Sores

Yīn sores and/or genital erosion are mentioned in the earliest texts of Chinese medicine, including the Shén Nóng Běn Cǎo Jīng (The Divine Husbandman’s Herbal Foundation Canon) and the Jīn Guì Yào Lǜe (Essential Prescriptions of the Golden Coffer). The text Zhū Bìng Yuán Hòu Lùn (The Origin and Indicators of Disease), written in 610 CE during the Sui dynasty, further developed discussions on the pathomechanisms of yīn sores. This text indicated that worms were an etiological factor in this disease, and also mentioned that right qì vacuity allowed the disease to develop.
By the time of the Song dynasty text Fù Rén Liáng Fāng (Good Remedies for Women), it was understood that heart vexation and depression, in conjunction with spleen-stomach weakness, was a factor in the development of yīn sores, which were also referred to as “invisible worms.” In the Ming dynasty, the Jǐng Yuè Quán Shū (Jǐng-yuè’s Complete Compendium) stated that vaginal sores were mostly caused by damp-heat pouring downward. Additional causative factors indicated by this text include fire formation from the seven affects and heat-toxin strike resulting from overindulgence in medicinal applications.

It is interesting to note that invisible worms were believed to be an etiological factor in this disease as late as the Qing dynasty. In the Qing Imperial classic on gynecology, the Yī Zōng Jīn Jiàn (The Golden Mirror of Orthodox Medicine), we find the following statement: “Sores of the yīn in women (i.e., genital sores) are known as ‘invisible worms.’ This malady is due to depression-fire from the seven affects damaging the liver and spleen, such that qì and blood congeal and stagnate, and damp-heat pours downward. After a long time, worms are engendered. Sores form as the worms feed, then pus drips; at times there is pain and at other times itching, and the patient senses crawling worms.” It is also worth noting that some descriptions of severe, incurable yīn sores that appear in pre-modern literature are likely descriptions of cancerous lesions.

Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.

by Eric Brand

Practitioners in the Americas use a diverse blend of methods and dosage forms. Korean extractors exist on the market and are prominent in Korean clinics, but they are rarely seen outside of the Korean community. Many Western practitioners use granules, and raw herbs are generally available. While most patients in Asia as well as the West abhor the taste of Chinese herbal medicine, one of the most striking aspects of the Western market is the variety of approaches used to reduce or mask the taste of Chinese herbal medicine. Gelcaps, tablets, syrups, liquors, and pastes are seen throughout the global world of Chinese medicine, but it is only in the West that these forms constitute a large portion of the practitioner-prescribed herbal medicine.

One of the most distinctive features of Chinese herbal medicine in the Americas is the widespread use of alcohol/water liquid concentrates and tinctures. Tinctures are traditional preparations that use a combination of soaking and maceration in alcohol, while the liquid concentrates are generally made by slow-cooking the herbs in an alcohol/water medium and reducing the liquid under low heat. These liquid concentrates and tinctures are not really seen on the marketplace in Asia, so in a sense they can be considered to be a distinctive feature of the practice of Chinese medicine by Western practitioners.

In Western herbal medicine, many substances are made into alcohol tinctures, which are the taken by the dropper. However, the Western-style tincture typically utilizes lower doses of plant product than the prescriptions of clinical Chinese medicine, and most historical Chinese formulas used only water rather than alcohol to extract the medicinals. Chinese medicine definitely has a rich tradition of making herbal liquors, but alcohol is only used for certain situations. Alcohol is considered to have a warming and freeing action that helps to quicken the blood. Because of this, medicinal liquors are commonly used in the treatment of impediment disease as well as in supplementing wines.

