Guest post: A view from Kampala, Uganda

This post is from Dr. Anne Dougherty, MD. She is almost in the middle of a six-week project at Mulago Hospital in Kampala where she is providing support and training to the OB/GYN staff. I will let her words speak for themselves.

Resigned helplessness – that is what the resident’s face said as she answered questions following her presentation.  The patient was a young woman who was transferred from an outside hospital for “confusion and severe anemia.”  On arrival at Mulago, the patient was tachycardic and tachypneic.  Her mental status was altered.  Her abdomen was distended and rigid.   She was bleeding per vagina.  A pregnancy test was performed and was positive.  My assumption at this point is that the patient has a ruptured ectopic pregnancy and is in danger of bleeding to death.  An IV was placed and normal saline was dripping into her vein.  No additional labs or studies were obtained.  This all happened at 1AM.  At 9AM – eight hours later, the resident stood before the department at morning meeting and related this story.  There was no more to the story than what I just told you.  For the last eight hours, the patient had lain in a bed on the ward where a single nurse watched over 40-50 patients with a single IV running crystalloid @ 125cc/hour.  The resident was asked, what did the ultrasound show?  Did you locate the pregnancy? What was causing the surgical abdomen?  Did you draw coagulation studies?  I was struck that in the telling of the story, the resident did not mention that these might be things that she considered.  When asked why such studies were not obtained, she simply stated that it was 1AM.   As if the main referral hospital in the country should close at a certain hour.  Well, as it turns out, it does or at least that is the perception that then becomes a reality.

A horrible inhumane experiment was performed with dogs in which they were placed in a cage with an electrified floor.  There was a high barrier in the cage over which the dogs could not jump.  The first few times the floor was electrified, the dogs tried desperately to get over the barrier, but as time went on, they would curl up in the corner until it was over.  The dogs continued to do this although the barrier was lowered such that the dog could jump over it.   This is not to say that humans are dogs, but it does demonstrate the effect of repeated negative events on the desire to keep trying, to keep striving.

I have seen repeatedly that when even a small challenge is presented here at Mulago, the answer is often, “it is impossible.”  And yet I know that it cannot be as I see some are able to overcome the challenges.  Today, while performing a series of exams on patients with suspected cervical cancer, I ran out of exam gloves.  I asked the “sister” (that is what the nurses are called) if she could get more gloves.  She said, we do not have any more and just stared at me.  She said the person who was supposed to go to the supply annex last night to restock did not turn up and so we were low on supplies.  Not being one to take no for an answer, I persisted.  Well, I said, where can we get them from now?  She said, give me a minute.  In a short time, the “sister” returned with a new box of gloves “borrowed” from another unit.

One of the things about cultural exchange is that you really have to leave yourself at home.  That is, you need to surrender your sense that “this is the way things have to be done.”  As long as you continue to compare here to there, it is easy to be irritated by the way things proceed within the foreign culture and ultimately become very frustrated.  And in that frustration you miss the cultural exchange.  In medicine that can sometimes be difficult.  When you have a patient in front of you who could be helped with a few basic diagnostic tests and swifter treatment, I feel another force at work that is complicated to separate from my own cultural context.  The feeling of responsibility I have to the patient while embedded in my cultural context feels like it stems from an inner part of my being and is so painful to let go even temporarily. And yet, that is really what you have to do here at Mulago or you will be crushed by the tragedy of it.

I am not sure that I understand entirely where the resigned helplessness comes from.  It is likely multifactorial.  Being subjected as a colonial territory plays a part.  Follow that with decades of struggle and war while surrounding countries began to get their independent “legs” under them.  Add in poverty, food scarcity, unemployment, resource shortages and a dejected passivity develops.  I am also quite sure that western world “charity” contributes.  Interestingly though, when you learn the stories behind some of these Ugandans and the life challenges that they have overcome, you are left with paradox.   Ne woman told a story of moving out of her stepfather’s house because he would beat her mother when she showed affection to the woman and her sister.  She moved in with a relative who took her on as household help (a common practice here), but the woman wanted to go to school.  So she moved onto the streets where she tried to earn some money during the day to support her sister and herself and then went to primary school as an adult. She taught herself English while living on the streets.  As a cleaner at Mulago Hospital, someone discovered that she spoke English and promoted her.  She worked her way to a stable job as an administrative assistant.  She continues to go to school and is now married, expecting a baby shortly.  Amazing.  And her story is only one of many.  So many Ugandans have witnessed horrendous violence either at home or at the hands of the government.   Most have been in a home without enough food to feed the whole family.  Many have inherited entire families of 6, 7, 8 children when parents pass away from HIV related illnesses.  They will work against all odds to send those children through school.  The strength and wherewithal to persevere through such trials is more than the average American in 2013 would tolerate I think. And yet that same woman might tell you there are no more gloves.   Such a strange paradox.

