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The tortoise (gui) is one of the four spiritually-endowed creatures (Figure 1) described in the Book of Rites of the Confucian Classics, where it serves as an emblem of strength, longevity, and endurance, and symbolizes the Universe (1). Each of these creatures is associated with a direction and element, the tortoise, usually depicted in conjunction with a snake (Figure 2), represents the north, and is thereby associated with the water, darkness (the color black), and the earth (28), the element which was later put into the five element system in the center.
The tortoise shell was long used in divination, by observing the patterns of cracks that developed when a hot instrument was touched to one of its many “divination points,” and then interpreting the implication of the pattern. The prognostications and insights learned from the cracks were often written right onto the shells, and it is from buried fragments of tortoise shells (along with some mammal bones that were used similarly) that we know the most ancient forms of Chinese writing (2; Figure 3). The Chinese character bu (Figure 4), which means to divine by looking at the cracks in the tortoise shell as the heat develops them, is represented by two lines depicting cracks. This character became incorporated into numerous others as a radical. Thus, the tortoise and its shell have been an important part of Chinese culture.
Further, the tortoise has been used as both food and medicine since ancient times, and is recorded as being used for these purposes since the Han Dynasty, 2000 years ago. Regarding their inclusion in the Chinese diet, E. N. Anderson comments that “Animals that are very tenacious of life, or very unusual-looking and -acting, are regarded as having special power; they are supplementing (bu). Notable supplementing foods are pangolins, raccoon dogs, soft-shelled turtles, tortoises, snakehead fish, birds of prey....(3)” Although the tortoise is not a major food in China today (turtles have long been preferred over tortoises for food), it remains one of the foods included in some diets. Anderson also points out that “During Han, and throughout Chinese history, the boundary between medicine and food was so vague as to be non-existent in practice. Many things were purely medicines, but medicines often became foods if people learned to like them; many foods became merely medicines when people stopped relishing them....”
ANIMAL MEDICINES AND THEIR CONSTITUENTS
Tortoise shells were described as medicines in the Shennong Bencao Jing (4), listed there as guijia (tortoise scale). They have become one of the standard items of the Materia Medica, with consistent use since the earliest recorded medical books. In fact, shells, along with similar animal materials, such as scales, antlers, and skins, are the most commonly used animal substances in the Chinese Materia Medica. Among these, oyster shell is probably the most widely used, followed by deer antler, tortoise shell, and pangolin scale, with lesser amounts of donkey skin gelatin and turtle shell being utilized, though still important to Chinese practice. These materials are rich in collagen and calcium compounds; collagens are the proteins that help determine the overall physical structure and the calcium compounds contribute to rigidity. Pangolin scale, as well as other animal materials such as cicada slough, snake slough, and horns (rhino, antelope, buffalo), are comprised mainly of another protein, keratin, which is similar to collagen; turtle and tortoise shells, as well as deer antlers contain some keratin (the hairs of antler velvet are mainly keratin).
Oyster shell, which is extremely hard, is mainly comprised of calcium carbonates and calcium phosphates with relatively little protein, while donkey hide is mainly comprised of collagen with a little calcium; the other materials mentioned above have intermediate content (see Appendix 1 for an analysis of the roles of these two compounds). As an example, deer antler in velvet (which is the most studied item) contains about 50% protein, with about half of it in the form of collagen that can be converted to gelatin. It also contains calcium carbonate, calcium phosphate, and calcium chloride, making up about 50% of the antler, and the amount of those components increases as the antler ages and becomes ossified (hardened), with a decline in the amount of collagen and other proteins. Tortoise shell and deer antler also contain chondroitin sulfate, a protein-polysaccharide complex that has recently been utilized to treat joint degeneration (it is a building block of the cartilage, comprised mainly of glucosamine). Small amounts of cholesterol and other animal substances are also present in the shells, scales, and skins. An alcohol extract of deer antler (alcohol doesn’t solubilize collagen or calcium), called pantocrine, is reported to have hemopoietic and androgenic activity; its ingredients have not been reported. Presumably, tortoise shell also contains some substances that contribute similar kinds of activity. A 70% alcohol extraction medium solubilizes 2–3% of the substances in tortoise and turtle shells (31). Traditionally, antler is said to tonify and open the governing vessel (dumai) while tortoise shell tonifies and opens the conception vessel (renmai), the two vessels that run along the midline of the body, back (yang) and front (yin), respectively. Perhaps there are slightly differing constituents that can be found to explain the differing attributes. The Chinese interpretation may have originated with the observation of the natural materials more than from observation of physiological responses: the antler arises from the back and top of the deer’s head (yang) and the plastron protects the tortoise’s underbelly (yin).
Tortoise shell, as a medicinal agent, is most often utilized in rehmannia-based formulas that nourish the yin and blood and settle the yang (5). Relatively little is known of the pharmacology of the individual herbs of these formulas, though the overall effects include changes in hormones and hormone receptors. It is possible that tortoise shell provides a nutritional component to some formulas, with calcium and protein, though the flesh of the tortoise would be a better source of protein. Until recently, oyster shell calcium was the main source for calcium in Western nutritional supplements (now, more absorbable forms are often used instead); these supplements are reputed to have several medicinal applications, especially for calcium-deficient individuals.
