I get cuts, scraps bumps, bruises and so do my patients. Some of them heal quickly, while others seem to remain at a standstill for months, oozing red tissue angrily and present weeks after the offending impact. Proper healing of wounds is dependent upon numerous factors and as such is a reflection of overall health.
But first here's a great resource, does everybody know about this nutritional information database?
But first here's a great resource, does everybody know about this nutritional information database?
Luckily, we have lots of options in Chinese Medicine to speed healing. First, from a Chinese Medicine perspective...
Just a quick heads up for those out there who aren't versed in Chinese Medical theory, the references to organs in this paragraph relate to their function within Chinese Medicine, which is distinct from their physiological function recognized by western medicine. We know that the spleen is the organ most closely associated with flesh, and also that the lungs regulate the skin. Sufficient function is required in both in order to have appropriate healing. The kidneys also play a role as the foundational yang substrate for the transformation and transportation of the spleen. The lungs also rely on healthy kidney function as the ability to properly effuse lung qi and moisture throughout the body, moistening the cou li requires unrestricted ventilation of the lungs, which pivots on sufficient grasping of the lung qi by the kidneys. The kidneys lastly play a pivotal role in healing by maintaining appropriate yin and yang balance in the body as a whole. For instance the decreased healing we see in Cushing's syndrome or menopause seems to have a basis in what our medicine would call kidney qi and yin deficiency respectively. Western medical recognizes the intricate work that the white blood cells do and makes clear the reliance on a healthy wei qi. The spleen in a western sense stores monocytes and deploys them when a wound requires more immune cells, a healthy healing process relies on sufficient stores of monocytes in the spleen whether you can relate this to the chinese medicine spleen or not seems murky.
Western Medicine wise...Healing of wounds passes through 4 main stages beginning with homeostatic (where the immediate danger of bleeding is addressed), then inflammatory (where numerous immune cells and inflammatory mediators cooperate to guide the initial patch work), then proliferative (where progressively more permanent materials are laid down) and finally the remodeling phase, where the wound is prettied up; fibrin that was laid down haphazardly is made to point the right direction.
A lot of the information about wound healing comes from the full text of this article, and good ol' wikipedia: here.
The inflammatory phase is the phase where most of our patients are going to be able to benefit from our help. It's the most complex in terms of the interaction of various cell types. It's arguably where our herbal interventions can have the most influence.
The inflammatory phase involves the immediate constriction of local vasculature mediated by prostaglandins and thromboxanes, which is followed shortly by vasodialation, mediated largely by histamine, which enhances the aggregation of immune cells both by increasing local perfusion and creating porous vessel walls.
Neutrophils are the initial responders, arriving on the scene within the first 24 hours. They are responsible for cleaning up foreign and damaged tissue at the sight of injury. Their function is important and it was found through rat experimentation that the lack of sufficient neutrophil presence resulted in poor debridement of the site and decreased fibrinoplasia.
The macrophages move in next and are key. They proliferate in the second to third day (48-96 hours) and carry out multiple functions: detecting the low levels of oxygen in the local tissue they are triggered to induce angiogenesis (the laying down of new blood vessels, and lymph vessels.) The presence of new vessels is key to the continued healing of the wound. They also coordinate the recruitment and aggregation of other cells at appropriate times through the secretion of cytokines and growth factors, thereby conducting the transition from step to step along the healing process. They "express inducible nitric oxide synthase, and are a source of nitric oxide production in the early phase of wound healing." Nitric oxide, besides having antimicrobial actions, also facilitates reepitheliazation, collagen deposition, and speeds the rate of wound closure. So numerous steps in the healing process are carried out by the macrophages, and numerous steps in the healing process are carried out by other cells, which are orchestrated by the macrophages. Wow, those macrophages are busy little blobs.
T-lymphocytes, moving in next, have actions in would healing that are not yet fully clear. Experiments done on rats showed that eradication of certain types of T cells (CD8) increase the strength of a healed wound, whereas eradication of all types of T cells results in a decreased strength of a healed wound. Lau and friends concluded that they "...may bracket control of the proliferation phase of wound healing." In other words they tell when to start and stop laying down fibrin and collagen. Too much fibrin and collagen and there is a big lumpy scar, too little and there is a weak closure that may open again. The T cells maintain moderation in this process.
What can't be overstated is just how crucial the immune cells are in this process. They are doing much more than just attacking invaders, but supervising and directing every stage of the healing process. We can see right away why conditions like diabetes that decrease immune function also affect wound healing. Also, knowledge about the cells active in each phase of wound healing can give us useful clues in how to best help our clients heal. We can look at the place where the healing process is going awry and stimulate specific components of the immune system. Such as the macrophages if the issue is presenting during the inflammatory phase, and specific immunity if it's the proliferation phase that is buggered up.
When it comes to stimulating wound healing there are a number of herbs that I remember from school stimulating healing: huang qi, hua shi, mo yao, ru xiang, and others. When we look at the classifications at the end of the Chen book "Chinese Medical Herblogy and Pharmacology" we find just 5 herbs listed as stimulating the generation of flesh: di yu, gu sui bu, lu hui, lu lu tong, and shan yao. And a trip through the medical literature reveals still a different list that includes: san qi, dan shen, shu di huang, sha ji, and huang qi.
This is a great study from Poland, looking at the proangiogenic actions of a handful of herbs and their application in wound healing. By proangiogenic they mean "making new blood vessels" this is what the macrophages do during the inflammatory phase to speed healing and bring more tissue to the site. It is crucial in the healing process. Anyway, this article is great, it is chalk full of little nuggets of scientific minutiae that bring a bit more clarity to our understanding of these herbs. First, they looked at ginseng (including ren shen, xi yang shen, and san qi.) Then, as western medicine loves to, they got all microscopic and looked at the chemical nature. What they found is that there are multiple ginsenosides (over 40) present in various types of ginseng and the types present and the quantities of each dictate the actions. In the author's words:
The study also looked at aloe vera. It wasn't clear whether they looked at Aloe Vera gel, or at what we know as Lu Hui, which are quite different. Lu Hui is the dark resinous material removed from the fiberous outer rind of the aloe plant, then dried, or charred. Aloe Vera gel on the other hand is the gelatinous material removed from the inner compartments of the stalks of the aloe plant. The chemical constituents are different, but one chemical that they both contain (and many wound healing herbs do) is sitosterol (in Lu Hui it's Beta sitosterol). This chemical has pretty strong actions on increasing angiogenesis and it's where this study put most of its money on why aloe works.
Sea buckthorn, or sha ji, has also demonstrated results in accelerating wound healing. It also contains large amounts of sitosterol (57-76 and 61-83% of the seed and peel respectively) as well as a high oil content, and a number of flavonoids. It has the special application in TCM of being used to treat hematomas, and Bensky also notes it can be applied topically to treat burns.
Sea Buckthorn, Aloe Vera, and Curcuma Longa (jiang huang) were tested together as a topical treatment for slow healing wounds by Gupta and friends. In Gupta's words: "treatment increased cellular proliferation and collagen synthesis at the wound site." He found benefit in both diabetic and normal rats. He used a water extraction of the first two ingredients and an alcohol extraction of the third, combined in a specific ratio (1:7:1) for best results. Sounds like a good thing to have on hand in the clinic.
Astragalus was investigated and found in some studies to contain the ingredients that should speed healing, but was found in another study that topical application did not speed healing of diabetic ulcers, until it was given combined with rehmanniae at a 2:1 ratio. Enter the synergistic actions of herb combining. This is an exciting new arena of research where they are attempting to examine how herbs interact. It's wicked complicated though, and the nice thing is we don't really need to know the why to continue prescribing our herbs in traditional combinations. For me this gives me more reason to respect the formulas created over the centuries. Besides being well balanced in their actions, the formulas that have persisted all these years likely have synergistic actions that go beyond their cumulative effects. It is also a good reason to try to always use herbal mixtures that are extracted or decocted together unless the classics specified another method. So for all the granule people out there, that means just pouring the 4 ingredient powders together to make si wu tang is different than buying the formula decocted together and granulated. You may be losing actions, or introducing other actions that weren't part of the traditionally recognized actions. I'd love to do a post someday on what science knows so far about herb combining. Anyway, back to wound healing...
I found it interesting that Huang Qi contains phytoestrogens that are able to bind to and stimulate estrogen receptors. Here's a nice study showing that. (the others that they looked at that also had estrogen activity, so you don't have to go look up the botanical names were: ge gen, yin yang huo, suo yang, she gan, huang qin, jue ming zi, bu gu zhi, hu zhang, he shou wu, and da huang, they didn't look at shan yao sorry.) As we know estrogen has a proliferative and protective effect when it comes to flesh; mucosa thin and skin thins in menopause and this seems a likely mechanism by which astragalus operates (when taken internally). Astragalus also has actions on increasing wbc count (specifically in regards to macrophages) and macrophages have so much going on in the process of wound healing it seems a no brainer to get our poor healers on huang qi (and our diabetics for that matter.)
So in conclusion there are numerous ways to improve wound healing from directly stimulating new tissue growth via topical application of powdered herbs or extractions with angiogenic actions (san qi, lu hui, sha ji, dan shen, etc.) if you use huang qi topically to improve healing you need to include shu di huang in a 1:2 ratio (huang qi : shu di). Giving herbs internally that regulate and support healthy immune function and improve white blood cell production such as adaptogenic herbs (huang qi, ren shen, san qi, dong chong xia cao, bu zhong yi qi, si jum zi tang etc) will support wound healing by making sure that the cells that are active in wound healing are available to complete the tasks. I know most people in this healing trade always look to treat the root as well as the branch and this area is no exception. Dab a bit of that 2:1 huang qi shu di juice on that thing, or better yet follow Gupta's lead and make your very own 1:7:1 mixture of sha ji, aloe gel and jiang huang but after you've addressed it on the surface, get that patient on some qi tonics as well.
Sorry there was so much mumbo jumbo from the science side in this post, I'll keep the next post a little more Chinese Mediciney.
All the best
The inflammatory phase is the phase where most of our patients are going to be able to benefit from our help. It's the most complex in terms of the interaction of various cell types. It's arguably where our herbal interventions can have the most influence.
The inflammatory phase involves the immediate constriction of local vasculature mediated by prostaglandins and thromboxanes, which is followed shortly by vasodialation, mediated largely by histamine, which enhances the aggregation of immune cells both by increasing local perfusion and creating porous vessel walls.
Neutrophils are the initial responders, arriving on the scene within the first 24 hours. They are responsible for cleaning up foreign and damaged tissue at the sight of injury. Their function is important and it was found through rat experimentation that the lack of sufficient neutrophil presence resulted in poor debridement of the site and decreased fibrinoplasia.
The macrophages move in next and are key. They proliferate in the second to third day (48-96 hours) and carry out multiple functions: detecting the low levels of oxygen in the local tissue they are triggered to induce angiogenesis (the laying down of new blood vessels, and lymph vessels.) The presence of new vessels is key to the continued healing of the wound. They also coordinate the recruitment and aggregation of other cells at appropriate times through the secretion of cytokines and growth factors, thereby conducting the transition from step to step along the healing process. They "express inducible nitric oxide synthase, and are a source of nitric oxide production in the early phase of wound healing." Nitric oxide, besides having antimicrobial actions, also facilitates reepitheliazation, collagen deposition, and speeds the rate of wound closure. So numerous steps in the healing process are carried out by the macrophages, and numerous steps in the healing process are carried out by other cells, which are orchestrated by the macrophages. Wow, those macrophages are busy little blobs.
T-lymphocytes, moving in next, have actions in would healing that are not yet fully clear. Experiments done on rats showed that eradication of certain types of T cells (CD8) increase the strength of a healed wound, whereas eradication of all types of T cells results in a decreased strength of a healed wound. Lau and friends concluded that they "...may bracket control of the proliferation phase of wound healing." In other words they tell when to start and stop laying down fibrin and collagen. Too much fibrin and collagen and there is a big lumpy scar, too little and there is a weak closure that may open again. The T cells maintain moderation in this process.
What can't be overstated is just how crucial the immune cells are in this process. They are doing much more than just attacking invaders, but supervising and directing every stage of the healing process. We can see right away why conditions like diabetes that decrease immune function also affect wound healing. Also, knowledge about the cells active in each phase of wound healing can give us useful clues in how to best help our clients heal. We can look at the place where the healing process is going awry and stimulate specific components of the immune system. Such as the macrophages if the issue is presenting during the inflammatory phase, and specific immunity if it's the proliferation phase that is buggered up.
When it comes to stimulating wound healing there are a number of herbs that I remember from school stimulating healing: huang qi, hua shi, mo yao, ru xiang, and others. When we look at the classifications at the end of the Chen book "Chinese Medical Herblogy and Pharmacology" we find just 5 herbs listed as stimulating the generation of flesh: di yu, gu sui bu, lu hui, lu lu tong, and shan yao. And a trip through the medical literature reveals still a different list that includes: san qi, dan shen, shu di huang, sha ji, and huang qi.
This is a great study from Poland, looking at the proangiogenic actions of a handful of herbs and their application in wound healing. By proangiogenic they mean "making new blood vessels" this is what the macrophages do during the inflammatory phase to speed healing and bring more tissue to the site. It is crucial in the healing process. Anyway, this article is great, it is chalk full of little nuggets of scientific minutiae that bring a bit more clarity to our understanding of these herbs. First, they looked at ginseng (including ren shen, xi yang shen, and san qi.) Then, as western medicine loves to, they got all microscopic and looked at the chemical nature. What they found is that there are multiple ginsenosides (over 40) present in various types of ginseng and the types present and the quantities of each dictate the actions. In the author's words:
It is the ratio between the two types that seems to have the real action on angiogenesis. A predominance of Rg1 lends to more angiogenesis actions while a predominance of Rb1 seems to limit angiogenesis. San Qi is predominantly Rg1, while ren shen and xi yang shen are both predominantly Rb1. This proangiogenic action of san qi might go a long way towards explaining it's apparently contradictory actions of stopping bleeding while invigorating blood. More blood vessels means holding that blood in the body, while also carrying it away from the site.The ginseng root contains 2–3 % ginsenosidesof which Rb1 and Rg1 are the most abundant (Senguptaet al., 2004). The mass-spectroscopic compositional analysisperformed by Sengupta et al. has revealed that Rg1and Rb1 are present in all investigated extracts, however,each extract displays distinct ginsenoside composition,especially in the ratio between the two.
