Proper Use of Strong Acting Herbs II. Tian Nan Xing
Arisaema refers to the Chinese herb tiannanxing obtained from several species of Arisaema (Araceae Family), mainly Arisaema erubescens and A. heterophyllum, which are cultivated for the herb market. The part used is said to be a rhizome, but is more accurately described as a tuber or corm. The common western name for this plant is Jack-in-the-pulpit, the name derived from the flower’s central spadix (spike, referred to here as Jack) within the unique pulpit-shaped flower. Originally, the Chinese had called the herb tiger’s paw (huzhang), because of the digitate leaves (fanning out like a spread hand or paw); the name was later changed to tiannanxing, which refers to the star-like (xing) shape of the leaves; tiannan, meaning southern heaven, probably referred to a region where the herb was gathered.
The writers of several Materia Medica appear to have failed to distinguish the processed herb used internally from the more rarely utilized raw herb, and this situation has led to several authors describing arisaema as toxic. In fact, while the raw material has significant irritant action, the processed herb has low toxicity. Thus, as an example, British physicians working in China (Smith and Stuart 1973) wrote that arisaema is ―considered exceedingly poisonous,‖ while noting that the herb is used for many diseases that are thought to be associated with phlegm.
Figure 1. Photo of Arisaema showing digitate leaves and pulpit-like flowers.
If one bites into a piece of the raw arisaema rhizome, it will promptly cause a sharp burning sensation in the mouth, and this has been attributed to substantial amounts of needle-shaped calcium oxalate crystals. These crystals are a strong irritant, especially to mucosal membranes, as in the mouth. The crystals are thought to accumulate in some plants as a defence mechanism against foraging animals. Oxalate, usually bound to calcium, is a substance found in many plants; calcium oxalate is the astringent component of spinach and chard, small berries, and rhubarb stems. At high enough doses, oxalate is toxic, but it is well-tolerated up to a certain point as indicated by it being found in ordinary foods. Rather, it is the long oxalate crystals (called raphides), as found in raw arisaema, which lead to its classification as toxic. Roasting or boiling the tubers breaks down the crystals and yields an edible product rich in starch that has been consumed as food by Native Americans (primarily Arisaema triphyllum, known as the Indian turnip).
The raw herb is used for its irritant effect, being applied topically for skin diseases with infection and swelling (e.g., abscesses); it damages the bacteria and stimulates a healing response. Calcium oxalate is water soluble and its removal is enhanced by using a basic substance, either alum (aluminium potassium sulphate) or quick lime (calcium oxide). Alum is mixed with ginger juice in the processing; similarly, quick lime is mixed with liquorice. The same method is used in the treatment of pinellia (banxia), a close botanical relative of arisaema. The crystals are removed by soaking the tuber for two days at moderate temperature; alternatively, the herb is boiled in the mixture for 2–3 hours.
Figure 2. Classic pulpit (12th Century), in Saanen Church, Switzerland, in a shape remarkably like the arisaema flower.
Raw arisaema is not exported from China, so herbalists elsewhere utilize only the processed herb that has the calcium oxalate removed. There is also a specially processed arisaema called dannanxing, where dan refers to bile. Bile is considered cooling and moistening, while arisaema is deemed warming and very drying, so bile-processed arisaema (which has a dark, nearly black colour) has the more extreme properties attributed to arisaema neutralized (the bile-processed material is even classified as somewhat cooling) yet the herb retaining its primary action: resolving phlegm. Bile products are used to resolve phlegm as well.
Figure 3. Calcium oxalate raphides; their presence is the primary reason arisaema is called "toxic"
The active components of arisaema remain unknown. There have been reports of an alkaloid being present (Chang and But 1987), but this is questionable as the finding of alkaloids has not been confirmed recently; the alkaloid contents of Arisaema and Pinellia species appear to be very low, so any alkaloids that are present most likely do not contribute significantly to the activity of the herbs. There are also reports of triterpene glycosides (saponins) in arisaema, and this remains a possible major active component, at least in terms of explaining some of the claimed effects of phlegm accumulation.
Figure 4. The dried arisaema corms, which have also been described as tubers or rhizomes.
Mild or Strong?
As is the case with arisaema, several Materia Medica list pinellia as being toxic, but, in fact, processed pinellia (the only one used internally these days) is a relatively mild herb; it can be placed somewhere between mild and strong acting. Processed arisaema may be considered a relatively strong herb, though its dosage in formulas is usually about the same as that for pinellia when the two are combined or when they are used in similar prescriptions. Arisaema’s activity is often described with an emphasis on potency. Yang Yifan (Yang 2002) notes that arisaema (italics added) has a very strong dispersing ability and can intensively dry dampness, dissolve damp-phlegm…and expectorate large amounts of white sputum. Chinese-English Manual (Ou Ming 1989) indicates that arisaema will deprive dampness and eliminate phlegm. Materia Medica (Bensky and Gamble 1993) notes that arisaema is extremely drying. Jiao Shu De (Jiao 2003) contrasts pinellia and arisaema saying that the former is static while the latter is not static, referring to the concept that arisaema has a very strong dispersing quality, which pinellia lacks. The Advanced Textbook of Traditional Chinese Medicine (Huang 1996) points out that pinellia is especially used for settling qi and applied for vomiting and gastric fullness, while arisaema is especially used for eliminating wind and relieving convulsions, thus used to treat stroke, vertigo, and tetanus. These applications of arisaema are related to it being non-static; it is thought that the herb goes through the jing and luo vessels clearing out obstructions, while pinellia mainly stays within the stomach and intestines, resolving problems of those organs.