The use of animal substances, such as tortoise shell, in the modern practice of natural healing is somewhat unusual for Westerners, many of whom view herbalism as a practice involving only plant materials (whereas Chinese “herbs” include minerals and animals). Indeed, for many Westerners, the use of herbs as a standard part of health care is often allied with practices, such as vegetarian diet, that differ from standard Chinese approaches and that would eliminate from consideration the ingestion of animal-derived medicinals. The use of tortoise shell is of particular concern to Westerners because some tortoises have been placed on the endangered species list, and are thereby prohibited from collection and trade. The tortoise shells used in Chinese medicine are obtained from aquatic but land-based tortoises, which are not included on the endangered species list, unlike sea tortoises or some desert species. However, due to the modernization of China (including plans to install a major dam across the Yangzi River), along with its large and still growing population, even these land tortoises may become endangered in the future. Increasing efforts are being made in China (and elsewhere) to raise the tortoises.
SPECIES AND SOURCE
According to the 1995 Chinese Pharmacopoeia (6), tortoise shell (guiban) is obtained from Chinemys reevesii; this is the same species that has been specified in earlier editions of the Pharmacopoeia of the PRC (7) and other sources (5, 8, 9, 10, 11). This is a land tortoise (Figure 5), found in rivers, lakes, and marshes, which is known in the West as the Reeve’s tortoise. It is particularly prevalent in the Yangzi (Yangtze) River region, with most of the commercial supply harvested in Hubei, Hunan, Jiangsu, and Zhejiang Provinces, though also obtained from Guangdong, Sichuan, Guizhou, Fujian, Shaanxi, and Henan Provinces (6, 12, 13). Two substitute species obtained from Anhui Province, Cuora amboinensis and Cuora flavomarginata, have been raised and sold on the market, but are not officially-recognized substitutes (14, 16). The latter species is thought to be the one denoted as shuigui in Li Shizhen’s Ben Cao Gang Mu (15). Other substitutes include Mauremys mutica and Testudo elongata (11). Another tortoise, Eretmochelys imbricata, is used as a separately listed item in the Chinese Materia Medica, known as daimao (Figure 6).
Although the Reeve’s tortoises and some of the substitute species are raised in China for their shells (17), there is still a huge natural supply and the majority of the shells are obtained from the wild resources. They can be collected all year round, but are usually obtained in autumn and winter. Tortoise collection, like that of fish in the same region, is mainly accomplished by use of nets.
The bottom part of the Reeve’s tortoise shell, known as the plastron, is the desired item; by contrast, for daimao and for the turtle (biejia), the top part of the shell, called the carapace, is used. It is not clear why the plastron was chosen, other than the historic value of the plastron in divination. Recent analysis shows that the tortoise carapace has twice the amount of extractable gelatin as the plastron (22), with no difference in composition; similarly, the carapace of the turtle has about twice the water-soluble protein, mainly gelatin, as the tortoise plastron. In a report on conserving drug resources (41), it was noted that the shell (carapace) of the Reeve’s tortoise could be used along with the plastron, as they have similar activities.
The plastron is separated from the flesh and skin of the animal after the whole carcass has been boiled, steamed, or scalded in hot sand. In earlier times, the plastron was separated after letting the animal partially decay in cool water (18); the method of heating before drying is more sanitary and quicker. If 20% lime water is used in place of clear water, the process of cleaning the plastron is even faster (19). Modern efforts at obtaining the medicinal plastron are aimed at improving the speed of the process and alleviating some of the difficulties (e.g., exposure to smoke and flue dust during the cooking, bad smell of the processed material due to decay), while maintaining or improving the content and extractability of the active components (20). A typical water processing method used in modern times involves steeping the shells in clear water for two days, steaming on a strong fire for about an hour, putting them into warm water, then scraping off the non-medicinal parts, and drying the plastron. A comparison of the chemical composition of tortoise shells processed by old and new methods was undertaken and no significant differences were noted (21). However, the details of processing are important: in a study of processed tortoise shell and turtle shell (29), it was shown that proper processing procedures could yield up to twice as much water-soluble substances.
Vinegar processing is the main additional method used by the Chinese. The plastrons isolated by the boiling method are first rapidly heated in a hot pot and then immediately dipped into vinegar; this process can be repeated. According to the report in Pao Zhi (30), the raw tortoise shell is mainly used for treating vertigo, tinnitus, deafness, headache, and convulsion due to wind agitation of liver yin deficiency (i.e., it settles yang, much like oyster and haliotis shells), whereas the vinegar-treated tortoise shell is appropriate for treating nightsweating, weakness of back and legs, insomnia, heart palpitations, and other disorders due to deficiency of liver and kidney (i.e., it nourishes yin and blood, much like rehmannia, ho-shou-wu, and lycium).
Tortoise shell gelatin is obtained by boiling the plastrons; the collagen is converted to gelatin during this process and is then formed into small hard blocks. The gelatin is especially used for treating impotence, low back pain, and uterine bleeding due to kidney essence deficiency. Turtle shell gelatin (biejia jiao) is made as a medicinal product and is also used to treat uterine bleeding; it is also used for hemoptysis associated with tuberculosis, but is not indicated for the kidney deficiency symptoms of back pain and impotence. According to the report in Dui Yao (38), when the turtle and tortoise are combined, they “make yin and yang interact; in addition, together, they enrich yin and clear deficiency heat, subdue yang, extinguish wind, and stop tremors.”