Alcohol is regarded as a distinct medicinal substance in Chinese medicine, and it is found in classical formulas such as gua lou xie bai bai jiu tang (Trichosanthes, Chinese Chive, and White Alcohol Decoction) from the Jin Gui Yao Lue (“Essentials from the Golden Coffer”). Most traditional practitioners believe that the warm, acrid nature of alcohol must be taken into account when using it in formulas, so it is often considered to be a less-than-ideal medium for heat-clearing formulas, such as yin qiao san (Lonicera and Forsythia Powder). Furthermore, while traditional Chinese herbal liquors are highly effective for gradual, long-term supplementation or slow, enduring treatment of impediment disease, liquors and tinctures are generally inadequate for delivering the doses required when decoction formulas are indicated.

Many Western patients are new to Chinese medicine, and strong-tasting herbs with unfamiliar delivery forms are not always easily accepted by Western patients. Consequently, many practitioners attempt to adapt the familiar Western tincture-bottle delivery form when using Chinese medicine. The harsh taste and comparatively low concentration of a traditional tincture has led some innovating companies to create water/alcohol extracts, which are concentrated at low heat to form a liquid concentrate. Glycerin may be added during this process to sweeten the flavor and strengthen the natural preservative effect of the alcohol. While this delivery method is often very acceptable to Western patients, it is difficult to concentrate a liquid extract beyond 1 gram of crude herb per milliliter of extract. Consequently, practitioners must either prescribe liquids at a dose that is significantly lower than the dosage used in a standard decoction, or else they must recommend quantities of liquid extracts that greatly exceed the standard few droppers used in Western herbal medicine.

Additionally, the use of alcohol as a solvent introduces unknown variables because most Chinese herbal formulas were historically only used as a water-based decoction. Alcohol is a very effective solvent, and undoubtedly some Chinese herbs are highly suited to alcohol extraction. Yet while increased beneficial effects may be achieved with some herbs by using alcohol as a solvent, other herbs may have alcohol-soluble constituents that have undesirable or even harmful effects that are not present when the herb is used in a traditional decoction. Because of this unknown confounding variable, many practitioners and researchers choose to emphasize only water-based extracts for formulas that were traditionally administered by decoction.

In an effort to find products that can achieve standard Chinese medical dosage levels while avoiding the strong herbal taste, many practitioners in the Americas choose to use concentrated extracts in a gelcap form. While this method is generally regarded as the best solution to the problems of dosage, convenience, and flavor, it has the disadvantage of being labor-intensive for a practitioner who gives customized formulas to each patient. For practitioners that can effectively use classical formulas on their own or in combination with other formulas on the market, capsules are often the best solution for patients that cannot accept the taste of raw herbs or granules. Capsules made from concentrated extracts can be purchased for a fraction of the cost of liquid extracts and compare favorably to granules and raw herbs in terms of value.

A key consideration with encapsulated products is the concentration ratio of the extract used. Because each gelcap holds only about 500mg, encapsulated products should be made with highly concentrated extracts that lack fillers. Generally speaking, capsules or tablets are only able to approximate the daily doses used in Chinese medicine if patients either consume large numbers of capsules or if practitioners prescribe concentrates that are at least 7:1 to 10:1. A single 10:1 gelcap provides the equivalent of about five grams of raw herbs, so patients can achieve decoction-strength doses with only 9—12 capsules per day. A high concentration is preferred because raw herbal formulas typically require 50 grams of crude drug per day or more, and patient compliance is much higher with 10 capsules of a 10:1 extract than with 20 capsules of a 5:1 or even 40 capsules of a 2.5:1 extract.

It could be said that the greatest overall differences in Chinese herbal medicine between the US and Asia relate to dosage. In Asia, raw herbs are generally taken by decoction at a dose of one pack per day, whereas in the Americas, one pack of raw herbs is often taken for two days. Despite the fact that North American patients tend to have a higher body weight than their Asian counterparts, they often consume Chinese herbs at a dosage that is essentially half of the traditional dose.

