LEUNG'S
(CHINESE) HERB NEWS
Number 28
September/October 2000

Herbs in this issue:

Aloe vera

Billberry

Sage

Chinese ginseng

A Note From Dr. Leung

 

More on/from the “Complete Guide to Herbal Medicines” by 2 PharmD’s (Issue 27, p. 2)

 

      If there were such a thing as a “book recall” (as in “drug recall”), this one should fit the bill.  Some years ago, a book on food plants published by the venerable scientific publisher, Academic Press, contained so much wrong information that Dr. Julia Morton, a well-known and respected economic botanist, called for its recall in her review of the book.  I remember one of the blunders was the author’s description of the litchi fruit as a nut.  It may be a “nut” to the uninformed layman, but it is not technically a nut any more than koala is a bear to a scientist.

     Although the Complete Guide contains much information that is wrong, the authors have probably avoided objection from the herbal industry by having included extensive lists of diseases for which each herb is allegedly being used to treat.  Extensive listing of such information certainly helps sell herbal products, no matter what they are. 

 

Dr. Leung is author of the Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics (Wiley-Interscience), which was published in 1980 and revised in 1996. He is also creator of PHYTOMED, a prototype computer database on Chinese herbal medicine developed under contract with the National Cancer Institute.


 

Thus, the authors, despite their intention“to give you the scientific facts about herbs – not to confuse or distract you with the myths or folklore that surround them” have done exactly the opposite of what they set out to do.  Instead of “not to confuse or distract..,” they confuse and distract us more than other books that they criticize, with their indiscriminate lists of diseases.  If you read about such diseases in a traditional herbal book, at least you know you have to take them under the traditional or folkloric context.  But when you see these diseases listed in their supposedly “scientific” and “unbiased,” “complete guide,” it makes you wonder how professional these authors are.  Let’s take the “Aloe” entry.  There are many things wrong with the information in this entry as provided by the authors.  According to them, people use “aloe” for the following conditions: acne, AIDS, arthritis, asthma, bleeding, blindness, bursitis, cancer, common cold, colitis (inflammation of the large intestine), constipation, depression, diabetes, glaucoma, hemorrhoids, lack of menstruation, seizures, skin conditions (abrasions, cuts, irritations, minor burns, frostbite, sunburn, and wounds), stomach ulcers, and varicose veins.  The authors don’t give us any indication as to which ones are legitimate uses and which ones are not.  Without this information, we may as well add another 2 to 3 dozen from some outrageous marketing brochures/flyers.  What is “aloe” anyway?  The authors don’t seem to have a clue.  According to them, “It comes from the aloe vera plant (also called Aloe barbadensis, A. vulgaris hybrids, A. africana, A. ferox, A. perryi, and A. spicata).  The plant’s large, bladelike leaves are the source of aloe vera gel.  Aloe preparations for oral use contain either the colorless juice that comes from plant’s top layer or a solid yellow latex obtained by evaporating the juice.”  First of all, what is the “it” they refer to?  Is it the gel or the drug aloe?  And what is “the colorless juice that comes from the plant’s top layer?”  What is the plant’s “top layer”?  Is it the tallest part of the plant, like the tip of the flower stalk?  Also, how does one obtain a “solid yellow latex” by “evaporating the juice”?  And what juice?  It is obvious the authors are totally confused.  If they had been even half diligent in seeking the truth to give us “the scientific facts about herbs – not to confuse” us, they would have readily found the truth about what “aloe” is in numerous reputable publications, including a reference listed by them.  Even the Lawrence Review (not known as a provider of consistently accurate information) distinguishes the 2 products!  In an article published back in 1977 in Drug and Cosmetic Industry, I clearly distinguished the 2 kinds of “aloe” which are: (1) aloe vera gel – the mucilaginous bland-tasting liquid from the center of the aloe vera leaf; and (2) the drug aloe – the dried bitter yellow latex from specialized (pericyclic) cells just beneath the skin of the leaf.  The 2 are completely different products.  The gel is an emollient with healing properties and is the one that has made “aloe vera” practically a household word over the past 2 decades.  It is NOT the drug aloe.  The latter, simply called “aloe” in the USP, is the dried bitter yellow latex that has cathartic properties.  It is normally used in laxative preparations, though sometimes also in sunscreen preparations, as well as erroneously in place of aloe vera gel in certain cosmetics.  Which is why it’s so important for a “complete guide” like this to clearly provide a distinction between them. 

        The authors’ confusion/ignorance continues in the dosage section.  In the “Common doses” section (maybe what they mean is “dosage forms”), the authors make absolutely no distinction between aloe gel and drug aloe.  They state that “aloe” comes as:

          capsules (75, 100,or 200 milligrams of aloe vera extract or aloe vera powder)

          gel (98%, 99.5%, 99.6%)

          juice (99.6%, 99.7%)

          cream, hair conditioner, jelly, juice, liniment, lotion, ointment, shampoo, skin cream, soup, sunscreen, and in facial tissues

To a small number of knowledgeable persons in the field, it is obvious the capsules referred to by the authors most likely contain drug aloe, though some may contain dried aloe gel.  The remaining categories (gel, juice and the cosmetics) are obviously derived from the gel and not from the drug aloe.  But how would the general public or even the medical and pharmaceutical professionals know?  The authors list 3 references, one of which is the comprehensive review by Grindlay and Reynolds.  Here is the second sentence from this article:  “This gel should be distinguished clearly from the bitter yellow exudate originating from the bundle sheath cells, which is used for its purgative effects.”  Yet it appears the authors never read this excellent paper.  Without clearly distinguishing 2 products that are as different as night and day, the information these authors present is worthless.  They have done their own profession and related professions as well as the general public a huge disservice.  This Complete Guide is the worst publication by alleged professionals I have ever come across.  And it will take many years of hard work for knowledgeable professionals to try to correct the damage already done.

Incidentally, I am curious why my colleagues are so quiet about this Complete Guide.  I am quite sure they are aware of it and its “atrociousness.”  But so far, I have only received comments from one colleague, though not in the pharmaceutical field.  The following are some of the comments by Sheila Humphrey, BSc.(Botany), RN, IBCLC.  They are directed towards Professional’s Handbook of Complementary & Alternative Medicines by the same 2 authors from which this “Complete Guide” has been adapted for the general public: 

I am writing to you to alert you to one of the most egregious aspects of this book, one where the authors have completely outdone themselves in their ignorance, namely breastfeeding.  I should mention here that I am an internationally certified lactation consultant (IBCLC) with 10 years experience working with breastfeeding mothers, and adept at answering drug questions.  I am also an RN.  As well, I am a herb information resource for La Leche League International and to lactation experts (MDs, Pharmacologists, etc.)…… 

…..The American Association of Pediatrics states that there are very few drugs that are absolutely contraindicated during breastfeeding – long-half-life radionucleotides and chemotherapeutics plus a few others.  (Knowing this, I take a hard look at herbs and have concluded that overall, most of the marketed herbs in USA and Canada don’t reach this level of toxicity and concern!)  The PDR contraindicates for most drugs as a legal statement from the manufacturers, and has no bearing on clinical practice.  The authors of this book do not seem at all aware of any of these basic facts about drugs and breastfeeding, let alone have even a slight working knowledge of lactation pharmacology…

So these poor PharmDs, without the guidance of even a single lactation-credentialed individual amongst their numerous sub-writers, allowed the contraindicating of most entities in the book.  This includes bilberry, the most innocuous fruit I can think of.  (They mix bilberry leaf and fruit considerations together in a hopeless tangle).  They also almost entirely overlook galactogogue OR antigalactogogue effects of herbs – an overlooked aspect in the pharmacological literature as well.  Lactation modulators of both sorts can lead to undesirable effects on breastfeeding.  And so they allowed a major stupidity regarding sage.

In discussing sage, currently used by LCs for oversupply and rapid weaning, these authors surprisingly did not contraindicate for breastfeeding, nor mention any warnings about use for the unsuspecting mother (caution a better term than contraindication, as the herb has its uses).  They list galactorrhea (which technically is the production of milk without a baby and not strictly referable to lactation) as one of the folk uses.  I would have expected them to jump all over the thujone content as a good reason to contraindicate during breastfeeding, even as they missed the implications of “galactorrhea.”  (For fun, compare the entries for wormwood and sage to see how inconsistent information from different sub-writers was allowed to stand.)

Bilberry and sage are two of the most egregious examples and I could go on all day – I shudder every time I think an MD or RN is using this book to answer a mother’s questions about herbs and breastfeeding (lactation specialists may be more savvy but are amazingly ignorant about herbs).

You would need a separate book to ferret out all the erroneous conclusions made about herbs and breastfeeding, let alone the more general issues.  I did want to alert you to this particularly galling (to me) aspect of the book, and to urge you to publish a review of the book somewhere where it could seriously offset their ability to hype this book as the ultimate in reliability, consistency and scientific objectivity.  Hah!

         I find the last paragraph especially fitting, because I have basically come to the same conclusion myself.  You would indeed need a separate book to document the errors!  The sad thing about this work is that you don’t have to make an effort to find misinformation, false conclusions, illogical thinking, and plain expressions of ignorance.  They are in every single entry that I have scanned so far, ranging from a few minor ones to numerous major blunders!  Where have our country’s pharmacy schools failed us?!  

Leung, A.Y., and S. Foster, Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics, Wiley-Interscience, New York, 1995, pp. 25-29, 84-85, 457-460.

  

Adverse Reactions of Asian Ginseng (Panax ginseng).

        Nothing is one-hundred-percent safe.  Somehow, somewhere, sometime, it will cause someone grief, depending on the amount ingested, the condition of that someone who has ingested it, and other factors.  Even though for clinical purpose, we like to consider the Homo sapiens as a single homogeneous entity that reacts uniformly to all drugs and foods, we know too well that no 2 of us are alike.  Yet we act as if these differences didn’t exist and often don’t take them into consideration when evaluating foods/herbs and drugs.  Then, when adverse reactions occur, we rationalize according to our preconceived notion, not science or tradition.  Hence, the decision to label something as undesirable due to its supposed adverse effects is not always based on logic or science.  More often than not, it is based on bias and/or politics.  I feel this is especially true with herbal supplements (medicines).

Before I get to the toxicity aspect of “ginseng,” I want to reiterate briefly the existence of 2 types of ginseng:  (1) the root from Panax ginseng (known as Asian ginseng, Korean ginseng, and Chinese ginseng) and (2) the root from Panax quinquefolius (known as American ginseng).  Asian ginseng has been used in China for thousands of years as a yang tonic to invigorate a weakened body, usually being used after a debilitating illness.  It has warming properties and may cause hypertension and nosebleeds in persons who are already energetic and vigorous.  In contrast, while American ginseng has been used by native American Indians for many centuries, its use in Chinese medicine started only in the 18th century when it was first introduced into China by the Jesuits.  At first, it was thought to be the same as Asian ginseng, but soon the Chinese found out that it was not, and have since been treating it as a distinctly different herb.  American ginseng has cooling properties and is considered a yin tonic, frequently used to cool down fevers and summer heat, particularly favored by the Cantonese.  As a yin tonic, it is traditionally used by people who have excessive yang or deficient yin, manifested as a ruddy complexion, tendency to be hot, thirsty, dry mouthed, constipated, vigorous, hypertensive, hyperactive, irritable, and other “hot” conditions for which Asian ginseng should NOT be used.  As with “aloe,” when doing research on or writing about “ginseng,” the type of ginseng must be clearly specified, otherwise results will be meaningless.  The chemistry of both ginsengs is very complex.  Although there are many common components (e.g., ginsenosides and polysaccharides) there are also distinct differences (e.g., higher ginsenoside Rb1/Rg1 ratios in American ginseng, ginsenoside Rf in Asian but not in American ginseng, etc.).  However, frequently, due to ignorance, impatience, or downright arrogance, we assume the “father knows best” attitude and choose to ignore the above clear traditional differences and practices.  Hence, despite thousands of studies on “ginseng” over the past few decades, we still don’t know what “ginseng” does or is “scientifically” shown to be good for, because few, if any, of these studies took into consideration the importance of traditional practices, nor paid attention to the identity of the “ginseng” being studied.  This has resulted in the publication of worthless research and its wide dissemination, the most notorious being the often-quoted “ginseng abuse syndrome.” (Issue 17, pp. 1-2)

        Assessing the adverse effects of an herbal medicine (even one with a well-characterized active principle like mahuang) is not an easy task, especially in persons simultaneously taking numerous conventional drugs.  Their assignment to any herb is often arbitrary.  The task becomes much more complex with herbs (like ginseng) that have multiple active components.  Consequently, one should take reports on “adverse reactions” of herbal medicines/supplements with an open mind.  Proper identification of the herb, its dosage, and other herbs and drugs simultaneously consumed, is a mandatory requirement for correctly assigning the adverse reactions to the herbal medicine concerned.  Without this, “adverse reactions” like the “ginseng abuse syndrome” are meaningless. 

         Adverse reactions to ginseng are mostly due to Asian ginseng.  Although countless numbers (10 million? 50 million?) of people use Asian ginseng worldwide on a daily basis, published reports of its adverse reactions are few.  These obviously do not reflect the actual number of such cases, as the majority probably remains unreported.  In a recent analysis of 34 cases of adverse reactions in 14 Chinese reports published between 1974 and 1995, 18 cases (52.9%) involved the nervous system, 4 cases (11.8%) the circulatory system, 3 cases (8.8%) the digestive system, another 3 cases (8.8%) resulting in shock or death, and 6 cases (17.7%) resulting in other conditions.1 

         Among the 18 cases involving the nervous system, 16 experienced euphoria, irritation, unrest, or confusion and 2 experienced dizziness.  Among the 4 cases involving the circulatory system, 2 were arrhythmic patients whose conditions worsened; and there was 1 case each of hypertension and hypokalemia.  There were 2 cases of abdominal pain with diarrhea and 1 of hiccup among the 3 involving the digestive system.  In addition, there were 1 case of shock, 2 cases of death, 2 cases of skin hypersensitivity (itching, papules, and blisters), and 1 case each of spitting blood, excessive sweating, edema, and recurrence of diabetes.  Except for the 2 fatal cases, all the others recovered after ginseng use was stopped, some with appropriate emergency treatment.  The patients’ ages ranged from 1 month to 74 years.  There were 20 males and 12 females while the sex of 2 others was not specified.  The dosage was 3-80 g, mostly administered orally as decoction, tincture, or raw root, chewed.  Adverse reactions occurred as early as a few minutes after ginseng ingestion to as late as after 30 days of continuous use.

         In the case of shock, review of the original report showed that the 43-year-old male patient received an i.m. injection of 4 mL of a “ginseng injection liquid” and went into shock 5 min after injection.2  It is highly debatable whether the shock was due to ginseng. 

         In 1 fatal case, a basically healthy person (with no signs of yang deficiency) consumed 2 X 40 g of red ginseng (a cured form of Asian ginseng) in the form of decoction over a period of several hours and died several hours later from massive cerebrovascular and GI hemorrhage and heart failure.3  It is obvious that there were 2 counts against this person: (1) the dose was 9 to 27 times the recommended daily dose, which is 3 to 9 g; (2) the person did not have yang deficiency that required a yang tonic like red ginseng, hence his various functions were overly stimulated. 

         Three other fatal cases involved 2 newborn infants who died after ingesting “relatively large doses” of ginseng and 1 person died after taking 500 mL “ginseng tincture.” 3  I don’t have the original reports on these, hence I don’t have the details.  But why was ginseng given to newborns? In the latter case, if the “ginseng tincture” were a regular tincture containing 10%-20% of ginseng, the ingested amount would be equivalent to 50-100 g of raw ginseng, which is a massive overdose. 

         The above sampling of adverse reactions of Asian ginseng, though small, provides an insight into the complexity of problems with herbs.  Besides the properties inherent in ginseng itself which can cause adverse reactions if ingested in excessive amounts or by healthy persons without yang deficiency, contaminants such as pesticides and additives may also play a role.  Hence, until these are taken into consideration and eliminated as a cause of the adverse reactions, the assignment of adverse reactions to ginseng (or any other herb/tonic/food) may not be correct.  In the case of ginseng (both Asian and American), pesticides, especially pentachloronitrobenzene (PCNB) and hexachlorobenzene (HCB), and sulfites are especially a problem.  These, and not ginseng itself, may cause the adverse reactions.  A search of databases on the toxicity of these chemicals at residual levels should throw some light on this issue. 

It should be noted that certain adverse reactions, including dizziness, internal hemorrhage, skin hypersensitivity, diabetes, shock, and heart failure are also some of the common conditions for which Asian ginseng is recommended.  This again shows that the human organism is extremely complex and cannot be treated as if it were a single-chemical entity.  And ginseng, being a tonic, does not “target shoot” at an illness or symptom as a typical conventional drug.  Instead, it normalizes the body and allows it to resolve its own problem(s).  This concept is really not that alien to science because homeostasis is a time-honored topic in physiology. 

(1) Z.K Zhang and G.C. Shi, “Analysis of 34 cases of adverse reactions to Chinese ginseng,” Shizhen Guoyi Guoyao, 10(4): 311(1999);  (2) S.J. Liu, “A case of shock due to Chinese ginseng,” Sichuan Zhongyi, (6): 49(1988);  (3) W.M. Li and Y.P. Li, “ Zhongguo Zhongyi Zazhi, 17(5): 312-314(1992);  Leung, A.Y., and S. Foster, Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics, Wiley-Interscience, New York, 1995, pp. 277-281.