MEDICINAL PREPARATIONS AND DOSAGE
In traditional Chinese formulas, tortoise shell is most often included in pills, with about 2 grams of shell per daily dose (similar to the amount of deer antler or oyster shell prescribed in pill form). Tortoise shell is also used in decoctions, in which case it is to be boiled for some time before adding other materials, since its gelatin and calcium are very slowly extracted. The dose of plastron to be used in decoction is generally 9–24 grams for a one day dose, though in several reference texts up to 30 grams is recommended. Tortoise shell gelatin may be powdered for making pills or may be added to the hot strained decoction after the other herbs have been thoroughly boiled; that is, the gelatin is not cooked further, but simply dissolved into the hot liquid.
The difference between dosage of tortoise shell used in decoctions versus pills is large, about 10:1, but this difference is relatively easily explained. Whereas the shell is very poorly soluble in hot water, yielding only a small fraction of the active constituents to the decoction, the shell is dissolved readily by stomach acid and is well extracted in the digestive system.
Calcium compounds make up about half of the tortoise plastron and turtle carapace (31). The calcium content of the plastron, when used in the dosages recommended by the Chinese texts, contributes a significant amount—several hundred milligrams—compared to the currently recommended nutrition levels of about 1 gram. The typical Chinese diet is often low in calcium. Therefore, a course of therapy using tortoise shell in the amount of several grams per day may treat those conditions which are responsive to calcium supplementation. In the West, calcium citrate, calcium carbonate, bone meal (calcium hydroxyapatite), and other preparations are available in tablet, capsule, and liquid forms that can easily provide amounts similar to the Chinese herb preparations with tortoise shells. Also, the Western diet includes milk products that provide considerable amounts of absorbable calcium; by contrast, the Oriental diet is essentially free of milk products, and vegetable-source calcium is of variable availability (e.g., oxalates in the vegetables render much of the calcium unabsorbable).
The bone disease rickets, which is due to impaired deposition of bone calcium in children, has been treated in China with shell formulas. For example, in a study (36) involving several hundred cases, Longmu Zhanggu Tang was administered. It is comprised of tortoise shell, oyster shell, astragalus, atractylodes, codonopsis, hoelen, dioscorea, schizandra, jujube, licorice, and gallus. The tea was made with 15 grams of the materials, and administered three times daily (thus, 45 gram daily dosage). Among 278 cases treated, it was reported that serum calcium and phosphorus levels increased, and bone mass (as detected by x-ray analysis) improved; nearly all symptoms were alleviated. A control group of 200 cases received cod liver oil (source of vitamin D), calcium, and calciferol. The effects were the same, except that the herb infusion, which included several spleen tonic herbs, was better in improving appetite. These results suggest that the calcium provided by the shells, like that provided to the control group as a supplement, was a key component of treatment.
Collagen, a fibrous protein that is converted to gelatin by boiling in water, makes up about 7% of the tortoise plastron. Collagen is the most abundant protein in higher animals, making up one-third or more of the total body protein of vertebrates, with most of it present in specific body structures (e.g., skin, bones, nails, hooves). The collagen forms a network of tough but pliable fibers (Figure 7) that are partially or completely solidified by calcium carbonates and phosphates. The plastron is formed basically in the same way that bones and horns are made, and is sometimes described as an exoskeleton.
It is unclear whether there is anything unique about tortoise collagen and gelatin compared to that obtained from other sources, such as deer antler or donkey skin. In fact, relatively little is known about the medicinal value of these proteins. Recently, interest has developed in the ability of ingested collagen to inhibit arthritis (perhaps by deflecting immune attacks against the joints to the ingested collagen) and for its ability to inhibit angiogenesis (blood vessel formation) as a means of inhibiting tumor growth. In the West, collagen from chicken bones has been tested for arthritis treatment, while collagen from sharks and cattle has been tested for cancer treatment. There may be some correlation with traditional uses of these substances in China. Bones, such as tiger, dog, and pig bones, have been used for arthritis treatment in traditional Chinese medicine. Deer bone gelatin was given orally at 10 grams twice daily in a trial for arthritis treatment (43); of 124 cases treated, more than half had marked improvement or complete resolution of symptoms with 10–20 days typical treatment time. Wang Weilan, a specialist in arthritis treatments (39) frequently recommended gelatins for treatment of deficiency-type arthritis. For example, in cases of soreness and pain of the back and spine, enlargement of the joints, sore legs, painful heals, inability to raise the upper limbs, difficulty lifting the legs, and in persons with obvious weakness, he prescribes a complex formula that includes tortoise shell, turtle shell, donkey skin gelatin, and deer antler gelatin. During the phase of remission, when there is absence of redness and swelling, but there is severe limitation of movement and rigid deformation, he recommends a complex prescription that includes tortoise shell gelatin and deer antler gelatin. He stated that “Deer antler gelatin and tortoise plastron gelatin warm and strengthen the conception and governing meridians. Since they are derived from an animal source, they are very compassionate to human beings; thus, they can invigorate the bone and replete the marrow. They are essential in the treatment of the late stage rheumatoid arthritis (deformity of joints, osteoporosis, defective cartilage of the joint surfaces, etc.). Their use is in accordance with the old saying: use the bone to tonify the bone—the seeking of the similar qi.”
It is possible that gelatin polypeptides (fragments after partial digestion) contribute to inhibition of bleeding, perhaps by a mechanism similar to that of carbonized materials (which the Chinese frequently employ to stop bleeding). In a study of treatment of vaginal bleeding in women above age 40 (37), those diagnosed with weakness of the chong and ren meridians (conception and penetrating vessels), were administered tortoise shell, deer antler gelatin, donkey skin gelatin, rehmannia, dioscorea, cornus, lycium, cuscuta, rubia, and schizandra. Most of the women so treated were cured of bleeding or had reduced bleeding. Other formulas were used to treat bleeding associated with uterine fibroids (turtle shell, which is reputed to resolve masses, was included).