In a similar paradox, Taiwanese granules are often prescribed at doses that are a fraction of the doses used in Taiwan. Part of the confusion seems to lie with the labeling information, which is required by US law to state a specific dose. Given the litigious nature of American society, most companies are understandably cautious in their dosage recommendation, so the dosage listed on the label is often well-below the dosage that is regularly used by a trained practitioner. Furthermore, most loose granules have the Asian labeling on concentration ratios removed for the US market, so practitioners are often at a loss to know how the powder corresponds to the raw herbal weight.

Taiwanese granules are generally used at a dose of around 18g/day in Taiwan, but many practitioners in the US use doses as low as 4—6 g/day. Perhaps the majority of Western practitioners prescribe granules in a dose range of around 6—12g/day, but many practitioners remain uncertain about how proper granule dosing is determined. Additionally, many instructors in American schools come from China but teach in schools that stock Taiwanese granules, which are more prominent on the American market. The granule product is different than what they used in their training in China, and teachers cannot effectively educate students on granule dosage because the standard raw dose equivalent is absent from the label. Consequently, practitioners often rely on the label information, which is essentially just an overly cautious (read: “please don’t sue me”) guideline that is required by FDA laws.

Truly we live in a diverse time. Everywhere around the world, cultures are interacting at a pace that has never been seen before. This cultural exchange allows us to really learn about what’s going on in the global world of Chinese medicine, and it is surprising to see how many differences there are between the West and the East. Certainly within East Asia alone there is an incredible diversity of medical approaches, and as Chinese medicine continues to globalize, the scope of these fascinating cultural encounters will only continue to increase. I wonder how they’ll start dosing granules in Africa, I really do.

Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.

by Eric Brand

In Korea, the most prominent method of herbal extraction relies upon small, pressure-based extraction machines. These “home extractors” are widespread in Korea, and they are a Korean invention that has had a dramatic effect on Chinese medicine worldwide. Their utility has caused them to spread outside of Korea, where they now dominate the landscape of hospitals and pharmacies throughout mainland China. Most of these extractors are essentially customized stainless steel pressure cookers, and they are generally paired with a packaging machine that dispenses the decoction into a durable, heat-stable plastic pouch. Korean-style extractors are currently in more widespread use than granules in both China and Korea.

Pressurized Korean extractors are essentially a home model of the pressurized steel extractors used in the manufacturing of granules. They can typically cook 5—30 packs of raw herbs per batch, and have been shown to significantly surpass home decoctions in the extraction of a variety of herbal constituents. The decoction is packaged without air so it has a relatively long shelf life even without refrigeration. In Korea, many patients regularly take supplementing decoctions in this form, and many pharmacies and even grocery stores sell pouches of ginseng and velvet antler extracts. Practitioners often prescribe a formula for several weeks at a time, and this delivery form is ideal for these customized, high-potency, long-term formulas. Because extractors can essentially make raw herbs convenient for patients, the corresponding formula composition style tends to parallel traditional herbal formulation approaches.
Generally, this is an excellent system. Prescriptions can be customized from raw herbs, and the traditional decoction process can be replicated with significantly less labor. Patients receive their decoction in single-dose, durable, heat-resistant plastic pouches that can be easily transported, re-heated, and consumed as needed. The pressurized cooking system allows for an extract that surpasses the traditional home decoction in terms of potency and efficiency, and the process reduces the human error of home decoctions in addition to providing convenience.

The efficacy of these home extraction machines has been well-demonstrated, as literally millions of doses have taken by patients in mainland China and Korea using this method. However, despite their ease of use and efficient extraction capacity, the home extractors do suffer from a few limitations that are not shared by the commercial machines used to make granule extracts.
Commercial Granule Technology vs. Korean Pressurized Extractors
Korean extractors allow private practitioners and clinics to make customized formulas with greater potency than raw formulas. They are easy to use and the medicinals are able to cook together, which many practitioners regard as an advantage over mixing dried individual extracts. Control over temperature and cooking duration makes extractors easy to use, and their comparatively small capacity makes them versatile for customized formulas. Additionally, extractors are commonly used by hospitals or clinics that maintain secrecy over formula ingredients; for example, I studied at a hospital in Taiwan that had proprietary research formulas cooked in Korean extractors so that the staff could not leak information about the formulas under investigation.