Uses of Arisaema
There are four major uses of arisaema: to expel large amounts of phlegm, to clear phlegm mist of the heart orifices, to remove phlegm-obstruction of the meridians (especially luo vessels), and to dry accumulation of phlegm-damp in the arms or throughout the body. For removing excess phlegm, arisaema is often accompanied by pinellia, chih-shih (zhishi), hoelen (fuling), and citrus (chenpi); for clearing orifices, it is often accompanied by herbs in the same plant family (Araceae), namely typhonium (baifuzi) and acorus (shichangpu), as well as by certain unrelated materials, especially gastrodia (tianma), polygala (yuanzhi), earthworm (dilong), and silkworm (baijiangcan). Arisaema, like gastrodia and earthworm, is said to eliminate wind as well as to clear phlegm, explaining their applications for treating convulsions, strokes, and other wind-phlegm disorders. Some sample formulas with arisaema are:
Dao Tan Tang (Expel Phlegm Decoction); includes pinellia, chih-shih, hoelen, citrus Qing Qi Hua Tan Wan (Cleanse Qi and Resolve Phlegm Pill); includes pinellia, chih-shih, hoelen, citrus
Di Tan Tang (Phlegm Eliminating Decoction); includes: pinellia chih-shih, hoelen, citrus, acorus
Er Zhu Tang (Two Processed Decoction); includes pinellia, hoelen, citrus Cang Zhu Dao Tang (Red Atractylodes Phlegm Expelling Decoction; includes pinellia, hoelen, citrus Yu Zhen San (Powder for Calming Convulsion); includes: typhonium, gastrodia Xiao Huo Luo Dan (Minor Pill for Opening Luo Vessels); includes: earthworm Zheng Rong Tang (Appearance Normalizing Decoction): includes typhonium, silkworm, pinellia Shen Bai San (Miraculous White Powder); includes typhonium, gastrodia Shen Xian Jie Yu Dan (Immortal’s Speech Recovering Pill); includes typhonium, acorus, polygala, gastrodia
In modern practice, arisaema is included in formulas for post-stroke syndrome when there is evident phlegm accumulation and for cases of Alzheimer’s disease; other applications include advanced (severe) arthritis, carpal-tunnel syndrome (especially in persons who are overweight), headaches (when phlegm obstruction is deemed one of the contributing factors), and bronchitis with sputum production.
Because of its reputation of having a very drying quality, arisaema is generally contraindicated in cases of yin deficiency, though the bile-treated arisaema can be used instead. Arisaema is contraindicated during pregnancy, because some ancient texts suggest that it has abortifacient activity.
Dosage in Formulas and Sample Formulas
The usual dosage of arisaema in decoction, according to various Materia Medica, is given as either 3-6 grams per day (e.g., Hsu 1986 Jiao 20013); 3-10 grams per day (e.g., Huang 1996), or 5-10 grams per day (Huang and Yang 1993), the higher dosing being found in texts describing more recent instances of use of this herb. It is unusual for Chinese doctors to prescribe higher doses than these, with 9–10 grams the amount commonly used for serious diseases. For this herb, 15 grams is the maximum prescribed, and only rarely, such as when used in treatment of obese patients. Arisaema is commonly included in pill prescriptions, and the dose of the herb (powdered and incorporated into pills, capsules, or tablets) taken in one day is about 1 gram.
An example of treatment for post-stroke patient relayed in the book Treatment with Knotty Diseases (Shao 1990) is as follows:
Silkworm 12 grams
Sinapis 12 grams
Pinellia 12 grams
Arisaema 10 grams
Gastrodia 12 grams
Uncaria 24 grams
Acorus 10 grams
Curcuma 12 grams
Polygala 10 grams
The decoction is given with 6 grams powdered scorpion, which is swallowed down with the decoction liquid. Sinapis (baijiezi, the mustard seed) is utilized like arisaema for dispelling large amounts of phlegm.