Westerners tend to get little gelatin in the diet, some coming from soups made from animals (when bones, tendons, and/or skin are included in the cooking) and a very slight amount coming from gelatin-based desserts. It has been proposed that gelatins may provide a nutritional benefit for the collagen portions of the body (e.g., gelatin to improve the nails), and one of the accompanying compounds, chondroiton, has been shown to nourish the joints.
There are also small amounts of fats, magnesium, trace minerals, such as zinc, and vitamins, including Vitamin D, in the tortoise shells. As with other natural calcium sources, there are small amounts of lead, but not enough to be of concern.
It is still difficult to explain some of the traditional indications for tortoise shell (see below) based on the limited knowledge of its constituents and their effects. Persons who have habitual low levels of calcium in the diet may experience health improvements when tortoise shell is used in adequate doses due to the calcium and protein it contains (gelatin may enhance calcium absorption); the protein contribution of tortoise shell is only significant when the plastron is used in decoction at high dosage. There may be substances in the shell that stimulate the body to produce hormones or generate another response that would explain the traditional indications, but these substances have not been identified. In one frequently cited study (23), it was shown that both rehmannia and tortoise shell could affect beta-adrenoreceptors in rats with induced hyperthyroidism, thus alleviating some of the symptoms of the thyroid disorder. A shell-based formula has been clinically tested for treating Grave’s disease, a hyperthyroid condition (34): twenty-five patients were treated with a decoction that included turtle, tortoise, and oyster shells, plus astragalus, codonopsis, polygonatum, scrophularia, brassica, arisaema, and prunella. This formula tonifies qi and nourishes yin, while the latter four herbs are used for treating a swelling in the throat that is due to qi stagnation and phlegm accumulation (see Treatment of thyroid diseases with Chinese herbs). According to the report, after administering the decoction three times daily before meals for three weeks, along with the Western drug methimazole and, if needed, propranolol, 14 of the patients showed complete remission of symptoms, and 10 others had partial but clinically significant remission.
COMPARING TRADITIONAL AND MODERN
INDICATIONS FOR USE OF TORTOISE SHELL
According to the Shennong Bencao Jing, tortoise is salty and balanced. It mainly treats “red and white leaking” (this is a usual description for uterine discharge, meaning uterine bleeding and leukorrhea, respectively), “breaks concretions and conglomerations” (this is the usual description for masses, especially those that occur in the abdomen), and cures “malaria, the five hemorrhoids, genital erosion, damp impediment, heaviness and weakness in the limbs, and non-closure of the fontanel in children.” The original uses of tortoise shell differ from many of the modern applications, which emphasize nourishing yin and blood and calming agitated yang. Today, turtle shell is preferred over tortoise shell for resolving masses, and oyster shell is more frequently used than tortoise shell for “white leaking.” Heaviness and weakness of the limbs is the main indication from ancient times that is still deemed important today.
As an example of the elaboration of uses in modern practice, the English-Chinese Rare Chinese Materia Medica (11) states the following actions and indications:
1. Nourishing yin and suppressing hyperactive yang. It is efficacious in the treatment of dizziness due to hyperactivity of yang caused by deficiency of yin, or, of stirring-up of endopathic wind of deficiency type resulting from impairment of yin in the course of febrile disease.
2. Reducing fever of deficiency type. It is efficacious in the treatment of hectic fever, consumptive fever, and night sweat, all due to deficiency of yin.
3. Tonifying the kidney and strengthening the bones. It is efficacious in the treatment of flaccidity and weakness of loins and feet, chondropathy (cartilage disorder), and infantile metopism (non-closure of fontanel).
4. Nourishing the blood and tonifying the heart. It is efficacious in the treatment of palpitations, insomnia, and amnesia due to deficiency of the heart.
Another elaboration that provides good insight is from the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (5):
1. To replenish yin and pacify yang. Indications: Kidney yin insufficiency leading to hyperactive yang in deficiency conditions marked by hectic fever and night sweating, for which it is often prescribed along with cooked rehmannia, anemarrhena, and phellodendron, as in Da Buyin Wan. Late stages of febrile diseases with consumption of yin fluid and hyperactivity of deficiency wind marked by dizziness and convulsion. For such cases, it is often combined with oyster shell, turtle shell, and raw rehmannia.
2. To nourish the kidney and strengthen the bones. Indicated for insufficiency of the liver and kidney marked by weakness of the lower back and limbs, weakness of the muscles and bones, and retarded and incomplete closure of the fontanel in infants, for which it is often combined with cooked rehmannia, achyranthes, and cynamorium.
3. To strengthen the meridians and check bleeding. Indicated for yin deficiency and blood heat in women marked by menorrhagia or metrorrhagia, for which it is often prescribed along with ailanthus, peony, and scute.
The treatment of flaccidity and weakness of loins and feet (alternatively described as weakness of the lower back and limbs) corresponds to treatment of heaviness and weakness in the limbs from the Shennong Bencao Jing; the treatment of uterine bleeding, corresponds to red leakage; and there is common mention of closure of the fontanel, connecting the ancient and modern uses. It is possible that the treatment of fever of deficiency type and treatment of malaria make reference to a common concern, since malarial fevers may have this appearance. However, most references to malarial fevers, both ancient and modern, do not indicate a yin-deficiency type syndrome.