Nonetheless, home extraction machines pose a challenge with retention of essential oils, whereas commercial operations typically have a more sophisticated method of capturing the oils and reintroducing them into the final product. While a few of the most expensive home extractors do have an added unit to capture essential oils, most of the home extractors do not. Instead, the oils can be captured by allowing the decoction to slowly cool without opening the pressure valve, but allowing the decoction to cool instead of packaging it immediately can potentially affect the shelf life and hygiene of the decoction. Furthermore, the pressure created in the extractor is usually used to effortlessly move the liquid from the extractor to the packaging machine after the decoction is finished. During this transfer to the packaging machine, steam is lost and some of the essential oils may dissipate. For this reason, home extraction machines ideally require one to cook delicate aromatic medicinals separately on the stove, and the short stovetop decoction is added to the packaging machine at the end. This takes extra effort and is often skipped, so home extractors often lose some essential oil in comparison to commercial operations that use a combination of pressure cooking and essential oil capture.

Temperature is another variable that should be optimized and controlled when making extracts. When water is heated under pressure, its boiling point can rise beyond 100 degrees Celsius (212 F). This increase in temperature may offer benefits such as increased solubility of active compounds; however, it does introduce an unknown variable into the equation, as historically the decoctions used were only able to extract whatever constituents came out at the natural boiling temperature of water.

The temperature of the water can be controlled in both small extractors and large-scale commercial pressure cookers. However, in a small extractor, the transfer of the decoction from the pressure cooking machine to the packaging machine is best achieved under a significant amount of pressure. This ideal pressure is typically achieved by bringing the water temperature up to 120 C (248 F) before packaging the decoction. The high temperature and pressure creates a very hygienic and potent extract, but the uniform use of high temperature extraction for all medicinals is common when using small extractors. By contrast, large commercial producers can research the optimal cooking temperature of individual medicinals; the extraction temperature can be better controlled for each individual product, and usually the liquid leaves the sealed pressure cooking container with simple gravity rather than by releasing pressure, so high temperatures and high pressure are not required (the receiving container is usually below the cooking container in a factory, whereas the packaging machine of a home unit is usually above the cooking machine, so it is requires pressure to push the liquid uphill).

Cooking duration is also relatively poorly controlled in a home extractor when compared to the commercial process. For example, when cooking da huang (Radix et Rhizoma Rhei), a short cooking time will produce a potent purgative effect, while a prolonged cooking time will reduce its purgative effect. The short cooking can be achieved by the factory by using an abbreviated cooking time, but the home extractor requires the “add at the end” (hou xia) medicinals to be cooked separately on the stove and added in at the end. The medicinals cooked in a home extractor are all generally cooked for a similar duration of time, because it takes about 30-40 minutes of cooking at peak temperature to build the ideal pressure required to move the liquid into the packaging machine.

Additionally, measurement is somewhat more precise when using commercial extracts instead of small extractors. Small extractors can control the amount of decoction dispensed per pouch, and it is generally quite easy to make the doses per pouch appropriate for each patient. While not lacking in clinical efficacy or ease of use, the home extractors are not able to achieve quite the same mathematical precision that one can achieve when using a precisely measured and openly labeled commercial extract. This degree of precision may not be necessary in clinic, but it is advantageous for easy calculations (or legal cases).

Unfortunately, the litigious nature of American society has hampered the market penetration of home extraction machines in the United States. Most practitioners are unclear exactly how the law classifies an extract for a patient that is cooked in the practitioner’s clinic. Does it fall under a food preparation license? Is it a dietary supplement, a tea? Does it need to be GMP? Clearly there is virtually no enforcement, no massive push by the FDA to crack down on small-scale licensed practitioners cooking up formulas for patients. Yet despite the apparent lack of lawsuits, many practitioners remain reticent to cook their own formulas in their office. The labor of cooking the herbs and cleaning the machines, coupled with the gray area of licenses and liability has caused this huge global TCM trend of home extractors to go largely untapped here in the US. Instead, US practitioners tend to favor granule powders or extracts that can be taken off the shelf and given directly to patients in a sealed bottle with full GMP compliance.
Despite these limiting factors of home extractors in comparison with large commercial approaches, they are clearly an excellent delivery system. The home extractors currently dominating the Chinese and Korean TCM landscape are one of the most prominent herbal medicine developments in our time, offering practitioners their own mini-factory, an intermediary choice between stovetop technology and full-scale industrial technology. Their popularity in Asia has reached a critical mass, many studies have been published that show favorable results when comparing pressure-cookers with home decoction methods. Seeing the quantifiable improvement in extraction efficiency achieved by cooking medicinals under pressure gives one an appreciation for the sophistication and science of the herbal medicine industry. As pressure cooking is only one aspect of advanced extract production, I suspect that in coming years we will see many more scientific reports that deepen our appreciation for the amazing developments in this modern age of herbal medicine.

Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.

By Eric Brand

Part One: Granules in Asia

The creation of concentrated extract powders represents one of the most important developments in the history of Chinese herbal medicine. As technology has advanced, Chinese herbalists increasingly find themselves armed with a vast arsenal of convenient preparations that bring centuries of formulas and thousands of cooking hours into a space the size of a small closet. Concentrated dry extract powders (“granules”) essentially place a full traditional pharmacy at the practitioner’s fingertips. Granules preserve the traditional methods of Chinese medicine while allowing practitioners to give patients a convenient option for herbal therapy. Their safety, efficacy, and popularity are well-established, and granules are quickly becoming the most prominent delivery form of Chinese herbal medicine in the West.

Japanese Roots
Granule technology was originally pioneered in Japan, where it was created for Japanese Kampo. In Japan, most use of granules is based upon either biomedical or traditional applications of classical formulas, which are often used in an unmodified form. The vast majority of the formulas used in Japanese Kampo were created prior to the Song dynasty in China (around 960 CE), and formulas from the Shang Han Lun and Jin Gui Yao Lue are particularly prominent in modern clinical use. Practitioners rarely build formulas from single ingredients, instead preferring to employ whole formulas or combinations of formulas. While few Westerners have studied Japanese Kampo itself at depth, the technology that was created to maximize the Kampo approach has impacted Western practitioners tremendously.
From Japan, the technology spread first to Taiwan. Granules have become deeply integrated into healthcare in Taiwan over the past 30 years, and their prominence there has created an entirely new style of Chinese medicine. Indeed, many doctors feel that the most distinctive feature of Chinese medicine in Taiwan is its use of granules. This development was largely stimulated by the convenience of granules for patients, along with the fact that Taiwanese government insurance covers granule extracts exclusively when it comes to Chinese herbal medicine coverage. Granules are desirable for large scale healthcare because they are well-regulated and hygienic, and they are ideal for research because batches are consistent and traceable. Significantly, Taiwanese patients pay very little out of pocket for granules yet have to pay a fair sum out of pocket for raw herbs; this has created an entire culture of granule use, with the vast majority of patients using herbs in a concentrated extract form.

Taiwanese Methods
The Taiwanese method of using granules is relatively distinct because whole formulas are commonly combined together. With a repertoire of over 400 compound formulas on the shelf, Taiwanese doctors build complex combinations that boggle the young student mind, yet there is nothing haphazard about the construction of a well-crafted Taiwanese style formula if one understands the approach. Good doctors in Taiwan typically have a broad range of formula ingredients mastered, with a well-developed ability to see the relationships, similarities, and differences in each. A core formula at a higher dose typically stands out at the center of the prescription, but instead of adding in just a few single herbs to accentuate certain directions, whole formulas may be added in. Here the formulas are used as a single principle, much as many of us add a single herb.

There are several reasons why compounding whole formulas together has become popular in Taiwan. Given the Japanese origin of the granule technology and the prominence of combining classical formulas in Japan, it seems reasonable to think that some of the initial inspiration for creating a wide range of whole formulas and combining them together may have been rooted in the technology’s Japanese roots. However, the most important guiding factor today is the widespread belief in Taiwan that formulas that are cooked together are clinically superior to formulas that are created from scratch by combining single herb extracts.

Indeed, there are measurable differences in the final chemistry of the end product when medicinals are cooked together versus when they are combined from single extracts. Taiwanese doctors point to these differences and often strongly believe that the results of using whole formulas surpass the results of combining singles from scratch. While there have been studies in China that show no statistical differences between the clinical results of combining singles from scratch in comparison with whole formulas that have been cooked together, the vast majority of doctors in Taiwan prefer to use formulas that have been cooked together.

In addition to starting with whole formulas (often compounding two or three whole formulas together), Taiwanese doctors commonly add single herb extracts when customizing the prescription. Their insurance system pays for granules up to a dose of 6.0g, and the typical 6.0g dose is usually given three times per day for a total of 18g of concentrated extract powder per day. While the precise extraction ratios for each product are clearly stated on Taiwanese granule labels, most doctors think less in terms of calculating extraction ratios and replicating raw herb doses by weight, and focus more on the ratio of herbs and formulas within the daily target dose of 18g/day.
The dosage used by most doctors in Taiwan tends to fluctuate between 12–18g/day, with 18g being the most common for adults. Each granule product in Taiwan varies somewhat in terms of its concentration ratio, but a quick mathematical calculation shows that this concentrated powder dose is slightly lower than the typical daily dose given by Taiwanese doctors when they are dispensing raw herbs (often over 100g/day of crude medicinals). Despite this somewhat lower dose, granules are extracted more efficiently than herbs cooked at home, so it is reasonable to assume that they are at least slightly more potent than the equivalent amount of crude herbs. Furthermore, the use of whole formulas instead of just single herbs makes it slightly less of a straight mathematical equation, as the heat-clearing effect of a whole formula like huang lian jie du tang (Coptis Toxin-Resolving Decoction) is more powerful than the equivalent weight of singles like huang lian (coptis) or zhi zi (gardenia) alone.
Although most of the granule products in use in America are made in Taiwan, thus far relatively few practitioners are well-informed about the Taiwanese methods of using granules clinically. Because granules dominate the insurance-based healthcare system in Taiwan, doctors there have amassed a tremendous amount of experience with issues such as dosage and formula combining. However, while most of us here in the US use their products, few of us use their methods and dose ranges, making their results more difficult to replicate.

Granules in Mainland China
In contrast to Taiwan, doctors in mainland China tend to combine whole formulas together much less, and primarily build formulas from scratch in a process identical to a normal raw decoction. While Taiwan has created a virtually new method of using herbal medicine based on their granule approach, granules in the mainland are largely an extension of the standard method of formula composition. In mainland China, whole formulas are less commonly available in a granule form, so nearly all prescriptions are made by combining singles. Rather than determining dose based upon a standard dose range of total extract powder, the dose is determined mathematically based on the raw herbal prescription.
While there are differences between mainland China and Taiwan in terms of their prescription composition when using granules, the biggest differences actually lie in their respective packaging and extraction technology. In mainland China, granules are often made without filler, and are packaged in single dose foil packs. In Taiwan, granules are made into a smooth flowing powder that is dispensed from small plastic bottles.