Anne K Dougherty MD
Attending Physician, Department of OB/GYN, Fletcher Allen Health Care
Assistant Professor, University of Vermont 

A brief and practical introduction to pulse and tongue assessment

Any assessment or diagnostic technique that seeks to make sense of what’s happening inside the human system is inherently pretty complex – be it a modern tool such as a CT scanner, or a traditional device such as the stethoscope. Interpretation is tricky, and the background knowledge required can often be intimidating. While using the tongue and pulse to get a glimpse inside the human body is not an exception, one can nevertheless glean really useful, actionable information with even a basic understanding of the technique. This basic understanding can become richer and deeper with ongoing practice. The complexity evidenced in traditional texts on the subject should not be a reason to keep you from experimenting!

Basics: Excess / deficient. Hot / cold. Dry / moist. The polarities!

            Pick two people and look at their faces. Feel their skin. Who is more red? Whose skin more dry? Who speaks more loudly and often? Who is more reserved and shy? The answers to these questions are clinically relevant, and it is in these basic categories that we will try to fit our observations of pulse and tongue. They have been universally recognized in traditional healing systems, from Chinese yin/yang theory to the Western humors.

The Pulse: Neuromuscular tension and tone

            When feeling the pulse, set your fingers on the radial artery. It can be found on the palm side of the wrist, right where the hand (thumb side) ends. You can often find a pair of strong tendons here; feel for the pulse in the little “trench” just above these.

            What we can learn from pulses: relative state of anxiety, tension, stress. Underactivity in the heart, vessels, and spirit (or, conversely, overactivity). 

            Herbs we can use to rebalance pulse: aromatic plants, and sometimes rooty, nourishing adaptogens. Archetypal plant for the pulse: Holy Basil (Tulsi – ocimum sanctum).

            Polarities to observe:

-         The pulse has a depth. It is right on the surface, somewhere in the middle, or deep down. This is determined by the amount of pressure required to find it. Surface pulse with no depth indicates “paper fire” (quick burnout, moody and changeable, hyper then crashing. Consider lavender, linden). Deep pulse that’s hard to find can mean depletion (hard to get going, tends to depression, fatigued. Consider ashwagandha, ginger, cayenne, green tea).

-         The pulse has a width. Think of the artery as a river, ideally flowing through the middle channel of depth. If it’s full and noticeable at all depths, it might be called “flooding” (excess function, high blood pressure, over-intensity. Consider motherwort, rose). If it’s thin and feels like a string, it might be called “tight” (high tension, excess sympathetic discharge. Consider motherwort again, lemon balm, scullcap). If it’s just thin, it might be a sign of deficiency and we would turn to the nourishing herbs (ashwagandha, oat, licorice, American ginseng).

-         The pulse has a speed. This is a pretty classic assessment: greater physical activity usually raises the pulse rate. When sitting, speedy pulses usually indicate anxiety or poor physical conditioning. Aromatic plants and exercise are called for. In extreme situations (requiring hospitalization: shock, toxicity, severe dehydration) you can see rapid, thin pulses too – but hopefully you won’t ever run in to these as they are emergency situations.

-         The pulse should respond to breath. Feeling the pulse, have the person take a deep, full breath slowly. The pulse should quicken on inhale, and slow down noticeably on exhale. Failure to do so indicates poor heart rate variability: if the pulse has low depth, feels thin or absent, consider nourishing and building here (ashwagandha, oat, licorice, American ginseng). If the pulse is of surface depth, flooding, or tight consider aromatherapy, and any aromatic plants (chamomile, linden, lemon balm, scullcap, mint, rose, yarrow).

-         The pulse should come back well after being completely blocked. Occlude the artery by pressing hard, then feel for the return of blood. Slow return to the “normal” state (taking more than 1 second) may indicate blood stagnation (purple color, cold, areas of chronic pain. Consider yarrow, elderflower, Salvia milthiorrhiza)

Basically, aromatic nervines make great teas and are often just the ticket for an imbalance in the pulse. This is because the radial pulse reflects the degree of sympathetic, or fight-flight, tone really well, and these plants are supremely useful for those who have either excessive or deficient tension in their systems. They modulate how we respond to change in the world within and without – and if we’re not doing a great job of it, the pulse tells us. If the pulse truly seems weak, sunken, and/or thin, you might want to add nourishing adaptogens as well to provide a literal foundation for stress hormone production, not just a way to balance response.

The Tongue: state of the mucous membranes

            When looking at the tongue, ask the person to really open wide and stick their tongue out completely. Then, tell them to relax it (often the “sticking out” causes the tongue to get really tight and weirdly-shaped).

            What we can learn from the tongue: relative state of activity and moisture of the membranes that line the GI tract, but also the respiratory passages by reflex. Degree of inflammation. Degree of swelling / moisture.

            Herbs we can use to rebalance the tongue: bitter and astringent plants. Archetypal plant for the tongue: Agrimony (Agrimonia eupatoria).

            Polarities to observe:

-         The tongue has a body color. This is the general hue of the tongue itself, not its coating, and indicates the degree of blood flow and activity in the mucous membranes. Pale tongue can indicate anemia, poor nutrition (consider yellowdock, rehmannia, protein). Red tongue indicates inflammation and irritation (consider dandelion and also slippery elm or meadowsweet depending on dry vs moist below). Purple: blood stagnation (see above).

-         The tongue has a coat. It should be whitish/gray, and relatively thin. Absent coat calls for soothing, especially with a red body (consider slippery elm, licorice, flax seed meal). Thick coat calls for bitters, especially if the coat has any signs of yellow in it – though watch for coffee stains! (consider dandelion, yellowdock, burdock)

-         The tongue has a shape, largely determined by its moisture (though the coat can tell us about moisture, too). Wider, thicker, glistening tongues indicate a swollen, boggy gastric mucous membrane. Often there will even be the scallops of tooth marks on the side (consider specific bitters such as goldenseal or barberry, but also meadowsweet, cleavers). Thin, wrinkly tongues indicate an atrophied, dry gastric mucous membrane (consider dietary oils such as sesame, bitters, and potentially soothers such as slippery elm especially with redness).

Basically, bitters are often a great choice for any tongue signs, except maybe in cases where the tongue is really pale and wet and there are symptoms of looseness in the bowel. This is because bitter herbs stimulate and awaken digestive function, and tone the mucous membranes in the process. They help us deal well with what comes to us from the world outside (most often food) by making sure that the interface (the mucous membrane) is functioning well. The tongue is a convenient piece of mucous membrane we can always observe!

Conclusion

            None of the diagnostic signs are infallible, of course – and should always be read in the context of symptoms and case presentation. The assessment of pulse and tongue can precede the oral interview, and guide it: for instance, feeling a tight and rising pulse with poor response to breath, you might want to ask about tension, anxiety, and a difficult response to life’s changes and stresses. Or noticing a dry and red tongue, you might ask about heartburn and/or constipation. Conversely, the assessment can come at the end of the oral interview, and be used to corroborate information obtained through conversation. Finally, the maxim: treat the person, not the tongue (or pulse)!

Plant allies for winter health

Enhancing immune activity

Why: Herbal allies to combat respiratory infection as it begins.

Echinacea, Andrographis, Elderberry, Hyssop, Garlic, Osha

These agents provide an immediate “boost” to immune function, particularly the body’s ability to produce antibodies against viral infections. Will shorten the duration of common winter infections, and can also be used longer-term as preventative agents particularly for those more at risk.

How to take: most acute-use antiviral herbs can be taken whole, or with minimal processing. I often will simply nibble on a small (1”) piece of Echinacea root, or an even smaller piece of Osha root, when the first warning signs of illness begin. Stored in a glass mason jar in a cool cabinet, they will keep at least a year.

Elderberry seems best taken as a syrup. These preparations are pretty widely available, or you can make your own by mixing an equal volume of fresh berry juice with raw honey, and storing in the fridge. The honey is really medicinal too! 2 TBS three to five times daily is typical.

Andrographis is extremely bitter and hard to take straight. Often, we recommend a tablet or capsule of this plant, at a dose of 400mg three times a day, again at the first signs of trouble.

Hyssop makes an excellent though somewhat biting tea, and Garlic can be included with food (though the more raw, the better).


“Deep” immunity

Why: Enhancement of our own immune function, to clear infection more quickly if it does begin, and help get rid of lingering problems or break the pattern of repeated illnesses.

Astragalus, Medicinal mushrooms, Spikenard, Tulsi

Good policy for anyone, these tonics are most indicated in conditions of convalescence, to rebuild strength, or in cases of repeated infection every season. Taken consistently, they will also improve immune activity, helping to shorten lingering colds and flus, and prevent them to begin with.

How to take: these herbs are an easy addition to your regular stock-making routine. If you’re not making stock regularly (once a week or so), consider doing it! Save your vegetable scraps and peels and any animal bones, and simmer them with Astragalus root ( ½ cup per gallon), dried mushrooms (Reishi, Turkey Tail, about ½ cup total per gallon) and some spikenard root (Aralia racemosa, about 2 TBS per gallon). This last one is especially indicated to help bring up vitality and kick out lingering congestion. Also, see a specific recipe variant in the “recipes” below.

Tulsi (aka Holy Basil) is a wonderful tea herb. Start it up in September if there are concerns about the coming season.



Adjusting mucous membrane function

Why: Our respiratory mucosa is our first line of defense. Ensuring it is not swollen, stuck, and/or inflamed not only improves symptoms immediately, but also improves defense.

Reducing swelling: Goldenseal, Barberry, Osha
Reducing thick secretions: Echinacea, Horseradish
Reducing dryness and irritation: Propolis, Licorice

How to take: These strong herbs usually don’t require a high dosage to accomplish their goals. Part of this may be due to the fact that reflex action mediates their effects – horseradish makes your eyes water, for instance, even though none is ever put in your eyes. So I usually suggest tinctures, good to have on hand and already picked out depending on what your respiratory passages tend to feel like when you get sick. Of these liquid extracts, try taking 15 drops or so every couple of hours and seeing how it makes you feel.