TRADITIONAL PRESCRIPTIONS RELYING ON TORTOISE SHELL
Whatever the indications for the tortoise plastron in modern Materia Medicas, its history of use is perhaps best observed via the well-known formulas that rely on it as a major ingredient. The traditional prescriptions that utilize tortoise shell as a key ingredient may be classified into three groupings:
1. Formulas for yin deficiency accompanied by deficiency fire. These formulas include Da Buyin Wan and its derivatives. Da Buyin Wan (Major Replenish Yin Pills) has four ingredients: tortoise shell, cooked rehmannia, anemarrhena, and phellodendron. The herbs are powdered, combined with honey, and made into large boluses of 9 grams each. Dosage is one pill each time, two or three times per day. Each pill contains about 6 grams of herbs and 3 grams of honey, with just over 2 grams of tortoise shell per pill. This formula is used for replenishing the yin and calming upflaring of kidney fire (deficiency fire). Typical indications include fever and night sweating, restlessness, red tongue, thin tongue coating, and rapid pulse. Tortoise shell also addresses weakness, heaviness, and pain in the legs. One of the best-known derivatives of this formula is Huqian Wan (Pill of Hidden Tiger; referring to stealthy walking of the tiger). This is made by combining the four ingredients of Da Buyin Wan with cynamorium, tiger bone, peony, ginger, and citrus (produced as honey boluses in the same manner). Today, tiger bone is not used, but may be substituted by other bones that are readily available (e.g., pig bones). Like tortoise shells, bones are mainly comprised of collagen and calcium compounds (with emphasis on calcium phosphate). The incorporation of cynamorium and tiger bone (or its substitutes) is intended to focus the action of the formula on flaccidity of muscles and bones, weakness of the lower back and legs, and difficulty walking. As a result, this formula, and modifications made by adding even more tonic ingredients, such as Jianbu Huqian Wan (sometimes called Pill of Flying Feet; literally, Healthy Steps Stealthy Tiger Pills), have been applied in recent times for disorders that cause leg paralysis (such as multiple sclerosis and ALS). Another formula that is based on Da Buyin Wan is Heche Dazao Wan (Placenta Great Nourishing Pills), which replaces anemarrhena with ophiopogon and asparagus, and includes the tonic group ginseng, eucommia, placenta, and achyranthes to tonify qi and yang and nourish blood.
2. Yin deficiency without deficiency fire, accompanied by a slight deficiency of yang. Tortoise shell is combined with deer antler for this purpose, as occurs in Gui Lu Erxian Jiao (Tortoise-Antler Two Immortals Glue). In this case, the two gelatin-containing ingredients are combined with ginseng and lycium in the form of a powder; this is taken in doses of 3 grams each time with some boiled water. The formula nourishes yin (tortoise and lycium) and invigorates yang (ginseng and deer antler), and is used to treat weakness of the back and legs. Another example is Zuogui Wan (Left Returning Pill; that is, pill for restoring the yin to the left kidney). In this formula, the gelatin of tortoise shell and of deer antler is added to a modification of Rehmannia Six Formula (Liuwei Dihuang Wan) containing rehmannia, dioscorea, cornus, lycium, achyranthes (or cyathula, chuanniuxi), and cuscuta.
3. Yin and blood deficiency with stirring of internal wind. Tortoise shell is combined with peony and other liver nourishing agents and with oyster shell (alone or with other wind suppressing agents) for this purpose. Examples are Zhengan Xifeng Tang (Decoction to Rectify the Liver Function and Reduce Wind), which contains the yin and blood nourishing agents tortoise shell, peony, achyranthes, scrophularia, and asparagus to prevent development of wind due to liver deficiency, and the heavy sedating agents hematite, dragon bone, and oyster shell to suppress the rising wind. In addition, the formula contains malt, melia, and capillaris to regulate liver qi in order to avoid having the liver overly suppressed by the combination of rich tonics and heavy sedatives. Another such formula is Da Dingfeng Zhu (Big Pearl to Calm Wind), which combines the yin and blood nourishing agents tortoise shell, egg yolk, gelatin, peony, raw rehmannia, and ophiopogon with oyster shell to suppress wind. A third example is Sanjia Fumai Tang (Decoction of Three Shells to Recover the Pulse) which nourishes yin and blood using tortoise and turtle shells, gelatin, ophiopogon, peony, and raw rehmannia, with oyster shell to suppress wind. These formulas all have a cooling quality to help calm the agitation of the liver. For heart agitation associated with yin deficiency, tortoise shell is combined with dragon bone, as in Zhenzhong Dan, which is comprised of these two ingredients along with acorus and polygala to open the heart orifices. This will treat insomnia and irritability; similar formulations have been applied in modern times to treat attention deficit disorder with hyperactivity.
It will be noted here that nourishing yin and blood are the primary functions of these formulas, and that some of the other indications, such as treatment of bleeding and closure of fontanel, are not mentioned directly, as they are secondary applications.
Acknowledgment: Dr. Fu Kezhi, at the Harbin office of ITM, conducted a literature search and provided valuable background information for this article.
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32. Chen Shuanghou, et al., Pharmacological study on Bushen Shengxue Yihao, Chinese Traditional and Herbal Drugs 1990; 21(6): 266–267.
33. He Guoxing and Wang Xiuhua, Treatment of 52 patients with thrombocytopenic purpura with Bushen Shengxue Tang, Shanxi Journal of Traditional Chinese Medicine 1991; 7(6): 23–24.