Another example is from Clinic of Traditional Chinese Medicine (Zhang 1990), which presents a formula for treatment of depression associated with phlegm stagnancy, a modification of Er Chen Tang:
Citrus 10 grams
Pinellia 10 grams
Hoelen 10 grams
Licorice 6 grams
Arisaema 10 grams
Chih-shih 10 grams
Cyperus 10 grams
Acorus 10 grams
Polygala 10 grams
Curcuma 12 grams
Cyperus (xiangfu) is one of the central Chinese herbs for treating depression (Dharmananda 2005). The trio of acorus, polygala, and curcuma, found in this and the previous example, is used to clear phlegm obstructing the orifices of the heart, thus improving brain function; arisaema intensifies that effect. A third example is treatment of obstructive emphysema (Hou and Geng 1997), when characterized by phlegm-heat:
Gypsum 30 grams
Trichosanthes 24 grams
Scute 9 grams
Apricot seed 9 grams
Citrus 9 grams
Pinellia 9 grams
Hoelen 9 grams
Arisaema (bile) 9 grams
Chih-shih 9 grams
Rhubarb 4.5 grams
Because the therapy was for a heat syndrome, bile-treated arisaema was chosen; the seed of trichosanthes (gualouren) was used as a cooling herb for resolving phlegm; gypsum (shigao) and scute (huangqin) are included for clearing heat from the lungs.
In the book Bi Syndromes (Vangermeersch and Sun 1994), the syndrome of accumulation of phlegm and blood stasis is described. This condition is exemplified by chronic arthritis with swelling and deformity of the joints, with limitation of extension and flexion. A sample formulation is modified Tao Hong Yin:
Persica 10 grams
Carthamus 5 grams
Tang-kuei 10 grams
Cnidium 10 grams
Arisaema 10 grams
Sinapis 10 grams
Silkworm 10 grams
Earthworm 10 grams
Mantis 6 grams
The combination of sinapis, silkworm, and arisaema in this formula, and also in the formula for treating post-stroke syndrome, scours out phlegm-mist in the orifices and meridians while quieting internal wind.
In a recent translation of Dan Xi Xin Fa (Yang 1993), a chapter on arm pain is presented; the pain is attributed to dampness in the upper burner running wildly in the channels and connecting vessels (that is, the jing and luo). Left arm pain is said to be due mainly to wind-dampness, while right arm pain is more often due to phlegm-dampness. The basic treatment described by Zhu Danxi in this chapter for eliminating this dampness is Er Chen Tang; the simple formula is to be modified with additional herbs; arisaema is considered particularly important for the right arm pain. Among the modern applications of this approach are frozen shoulder, lymphedema ((Dharmananda 2000), tennis elbow, and carpal tunnel syndrome. A tablet designed for these uses (Dharmananda 2004) was derived from Er Zhu Tang, a formula of the "arm pain" category of the book Wanbing Huichun (published 1587), from which many formulas were absorbed into Japanese practice of Chinese medicine, called Kampo (Dharmananda 2001). Arisaema 10 and Er Zhu Tang (referring to the two "zhu", baizhu and cangzhu, in the formula) also has the damp-removing herbs mentioned previously—arisaema, pinellia, hoelen, and citrus—as well as another component, namely aromatic qi regulating and dispersing herbs: chih-ko (zhike), cyperus (xiangfu), and chiang-huo (qianghuo), to help move the stagnation in the arms.
Chang HM and But PPH (1987), Pharmacology and Applications of Chinese Materia Medica, World Scientific, Singapore
Dharmananda S (2000), Chinese HerbsfFor Lymphedema: Exploring the Principles of Treating Phlegm-Damp Accumulation, START Manuscripts, ITM, Portland, OR
Dharmananda S (2001), Kampo Medicine: The Practice of Chinese Herbal Medicine in Japan, START Manuscripts, ITM, Portland, OR Dharmananda S (2004), A Bag of Pearls, Institute for Traditional Medicine, Portland, OR
Dharmananda S (2005), Cyperus: Primary Qi Regulating Herb Of Chinese Medicine, START Manuscripts, ITM, Portland, OR
Hou Jinglun and Geng Xiu’e (chief editors) (1997), Traditional Chinese Treatment for Senile Diseases, Academy Press, Beijing
Hsu HY, et.al. (1986), Oriental Materia Medica, Oriental Healing Arts Institute, Irvine, CA
Huang Bingshan and Wang Yuxia (chief compilers) (1993), Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, Heilongjiang Education Press, Harbin
Huang Yarong, compiler (1996), Advanced Textbook on Traditional Chinese Medicine and Pharmacology, volume 2, New World Press, Beijing
Jiao SD (2003), Ten Lectures on the Use of Medicinals, Paradigm Publications, Brookline, MA
Ou Ming (chief editor) (1989), Chinese-English Manual of Common Used Herbs in Traditional Chinese Medicine, Joint Publishing Company, Hong Kong
Shao Nianfang (1990), The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine, Shandong Science and Technology Press, Jinan.
Smith FP and Stuart GA (1973), Chinese Medicinal Herbs, Georgetown Press, San Francisco, CA
Vangermeersch L and Sun PL (1994), Bi Syndromes, SATAS, Brussels, Belgium Yang Shouzhong, translator (1993), The Heart and Essence of Zhu Danxi’s Methods of Treatment, Blue Poppy Press, Boulder, CO
Yang Yifan (2002), Chinese Herbal Medicines: Comparisons and Characteristics, Churchill-Livingstone, London
Zhang Enquin (1990), Clinic of Traditional Chinese Medicine, Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai