ALTERNATIVE MEDICINE . MEDECINE PARALLELE
Ayurvedism: Eastern medicine moves west
Brian Goldman, MD
In the last issue of CMAJ, Dr. Brian Goldman discussed attempts to introduce ayurvedic medicine in North America (144: 53-55). In this article he compares it with western medicine and discusses the vast differences. W M j ' odern health care poses a conundrum. Researchers are pushing the frontiers of medicine ever outward, surgeons are transplanting organs and geneticists are mapping the human genome with increasing precision, yet scientific medicine is being met by waves of discontent. Patients dutifully swallow their pills, but today many want more than a normal checkup. They want to feel better. Physicians have incorporated magnetic resonance imaging and T4 lymphocyte counts into their armamentarium but many of them want something more, too. Why aren't they promoting health instead of treating disease? they ask. The result is a search for new approaches to health and health care by people on both sides of the doctor-patient relationship. One of these new approaches Brian Goldman, a Toronto emergency physician, is a CMAJ contributing editor. 218
CAN MED ASSOC J 1991; 144 (2)
Some call it a new and exciting philosophy for living and for treating patients. Others say it is little more than a marketing ploy designed to cater to the neuroses of the affluently ill.
is several thousand years old. It is called ayurvedic medicine, and some call it a new and exciting philosophy for living and for treating patients. Others say it is little more than a marketing ploy designed to cater to the neuroses of the affluently ill. Whatever one thinks, it is an intriguing blend of biology, eastern philosophy and religion, with an added dash of quantum mechanics. Last year, a leading proponent of ayurvedism came to the Metro Toronto Convention Centre to extol its virtues. "What I'd like to explore today is a new way of looking at the body," announced Dr. Deepak Chopra, the Boston endocrinologist who serves as president of the American Association of Ayur-Vedic Medicine. "The more we understand the me-
chanics of perception, the clearer it becomes that our current model of the human body, perhaps, is based on a superstition, even though we call it the 'scientific' model." Ayurvedism - roughly translated, it means "knowledge of life" - first appeared in India more than 6000 years ago. In recent years it has been revived by the Maharishi Mahesh Yogi, who is best known for introducing the West to transcendental meditation
(TM).
Ayurvedic medicine attempts
to improve health by harmonizing mind and body. To do this it employs a seemingly eclectic combination of herbal remedies, massage therapy, yoga and pulse diagnosis. Proponents such as Chopra claim that ayurvedism can slow or
Chopra, who cloaks himself carefully in the mantle of "rational western physician, " gives western physicians failing grades for their treatment of hypertension, sleep disorders, stress and chronic fatigue.
reverse aging and disorders ranging from cancer to rheumatoid arthritis. In Canada, ayurvedic medicine is taught by the Canadian Association of Ayur-Vedic Medicine, which says more than 1200 North American physicians have received training. There are already three ayurvedic health centres in Canada - in Montreal, Ottawa and Huntsville, Ont. Western medicine and ayurvedic medicine are polar opposites. The former is objective, the product of logic; the latter is subjective, the product of intuition. The two do make strange bedfellows, but Chopra manages to practise both. Born in India, he received some of his training in the US and settled into a successful career as an endocrinologist and chief of staff at a New England hospital. In 1980 he taught himself TM and found that it made him feel better and work more efficiently. Five years later, after meeting the Maharishi Mahesh Yogi, he accepted an offer to help establish ayurvedic medicine in the West. Chopra has taken the task to heart and has written some best-selling books on ayurvedic medicine, including Perfect Health. The Complete Mind/Body Guide (Crown Publishers Inc., New York, 1990). Using lectures and books, Chopra takes aim at the most fundamental precepts of western medicine. He preaches that western physicians steer patients toward treatments that actually increase morbidity and mortality;
he advocates a therapeutic approach that marshals the patient's mind against disease, a process called "quantum healing." He is canny enough to realize that science holds the key to convincing western physicians to give ayurvedic medicine a try. "What I bring from Ayur-Veda [ayurvedic medicine is based on the teachings of Maharishi Ayur-Ved] is a body of knowledge that never really separated psyche from soma, or mind from body," says Chopra. "Since they were never separated, there was no need to invent psychosomatic medicine, which seems to be a kind of recent innovation here [in North America]." In building his case against western medicine, Chopra cloaks himself carefully in the mantle of "rational western physician." He cites articles by western physicians that criticize modern medicine - a favourite is a 1981 New
