Ginseng and Astragalus Combination (Bu Zhong Yi Qi Tang)
By Peter Townsend and Will Maclean
Ginseng and Astragalus Combination
(GAC) is a very commonly used formula in traditional Oriental medicine. Its inclusion
as an approved prescription in the Japanese Ministry of Health and Welfare's health
insurance scheme also attests to its efficacy. Although it is mainly used for
fatigue and various types of prolapse, its creator, Li Dong-Yuan, mainly designed
it to treat febrile diseases. In this article I wish to re-examine Dong-Yuan's
notes at the time he formulated GAC and compare them with modern usage and research.
Dong-Yuan lived from 1180 A.D. to 1251 - the period the Song dynasty fell to the
invading Jin (Tartars) and Yuan (Mongols). The story goes that as the Jin army
advanced South, an epidemic (febrile disease) broke out in the walled cities,
- it is said that in one city alone between one thousand and two thousand bodies
were taken out of its 12 gates every day.
In the treatment of this epidemic
Dong-Yuan writes in the Nei Wai Shang Bian Huo Lun (Clarifying Doubts about Injury
from Internal and External Causes):
"...use Sweet and Cold to purge Fire,
but if there is tiredness (Qi deficiency) or injury it should be warmed, and I
say again, warmth can expel strong Heat. Bitter Cold herbs should not be used,
as they will purge the Stomach Earth. Sweet and warm should be used to tonify
the Middle and cause Yang to rise, Sweet and Cold is used to purge fire (not to
treat fever due to deficiency)."
The doctors of Dong-Yuan's time considered
this illness to be Shang Han (Cold Injury), a type of infectious disease, and
therefore treated their patients with diaphoretic, emetic and laxative methods
(according to Shang Han Lun theory) to purge the pathogen from the body. However,
after this type of treatment most patients took an acute turn for the worse and
died. Dong-Yuan reasoned that this febrile disease was not due to Shang Han or
other exogenous influences, but was due to malnutrition, fatigue, anxiety and
other endogenous causes. In contrast to exogenous diseases like Shang Han, he
called diseases that were endogenous Nei Shang (Internal Injury). Since Shang
Han diseases are the reaction of the body to an invading pathogen and Nei Shang
is an internal deficiency, Dong-Yuan goes on to say:
should be purged, deficient Nei Shang should be tonified. If the doctor fails
to recognize the difference between these two and attempts to purge an endogenous
disease, the deficiency will become more deficient. If deficiency is made more
deficient (by purging) or if excess is made more excessive (by tonifying), then
the doctor will kill the patient."
To treat these types of deficiency
he designed GAC. (See Minor Cinnamon & Paeonia, Steve Clavey, for more about
Qi deficient fever.)
Indications and Pathology In modern TCM
GAC has three
" Collapse of Central Qi, Pure Yang Failing to Rise
Spleen Not Governing Blood
" Qi Deficient Fever
The first usage,
collapse of central Qi, is a condition which arises from chronic Spleen Qi deficiency
where there is a lack of tone of the skeletal and smooth muscles, and supportive
tissue. This in turn leads to gastric atony, floating kidney, hernia, rectal prolapse,
uterine prolapse, and other forms of prolapse. Constipation may also occur due
to loss of tone of the intestinal smooth muscles or, contrarily, diarrhea may
occur due to a lack of fluid absorption. Loss of tone of the muscles of the urinary
bladder may also cause trouble initiating urination. Muscular contraction, therefore,
does not occur until a large volume of urine has accumulated. Urinary incontinence
in the elderly, infants, postoperative, and postpartum patients can also occur
due to atonicity of the sphincter muscles.
Pure Yang failing to rise is a condition
characterized by dull headaches, dizziness upon standing, vague consciousness,
sleepiness, fatigue and weak extremities. Although not necessarily part of this
condition, many of these patients tend to have hypotension with especially low
diastolic pressure. This is accompanied by reduced CNS excitement and loss of
tone of the sweat glands, so the patient may sweat very easily (even upon only
mild exertion). Spleen not governing Blood is characterized by persistent but
scanty, intermittent hemorrhaging. This usually occurs in the lower body or subcutaneously.