34. Zhang Yuanyan, Treatment of 25 cases of Grave’s Disease by dispersion-invigoration therapy, XinJiang Journal of Chinese Medicine 1988; 1: 23–25.
35. Wang Zhishun, Treatment of 300 cases of aplastic anemia, Shandong Journal of Traditional Chinese Medicine 1994; 13 (10): 442–443.
36. Dong Lili, et al., Treatment of rickets with the new drug Longmu Zhuanggu Infusion, Zhongchengyao Yanjiu 1987; 3: 20–21.
37. Gao Huifang and Yan Hongyu, Treatment of 110 cases of vaginal bleeding in women above 40 years old by traditional Chinese medicine, Xinjiang Journal of Traditional Chinese Medicine 1987; 1: 35–36.
38. Sionneau P, Dui Yao: The Art of Combining Medicinals, 1997 Blue Poppy Press, Boulder, CO.
39. Lin Jiehou, Bi-entity (arthritis): Clinical experience of master physician Wang Weilan, Journal of the American College of Traditional Chinese Medicine 1983; 3: 3–28.
40. Pei Zhenxue, The experience of distinguished old physician Pei Shen in the treatment of aplastic anemia, Journal of the American College of Traditional Chinese Medicine 1983; 4: 50–56.
41. Xu Guojun and Wang Zhengtao, Advances in Pharmacognosy in China from 1985–1988, Abstracts of Chinese Medicine 1989; 3(4): 398–413.
42. Qiang Fengwei, Ye Genyao, and Jiang Benrong, 22 cases of chronic aplastic anemia treated with traditional Chinese medicine and large doses of androgen, Journal of Traditional Chinese Medicine 1987; 7(1): 68.
43. Gao Yuncheng, Sun Yali, and Gao Wa, Treatment of cold-type or wet-type arthralgia with deer bone gelatin, Liaoning Journal of Traditional Chinese Medicine 1988; 12(8): 20–21.
APPENDIX 1: Effects of Collagen and Calcium from Chinese Medicines
The main sources of gelatins, which are derived from collagen, are found in tortoise and turtle shells, deer antlers, and, as one of the purest sources, donkey skin gelatin. Their properties are described in Oriental Materia Medica as follows:
• Gelatin (ejiao): supplements blood, controls bleeding, nourishes yin, moistens dryness.
• Antler gelatin (lujiao jiao): supplements kidney yang, reproduces sperm (nourishes jing) and blood, and promotes tissues regeneration.
• Turtle shell (biejia): nourishes yin, clears heat, disperses blood, softens hard lumps, disperses accumulations.
• Tortoise shell (guiban): nourishes yin, subdues yang, strengthens tendons and muscles, cools blood, supplements blood.
• Daimao (another type of tortoise): causes yang to descend, suppresses liver wind, removes toxic heat.
Although not mentioned here, tortoise shell is sometimes recommended to treat uterine bleeding (consistent with the Shennong Bencao Jing description); this is true also of antler gelatin. Therefore, the gelatins appear to have the common properties of nourishing yin and blood, subduing yang, and stopping bleeding. Turtle shell stands out as having the unique attribution of dispersing stagnation in the form of lumps and accumulations.
Substances that are used extensively and provide mainly calcium are oyster shell, haliotis, and dragon bone. Their properties are:
• Oyster shell (muli): tranquilizes spirit, subdues exuberance of liver yang, astringes, softens hardness, disperses accumulations, controls pain. According to the Illustrated Materia Medica (24), oyster shell also treats spontaneous sweating and night sweating, abnormal uterine bleeding, and excessive leukorrhea.
• Dragon bone (longgu): tranquilizes mind, tranquilizes and nourishes spirit, stabilizes soul, fortifies sperm (nourishes jing), subdues exuberance of liver yang.
• Haliotis (shijueming): causes yang to descend, suppresses liver wind, reduces heat, clears vision.
These substances have a cold nature, and their common quality is to treat mental agitation and subdue liver yang. This may well be the role of the calcium component. Other substances that are rich in calcium are also classified as cooling in nature or action (exception: stalactite, sepia bone, tiger bone), including several shells and shell materials:
• Cowry shell (beici): cleanses heat, promotes diuresis, calms the liver, clears vision, tranquilizes heart and spirit.
• Pearls (zhenzhu) and mother of pearl (zhenzhumu): tranquilizes spirit, stabilizes fright, reduces heat, removes toxin, astringes, promotes tissue regeneration.
• Arca (walengzi): disperses blood stagnation and mass formation, controls pain. This is also mentioned as being an expectorant in Illustrated Materia Medica.
• Coral (shanhu): clears vision, sedates and tranquilizes heart, disperses stagnant blood, removes dampness.
• Sepia bone (wuzeigu): astringes and controls bleeding, fortifies sperm (jing), controls leukorrhea, absorbs wounds (topical).
• Clam shell (haigeqiao): reduces heat, delivers dampness, resolves phlegm, resolves accumulation.
• Tiger bone (hugu): disperses wind and cold, strengthens tendons and muscles, controls pain, subdues fearfulness.
• Fish otolith (yunaoshi): dispels heat, removes toxin, promotes diuresis, smoothes urination.
• Sea foam (fuhaishi): expectorant, anti-tussive, antitumor.
• Cyrtiospirifer fossil (shiyan) and Telphusa fossil (shixie): diuretic, clarifies vision, hemostatic.