The study also looked at aloe vera. It wasn't clear whether they looked at Aloe Vera gel, or at what we know as Lu Hui, which are quite different. Lu Hui is the dark resinous material removed from the fiberous outer rind of the aloe plant, then dried, or charred. Aloe Vera gel on the other hand is the gelatinous material removed from the inner compartments of the stalks of the aloe plant. The chemical constituents are different, but one chemical that they both contain (and many wound healing herbs do) is sitosterol (in Lu Hui it's Beta sitosterol). This chemical has pretty strong actions on increasing angiogenesis and it's where this study put most of its money on why aloe works.
Sea buckthorn, or sha ji, has also demonstrated results in accelerating wound healing. It also contains large amounts of sitosterol (57-76 and 61-83% of the seed and peel respectively) as well as a high oil content, and a number of flavonoids. It has the special application in TCM of being used to treat hematomas, and Bensky also notes it can be applied topically to treat burns.
Sea Buckthorn, Aloe Vera, and Curcuma Longa (jiang huang) were tested together as a topical treatment for slow healing wounds by Gupta and friends. In Gupta's words: "treatment increased cellular proliferation and collagen synthesis at the wound site." He found benefit in both diabetic and normal rats. He used a water extraction of the first two ingredients and an alcohol extraction of the third, combined in a specific ratio (1:7:1) for best results. Sounds like a good thing to have on hand in the clinic.
Astragalus was investigated and found in some studies to contain the ingredients that should speed healing, but was found in another study that topical application did not speed healing of diabetic ulcers, until it was given combined with rehmanniae at a 2:1 ratio. Enter the synergistic actions of herb combining. This is an exciting new arena of research where they are attempting to examine how herbs interact. It's wicked complicated though, and the nice thing is we don't really need to know the why to continue prescribing our herbs in traditional combinations. For me this gives me more reason to respect the formulas created over the centuries. Besides being well balanced in their actions, the formulas that have persisted all these years likely have synergistic actions that go beyond their cumulative effects. It is also a good reason to try to always use herbal mixtures that are extracted or decocted together unless the classics specified another method. So for all the granule people out there, that means just pouring the 4 ingredient powders together to make si wu tang is different than buying the formula decocted together and granulated. You may be losing actions, or introducing other actions that weren't part of the traditionally recognized actions. I'd love to do a post someday on what science knows so far about herb combining. Anyway, back to wound healing...
I found it interesting that Huang Qi contains phytoestrogens that are able to bind to and stimulate estrogen receptors. Here's a nice study showing that. (the others that they looked at that also had estrogen activity, so you don't have to go look up the botanical names were: ge gen, yin yang huo, suo yang, she gan, huang qin, jue ming zi, bu gu zhi, hu zhang, he shou wu, and da huang, they didn't look at shan yao sorry.) As we know estrogen has a proliferative and protective effect when it comes to flesh; mucosa thin and skin thins in menopause and this seems a likely mechanism by which astragalus operates (when taken internally). Astragalus also has actions on increasing wbc count (specifically in regards to macrophages) and macrophages have so much going on in the process of wound healing it seems a no brainer to get our poor healers on huang qi (and our diabetics for that matter.)
So in conclusion there are numerous ways to improve wound healing from directly stimulating new tissue growth via topical application of powdered herbs or extractions with angiogenic actions (san qi, lu hui, sha ji, dan shen, etc.) if you use huang qi topically to improve healing you need to include shu di huang in a 1:2 ratio (huang qi : shu di). Giving herbs internally that regulate and support healthy immune function and improve white blood cell production such as adaptogenic herbs (huang qi, ren shen, san qi, dong chong xia cao, bu zhong yi qi, si jum zi tang etc) will support wound healing by making sure that the cells that are active in wound healing are available to complete the tasks. I know most people in this healing trade always look to treat the root as well as the branch and this area is no exception. Dab a bit of that 2:1 huang qi shu di juice on that thing, or better yet follow Gupta's lead and make your very own 1:7:1 mixture of sha ji, aloe gel and jiang huang but after you've addressed it on the surface, get that patient on some qi tonics as well.
Sorry there was so much mumbo jumbo from the science side in this post, I'll keep the next post a little more Chinese Mediciney.
All the best
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