MEDICAL HERBALISM: A Journal for the Clinical Practitioner
Sample issue
MEDICAL HERBALISM VOL 6 NO 1. Spring 1994
Copyright 1994 by Bergner Communications
This electronic sample does not contain all articles and graphs.
It has been widely reported in English language herbal circles in recent years that echinacea loses some of its ability to stimulate the immune system after about ten days of treatment. It is thus often recommended that patients take echinacea long-term in a ten-day-on, five-day-off pattern. This recommendation appears to be without basis. A study by Jurcic et al, which was published in 1989 in German, is invariably given as the basis for this recommendation. The accompanying graph, from that article, indeed shows phagocytosis (one measure of immune activity) declining after day five and trailing off to a plateau from day eight to ten. However, the dose of echinacea, indicated by the vertical arrows at the bottom left of the graph, (and reported in the body of the article), was discontinued after day five. The original article is in German, and the duration of the dose was apparently not translated, or was mistranslated. Thus, instead of showing any diminished response to echinacea over ten days, it shows a persistent elevation of immune response for five days even after echinacea is discontinued. The plateau at the end of the curve, from days eight through ten, shows an increase in phagocytosis of 20%. Our thanks to Dr. Kerry Bone of Australia for bringing this to our attention.
Silybum marianum (Carduus marianum), commonly known as milk thistle after the prominent white veins on the large spiny leaves, is currently one of the most popular herbs in common usage. Its fame has spread far beyond the herbal dispensary, with members of the public clamouring for the herb in reponse to a marketing blitz by herbal companies. Research from Europe, chiefly Germany, testifies to the long held belief that Milk Thistle is supreme at healing chronic or acute liver damage and protects the liver against many toxins and pollutants (Weiss). It has been mentioned in literature for hundreds of years, even being used by Dioscorides, a herbalist of ancient Greece, to cure the bite of a mad dog (Hobbs). Gerard in 1596 stated that My opinion is that this is the best remedy that grows against all melancholy (bile-liver) diseases (Willard 1991). Culpepper used it for obstructions of the liver and spleen and the Eclectics used it for liver congestion as well as varicose veins, menstrual disorders and other conditions now known to be associated with liver disorders (Willard 1991). In clinical practice we use Milk Thistle where liver stress is a factor in the disease process. Thus when toxicity states occur such as in chronic (even low grade) alcohol abuse, drug use (recreational or pharmaceutical), coffee habituation, intake of chemically raised meats and vegetables, poor quality water or any other situation of liver overload, milk thistle is chosen for its ability to tonify the liver and aid in regeneration. Milk thistle is frequently and erroneously used as a liver stimulant. In fact it works by literally strenghtening the liver cell walls so that toxins cannot enter as easily. Milk thistle appears to act by inducing the formation of liver cell proteins which are then incorporated into the cell wall rendering it stronger and more resistant to toxins (Willard 1991). Milk Thistle also helps to prevent depletion of glutathione in liver cells, a substance which serves as a mediator of cell metabolism (Willard 1992). The medicinally active constituent of milk thistle is found in the seeds and appears to be a group of flavanolignans called silymarin which comprises the flavonoid isomers silybin, silydianin and silychristin. The main activity comes from the silymarin of which up to 47% is absorbed from the gut and which takes 24 hours to be completely eliminated from the body (Zelystra). In modern phytotherapy a solid extract of the seeds is used, standardised to 70% silymarin content. The dose is given as 100 - 300 mg three times daily (Willard 1992). In traditional herbal medicine, of course, standardised extracts were not used, and yet significant therapeutic results were obtained, as evidenced by the enthusiastic writings of Gerard among others. In my clinical practice over the past seven years I have had extensive experience using milk thistle in simple galenical tinctures (usually in a 1:3 or 1:4 strength) and have been consistently pleased with the results. Unfortunately the flavanolignans are not very soluble in water and so alcohol is used in the extraction, usually at a strength of 45%. We then usually recommend the patient take the tincture in boiling water to evaporate away as much of the alcohol as possible. Case report Miss N. first presented in my clinic in October 1993. She was 27 years old and of East Indian origin. She had been diagnosed at 16 with Wilson's Disease, an autosomal recessive condition of liver enzyme defects causing accumulation of copper in the liver and brain. The condition had been stable for some years but had recently degenerated significantly and at the time of our first consultation she was on the waiting list for a liver transplant. Her symptoms included extreme fatigue, sleep/waking reversal (ie. sleeping in the day and being awake in the night), poor appetite and significant weight loss, night chills, bone pain, muscle wasting, right upper quadrant pain that varied in severity but was always present to some degree, dry and itchy skin, falling hair, easy bruising and prolonged clotting time, dizziness, leg cramps, amenorrhoea, alternating constipation and diarrhoea and swollen ankles. Blood work in August 1993 had shown the following results:
Patient values : normal values
Hb. 9 g/dl : 12 - 16
Albumin 24 g/dl : 3.2 - 5.6
Total bilirubin 56 mg/dl : 0.3 - 1.4
Alkaline phosphatase 283 U/dl : 4 - 13
ALT (SGPT) 64 iu/L : 5 - 24
AST (SGOT) 96 iu/L : 3 - 21
An ultrasound taken in August 1993 had revealed a shrunken liver with multiple cirrhotic lesions, a gallstone of indeterminate size and evidence of splenomegaly. The prognosis for this patient was bleak, unless she received an urgent liver transplant, an idea with which she had many ethical and religious problems. She had been treated conservatively with cuprimine (D penicillamine) since the age of 16. This drug is a chelating agent for metals in the body to make them water soluble for renal excretion. She had also been on spironolactone (an aldosterone antagonist and potassium-sparing diuretic) for many years due to her episodic ascites and generalised edema. She had recently consulted with a naturopathic doctor who prescribed an anti-candida program. She was dissatisfied with this because she did not feel she was manifesting symptoms of candida. Her diet included a lot of dairy products (milk and ice cream) as well as fried foods. There were some vegetables, but mostly canned or frozen. She ate fish or chicken several times a week. The main fluid consumed was fruit juice, and no coffee was taken. She was also taking, on the advise of the naturopath, a daily glass of olive oil with the juice of two limes. She complained of severe digestive pain and intense nausea immediately after taking this for about fifteen minutes. My recommendations to this client were as follows: Avoid fried or fatty foods and all dairy products. The oils as well as the hormone and pesticide residues will create more work for the liver. Avoid also the olive oil/lime juice cocktail, this is not appropriate for such a stressed liver as this client had. Drink more water<|> <|>at least eight glasses a day. Drink fresh carrot juice with a little beets and some green barley powder. This will cleanse the liver and provide chlorophyll to rebuild the hemoglobin. Take lipotropic factors (phosphatidyl choline, L-methionine and inositol) at 1 gram of each per day. This stimulates and cleanses the liver and aids in the elimination of fats from the body. Eat plenty of fresh fruit and vegetables and eat only organic food if possible.
I also gave her the following herbal formula:
Taraxacum folia (Dandelion leaf) 1:4 15 mls.
Silybum marianum (Milk thistle) 1:2 20 mls.
Chelidonium majus (Celandine) 1:3 15 mls.
Ginkgo biloba 1:3 15 mls.
Eleutherococcus s. (Siberian ginseng) 1:3 15 mls.
Verbena off (Vervain) 1:3 20 mls.
sig. 5 mls. bid aq. cal. a.c. 100 mls.
The dandelion leaf was given as a diuretic and a hepatic and biliary stimulant; the milk thistle was given as an hepatic trophorestorative; the celandine was given as an hepatic decongestant; the ginkgo and ginseng were given as energy boosters and anti-inflammatories; the vervain was given as a bitter hepatic stimulant and for its relaxing nervine effect. She was also given Bach Flower remedies for indecision and adjustment to new situations (scleranthus and walnut), fear of known origin (mimulus) and utter fatigue (olive). Because of the impending surgery I also gave her echinacea, Calendula off. (marigold), and Galium aparine (Cleavers) to help her recover from the anesthetics. This was to be taken immediately pre- and post-operatively. I saw Miss N. again a month later and she reported a significant improvement in her symptom picture. She was less tired and sleeping more regularly, the upper right quadrant pain was much less, the appetite was better and she was sticking faithfully to the recommended dietary changes, the bone pain and night chills were lessened and the ankle edema was also reduced. Bowel movements had been regular and normal. Her blood picture at this time showed an increase in the hemoglobin level (11 g/dl) and a reduction in albumin (22 g/dl), total bilirubin (38 mg/dl) and alkaline phosphatase (253 U/dl). ALT and AST remained significantly elevated. I repeated the herbal formula, this time suggesting that she take it at the does of 5 ml three times a day. Just after Christmas Miss N. phoned to say that the doctors had taken her off the critical transplant list and she was going to visit with her family in Ontario for a while. She took enough herbal formula away with her to last two months. Last week she phoned again to say that her blood work was steadily improving and she was feeling the best she had for years. The doctors were pleased with her progress although she remained on the non-critical liver transplant waiting list. This was a particularly challenging case because with congenital genetic disorders there is really no chance of a cure. As I explained to Miss N. the best that I could offer was a slowing of the disease progression and a lessening of the symptoms. She will certainly need the transplant at some time but the longer we can delay it the better for her. Because I gave a formula containing several herbs it is impossible to say which one was actually responsible for the significant improvement that occurred. It is my belief that the synergy of all the herbs as well as the dietary adjustments and the Bach flower remedies was responsible for the improvement. In summary, use milk thistkle wherever there is stress to the liver. It is a great tonic and rejuvenator and may be used prophylactically as well as for existing conditions.
Herbalism today is not immune from the world view of reductionist science and allopathic medicine. Too often we think of Herb A for Condition B, and an herb gets pigeonholed. Thus we now think of milk thistle as a liver herb, and its well that we should. But we shouldn't limit our thinking to using it only for overt liver disease, such as hepatitis or cirrhosis. As we related at length in our last issue, many diseases may be related to liver dysfunction. Furthermore, because milk thistle is proven to be a liver herb doesn't mean that it's only a liver herb. A description follows of the clinical use of milk thistle seed (tincture) by Finley Ellingwood, MD, who introduced the herb into Eclectic medical practice in the late nineteenth century. The Eclectics were known as careful clinical observers who shied away from extravagant claims. Carduus marianus [(Silybum marianum)] Harvey, in the California Medical Journal, says the indications are so plain that a tyro can prescribe it with certainty. It is indicated where there is venous stasis, the true veins enlarged and clogged with blood. This is true of either the large or small veins. He says he cured one case where the veins from the hips to the toes were as large and as hard as twisted Manila rope. They could be felt through the clothing. He cured completely a varicose tumor in the popliteal space [ed: behind the knee]. It was about four inches long, and three inches wide. The skin of the neck and hands was discolored. There was a troublesome chronic cough with the expectoration of large quantities of offensive matter. He believed these symptoms to be associated with disease of the spleen. He has observed these colored spots in other cases, and sometimes found long continued soreness and tenderness of the joints of the feet. Carduus, in five-drop doses three or four times a day, cured all the symptoms in this case, restoring the patient to perfect health. The remedy acts slowly and must be persisted in. Ellingwood names the following possible indications for milk thistle seed:: Dull aching pain over the spleen, which radiates up to the left shoulder blade, associated with debility and despondency, splenic pain with or without enlargement, when there is no evidence of malaria. Congestion of the liver, spleen, or kidneys. General bilious conditions accompanied with stitches in the right side, with hard and tender spots, gallstone, jaundice, hepatic pain and swelling. Vomiting of pregnancy, when liver and spleen are involved. For hemorrhages, when there is congestion of the liver or spleen. Periodic gall stones. Pelvic congestions. Caruncular growths in the female urethra. Blood in the urine, with sensation of weight and tension in the pelvis, when accompanied by varicosities in the rectal veins. Hemorrhoids and varicose veins.
This picture shows the loss of limiting the consideration of milk thistle seed to overt liver conditions. Notice also that, despite the claims of modern herb marketers that only the concentrated solid extract is effective, in the case above, severe varicose veins were effectively treated with five-drop doses of a strong alcohol tincture three or four times a day.
Milk thistle seed extracts, usually standardized to 70% silymarin content, are commonly used in conventional medicine in Europe, where it has been officially available since 1969. More than $180 million in silymarin products were sold in Germany alone in one recent year. The trials below all used this 70%-silymarin pharmacetuical preparation, but this does not in any way prove that only such preparations would have this clinical result. See the accompanying articles for reports of clinical use of other forms of milk thistle seed.
Your Be sure it's scullcap piece in Vol. 5, No.4 of Medical Herbalism may have been more appropriately titled Be sure it's accurate. The non-critical use of the ambiguous common name germander serves to further confuse the problem associated with Teucrium hepatotoxicity. The genus Teucrium of the mint family (Lamiaceae) consists of about one hundred species of herbaceous and woody plants, primarily from Europe (with forty-nine species). The best known species is Teucrium chamaedrys, the common germander. Other species traded as minor commodities in botanical markets have included Teucrium marum, known as herba mari vari, or cat thyme, which like catnip, produces the catnip response in felines (Tucker and Tucker 1988). Teucrium scordium, known under the common name garlic herb , and the related Teucrium scordonia, wood-sage , are minor commodities primarily used by herbalist in Europe. Another Mediterranean species Teucrium polium was traditionally used as an antispasmodic and hypoglycemic agent. A 1989 study by Gharaibeh et al. evaluated the anorexic effect of the herb in rats, and found that administration of the herb caused a marked, dose-dependent, reversible, anorexic effect. Such studies heightened the position of Teucrium species in weight-loss products, especially in Europe. The North American native, Teucrium canadensis, known as wild germander, wood sage or wild basil, has traditionally been used to induce menstruation, urination, and sweating. It has also been known as a widespread adulterant to commercial supplies of scullcap (Scutellaria lateriflora) as first reported in the pages of HerbalGram nine years ago (Anon. 1985). Teucrium chamaedrys, common germander, has long been known in Europe as a folk remedy in the treatment of obesity. Various products were available in Europe including teas, a medicinal liquor, capsulated products, a product mixed with green tea, as well as bulk herb (Larrey et al. 1992). The plant had been approved by the French Ministry of Health and Humanitarian Action as an adjuvant in slimming diets, in the symptomatic treatment of mild diarrhea, and as a topical analgesic for oral cavity infections. Products were available both at pharmacies and health specialty stores (WHO 1992). A paper published in the 15 July 1992 issue of Annals of Internal Medicine by D. Larrey et al. presented case reports of seven patients who developed acute hepatitis with germander (Teucrium chamaedrys) ingestion. In the seven patients no other cause of hepatitis was detected. A clear chronological relationship was also established between ingestion of Teucrium chamaedrys and the onset of hepatitis. Liver dysfunction was reversed after use of Teucrium chamaedrys products was discontinued. The mechanism of Teucrium chamaedrys hepatoxicity could not be determined. Prior to the publication of the above report, the French Ministry of Health was aware of the possible problem with Teucrium chamaedrys and had been monitoring it closely. By the spring of 1992 French drug surveillance centers had collected twenty-six reports of acute hepatitis associated with Teucrium chamaedrys ingestion. All of these cases were benign with an onset delay of six weeks to six months. Finally in April 1992 the French Ministry of Health prohibited the sale of the herb (Mostera-Kara et al. 1992). In the September 1992 issue of Lancet Mostera-Kara et al. report on a fatal case of hepatitis after the use of a germander product, despite the fact that the manufacturer had withdrawn the product from sale in February of 1992. The ingestion of germander (Teucrium chamaedrys) has been established as a causative factor in cases of acute hepatitis, and one case of fatal hepatic dysfunction. Given the fact that an indigenous North American Teucrium species (Teucrium canadense) has been implicated as an adulterant to scullcap (Scutellaria lateriflora), as reported in HerbalGram in 1985, the question must be raised as to whether or not other species of Teucrium, besides T. chamaedrys may cause acute hepatitis. However, the 100+ species in the genus should not be confused by ambiguously referring to them as germander . This question is especially poignant in light of the fact that several cases of hepatoxicity have been linked to scullcap-containing products. MacGregor et al. 1989 reported on four cases of hepatotoxic effects resulting from products containing both scullcap and valerian. By association, valerian has been implicated to have hepatotoxic potential. You failed to point this out in your piece. Furthermore, the authors wrote that during an investigation of herbal medicines available in the United Kingdom it was found that scullcap available from some wholesalers was not a Scutellaria sp. As pointed out by Ryan Huxtable in his editorial in the 15 July 1992 issue of the Annals of Internal Medicine the importance of botanical identification of herbal preparations involved in poisoning cases is paramount. Persistent, long-standing instances of adulteration and mislabeling of improperly identified botanicals, such as in the instance of scullcap adulteration with Teucrium canadense, and adulteration of Echinacea purpurea root supplies with Parthenium integrifolium, have in my opinion received inadequate attention, despite the problems of being brought to the public attention. In the WHO Guidelines for the Assessment of Herbal Medicines, reprinted in their entirety in HerbalGram 28 (Akerele 1993), one of the most important statements in this writer's opinion is the paragraph on Crude plant material, which states: The botanical definition, including genus, species, and authority should be given to insure correct identity of a plant. A definition and description of the plant from which the medicine is made (e.g. leaf, flower, root) has to be provided as well as indications as to whether fresh, dried or traditionally-processed material is used. The active constituents should be specified, and if possible content limits defined. Foreign matter, impurities and microbial content should be defined or limited. Voucher specimens representing each lot of plant material processed should be authenticated by a qualified botanist and should be stored for at least a ten year period. A lot number should be assigned and this should appear on the product label. Attention to proper botanical identification of plant material sold in the botanical trade, accompanied with vouchers corresponding to lot numbers, could help to eliminate implication of herbs in toxicity cases, such as scullcap (Scutellaria lateriflora) and by association valerian (Valeriana officinalis). An industry mechanism should be developed for the immediate removal of known adulterants from the marketplace as soon as such reports become known and are verified. Furthermore, when reporting on toxicity cases careful attention should be paid to species (and even chemotype identity), rather than tossing around ambiguous common names as if they were meaningful.
Licorice root (Glycyrrhiza glabra) is a time-honored herbal medicine in all world herbal traditions. It is used as a primary herb in perhaps more categories than any other medicinal plant. It is used with success for acute respiratory problems, gastric ulcers, gastritis, inflammatory conditions in general, and adrenal exhaustion. Components of licorice root have both estrogenic and anti-estrogenic activity (Leung; Kraus; Kumagai et al; Sharaf and Goma; Tamaya et al). It is thus an important herb for treating hormone-related female problems. It has not traditionally been used as a liver herb, but medical research over the past two decades in Japan and China has shown that licorice is also an important liver herb with strong hepatoprotectant properties. This should not be thought of as just another minor use for licorice. It is as signficant a hepatoprotectant as the better-known milk thistle seed, and acts through separate mechanisms than that herb. The two together should be considered in any hepatoprotectant formula or treatment plan.
Most of the Asian clinical research and practice has been with glycyrrhizin, a major constituent of licorice root. The product in most Japanese trials is Strong Neominophagen-C (SNMC) which contains 40 mg glyzyhhrizin, 20 mg cysteine, and 400 mg glycine in 20 ml saline solution. Cysteine and glycine are amino acids. A typical treatment for hepatitis is 40 ml of SNMC a day for thirty days delivering 80 mg of glycyrrhizin per day (Hikino). The upper range of clinical trials has been 200 ml SNMC (400 mg glycyrrhizin) (Mori et al, 1989, 1990), but trials above 100 ml (200 mg glycyrrhizin) have been rare, due to concern over possible side effects (see below) (Hikino). Oral extracts Comparable therapeutic levels of glycyrrhizin can probably be reached with oral preparations. Glycyrrhizin is the most important active constituent of licorice, and therapeutic levels for a wide variety of conditions are easily achieved with oral administration. Licorice root (G. glabra) contains 6-14% glycyrrhizin (Merck), so an oral dose of 7-8 grams powdered licorice would deliver the highest range of glycyrrhizin used in the hepatitis trials to the gut. This compares to a traditional Chinese oral dose of 3-12 grams G uralensis (Bensky). How much of this would reach the plasma, and thus be equivalent to the intravenous trials, has not been tested. Oral administration of glycyrrhizin alone or as licorice root extract has been tested in mice (Ozaki et al), and found to be comparable, with each form acheiving similar levels of glycyrrhizin or its active metabolites in the plasma. Hepatitis Clinical trials for hepatitis, especially chronic active hepatitis, have been so successful in Japan that glycyrrhizin is now a standard medical treatment there (Kumada et al; Matsunami et al.; Ohta et al; Su et al; Suzuki et al; Wang; Zhang et al).
The mechanisms of hepatoprotection are diverse, and include antioxidant activity (Kiso et al; Abdugafurova et al; Tan; Ju et al), direct antiviral effects (Hikino; Crance), enhancement of interferon production (Hikino; Shinada); enhanced antibody production (Hikino), enhancement of extrathymic T-Cell activity in the liver (Kimura et al), and protection from immunological (auto-immune) injuries (Hikino; Mizoguchi et al). A number of animal and in vitro trials have shown that glycyrrhizin can protect liver cells from damage from a variety of chemical or immunological agents (Nakamura et al; Mizoguchi et al; Shibayama; Shiki et al; Zhao et al). Other Clinical trials Glycyrrhiza has also been effective in treating HIV/ARC in hemophiliacs, and, notably, improved liver dysfunction in these patients (Mori et al, 1990; Mori et al, 1989). It has also been effective in preventing the hepatic side effects of chemotherapy with a methotrexate combination or interferon (Akimoto et al; Hayashi et al), and in treating general hepatic failure (Acharya).
One reason licorice is so effective in treatment of the liver is that it enters the enterohepatic loop, that is, it is excreted in the bile, then reabsorbed in the gut to recycle repeatedly through the liver (Ichikawa; Ishida).
Licorice produces well-documented side effects when taken in large doses (>50 g/day) or for long duration (>>six weeks) (Wichtl). No such side effects have been observed in clinical trials of 40 ml SNMC/day for thirty days, or with 100 ml SNMC (200 mg glycyrrhizin/day) for a short period (Hikino). With widespread use of SNMC in japan, hyperaldosteronism was seen with larger doses and extended use (SNMC). The side effect is reversible on discontinuation of glycyrrhizin. Licorice or glycyrrhizin may also interact with herbs or other medications containing cardiac glycosides.
Hepatotoxicity of pyrrolizidine alkaloids
by Paul Bergner
The question of hepatotoxicity of pyrrolizidine alkaloids (PA) in herbal medicines has come to be a matter of clamorous debate in herbal circles. An number of national and international regulatory agencies have banned the sale of comfrey for internal use (WHO) after several cases of acute hepatotoxicity appeared after ingestion of comfrey products (Awang; Bergner 1993; Bergner 1989). A newborn infant also died in Switzerland after the mother took an herbal tea containing pyrrolizidine alkaloids during her pregnancy (Roulet et al.). Although the US Food and Drug Administration has not taken action here, the American Herbal Products Association has recommended against selling comfrey products for internal use. Some traditional herbalists have responded with disbelief that traditional plants were the cause of disease in these cases. In the interest of injecting some objective information into the debate, we provide here the biochemical mechanism of hepatotoxicity of PAs. There is really nothing to debate about whether PAs as a class can cause the serious a liver disease known a hepatic veno-occlusive disease in which the veins of the liver become blocked and liver tissue is destroyed. PAs in many plants are known to be hepatotoxic. The first cases were observed in animals that were poisoned after foraging on PA-containing plants (Mattocks 1986). Epidemics have also been observed in human population who consumed grain contaminated with PA-containing plants. Hepatic veno-occlusive disease has been reproduced experimentally in animals by giving them PA-containing plants (Mattocks). PAs themselves can vary widely in their toxicity; one alkaloid can be six or more times more toxic than another, and some are not toxic at all (Mattocks 1968). Furthermore, plants can vary widely in their PA content, from species to species, from one plant part to another, and from one season to another. PAs themselves are usually of only low reactivity. The presumed basis for their toxicity is that a portion of ingested PAs are converted to toxic pyrroles by liver enzymes, and immediately begin to destroy liver tissue. Thus the liver's attempt to alter the compound to make it excretable in fact turns it into a more toxic substance. In rats, the process begins within five minutes of ingestion. Because the toxic pyrroles are formed in the liver, they tend to concentrate there, but have also been found in the lungs, heart, spleen, and kidney. Some of the pyrroles are excreted in the urine, but others are bound strongly to the tissue where they continue to damage adjacent tissue that they come in contact with. There is a direct correlation between the amount of PAs consumed and the amount of liver damage. Thus PA poisoning is insidious: the toxic pyrrole substances are created by the liver's natural attempt to eliminate the non-toxic PAs.
Will milk thistle see protect from PA poisoning? Milk Thistle seed is a well-known hepatoprotectant. It is assumed to work through several mechanisms, including strengthening the cell walls of liver cells, promoting regeneration of liver cells, and protection through antioxidant effects. It is unlikely to be of much clinical use in poisoning by pyrrolizidine alkaloids, however, because PAs themselves are not toxic. It is only after they have entered the liver cells that they are transformed into toxic pyrroles, which destroy the cell from within. Furthermore, the hepatic veno-occlusive disease characteristic of PA poisoning is caused by proliferation of cells lining the veins of the liver, choking them off, rather than the liver cells themselves. Milk thistle seed has no known protective effect on these liver vein epithelial cells.
The following list of herbs was compiled from a year-long survey of readers of Medical Herbalism, between Spring of 1993 and Spring of 1994. Respondents were asked to rank the ten most important herbs in their practice. There were eighty-nine respondents. The numbers for rank on the list indicate the number of times the herb appeared on anyone's top ten list. Latin names may not be precise because most were indicated by common name, many of which have several species. The most common use of the herb is listed, although some herbs have additional properties that are not as well known in popular practice.
Number of Votes : Latin Name : (common name) : major therapeutic uses
In 1921, the Lloyd Brothers company in Cincinnati, then the leading distributor of botanical extracts to physicians, compiled a list of their best selling herbs. They were (exact species not originally indicated):
Echinacea, Echinacea spp
Chionanthus (fringe tree), Chionanthus virginicus
Macrotys (black cohosh), Cimicifuga racemosa
Crataegus (Hawthorn), Crataegus oxycantha
Pulsatilla, Anemone pulsatilla
Gelsemium, Gelsemium sempervirens
Thuja, Thuja occidentalis
Phytolacca (Poke), Phytolacca decandra
Cactus (night-blooming cereus), Cactus grandiflorus
Passiflora (passion flower ), Passiflora incarnata
All these herbs remain in use in naturopathic medical practice in the U.S. Only echinacea, crataegus, black cohosh, passion flower, and poke appeared on anyone's top ten lists in the accompanying poll, and only echinacea and hawthorne made the top ten in that poll.
Gynecological and Naturopathic Medicine: A Treatment Manual Tori Hudson, ND, TK Publications, 19135 Butternut Drive, Aloha, OR 97007 (503-591-5428), 1992, $25
This manual covers sixteen conditions, from amenorrhea, cervicitis and endometriosis to menopause, fibroids, cysts and more. "Intended for the naturopathic student and practitioner of gynecology," Tori Hudson has provided outlines of treatment plans based on ten years of clinical practice with women. Those not trained in naturopathy will find some terms unfamiliar and wish for more explanation. However, this manual is full of valuable information. Each section lists key concepts, such as acute/chronic aspects, possible cause, related events like sexual abuse and preventive suggestions. Initial approaches are followed by additional therapies if the first are not sufficient and include fundamentals like diet, stress and counseling along with detailed herbal formulas, homeopathics, supplements, products like "vag paks" for dysplasia and hydrotherapy. Hudson is familiar with gynecology from both the modern medical and holistic point of view, and she offers details on indications for probable need for more "aggressive" medical treatments and drugs. As someone who lived for years with cervical dysplasia and positive pap smears and found little information on holistic approaches, I am thrilled by Tori's detailed listing of what to do for different degrees of cervical abnormalities up to but not including cancer. In her workshop on this topic at the 1993 Gaia Conference on Naturopathic Medicine, Tori shared that of forty- three women with conditions from cervical atypia to carcinoma in- situ who carried out her suggestions, thirty-eight no longer had any signs of cervical distress with repeated tests afterward, three had partial improvement, two showed no change, and no one got worse. For non-naturopaths like myself, the outlines are greatly clarified by hearing Tori's Gaia presentations. A catalogue of the tapes is available from 1-(800)-252-0688.
In the U.S. as well as other industrialized countries, scientists are looked upon by some with the same awe and reverence one would give to a priest or shaman. There is often no questioning the researchers' authority, how the information was obtained, or if there is an ulterior motive behind their research. Although I am appalled at how easily our society is willing to blindly follow the word of scientists, I also must admit I am a born-again research scavenger. I find myself getting excited about the latest research on lowering serum glucose with fenugreek seeds or alleviating symptoms of benign prostatic hypertrophy with stinging nettle roots. However, a little voice always reminds me of the following: 1) Results often only reiterate knowledge previously well-known by practitioners of the healing arts. Often to prove this previously well-known information, animals are maimed and sacrificed. 2) The research lab is a contrived situation and far-removed from everyday life. Many factors can cause the research to be unrealistic when compared with the daily life of a human, including: environment, preparation of plant material, method of administration, idiosyncrasies with the patient, plant interaction can vary, energetic qualities of the plant are not accounted for, plant constituents may not have the same action as the whole plant, research is often on animals, not humans. 3. Ulterior motives are possible in the researcher as well as the financial backers of the research. 4. Contradictions can be found between one researcher and her experiments and other researchers. I still find myself reading the research journals enthusiastically looking for a small piece of wisdom to fill an incomplete puzzle. Occasionally I find something worth while. The important thing to keep in mind when reading research articles is to use the information as a building block to understand the larger picture.
Do not let it become the whole picture, and always question the motives behind the research. If you find that current research conflicts with wisdom of elder herbalists or your own botanical knowledge, trust the tried and true, but keep an open mind.
Summary: The pyrrolizidine content of thirteen commercial Comfrey products sold in Canada was examined due to concern about its safety. The samples were representative of the variety of sources, shapes and forms of commercially available products. Echimidine which is probably the most toxic PA of Symphytum spp. was detected in nine of the thirteen samples. Chemotaxonomic studies have indicated echimidine is often not found in Symphytum officinale and when it is, the PA is in low levels. High levels of echimidine are regarded as a strong indicator of non-Symphytum offinale origin. It is a significant component of Symphytum asperum, and S.asperum's hybridization with S. officinale such as S.uplandicum (Russian comfrey). The level of Echimidine was highest in the root samples while leaf samples were so low as to be detectable only by the highly sensitive GC-MS method. The level of echimidine varied widely, from very little to the most abundant component of the extracted PA's in two of the products. Six of the samples were labeled as S. officinale. Only 3 were found to be free of echimidine. The high incidence of echimidine in these commercial comfrey products raised doubts about the authenticity of herbal products labled S. officinale actually being Symphytum officinalis. Commentary: Proper identification of Symphytum spp, is very important if you are planning to use it. Unfortunately commercial preparations are often labeled incorrectly and, to make matters worse, research on comfrey has been confusing due to errors or lack of clarity in species identification. See the related Toxicology of pyrrolizidine alkaloids on page ten.
BOTANICAL SHORTS (for those of use who lack a long attention span) These are taken from lectures at the 41st Annual Congress in Dusseldorf Germany from 8-31-93 to 9-4-93.
Summary: Fifty different herbs commonly purchased by drug users to interfere with urinalysis, were tested for interference in drug testing. Drug testing is done by using fluorescence polarization immunoassay or thin layer chromatography. The herbs were analyzed at different concentrations to see if they would interfere with testing for amphetamines, opiates, barbiturates, cocaine, metabolites, methadone, and their analogs. None of the herbs interfered with the TLC or FPIA.
Commentary: It is very common for drug users to use herbal products in the hopes it will yield a negative test for drugs they are currently using. This study has shown the fifty herbs most commonly uses to avoid positive drug tests to be inadequate for that purpose. Many of the companies selling products to help drug users pass these tests tell them to drink copious quantities of the product as tea. This would dilute the urine and decrease the chance of a positive test. Large amounts of water could have the same effect.
Antibiotic activity was examined in the rhizomes leaves, flowers, and upper stems. An alcohol extract of the plant was mixed with a water extract of the plant (1 ml = 1 g herb) and found to be effective against Streptococcus pyogenes hemolyticus, Staphylococcus aureus hemolyticus, Escherichia coli, Shigella flexneri, Klebsiella pneumoniae, and Bacillus subtilis in concentrations of 5% and 10% (g extract to 100 ml culture medium).
Summary: Most of you know Filipendula ulmaria for its antirheumatic, anodyne, diuretic effects. It appears to have some antimicrobial activity as well.
Summary: Hop (Cannabidaceae)(Cannabaceae) extracts were administered to mice of equal weights and age at doses of 100mg, 250mg, or 500mg/kg 30 minutes before each test. Standard animal tests showed a sedative effect on motor activity, increased anticonvulsant activity, analgesia, enhanced sleep-inducement, and, at the highest dose, a significant fall in rectal temperature.
Commentary: Hops has a well known reputation as a nervine. This research has reiterated what is well known, and added information about temperature reduction. It is no surprise that a relative of Cannabis would be used to relax the central nervous system.
Researchers at Guang'anmen Hospital in Beijing administered a traditional Chinese herbal tonic formula to sixty-two patients receiving chemotherapy treatments over a six week period for a variety of carcinomas. Patients were divided into two matched groups. One group received the formula just before breakfast and lunch; the second group received it before lunch and dinner. The group receiving the formula earlier in the day had a statistically lower incidence of leukopenia (lowered white blood cell count), 4 of 31 cases (12.9%), than the group receiving the formula later in the day, 15/31 cases (48.4%)<|> <|>(P 0.01). The chemotherapy completion rate in the early group was 96.8%. In the later group it was 74.2%<|> <|>(p 0.05).
The traditional Chinese formula, Yi Qi Sheng Xue Decoction, had the following recipe:
Radix Astralagi seu Hedysari 60g Radix Angelicae sinensis 12g Colla Corii Asini 12g Caulus Spatholobi 30g Folium Pyrrosiae 30g Fructus Ziziphi Jujubae 12g Fructus Hordei Germinatus (fresh) 20g Pericarpium Citri Reticulatae 6g Radix Glycyrrhizae 5g
Up to three other non-tonic herbs were added to the formula of some patients, as needed, to modify nausea and vomiting or abdominal distension.
The formula consists of traditional Chinese Energy (qi) and Blood (xue) tonics. For example, astragalus and angelica are used in combination in traditional Chinese formulas to tonify and invigorate the xue after severe bleeding and for consumptive fatigue. Pyrrosia is used in combination with ziziphus for leukopenia. The authors note that as long ago as the Jin Dynasty (1115-1234 AD) it was recommended that qi and xue tonic combinations be given in the morning and before noon. They further point out that modern research demonstrates that the bone marrow cells, which generate blood, have their highest rate of proliferation from morning to noon. This trial not only demonstrates the blood-strengthening properties of traditional tonic formula, it verifies the traditional observation about the best time to administer them.
Michael Castleman, writing in The Herb Quarterly, suggests a variety of herb classes that may be helpful or harmful to the patient undergoing surgery and hospitalization. Helpful groups include antibiotics (goldenseal, etc); anti-emetics (ginger, etc); anti-inflammatories (ginger, licorice, etc); Immune stimulants (echinacea, etc.); and tonics (ginseng, etc.); tranquilizers (chamomile, valerian, etc). Herbs to avoid in the weeks before surgery include those which reduce blood-clotting. These include garlic, willow bark, meadowsweet, and wintergreen.
The Australian Journal of Medical Herbalism regularly publishes extensive herb monographs, sometimes as many as three per issue. In a recent review of chaste berry (Vitex agnus-castus), author Cheryl Du Mee reviews reports of contraindications and dosage. She suggests that vitex is not appropriate for children, post-menopausal women, or when hormones are being prescribed for birth control or estrogen replacement. The only side effects she reports are possible increase in menstrual flow volume, and rare but dose-dependent persistent headache. She recommends a daily dose of 3-10 mL of a 1:5 tincture per day taken as a single dose each morning throughout the cycle. If a larger dose is needed, a second dose can be taken at 4PM. Prolonged high doses should be avoided. Normally, vitex prescriptions should be persisted in without break for six months, even if benefits are noted in the first few cycles.
A review article on hawthorn (Crataegus oxycantha), traditionally used as a heart tonic, reports the effect of a concentrated extract of the herb on all areas of the peripheral vessels. Four clinical placebo-controlled trials also showed improvement in changes in stress tolerance and anaerobic threshold. In one study, the hawthorn extract was found to be clinically equivalent after fifty-six days of use to captorpil, an allopathic ACE-inhibitor used in congestive heart failure and hypertension.
Non-hepatotoxicity of mistletoe Mistletoe (Viscum album) was reported to be hepatotoxic in 1981 in a clinical article in the British Medical Journal. The reference has haunted the herb ever since, and a British agency has apparently proposed banning the herb on the basis of this article. As we pointed out in our last issue (MH 1993;5(4):3), the formula in question also purported to contain scullcap (Scutellaria lateriflora),; but European scullcap is frequently adulterated with a potentially hepatotoxic species of germander (Teucrium chamaedrys), which could have been responsible for the hepatotoxicity in question. Now Zoë Capernaros, writing in the European Journal of Herbal Medicine, points out that the product in question contained no mistletoe at all. The company producing the product had lost its license to use mistletoe in their products, but was till using a batch of old labels. Capernaros also points out that a poisons unit that was consulted 57 times over a period of 15 years with regard to ingestion of Viscum berries found no instances of liver dysfunction; gastroenteritis was the most common symptom. She also notes that the berries of American mistletoe (Phoradendron flavescens) are more toxic, as reflected by report st poison control centers.
Hypericin, the red pigment in Hypericum perforatum (St. John's Wort) has recently received much attention as an antiviral agent against enveloped viruses and in particular HIV. Recent studies have confirmed the potent antiviral activity and also contributed to a better understanding of the mechanism of action. Hypericin was active against the enveloped viruses herpes simplex virus (HSV) I and II, vesicular stomatitis virus, parainfluenza virus type-3 and vaccinia virus (Wood S et al, Planta Medica 1991;56:651). it was inactive against rhinovirus type 2, a naked virus. Hypericin was particularly active against HSV II indicating that oral and topical use of St John's Wort for genital herpes should prove beneficial. Pharmacokinetic studies of hypericin and pseudohypericin demonstrated that the compounds are slowly absorbed after oral administration and are distributed throughout the major organs, mainly in blood and muscle tissue. Hypericin, which is more antiviral than pseudohypericin, is also better absorbed (Stock S, Hölzl J. Planta Medica 1991;57(suppl 2):A61) Two research groups published almost simultaneously their finding that the antiviral activity of hypericin depends on exposure to light. Hudson and co-workers found that hypericin had two modes of antiviral activity" one directed at virus-infected cells. Both activities were substantially enhanced by exposure to light (Hudson JE et al. Antiviral res 1991;15:101-112). The other study found that exposure of virions to hypericin resulted in loss of their infectivity only if this was conducted in the presence of light (Carpenter S, Kraus GA. Photobiol Photochem 1991;53:169-174) Comment The significance of the discovery of the antiviral activity of hypericin must be stressed. This is a non-toxic compound, freely mobile through body tissues and probably capable of crossing cell membranes. It is active against enveloped viruses which are responsible for more human diseases than naked viruses. Now we understand that the antiviral activity is linked to light exposure. In Germany it is often recommended that patients taking St John's Wort avoid excessive sunbathing because of the photodynamic activity of hypericin. While this is sensible advice, complete avoidance of full sunlight will possibly detract from any antiviral effect of St John's Wort. Hence light exposure is to be recommended in this instance, but it should not be excessive.