Although there is some variability in the applications described, all the calcium-rich materials are reputed to calm agitation except for arca shell, cuttle bone, and fish otolith; these three may produce that action but are relied upon primarily for other purposes. Therefore, it seems likely that calcium compounds in these various materials provide a sedative effect for the prescriptions they are used in, especially for persons with calcium deficiency. In addition several of the calcium carbonate compounds are said to clear vision: cowry, haliotis, coral, and the fossils. Modern texts on Chinese medicine often mention that the various shells will inhibit excess stomach acid, and thereby treat pain due to hyperacidity.
There is an overlap of effects claimed for some of the materials that rely mainly on cartilage and/or calcium:
1. Dispersing accumulations: oyster shell, arca, coral, turtle shell, clam shell.
2. Promotes tissue regeneration: pearls and mother of pearl, antler gelatin.
3. Strengthens tendons and muscles: tiger bone, tortoise shell.
4. Astringes: oyster shell, sepia bone.
5. Expectorant: arca, sea foam, clam shell.
6. Diuretic: cowry shell, coral, clam shell
According to Nutritional Influences on Illness (27), the following are symptoms of calcium deficiency:
• Nervous system and neuromuscular disorders: agitation, cognitive impairment, delusions, depression, hyperactivity, insomnia, irritability, muscle cramps, nervousness, neuromuscular excitability, palpitations, tetany, limb numbness, parasthesias, hypertension
• Cartilage and calcium disorders (nails, teeth, bones, and skin): brittle fingernails, tooth decay, osteomalacia, osteoporosis, rickets, stunted growth, eczema.
The Chinese recommendations to use calcium-based animal substances for nervous system and neuromuscular disorders and for tissue repair and strengthening tendons and bones seems reasonable based on modern understanding of the effects of calcium deficiency. Topical application of calcium compounds for astringent effect is also recognized, though internal use would not necessarily be supported. The Chinese recommend topical application of clam shell, mother of pearl, and other shell materials in the treatment of eczema, and perhaps this is an effective treatment for calcium-deficiency type eczema. The action of dispersing accumulations, clearing vision, promoting diuresis, or providing an expectorant effect is not currently explained by the action of known active constituents of the materials.
Of the animal sources of gelatin, the most renewable is the deer antler. Deer are raised for their antler not only in China and Korea, but also in New Zealand, Canada, and the U.S. The antler is cut off without killing the animal, and it is regrown. The sika deer that the Chinese prefer as a standard source of antler is a small animal that can be raised in large numbers. By contrast, the large donkey can not be raised in adequate numbers and must be killed for the skin gelatin; the tortoise and turtles depend on aquatic conditions, which are more difficult to maintain than the open lands used for raising deer, though raising tortoises and turtles is not too complex. Still, the turtles and tortoises must be killed for their shells, and the amount of shell material from each animal is not very great.
Calcium-based nutritional supplements obtained from animal byproducts (bone, shell) or from mineral sources (converted to absorbable forms such as calcium citrate) could be used instead of the other animal source substances, at least for the healing benefits of the calcium.
APPENDIX 2: Aplastic Anemia and Thrombocytopenia
Aplastic anemia refers to a deficiency in circulating red blood cells that occurs because the bone marrow is failing to produce the cells at an adequate rate. This type of anemia stands in opposition to iron deficiency anemia that might arise with inadequate intake or absorption of iron or an autoimmune anemia in which the red blood cells are removed from circulation too quickly. Aplastic anemia may occur with chemical damage to the bone-marrow stem cells that produce red blood cells; these chemicals may be intentionally introduced to the body as a treatment for disease, with aplastic anemia as a side effect. Other causes include viruses, chemical pollutants, genetic disorders, radiation, and leukemias.
In China, aplastic anemia is frequently treated by herbal therapies. There seems to be little agreement on the best formulations to use, as the number of published formulas that differ markedly from one to the next is large, but most of the prescriptions rely heavily on tonic therapies, as might seem appropriate to this disease characterized by a blood deficiency. From the traditional Chinese perspective, the blood is stored in the liver, and there are a group of “liver blood” tonics that are thought to promote the accumulation of blood; the spleen is the source of blood nutrients, so qi tonics are usually deemed important to producing more blood; and the kidney system, which includes the bone marrow, is the ultimate source of blood and is stimulated by a combination of yang tonics to invigorate its activity and yin nourishing herbs to provide essential substance. It is common for the herbal prescriptions recommended to patients with aplastic anemia to be large, incorporating three or four herbs from each of the tonic categories: qi, blood, yin, and yang.
Anemias are often accompanied by fever, and the traditional description is that the blood deficiency, a type of yin weakness, gives rise to a deficiency heat (the heat is not adequately controlled). Thus, some formulas for treatment of aplastic anemia include heat clearing herbs, with a focus on those that clear heat from the blood. Some anemias are accompanied by reduced production of platelets, a condition that can lead to spontaneous bleeding; therefore, some cases of aplastic anemia are treated with herbs that inhibit bleeding.
It has been proposed that as a focus of treatment, for red blood cell deficiency focus on tonifying qi and blood; for platelet deficiency tonify yin; and for leukocyte deficiency tonify yang. Integrated Chinese and Western medicine is sometimes applied, using androgens, such as testosterone or stanazolol, or stem cell growth factors (i.e., erythropoeiten: EPO).