Protecting and toning the respiratory tract

Why: If lungs are consistently affected. This isn’t an issue for everyone, but if it tends to be, best to include these herbs right away before the illness gets there.

Thyme, Garlic, Usnea

These herbs are especially useful for those whose lungs are prone to weakness (history of pneumonia, repeated bouts of bronchitis or bacterial infection, or smokers).

How to take: Thyme can be inhaled as a steam by brewing strong tea and breathing deeply. After that, go ahead and drink the tea too! With a little raw honey. Usnea lichen is eaten whole, or taken as a capsule – though I really like the effect of the raw herb as it goes down the throat. It kills viruses and bacteria that contribute to sore throat, and enhances lung immunity once you absorb it internally. 1-2 grams of Usnea twice daily is usually plenty.


Encouraging lymphatic activity

Calendula, Cleavers

Useful in the latter phases of an illness, after the fever or acute symptoms have abated, to clear lingering inflammation and hasten recovery. Can also be used right at first if there is a history of lymph node (gland) tenderness.

How to take: Most often as teas. The extra fluid is really helpful too. 4-6 TBS per quart of water.


Encouraging circulatory activity

Ginger, Garlic, Cayenne

This often is all you’ll need for a common cold in those of strong constitution. Helpful for all to stimulate warmth, encourage perspiration and speed recovery, but particularly indicated in a colder person.

How to take: Special hot sauce? Or a home-made version thereof where the above three herbs are blended, to taste, with apple cider vinegar. Try ½ teaspoon twice a day to start.



Herbal Recipes for Winter Health

Remember that, when using herbs for healing and wellness, it is important to bring their powers into your life from many different angles – use a tea, tincture, and/or an aromatherapy steam to reinvigorate a weak constitution, and think preventatively to strengthen immunity during times of good health.

Immune ‘soup’:

This simple blend can serve as a base for any soup, or can be taken ‘as is’. It strengtens the immune system and can help prevent weakness during the winter months. It is quite powerful, but as with any herbal tonics (blends designed to strengthen over the long term) it is best used on a regular, daily basis.

Astragalus (Astragalus membranaceus) root 1 cup of dry root

Ashwagandha (Withania somnifera) root ½ cup dry root

Red Reishi (Ganoderma lucidum) mushroom ½ cup dry mushrooms

Burdock (Actium lappa) root ½ cup dry or fresh root

Garlic (Allium sativum) bulb 4 minced cloves

Take the above ingredients, and simmer them, covered, in a pot with 2 quarts of spring or well water (this process is called a decoction). Simmer on very, very low heat for at least one hour (in China, these types of tonics are often simmered for a whole day – a crock pot can be helpful. Be sure to keep an eye on the soup, and add water as needed. Don’t scorch the pot!). Strain and serve, perhaps with a little honey, or freeze for storage. The daily dose is 8 fluid ounces (1 cup).

Get creative with this soup! Add onions, carrots, seaweed (dulse, arame for example) and salt to taste. You can also add cabbage, potatoes, and cooked beans to make it more of a hearty meal. Or herbs and spices like Cayenne, Thyme, and Parsley. These soups remind us that our daily food is our best medicine!



Tea #1 – For lung congestion

Sometimes a cold can ‘go down’ into the lungs, making it difficult to breathe and producing a deep and sometimes painful cough. In these cases, this blend can help.



Mullein (Verbascum thapsus) leaves 3 Tablespoons dry leaves

Thyme (Thymus vulgaris) leaves 1 Tablespoon dry leaves

Licorice (Glycyrrhiza glabra) root 1 Tablespoon dry root

Ginger (Zingiber officinalis) root powder 2 Teaspoons dry powder



Place all the ingredients in a teapot or mason jar, add 1 Quart of boiling-hot water, cover, and steep for 15 to 20 minutes (this process is called an infusion), then strain. Drink the whole quart over the course of a day. You can prepare this tea the night before, and let it steep all night if you’d like, but I have found that teas for colds and flus work better if you drink them hot.

Add honey to taste.




Tea #2 – For nose and sinus congestion

Often times the worst part of a cold is a stuffy nose. This blend can help relieve that congestion, drying up the nasal passages a bit. It is also useful, I’ve found, after the worst of a cold or flu is done, to help relieve lingering symptoms of congestion.


Elder (Sambucus nigra) flowers 2 Tablespoons dry flowers

Red Clover (Trifolium praetense) flowers 2 Tablespoons dry flowers

Catnip (Nepeta cataria) leaves 1 Tablespoon dry leaves

Ginger (Zingiber officinalis) dry root powder 1 Teaspoon dry powder

Place all the ingredients in a teapot or mason jar, add 1 Quart of boiling-hot water, cover, and steep for 15 to 20 minutes (this process is called an infusion), then strain. Drink this quart of tea over the course of 4 hours, then repeat if necessary. You can add a little honey to taste if desired, although I’ve found too much sweetness can make nasal congestion worse.




Tincture – Echinacea purpurea

Tinctures are alcohol-based extracts of herbs. Usually quite potent and concentrated, they require a solvent such as Vodka to create. The dose is usually much, much smaller than that of a tea.

Echinacea (Echinacea purpurea) root 2 or 3 Tablespoons fresh or dry

Vodka (100 proof) 8 fluid ounces (1 cup)

Chop the root as finely as is possible, and place it in a jar you can close securely (mason jars work well, I’ve found). Pour the vodka over the chopped root, close the jar, and shake it really well for at least 30 seconds. Label your tincture (name of herb and date are the mimimum requirements) and put it in a cool, dark place. Shake it well at least every other day.

After two weeks (better yet, wait four weeks if you can), strain your tincture, discard the spent roots, wash out the jar, and put the tincture back in. It should have turned a nice reddish-brown color, and is ready to use!

Echinacea tincture is taken 1 teaspoon at a time, in a little water, once every hour when you feel the first signs of a cold or a sore throat.




Aromatherapy steam

This process is very useful to help relieve congestion in the nose and lungs. Usually best to do at night, before bed, to clear the breathing passages and encourage restful sleep.
Boil a pot of water. When the water is hot, remove from heat and place it on a safe surface (a stone or trivet works well).
Add 2 drops each of these essential oils (highly concentrated plant essences – use only a few drops, never internally, and be careful because, undiluted, they can irritate the skin):
Rosemary
Thyme
Eucalyptus
Cover your head with a towel and breathe in the steam for 5-10 minutes.

Some sping tonic formulas for extraction

You can reference these herbs in a previous entry, which goes in to Spring roots, leaves, tonics and cleansing at length. Below are just some ideas on combinations.

1 ounce is almost 30 grams

extract in a pint / quart jar with about 15 ounces of alcohol

Dandelion root 30g

Burdock root 30g

Sarsaparilla 30g

Nettle 15g

Gentle revitalizer, especially if the skin gets dry and bothersome by the end of Winter

Dandelion root 15g

Spikendard root 15g

Echinacea root 40g

Wintergreen 7g

Mustard 13g

Enhance immunity and protect/reawaken the respiratory system

Dandelion root 30g

Yellowdock root 30g

Goldthread root and leaf 7g

Cleavers 13g

Enhance liver function and correct feelings of being “swollen”, sluggish

Sarsaparilla 30g

Wild Sarsaparilla 30g

Dwarf Ginseng (fresh) 30g

Dandelion root 30g

Overall hormone and adrenal tonic; reawakens, counteracts fatigue

Soy (and phytoestrogens) are safe and helpful in breast cancer

December 9th's JAMA has an interesting study in it which is receiving a lot of press already. An analysis of over 5,000 Chinese women who survived breast cancer was conducted at Vanderbilt University. Dr. Xiao Ou Shu (and others) reviewed the women's intake of soy alone and in combination with Tamoxifen, and found significant evidence that consumption of soy at levels of about 1/4 cup of tofu daily is actually quite protective and lessens the chance of breast cancer recurring. There were over 30% fewer cases of recurrence in the women who consumed about 11 grams of soy protein daily.
This is excellent news and should serve as yet another piece of corroborating evidence that phytoestrogens are safe, useful adjuncts to both menopausal symptom treatment and cancer support, even in cases of estrogen-positive tumors.
The researchers at Vanderbilt postulated that the phytoestrogens "blocked" human estrogen from stimulating the estrogen receptor. A more sophisticated understanding includes an awareness of the two different estrogen receptor subtypes, and how phytoestrogens specifically activate the beta subtype. Estrogen-receptor beta seems to counteract the growth and division that human estrogen normally stimulates. It is very probable that phytoestrogens work at least in part by this mechanism in protecting against breast cancer.
One final note: the researchers in this current study kindly point out that soy from protein isolate or candy bars is probably not as good, and that the women in the study really ate whole-soy products like tofu and tempeh. To quote Gina Villani, director of heme/onc at the Brooklyn Medical Center:

"The take-home lesson is that whole foods are what we need to eat more of. Try to stay away from the processed stuff. Don't bulk up on soy milk or soy candy bars."

Ya think?

Safety of phytoestrogens reviewed

Am J Med. 2009 Oct;122(10):939-46.e9.

Side effects of phytoestrogens: a meta-analysis of randomized trials.

Tempfer CB, Froese G, Heinze G, Bentz EK, Hefler LA, Huber JC.

Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria. clemens.tempfer@meduniwien.ac.at

BACKGROUND: Phytoestrogens are widely used by postmenopausal women for the treatment of the climacteric syndrome. The risk of adverse effects of this treatment, however, is unknown. METHODS: Using a fixed-effects model, we performed a meta-analysis of side effects comparing phytoestrogen treatment with placebo or no treatment in randomized controlled trials. RESULTS: We identified 174 randomized controlled trials. Side effects were reported in 92/174 randomized controlled trials with 9629 participants. The overall incidence of side effects in the phytoestrogen and control groups was 2019/5502 (36.7%) and 1824/4806 (38.0%), respectively (P=.2; incidence rate ratio [IRR] 1.01; 95% confidence interval [CI], 0.95-1.08). Comparing various side effect categories, we found significantly higher rates of gastrointestinal side effects among phytoestrogen users (P=.003; IRR 1.28; 95% CI, 1.08-1.50). Gynecological (IRR 0.94; 95% CI, 0.74-1.20), musculoskeletal (IRR 1.20; 95% CI, 0.94-1.53), neurological (IRR 0.91; 95% CI, 0.70-1.19), and unspecific side effects (IRR 0.95; 95% CI, 0.88-1.03) were not significantly different between groups. Within side effect categories, we found no significantly higher rates of side effects in women using phytoestrogens. Specifically, the rates of hormone-related side effects such as endometrial hyperplasia, endometrial cancer, and breast cancer were not significantly different between groups. CONCLUSIONS: Based on the available evidence, phytoestrogen supplements have a safe side-effect profile with moderately elevated rates of gastrointestinal side effects. Rates of vaginal bleeding, endometrial hyperplasia, endometrial cancer, and breast cancer were not significantly increased among phytoestrogen users in the investigated studies.

Herbal support for Influenza

By popular demand, here is a copy of some notes on the upcoming flu season. Looking at the flu trend reports from Google, it seems we're already seeing a national spike in H1N1 cases - and it's not (quite) even October yet! Not to be alarmist, but herbalists can play an important role now and in the future, given the issues with vaccination and the relatively ineffectual drugs like Tamiflu.

Influenza is an acute respiratory illness caused by an RNA virus from the Orthrosynovitic family, of which three serotypes are known (A, B and C). Influenza causes an acute febrile illness with myalgia, headache and cough. Uncomplicated influenza generally resolves over a two to five day period. However, in a significant minority, symptoms of weakness and malaise may persist for several weeks, particularly in the elderly. Complications of influenza include otitis media, pneumonia, exacerbation of chronic respiratory disease, croup and bronchiolitis. Additionally, influenza can cause a range
of non-respiratory complications including febrile convulsions, Reyes’s syndrome and myocarditis. The influenza virus is transmitted primarily via virus-laden large droplets from sneezing, coughing or talking. Transmission may also occur by direct
(for example, person-to-person) or indirect (person-to-person) contact and accounts for 30,000 deaths per annum, US.

H1N1 flu (“swine flu”) is an A subtype, generally affecting the upper respiratory passages and the lungs less so, though can be characterized by a spasmodic, dry cough esp. in the initial stages. Those over 65 appear to be at lower risk because of exposure to the H1N1 type, which is the same as the 1918 flu. This serotype has been largely absent for some time. Most at risk are pregnant mothers and infants under 6 months. H1N1’s most troubling characteristic seems that it spreads 2-3x more readily that most seasonal influenzas.

H5N1 flu (“bird flu”) is also an A subtype, but appears to be much more focused on the lungs for invasion, replication, and symptoms. This serotype has been implicated with the “cytokine storm” (see below), making it more dangerous to those with health immune systems.

H1N1, which caused Spanish flu in 1918, and the 2009 flu pandemic

H2N2, which caused Asian Flu in 1957

H3N2, which caused Hong Kong Flu in 1968

H5N1, a current pandemic threat

Serotypes are determined by the Hemagglutin and Neuraminidase surface markers on the viral capsule. These markers also serve to trigger immune reactions in respiratory epithelial cells.

The symptoms of 2009 H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people may have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1 and have respiratory symptoms without a fever.

In children, emergency warning signs that need urgent medical attention include:

• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough

In adults, emergency warning signs that need urgent medical attention include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough

• 104 °F: up per range at which most bodily functions are not altered.
• 106 °F: threshold for possible seizure activity. Normally human body temperature does not rise above this.
• 108 °F: brain damage may occur due to protein destruction.
• 110 °F: human cells begin to die.
In infants aged 1 month, 101.4 °F may be a critical temperature. This rises to 102 °F at 2 months of age.

Clinically, this H1N1 strain seems to require management in 3 general phases:

1. Cool, clammy skin with weak (relatively) pulse requires warming herbs that are also immunomodulants. Ginger, Turmeric, Garlic. Avoid foods.
2. Warm, dry skin and perhaps facial flushing with strong pulse and development of spasmodic cough. Cooling diaphoretics like Peppermint, Bonest are traditionally indicated, along with respiratory antispasmodics. Cooling bitters, esp. Andrographis, can play a role here too.
3. Demulcents and restoratives are important for the final period which can last 2-3 weeks. Consider Licorice, Slippery Elm, Pleurisy Root.

Prevention is, of course, the best medicine. Consistently use Astragalus and Garlic, as well as assessing Vitamin D levels and supplementing as necessary. Modest, plant-rich diet and abundant sleep are also crucial. Finally, limit spread through hygiene and limited contact.

The cytokine storm does not seem to be a crucial component to the 2009 H1N1 flu, but remains a concern nonetheless. This is a severe inflammatory reaction which usually occurs in the bronchiopulmonary system and causes excessive destruction of healthy tissue. It may have been a contributing factor in the deaths related to H5N1 bird flu, as well as the US epidemics of 1957 and 1968.