England Journal of Medicine study reporting that 36% of patients admitted to the general internal medicine service of university hospitals suffer from iatrogenic ailments. He gives western physicians failing grades for their treatment of hypertension, sleep disorders, stress and chronic fatigue. The central distinction between western medicine and ayurvedism is the relationship between matter and consciousness. To the former, matter is supreme and consciousness is an epiphenomenon of matter. With ayurvedism, consciousness is supreme and is the driving force behind all
kinds of matter, including the physical body. At the Toronto meeting Chopra said a person's view of the world is shaped by early sensory experiences; these in turn shape the nervous system in a way that reinforces the initial sensory experience, a fact that Chopra says has profound implications. "The whole system of indoctrination [including cultural and religious indoctrination] that we can call the hypnosis of social conditioning, results in a nervous system that then allows us to perceive only that which we now hold to be true," Chopra concluded. "The popular saying, of course, is that seeing is believing. But it's not true at all. It's the other way around. "We look at the human body as a machine that has learned how to think. As a result, we also have an approach that is completely materialistic. We have 'magic bullets' that are supposed to take care of disease. All of our endeavours in scientific research today are aimed at developing newer and better magic bullets." These magic bullets include antacids for indigestion, ben-
zodiazepines for insomnia, nitroglycerine for ischemic chest pain. But Chopra argued that none of these magic bullets - one conspicuous exception is antibiotics - alters mortality figures. "In the last three decades, there has not been even a 1% change in the age-adjusted mortality from cancer. In fact, there has been a slight increase. So, while it CAN MED ASSOC J 1991; 144 (2)
219
.M
"I'd like to suggest that the whole scientific endeavour is not going to solve the basic problems that address humankind because, perhaps, we have the wrong model of the human body. " -
is also true that we can get rid of some types of cancer because of newer chemotherapeutic agents, it is also true that we have had no impact on the overall morbidity and mortality of cancer. "I don't think this is because we aren't well motivated as physicians. Certainly we are - we want to do good for our patients - but I'd like to suggest that the whole scientific endeavour is not going to solve the basic problems that address humankind because, perhaps, we have the wrong model of the human body." Chopra admits that it would be misleading to suggest that all drugs provide only symptomatic relief. Although he uses ayurvedic techniques in his practice he is still a practising endocrinologist and if a patient presents with hypothyroidism he still prescribes thyroid replacement therapy. He acknowledges that antibiotics and cancer chemotherapeutic agents interfere with the mechanism of disease. However, ayurvedism says that the mechanism and origin of disease are not the same. "Even if we interfere with the mechanism of disease, if we don't look at the origin then disease will find an alternative way of expressing itself," Chopra maintains, "as happens with antibiotic-resistant organisms, as happens with the emergence of new types of cancer, as happens with drug addiction as a result of medically prescribed chemicals. "Right now, our current approach to medical intervention merely redefines, but does not 220
CAN MED ASSOC J 1991; 144 (2)
Dr. Deepak Chopra
reduce, the overall morbidity in a population - it just redefines its expression. It's true that we don't have the epidemics of polio that we had 50 years ago but we have modern-day epidemics of coronary artery disease, bronchitis, hypertension, obesity, cancer, arthritis, diabetes and a whole host of mental disorders that were not so prevalent 50 or 60 years ago." In building the case in favour of ayurvedic medicine, Chopra invokes well-known concepts of physics that have been established for decades, yet have never been applied at the physiological level. For example, although man sees himself as having a distinct form, on the molecular level he is little more than a large number of wellspaced atoms emitting energy and spinning around at enormous speeds. Using the molecular frame of reference, the human body as matter is nothing more than an artifact of perception. Six thousand years ago, ayurvedic physicians described the body as coexisting fields or voids of energy, information and intelligence. According to ayurvedism, the body is very much like a river - although it appears the same at all times, it is not the same from one moment to the next. Ayurvedism also says that the orderly replication of biological processes is driven by a person's thoughts, feelings and desires. There is circumstantial evidence supporting this. Neuropeptides are thought to be the molecular mediators of thoughts, feel-
ings and memories. In fact, receptors for these neuropeptides are located all over the body, not just in the nervous system. It is tempting to postulate that neurochemicals are the substrates for the elusive mind-body interface. White blood cells are also re-
positories for neuropeptide receptors, and Chopra speculates that this is no accident. "If neuropeptides are the equivalent of thought, feeling, emotion and desire, then it's obvious that the immune cell is literally eavesdropping on your internal dialogue," says Chopra. "Then, in fact, you cannot have a thought without your monocytes knowing about it." Studies in immunology have demonstrated that people who experience an intense grief reaction show decreased immune competence, and are more prone to infections and cancer. Monocytes also manufacture neuropeptides and Chopra postulates that the cells actually "think" - in a way, the immune system is nothing more than a circulating nervous system. Recently, the gastrointestinal tract has been shown to manufacture neuropeptides. Chopra maintains that ideas do not have to originate in a person's skull, as most people think. "Now, when you say you have a gut feeling about something, you're not speaking metaphorically at all," says Chopra. "You're speaking literally, because the gut makes the same chemicals that the brain makes
when it thinks. The gut feeling is probably a little more accurate because the gut hasn't yet evolved to the stage of self-doubt that the neuron has." What is the notion of thirst? Chopra argues that the answer depends on the bias of the observer. To the molecular biologist, it is the end result of a molecular process involving substances such as angiotensin II. To a quantum physicist, the same molecules consist of atomic particles that are actually fluctuations of energy in an energy field. "If you're an [ayurvedic] scientist," says Chopra, "[thirst] is just an idea, just a notion." Chopra said people tend to think the same thoughts day after day, and once a notion or thought is strongly held it is hard to dislodge. According to ayurvedic principles, this is also true of the body in general. This concept would hold tremendous implications for our understanding of pathophysiology and treatment of disease. Under ayurvedism, patients' thoughts aren't merely important to their health, but actually determine it. For example, the prototypical harried executive who dies of coronary artery disease at age 40 does so because he lived with the belief that "time is running out." Cho-
pra says people who live with the feeling of time-related pressure manufacture excessive levels of cortisol, insulin, growth hormone and other stress mediators. Compared with others who don't experience this pressure, the patient has a faster heart rate, higher blood pressure and stickier platelets. What implications does ayurvedism hold for treatment? The key one is that patients have options in what they think and perceive. For instance, the harried executive can exercise the option not to be harried. Chopra says most people are conditioned to behave as if they have no options, but ayurvedism preaches the availability of an infinite number of them. To develop the ability to exercise them, Chopra says a patient must begin to witness his own behaviour. "The goal of AyurVeda is to become the silent, nonevaluative, noninterpretive, nonanalytical, nonjudgemental witness. With the witnessing comes the spontaneous ability to restructure those patterns that create our biological responses. "We then spontaneously undergo what can only be described as a mutation in consciousness," he concluded. "If the body is an expression of consciousness, that
mutation in consciousness will spontaneously result in a mutation in biology." Chopra's message about ayurvedism and TM went over well with his Toronto audience, which was already sympathetic to his views. For his listeners, ayurvedic concepts are intuitively true. But ayurvedic medicine has its share of critics. "Essentially, we're talking about primitive medicine," says William Jarvis, PhD, professor of preventive medicine at Loma Linda University in California. "When you go back into folk medicine, they did not differentiate between mental, spiritual and physical disorders. In primitive medicine, by definition, the belief is that health and disease are dependent on supernatural forces forces beyond our reach. "It was Hippocrates who turned medicine into a science by saying that health and disease are natural phenomena. Essentially, it's prescientific medicine." Chopra may appear to have turned his back on science but, ironically, it is going to take scientific evidence, not intuition, to convince a sceptical North American medical community that ayurvedic medicine is something more than a flight of fanciful speculation.-
b4..
Some people would rather... Walk barefoot
...than suffer
on
hot coals
~~WI ...,Fw4.z
hemorrhoidal
pam. But most of your rpatients would prefer the effective pain relie)f of Proctosedyl.
o,, 0 w ; '~it h ADPR-01/01/91
lk,-~
roc 0o.
C
\stroidlocal arnesthetic
antibiotic
astrentY.HC
The only maijor brand containing a anesthetic.
woO Q G 5
n
CCCI L ROUSSE
ROUSSEL
c7 2Ointment: 15 g and 30 g tubes with cannula. G Suppositories: boxes cof 12 and 24.
Ayurvedism: Eastern medicine moves west
Brian Goldman, MD
In the last issue of CMAJ, Dr. Brian Goldman discussed attempts to introduce ayurvedic medicine in North America (144: 53-55). In this article he compares it with western medicine and discusses the vast differences. W M j ' odern health care poses a conundrum. Researchers are pushing the frontiers of medicine ever outward, surgeons are transplanting organs and geneticists are mapping the human genome with increasing precision, yet scientific medicine is being met by waves of discontent. Patients dutifully swallow their pills, but today many want more than a normal checkup. They want to feel better. Physicians have incorporated magnetic resonance imaging and T4 lymphocyte counts into their armamentarium but many of them want something more, too. Why aren't they promoting health instead of treating disease? they ask. The result is a search for new approaches to health and health care by people on both sides of the doctor-patient relationship. One of these new approaches Brian Goldman, a Toronto emergency physician, is a CMAJ contributing editor. 218
CAN MED ASSOC J 1991; 144 (2)
Some call it a new and exciting philosophy for living and for treating patients. Others say it is little more than a marketing ploy designed to cater to the neuroses of the affluently ill.
is several thousand years old. It is called ayurvedic medicine, and some call it a new and exciting philosophy for living and for treating patients. Others say it is little more than a marketing ploy designed to cater to the neuroses of the affluently ill. Whatever one thinks, it is an intriguing blend of biology, eastern philosophy and religion, with an added dash of quantum mechanics. Last year, a leading proponent of ayurvedism came to the Metro Toronto Convention Centre to extol its virtues. "What I'd like to explore today is a new way of looking at the body," announced Dr. Deepak Chopra, the Boston endocrinologist who serves as president of the American Association of Ayur-Vedic Medicine. "The more we understand the me-
chanics of perception, the clearer it becomes that our current model of the human body, perhaps, is based on a superstition, even though we call it the 'scientific' model." Ayurvedism - roughly translated, it means "knowledge of life" - first appeared in India more than 6000 years ago. In recent years it has been revived by the Maharishi Mahesh Yogi, who is best known for introducing the West to transcendental meditation
(TM).
Ayurvedic medicine attempts
to improve health by harmonizing mind and body. To do this it employs a seemingly eclectic combination of herbal remedies, massage therapy, yoga and pulse diagnosis. Proponents such as Chopra claim that ayurvedism can slow or
Chopra, who cloaks himself carefully in the mantle of "rational western physician, " gives western physicians failing grades for their treatment of hypertension, sleep disorders, stress and chronic fatigue.
reverse aging and disorders ranging from cancer to rheumatoid arthritis. In Canada, ayurvedic medicine is taught by the Canadian Association of Ayur-Vedic Medicine, which says more than 1200 North American physicians have received training. There are already three ayurvedic health centres in Canada - in Montreal, Ottawa and Huntsville, Ont. Western medicine and ayurvedic medicine are polar opposites. The former is objective, the product of logic; the latter is subjective, the product of intuition. The two do make strange bedfellows, but Chopra manages to practise both. Born in India, he received some of his training in the US and settled into a successful career as an endocrinologist and chief of staff at a New England hospital. In 1980 he taught himself TM and found that it made him feel better and work more efficiently. Five years later, after meeting the Maharishi Mahesh Yogi, he accepted an offer to help establish ayurvedic medicine in the West. Chopra has taken the task to heart and has written some best-selling books on ayurvedic medicine, including Perfect Health. The Complete Mind/Body Guide (Crown Publishers Inc., New York, 1990). Using lectures and books, Chopra takes aim at the most fundamental precepts of western medicine. He preaches that western physicians steer patients toward treatments that actually increase morbidity and mortality;
he advocates a therapeutic approach that marshals the patient's mind against disease, a process called "quantum healing." He is canny enough to realize that science holds the key to convincing western physicians to give ayurvedic medicine a try. "What I bring from Ayur-Veda [ayurvedic medicine is based on the teachings of Maharishi Ayur-Ved] is a body of knowledge that never really separated psyche from soma, or mind from body," says Chopra. "Since they were never separated, there was no need to invent psychosomatic medicine, which seems to be a kind of recent innovation here [in North America]." In building his case against western medicine, Chopra cloaks himself carefully in the mantle of "rational western physician." He cites articles by western physicians that criticize modern medicine - a favourite is a 1981 New
England Journal of Medicine study reporting that 36% of patients admitted to the general internal medicine service of university hospitals suffer from iatrogenic ailments. He gives western physicians failing grades for their treatment of hypertension, sleep disorders, stress and chronic fatigue. The central distinction between western medicine and ayurvedism is the relationship between matter and consciousness. To the former, matter is supreme and consciousness is an epiphenomenon of matter. With ayurvedism, consciousness is supreme and is the driving force behind all
kinds of matter, including the physical body. At the Toronto meeting Chopra said a person's view of the world is shaped by early sensory experiences; these in turn shape the nervous system in a way that reinforces the initial sensory experience, a fact that Chopra says has profound implications. "The whole system of indoctrination [including cultural and religious indoctrination] that we can call the hypnosis of social conditioning, results in a nervous system that then allows us to perceive only that which we now hold to be true," Chopra concluded. "The popular saying, of course, is that seeing is believing. But it's not true at all. It's the other way around. "We look at the human body as a machine that has learned how to think. As a result, we also have an approach that is completely materialistic. We have 'magic bullets' that are supposed to take care of disease. All of our endeavours in scientific research today are aimed at developing newer and better magic bullets." These magic bullets include antacids for indigestion, ben-
zodiazepines for insomnia, nitroglycerine for ischemic chest pain. But Chopra argued that none of these magic bullets - one conspicuous exception is antibiotics - alters mortality figures. "In the last three decades, there has not been even a 1% change in the age-adjusted mortality from cancer. In fact, there has been a slight increase. So, while it CAN MED ASSOC J 1991; 144 (2)
219
.M
"I'd like to suggest that the whole scientific endeavour is not going to solve the basic problems that address humankind because, perhaps, we have the wrong model of the human body. " -
is also true that we can get rid of some types of cancer because of newer chemotherapeutic agents, it is also true that we have had no impact on the overall morbidity and mortality of cancer. "I don't think this is because we aren't well motivated as physicians. Certainly we are - we want to do good for our patients - but I'd like to suggest that the whole scientific endeavour is not going to solve the basic problems that address humankind because, perhaps, we have the wrong model of the human body." Chopra admits that it would be misleading to suggest that all drugs provide only symptomatic relief. Although he uses ayurvedic techniques in his practice he is still a practising endocrinologist and if a patient presents with hypothyroidism he still prescribes thyroid replacement therapy. He acknowledges that antibiotics and cancer chemotherapeutic agents interfere with the mechanism of disease. However, ayurvedism says that the mechanism and origin of disease are not the same. "Even if we interfere with the mechanism of disease, if we don't look at the origin then disease will find an alternative way of expressing itself," Chopra maintains, "as happens with antibiotic-resistant organisms, as happens with the emergence of new types of cancer, as happens with drug addiction as a result of medically prescribed chemicals. "Right now, our current approach to medical intervention merely redefines, but does not 220
CAN MED ASSOC J 1991; 144 (2)
Dr. Deepak Chopra
reduce, the overall morbidity in a population - it just redefines its expression. It's true that we don't have the epidemics of polio that we had 50 years ago but we have modern-day epidemics of coronary artery disease, bronchitis, hypertension, obesity, cancer, arthritis, diabetes and a whole host of mental disorders that were not so prevalent 50 or 60 years ago." In building the case in favour of ayurvedic medicine, Chopra invokes well-known concepts of physics that have been established for decades, yet have never been applied at the physiological level. For example, although man sees himself as having a distinct form, on the molecular level he is little more than a large number of wellspaced atoms emitting energy and spinning around at enormous speeds. Using the molecular frame of reference, the human body as matter is nothing more than an artifact of perception. Six thousand years ago, ayurvedic physicians described the body as coexisting fields or voids of energy, information and intelligence. According to ayurvedism, the body is very much like a river - although it appears the same at all times, it is not the same from one moment to the next. Ayurvedism also says that the orderly replication of biological processes is driven by a person's thoughts, feelings and desires. There is circumstantial evidence supporting this. Neuropeptides are thought to be the molecular mediators of thoughts, feel-
ings and memories. In fact, receptors for these neuropeptides are located all over the body, not just in the nervous system. It is tempting to postulate that neurochemicals are the substrates for the elusive mind-body interface. White blood cells are also re-
positories for neuropeptide receptors, and Chopra speculates that this is no accident. "If neuropeptides are the equivalent of thought, feeling, emotion and desire, then it's obvious that the immune cell is literally eavesdropping on your internal dialogue," says Chopra. "Then, in fact, you cannot have a thought without your monocytes knowing about it." Studies in immunology have demonstrated that people who experience an intense grief reaction show decreased immune competence, and are more prone to infections and cancer. Monocytes also manufacture neuropeptides and Chopra postulates that the cells actually "think" - in a way, the immune system is nothing more than a circulating nervous system. Recently, the gastrointestinal tract has been shown to manufacture neuropeptides. Chopra maintains that ideas do not have to originate in a person's skull, as most people think. "Now, when you say you have a gut feeling about something, you're not speaking metaphorically at all," says Chopra. "You're speaking literally, because the gut makes the same chemicals that the brain makes
when it thinks. The gut feeling is probably a little more accurate because the gut hasn't yet evolved to the stage of self-doubt that the neuron has." What is the notion of thirst? Chopra argues that the answer depends on the bias of the observer. To the molecular biologist, it is the end result of a molecular process involving substances such as angiotensin II. To a quantum physicist, the same molecules consist of atomic particles that are actually fluctuations of energy in an energy field. "If you're an [ayurvedic] scientist," says Chopra, "[thirst] is just an idea, just a notion." Chopra said people tend to think the same thoughts day after day, and once a notion or thought is strongly held it is hard to dislodge. According to ayurvedic principles, this is also true of the body in general. This concept would hold tremendous implications for our understanding of pathophysiology and treatment of disease. Under ayurvedism, patients' thoughts aren't merely important to their health, but actually determine it. For example, the prototypical harried executive who dies of coronary artery disease at age 40 does so because he lived with the belief that "time is running out." Cho-
pra says people who live with the feeling of time-related pressure manufacture excessive levels of cortisol, insulin, growth hormone and other stress mediators. Compared with others who don't experience this pressure, the patient has a faster heart rate, higher blood pressure and stickier platelets. What implications does ayurvedism hold for treatment? The key one is that patients have options in what they think and perceive. For instance, the harried executive can exercise the option not to be harried. Chopra says most people are conditioned to behave as if they have no options, but ayurvedism preaches the availability of an infinite number of them. To develop the ability to exercise them, Chopra says a patient must begin to witness his own behaviour. "The goal of AyurVeda is to become the silent, nonevaluative, noninterpretive, nonanalytical, nonjudgemental witness. With the witnessing comes the spontaneous ability to restructure those patterns that create our biological responses. "We then spontaneously undergo what can only be described as a mutation in consciousness," he concluded. "If the body is an expression of consciousness, that
mutation in consciousness will spontaneously result in a mutation in biology." Chopra's message about ayurvedism and TM went over well with his Toronto audience, which was already sympathetic to his views. For his listeners, ayurvedic concepts are intuitively true. But ayurvedic medicine has its share of critics. "Essentially, we're talking about primitive medicine," says William Jarvis, PhD, professor of preventive medicine at Loma Linda University in California. "When you go back into folk medicine, they did not differentiate between mental, spiritual and physical disorders. In primitive medicine, by definition, the belief is that health and disease are dependent on supernatural forces forces beyond our reach. "It was Hippocrates who turned medicine into a science by saying that health and disease are natural phenomena. Essentially, it's prescientific medicine." Chopra may appear to have turned his back on science but, ironically, it is going to take scientific evidence, not intuition, to convince a sceptical North American medical community that ayurvedic medicine is something more than a flight of fanciful speculation.-
b4..
Some people would rather... Walk barefoot
...than suffer
on
hot coals
~~WI ...,Fw4.z
hemorrhoidal
pam. But most of your rpatients would prefer the effective pain relie)f of Proctosedyl.
o,, 0 w ; '~it h ADPR-01/01/91
lk,-~
roc 0o.
C
\stroidlocal arnesthetic
antibiotic
astrentY.HC
The only maijor brand containing a anesthetic.
woO Q G 5
n
CCCI L ROUSSE
ROUSSEL
c7 2Ointment: 15 g and 30 g tubes with cannula. G Suppositories: boxes cof 12 and 24.