Gelatins from tortoise, turtle, antler, or donkey skin are prescribed in some formulas for the treatment of aplastic anemia. One example is an evaluation that involved 300 patients recruited during a 27-year period and treated with Chinese herb formulas (35). There were four formulas administered, but all contained donkey skin gelatin, rehmannia, and licorice; in the case of hyperactivity of yang and deficiency of yin as a traditional diagnosis, the patients were also treated with tortoise shell, turtle shell, stellaria, picrorrhiza, and lycium bark. While the cure rates were relatively low (except for patients with simple yang deficiency diagnosis), the improvement rates were said to be high; in the case of yin deficiency and yang hyperactivity, 77% of patients were reported to respond to this treatment method.
Another example is the use of Buxue Tang (Blood Nourishing Decoction) plus Buxue San (Blood Nourishing Powder) used in a study of treatment for aplastic anemia (25). The decoction included turtle shell and tortoise shell, the blood cooling and nourishing group of raw rehmannia, moutan, peony; the qi tonics astragalus, atractylodes, dioscorea, and codonopsis; the blood nourishing ho-shou-wu and lycium; and the astringents schizandra, cirsium, and rubia. The powder contained donkey skin gelatin and deer antler, plus ginseng, eucommia, sanqi, and gallus. The decoction and powder were taken twice daily. Of 25 patients so treated, it was reported that 17 were essentially cured, 5 were in remission, and only 3 did not respond after a course of therapy lasting one month. These formulas, rich in gelatins from four animals, mainly focus on the traditional categories of tonifying qi and blood.
A version of this protocol, using Bushen Shengxue Yihao (Tonify Kidney, Generate Blood No. 1), has the main ingredients tortoise gelatin, donkey hide gelatin, rehmannia, and astragalus. This was tested in laboratory animals (32) and shown to increase plasma testosterone levels, an effect that has also been claimed for deer antler and its gelatin. Testosterone is sometimes given along with Chinese herbs to treat aplastic anemia; in one study (42), patients with chronic aplastic anemia were given large doses of testosterone by injection and a decoction of Chinese herbs according to constitution. For patients classified as having yin deficiency, the formula incorporated tortoise shell, tortoise shell gelatin, antler gelatin, lycium, eclipta, ligustrum, and ho-shou-wu. Among 13 of 22 patients who had good response to the combined therapy, 9 had no relapse for at least a year.
Thrombocytopenia, or platelet deficiency (usually due to bone marrow disorder), is treated similarly. For example, one of the versions of Bushen Shengxue Tang, containing tortoise shell gelatin, deer antler gelatin, rehmannia, astragalus, ho-shou-wu, codonopsis, tang-kuei, epimedium, salvia, rubia, ligustrum, and licorice, was given to 54 patients with thrombocytopenia (33). It was reported that all but 2 of the patients responded with increase in platelet counts and halt bleeding due to platelet deficiency.
Another example of treatment strategy is relayed in The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs (26), formulas listed for treating this disorder include Ciyhin Cangxue Fang, which is comprised of tortoise shell, oyster shell, and herbs to clear heat (phellodendron, lycium bark, gardenia), stop bleeding (bleeding is an effect of having low platelets; biota tops, sanguisorba, scute), and tonify deficiency (eucommia, lycium).
According to Pei Shen (40), when treating bone marrow deficiencies, one should tonify the yang to raise leukocytes, nourish the yin to raise platelets, and tonify qi and nourish blood to raise red blood cells. For raising platelets, he recommended tortoise shell gelatin, deer antler gelatin, and donkey skin gelatin, along with polygonatum, jujube, yu-chu, and raw rehmannia, as valuable ingredients.
APPENDIX 3: Parkinson’s Disease
Parkinson’s disease, marked by a combination of muscular paralysis and shaking, is viewed by the Chinese as a representative disease of liver yin and blood deficiency accompanied by liver wind. Its onset is usually later in life when there is a natural decline in the yin, and the symptoms are typical of wind. Treatments generally incorporate herbs for nourishing the liver and various medicinal materials, often of animal source, for inhibiting wind. According to Western medical analysis, the disease is related to a deficiency of a neurotransmitter, the level of which can be boosted by modern drug therapy, thus, controlling the symptoms.
As relayed in The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, formulas for treating Parkinson’s disease frequently include tortoise shells and other gelatins. An example is Yinao Qiangshen Wan, a pill made for this purpose; it contains tortoise gelatin, deer antler gelatin, daimao (a tortoise shell), sea horse, and a number of plant materials, including rehmannia, lycium, ho-shou-wu, polygonatum, cornus, and schizandra, that nourish and astringe the essence. The herbs are ground to powder, made into honey pills and taken one pill each time, three times daily (about 12 grams of powdered herb). Another example is a modification of Anemarrhena, Phellodendron, and Rehmannia Formula (Zhi Bai Dihuang Wan), comprised of cooked rehmannia, cornus, dioscorea, moutan, hoelen, anemarrhena, phellodendron, and tortoise shell. Yet another example is a derivative of the Jisheng Tusizi Wan (Cuscuta Pill), which is comprised of antler gelatin, oyster shell, cuscuta, cistanche, aconite, schizandra, lindera, gallus, alpinia, dioscorea, and mantis eggcase.
Figure 2: The tortoise-serpent pair, ca. 200 A.D.
Figure 3: Tortoise plastron with divination cracks and markings.
Figure 4: Derivation from tortoise plastron cracks of the character bu,
which is now a commonly used “radical” in forming Chinese characters.
Figure 5: Land tortoises used as sources of plastrons for guiban.