Granules that are made without filler must be packaged immediately to prevent clumping, which occurs rapidly if filler-free extract powder is exposed to air. The most common packaging method used in mainland China is a single dose foil pack that contains the concentrated equivalent of a standard daily dose of a given raw herb. Each herb has the potential to achieve a slightly different concentration, so the concentration ratio of each product (and the corresponding dose weight) varies. For an herb such as yan hu suo (corydalis), a 10:1 extract can be achieved, and the foil pack will contain 1g of extract because 10g of the raw product is used as an average daily dose. Another herb such as pu gong ying (dandelion) can only reach a 7.5:1 concentration, so a daily dose foil pack of pu gong ying contains 2g of extract, which is equivalent to 15g of the raw herb, again a typical daily dose.

The mainland Chinese method of using foil packs is convenient because a scale is not required, the formula can be easily modified, and ingredients can be subtracted if side-effects develop. However, the foil packs are slightly cumbersome because many packs must be opened with each daily dose, and there is more disposable waste associated with the foil packs.

As an alternative to the foil packs, some Chinese manufacturers have begun to produce products that dilute the pure concentrate with pharmaceutical starch (starch with the proteins removed to make it hypoallergenic) so that an even 5:1 consistency can be achieved. This allows the product to be exposed to air and stored in plastic bottles like the Taiwanese products.

Similarities and Differences in Granule Technology
Both mainland Chinese granules and granules made in Taiwan share many basic characteristics. Reputable companies all capture and reintroduce essential oils, determine species identity with liquid chromatography, and evaluate potency by assessing marker chemicals in both the raw material and the finished product. The temperature is controlled, and the ideal concentration ratio, water quantity, and cooking duration are determined by researching each product. Batch testing assesses the final product to ensure that heavy metals, bacteria, and fungi are all absent, and most companies test the dissolution time in water.

However, despite these common features, significant differences remain between the technology used in mainland China and Taiwan. In Taiwan, the herbal concentrate is reduced under a vacuum or forced air and low temperatures, and it is reduced to thick, viscous syrup that is then sprayed onto a carrier. The carrier is typically either pharmaceutical starch or finely ground crude herbs. Each herb achieves a different concentration ratio depending on how water soluble it is, as well as how sticky and rich it is by nature; these factors play a role in determining how much material can be extracted, and also influence the quantity of filler required to make the powder flow evenly.

By contrast, the mainland Chinese products are made into a dry extract without filler, and are immediately packaged in a sealed foil pack. Each foil pack contains the equivalent of a standard daily dose of the crude medicinal. This method does not allow for smooth flowing bulk powders that can be exposed to air for prolonged periods, so it is not suitable for the style of product required for the Taiwanese prescribing method. However, it is suitable for the mainland Chinese method of simply using concentrated powders to give a daily dose that equates to the normal raw decoction dose, and the foil packaging allows it to be conveniently dispensed.

Both the mainland and Taiwanese technologies offer unique advantages and disadvantages, but they produce slightly different final products. Taiwanese powders are often made into a relatively fine powder (xi fen), while mainland Chinese powders are often made into a slightly larger granule (ke li) when they are sold in the 5:1 state. The mainland products are often able to achieve a higher and more consistent concentration ratio and tend to have less filler, but the Taiwanese products often tend to have a slightly stronger odor. Additionally, the method of processing mineral medicinals often varies between the two regions, and the availability of herbs in a variety of pao zhi forms varies as well. Mainland China has a slightly wider selection of herbs with different types of pao zhi on the market, but Taiwan has a wider range of pre-made classical formulas available.
All of these factors illustrate the fact that the modern granule landscape is relatively diverse. Multiple styles abound, both in terms of formula composition as well as manufacturing styles, and each practitioner has a wide range of choice in determining which products and approaches are best for their clinical needs. Unfortunately, at present many Western practitioners have not deeply investigated the Asian trends in granule prescribing, and often remain uncertain on issues such as dosage calculation. Few practitioners realize that different technological methods are used in mainland China and Taiwan, and often fail to take these differences into account when determining dosage. As we move into a direction of clearer product labeling and increased cultural exchange, hopefully the West will begin to acquire more of the experience that our Asian colleagues have amassed in this fascinating field. Given the fact that granules are quickly becoming the most common form of herbal medicine in the Western clinic, it appears essential that we strive to better understand these products in terms of their dosage and clinical applications.

Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.

by Bob Flaws

Several months ago, Blue Poppy Press published Lorraine Wilcox's scholarly book on the history of moxibustion in the late Ming-early Qing dynasties. At the time, trying to make the whole publication process as comfortable as possible for a first-time author, we accepted Lorraine's title as she submitted it: Moxibustion: The Power of Mugwort Fire. We had already changed so much of what she wrote in the editing process that we were trying to find places and ways we could keep it "hers." Unfortunately, as we have subsequently found out, at least in terms of the title, that was a mistake.

A number of purchasers have bought this book thinking it is a clinical manual on the practice of moxibustion and, because this is not what this book is, have been disappointed. While this book does include various treatment protocols, the book was not meant to be a clinical manual. Rather, it is a record of how such famous Ming and Qing dynasty Chinese authors as Yang Ji-zhou, Li Shi-zhen, and Zhang Jie-bin thought about and used moxibustion. To remedy this situation, when this book comes up for reprint (in 9-12 months), we will be changing its title to reflect that it is specifically about moxibustion during a particular historical era. We are extremely sorry about this misjudgement on our part.

The good news is that Lorraine has now written a clinical manual of moxibustion which should be released by Blue Poppy Press in several months. This book has plenty of detailed moxa protocols for a host of conditions. Most conditions have direct and several indirect treatment options. There are also detailed instructions on how to roll moxa cones, make moxa rolls, and use all the various moxa appliances now on the market. The book will also be accompanied by either a CD or a companion website full of hundreds of photos on how to do the many techniques described in the body of the book. So we think this second book and its accompanying visual aids will be a great boon for anyone seriously interested in using moxibustion in their practice.

Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.

by Bob Flaws

Yesterday I translated an article on the prevention of nocosomial fungal infections with Bu Zhong Yi Qu Tang (with one or two added ingredients). Nocosomial infections are infections contracted or developed in hospitals which are not the reason for the person being hospitalized in the first place. Such nocosomial infections have been on the rise in U.S. hospitals since the 80s. They especially attack those with compromised immune systems (due to cancer, chemo, diabetes, AIDS, etc.) and those who have taken antibiotics and corticosteroids, and Candida albicans is a major culprit (along with several other, lesser known fungi, such as Aspergillus) involved in fungal nocosomial infections.

In any case, I translated this article from China comparing a bunch of patients in ICU who were treated either with supportive therapy alone (IV saline and electrolytes, balancing pH) or supportive therapy plus Bu Zhong Yi Qi Tang. Those patients who also got the Bu Zhong Yi Qi Tang preventively had 1/3 less positive fungal cultures in their mucus, blood, and urine at one, two, and three weeks of hospitalization and 1/3 less actual nocosomial fungal infections. (I should hasten to add that all patients in both groups did meet the criteria for a qi vacuity pattern.)

Just think about this: What if every patient admitted to ICU were screened for a CM qi vacuity pattern? Of course, the overwhelming patients in ICU will meet this criterion. Lack of strength, fatigue, disinclination to speak due to fatigue, possible shortness of breath, qi vacuity fever. Then, what if every such qi vacuous patient in ICU were prophylactically administered Bu Zhong Yi Qi Tang? This would be huge! It would be a huge benefit to patients and practitioners alike and a huge savings in money spent on treating such nocosomial infections. It could even be hugely life-saving. Fifty percent of patients with candidemia, a Candida infection of the bloodstream, die. This would really put CM on the map in the world of Western health care. Just this one protocol could change forever how Chinese medicine is seen in the U.S., and along with this would, undoubtedly, come increased usage of CM for other things as well.

This translation will be posted a our Blue Poppy Free Articles section/TCMinfoline. If you know any hospital administrators or ICU docs, see if you can get them interested in doing an American trial.

Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.