This inflammatory reaction is set in motion by the immune system and involves cellular players such as helper T-cells, as well as chemicals (“cytokines”) such as interleukin-6 (IL-6), tumor-necrosis-factor-alpha (TNF), and mitogen-activated protein kinases (MAPK, specifically of the p38 variety. This latter agent seems to be a major initiating player and is overexpressed as part of the reaction to certain flu strains). Additionally, if exposed to strains that show evidence of initiating a cytokine storm, virus-infected cells seem to exhibit increased resistance to the inflammatory chemicals that would normally hurt them.

Caution may be advisable with herbal agents such as Echinacea and Elderberry which may stimulate TNF and other cytokines. However, this danger is unclear. More important is the addition of herbs that down-regulate dangerous cytokines while also exhibiting antiviral effects (for instance, St. John’s wort, Baikal Scullcap, Salvia milthiorrhiza, Ginger, Turmeric).

The role of vitamin D in the seasonal nature of the flu bears mention. It has been postulated (Bergner et.al.) that the crucial role of D in promoting healthy immunity.

The crucial role of vitamin D in the innate immune system was discovered only very recently. Both epithelial cells and macrophages increase expression of the antimicrobial cathelicidin upon exposure to microbes, an expression that is dependent upon the presence of vitamin D. Pathogenic microbes stimulate the production of an enzyme that converts 25(OH)D to 1,25(OH)2D, a seco-steroid hormone. This in turn rapidly activates a suite of genes involved in pulmonary defense. In the macrophage, the presence of vitamin D also appears to suppress the pro-inflammatory cytokines. Thus, vitamin D appears to both enhance the local capacity of the epithelium to produce endogenous antibiotics and at the same time dampen certain destructive arms of the immune response, especially those responsible for the signs and symptoms of acute inflammation, such as the cytokine storms operative when influenza kills quickly.

While it is unlikely that the increased deaths in healthy, young adults in the 1918 flu pandemic were entirely due to D deficiency, it is important to ensure adequate immunity esp. in the at-risk populations through testing (if necessary) and supplementation.

Herbal support and supplementation notes:

· Preventative health:

Vitamin D

The only supplement I recommend adding if your diet is adequately plant based. Recommended blood test levels are around 35 ng/mL, but that’s just for adequate calcium metabolism. For immune function, required levels are closer to 50 ng/mL. Supplementation with 5,000 IU daily is necessary.

Astragalus

As a preventative, it should be withdrawn once symptoms begin. Take 3-5 grams of root daily in capsule, or simmer 2-3 TBS in a pint of water and drink through the day. Tinctures are taken at 1 tsp doses once or twice daily.

Garlic

Directly antiviral, ameliorates influenza symptoms, and its pungent compounds have been found to reduce cytokine storm. 3-4 cloves daily is ideal, as close to freshly cut as possible (chop first).

· Herbs that are directly anti-influenza:

Note: for most antiviral herbs, frequent dosing is relatively important in order to maintain physiological levels of herbal medicine ahead of the viral replication curves. Viral populations can easily more than double in an 8 hour period, so it is beneficial to work with antiviral and anti-inflammatory herbs on a 6-8 dose/day schedule. This is a dose roughly every 3-4 hours.

Boneset

Infusion, 1 TBS per pint along with other herbs, sipped every hour or so. Tinctures can also be used, 45-60 drops in warm water every hour or so.

Elderberry

Amazing clinical results against most influenza strains. Safe for H1N1, perhaps caution in H5N1 or other cytokine-storm-inducing strains due to potential TNF stimulation.

Use syrups (1TBS 3-5 times daily) or a fresh preserved succus / juice at the rate of 1tsp every 2-3 hours.

Elder flower tea is useful also, as a cooling way to induce sweating in the latter phases.

Echinacea

There is evidence of activity against influenza viruses, especially when combined with Thuja and Wild Indigo (Esberitox). It is potentially contraindicated in cytokine-storm influenza. Use Esberitox, or a good fresh tincture at doses of 1tsp. every 3-4 hours. Usually best at the first signs of imbalance – fatigue, sore throat, headache.

· Herbs that reduce cytokine storm activity and buffer “hot” influenza symptoms:

Baikal Scullcap root

Reduces cytokine storm and acts as an inhibitor of influenza symptoms. Take 60-90 drops three times a day of a good tincture. Avoid in cases of diarrhea.

Salvia milthiorrhiza root

Immunomodulant for cytokine storm, esp. with a constricted, wiry pulse. Take ½ tsp. of a good tincture three times daily.

Ginger and Turmeric

Both rhizomes are anti-inflammatory and inhibit inflammatory cytokines. This protects respiratory tissue as well as relieving symptoms. Most indicated in the initial phases of the flu as warming agents. Add fresh ginger to teas, or use powders of both at doses of 1-3 grams 2-3 times daily (about ¼ to ½ tsp.).