It is thought that this is due to loss of tone of the blood vessel walls or thrombocytopenia
and may be compounded by reduced digestive function leading to an insufficient
supply of protein and thus coagulants. The third usage, Qi deficient fever, was
the disorder which Dong-Yuan was addressing when designing GAC. This type of fever
may accompany an exogenous febrile disease, as was most likely the case in Dong-Yuan's
time, or may be only due to general deficiency. In either case, however, the patient
usually suffers from both mental and physical fatigue which may be accompanied
by dull headaches, chills and sweating. The fever itself is low-grade and may
only be subjective. In cases where the condition has come about due to an external
pathogen, the patient is usually in the recovery stage from influenza or other
similar illnesses but does not quite have the vitality to fully recover. Modern
research has not yet been able to shed much light on the mechanism of this type
of fever, but it is thought that a generally weakened metabolism and bodily functions
with autonomic nervous system disorders may cause an imbalance in the body's thermostat.
Habitual hyperthermia, a constitutional propensity to higher body temperature,
may also be a factor.
Astragalus tonifies Qi, helps
Yang to rise and consolidates the Surface (skin), it stimulates the central nervous
system, has cardiotonic and sex hormone-like actions, it strengthens muscle tone
and promotes general metabolism. It has been found that in small quantities Astragalus
raises blood pressure, but that in large quantities (over 30g/day) it lowers it.
This, perhaps, partially justifies its use pharmacologically in Bu Yang Huan Wu
Tang, a formula used for apoplexy which contains between 30g and 100g of Astragalus!
Ginseng stimulates the CNS, increases digestive absorption, and strengthens general
bodily functions. Atractylodes promotes the absorption of fluid from the digestive
tract thus stimulating diuresis. Licorice strengthens general bodily functions
and works with Astragalus to increase its efficacy. Ginseng, Astragalus and Atractylodes
promote protein synthesis, and with Dang Gui also promote macrophage phagocytosis
and antibody production. Bupleurum and Cimicifuga, when used in small quantities
with Astragalus, help Qi to rise and strengthen muscle tone*. Dang Gui tonifies
Blood and aids the action of the other herbs through nourishing the body and promoting
circulation, it also prevents the parching herbs from over drying.
in larger quantities, Bupleurum and Cimicifuga are mainly used for their anti-inflammatory
and antipyretic actions (Heat clearing). Their use in this context, however, is
to aid the rising qualities of Astragalus. It has been reported that, experimentally,
although a marked increase in muscle tone was reported when Astragalus, Bupleurum
and Cimicifuga were used in combination; the action of only Bupleurum and Cimicifuga
together was found to be quite weak.
Citrus (chen pi) and Ginger (sheng jiang)
increase peristalsis and the secretion of stomach juices, aiding the absorption
of the other ingredients, while Jujube harmonizes the ingredients and promotes
Formulation In modern TCM theory
GAC is considered to be a variation
of Four Major Herb Combination (Si Jun Zi Tang), and although this is true from
the point of view of GAC being a Qi tonic, historically Dong-Yuan based his formula
on Minor Bupleurum Combination (xiao chai hu tang), a prescription from the Shang
Han Lun used to treat Shao Yang Bing. He removed the Scute (huang qin) and Pinellia
(ban xia) from MBC and then added Astragalus (huang qi), Cimicifuga (sheng ma),
Atractylodes (bai zhu), Dang Gui and Citrus (chen pi).
As mentioned before,
since Dong-Yuan reasoned that sweet-warming herbs should be used for Qi deficient
conditions, he removed the pungent-warming Pinellia and bitter-cooling Scute.
Scute is mainly used to clear excess Heat in MBC. Since the fever due to Nei Shang
is due to deficiency, the inclusion of Scute would be inappropriate. The inclusion
of Pinellia is also not necessary in GAC, as its anti-emetic, anti-tussive and
expectorant actions are mainly used for Phlegm-Damp accumulation. Its parching
effects may also be too strong for deficient conditions - especially when combined
with the other herbs in GAC.
An elegant variation of GAC also designed by Dong-Yuan
is Tiao Zhong Yi Qi Tang (Regulate the Middle and Invigorate Qi Decoction). This
is for Collapse of central Qi accompanied by a heavy body sensation, loose to
watery stools, abdominal distention, sticky sensation in the mouth and other middle
Jiao Damp symptoms. From GAC, he took Atractylodes macrocephala (Bai Zhu) and
replaced it with Atractylodes lancea (Cang Zhu) for its stronger Damp expelling
properties, removed Dang Gui because of its "sticky" nature, and added
Saussurea (mu xiang) to move Qi. The addition of Saussurea, Coix (yi ren), Atractylodes
lancea and/or Hoelen (fu ling) to GAC would also achieve similar results. Dong-Yuan
is primarily known as being the founder of the Earth Tonifying school, and therefore
focused much attention on the tonification of Spleen Qi. The Pi Wei Lun (Treatise
on the Spleen and Stomach) explains his Spleen tonification theories and treatment,
while the Nei Wai Shang Bian Huo Lun is a treatise on the differentiation and
treatment of exogenous and endogenous diseases. Although fever due to a deficiency
of Yin was a well-recognized pattern before Dong-Yuan's time (Anemarrhena Phellodendron
& Rehmannia Formula, [qi ju di huang wan] being an example of a formula used
to treat this condition), this type of Qi or Yang-Qi deficient fever was not really
fully understood. Even now, very few texts even mention this relatively common
clinical phenomenon. That Dong-Yuan was able to recognize and formulate a treatment
method for this condition says much about the depth of knowledge and innovative
character of this man.
Protection against Chemotherapy
shows protective effects on the kidney and bone marrow in patients being treated
with chemotherapy. When used in high doses (up to three times normal dose) pre
and post chemotherapy, serum markers like BUN, serum creatinine were decreased
relative to controls, and white blood cells and platelets were maintained significantly
. Adverse toxic effects induced by antitubercular medication (rifampicin, streptomycin
and isoniazid), including fever, hepatic dysfunction, agranulocytosis and systemic
eruption were significantly moderated in a 58 year old patient. Adjuvant therapy
with GAC and Minor Bupleurum Combination (xiao chai hu tang) suppressed the hepatodermatological
toxicosis moderately and the high fever completely .
GAC has a regulatory effect on the adrenal cortex and autonomic nervous
function. Studies from Japan on patients with non-ulcer dyspepsia and psychovegetative
syndrome demonstrated that when serum cortisol was high, administration of GAC
decreased it, and when low and normal increased it. This modulatory effect is
thought to be mediated by ACTH secretion .
Effect on Obstructive Sleep Apnea
GAC has been used with some success on patients with OSAS.
This disorder is characterized by recurrent obstruction of the upper airway leading
to hypoxia and frequent arousal from sleep. Patients often present with daytime
sleepiness, obesity, snoring, digestive system dysfunction, loss of appetite,
impotence, weakness and poor muscle tone. These symptoms are consistent with the
TCM diagnosis "Spleen failing to hold muscular structures in place"
for which GAC is the indicated formula. The probable mechanism of OSAS is weakening
of the structures which support the epiglottis with consequent airway blockage.
This formula has been found to be effective in Japan  and by the author.
In clinical tests with 35 patients suffering from rheumatoid arthritis,
Sjoegren's syndrome, or bacterial infections, administration of GAC was shown
to significantly increase natural killer cell (NK) activity. Eight of the patients
had an improvement in clinical symptoms and it was noted that these patients also
had the greatest rise in NK activity. Interestingly, it was found that patients
who already had a high NK activity before administration of GAC demonstrated a
slight decrease in NK activity.
These results were also supported with in
vitro research. Human peripheral blood lymphocytes cultured with GAC demonstrated
an augmentation of NK activity. However, NK activity in human peripheral blood
lymphocytes with high activity prior to treatment was suppressed by GAC. The authors
suggest that GAC has a biphasic (regulatory) action on human NK activity both
in vivo and in vitro . Oral and intraperitoneally administered GAC has been
shown to enhance the phagocytic activity of peritoneal exudate cells (PEC) in
mice as well as stimulating the phagocytosis of spleen cells and bone marrow cells
Effect on Male Fertility
GAC can be used to treat male infertility.
In order to demonstrate this pharmacologically, GAC was used on cultured hamster
epididymal cells. A significant increase in 3H-leucine uptake was observed in
the treated group suggesting that GAC has a stimulative effect on epididymal function
. Experiments with mice have also shown that in mice treated with adriamycin
(ADR), GAC significantly inhibited a decrease of testis weight compared to mice
treated only with ADR. The GAC treated group had a decrease of seminiferous tubules
without germ cells, however at the same time there was a significant increase
in the proportion of normal seminiferous tubules and the Sertoli cell ratio of
spermatocytes as compared with the ADR-treated group .
Sugiyama K, Yokota M, Ichio Y, Ueda H (1993). Protective effects of Kampo medicine
against cis-diaminedichloroplatinum induced nephrotoxicity and bone marrow toxicity
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