St. John’s wort

This is a potent antiviral herb, prized as a restorative in deficient, depleted constitutions. Modern evidence points not only to its pharmacological effect on dampening the cytokine storm by suppressing IL-6 and MAPK, but also to its targeted and specific antiviral effect against the H5N1 strains of bird flu, both in the petri dish and in infected poultry. The dose of tincture is 90-120 drops three times daily.

Cannabis?

This herb is potentially a down-regulator of TNF in certain situations, and may have a role to play in especially “hot” influenza strains. It is also an activator of the endogenous cannabinoid system, which stimulates immunoglobulin production in the respiratory epithelium. Not for smoking – low doses of oil-based preparations are best.

Adjuvant herbs (beyond the virus and inflammation):

Dry, spasmodic cough:

A very intense and painful cough can accompany H1N1 2009 influenza. It usually appears after the first 24 hours or so, and affects the beginning of the bronchial tree causing violent coughing with whole-body spasms. The warm drying expectorants (such as Elecampane, Mullein, and Aster) are probably best avoided in favor of the soothing, demulcent expectorants listed below.

Licorice

Its antiviral action may be due in part to the inhibition of virulence factors such as the hemagglutin proteins on the viral capsule. While it is still unclear if it has specific inhibitory effect on H1N1 or H5N1 strains, it remains an excellent demulcent for people of all ages and reliably loosens the dry cough within a day or at most two. This is especially important to help with disturbed sleep. Tincture, 2 droppers in a little water every 2-4 hours. Infusion, 1 TBS of root per cup. 1-2 TBS of infusion every 2-4 hours.

Pleurisy root, Butterfly weed

This demulcent expectorant is particularly indicated if the re is a burning sensation in the chest wall that accompanies the cough. Any spitting of blood, while perhaps a clear sign of cytokine storm and certainly of the need for immediate treatment, was traditionally an indication for this herb. It is also relaxing and mildly diaphoretic. Take 30-60 drops of the tincture 3 times a day.

Lobelia

Strongly antispasmodic, it relieves the whole-body paroxysms associated with the dry bronchial cough and is also a gentle expectorant. Use 10-30 drops of tincture every 3 hours or so, depending on tolerance because it is quite nauseating if given in excess.

Wild Cherry, Peach pit

These herbs contain glycosides of hydrogen cyanide (HCN), which in small doses is calmative and strongly antispasmodic to the lungs. They are valuable as part of a comprehensive protocol that also includes expectorants and antiviral herbs. Cold-infusion is best. Heating dissipates HCN readily tincture is dosed 5-30 drops bid. Wild Cherry bark syrup: 1 pint overnight cold infusion of 1 oz bark; strain, add 2 lbs honey.

Diaphoretic herbs not previously mentioned:

Honeysuckle flower

This remedy from the Chinese pharmacopoeia helps to cool and break a fever. Best during the first and early second stages of the flu to release internal heat and bring warmth to the surface. Usually infused, along with Platycodon for the lungs, Catnip as another antiviral diaphoretic, peach pit as a pulmonary antispasmodic, and Licorice.

Catnip herb

Especially useful as a mildly calmative antiviral diaphoretic for kids. Usually added to tea blends, perhaps with a little Ginger and/or Licorice.

Peppermint

Has some mild antiviral quality, and certainly is cooling and helps break a fever, as well as improve the flavor of herbs such as Boneset. A classic formula: equal parts of Peppermint, Boneset, Elderflower, and Yarrow in the late first / early second stage of the flu, when heat is manifest but the skin still dry and the body still achy, with a tense, tight pulse.

Bitter tonic herbs with antiviral / mucosal tonic effect:

Goldenseal

Not antiviral, but astringent and tonifying to the upper respiratory mucosa. Can alleviate congestion and improve appetite in the second or third stages of the flu.

Andrographis

Also called the “king of bitters”, this herb has shown excellent results when combined with Siberian Ginseng in large trials for the flu. It has antiviral effect and also improves GI tract function and may help regulate cytokine activity and prevent the cytokine storm.

dried herb - 1.5- 5 g/day; tea- 1/2- 1 teasp. steeped in 8 oz water, drink 4oz 3 X day
tincture- 20-60 drops 3 X day. standardized tablets- 100mg. w/ 5mg andrographolide and deoxyandrographolide, take 4 tablets 3Xday

Adaptogenic herbs not previously listed:

Panax quinquefolium

This is the American ginseng root, and while most of the evidence in humans pertains to the cold rather than the flu, it has good immune-enhancing (modulating) effect. It is especially indicated if there is severe stress and/or recurrent infections of all types related to deficient immunity. Take ½ tsp. of tincture 3 times daily, or 2-7 grams daily as whole root or capsule.

Siberian ginseng, though a very different plant, can be used similarly.

Specific pulmonary anti-inflammatory herbs not previously listed:

Platycodon

The balloonflower is used in Chinese medicine to clear heat from the lungs. As such, it seems more specific for the dry, painful and recurrent bronchitis than for moist, low-grade symptoms. It makes a good addition to tincture formulas for those who always have “every cold go to the lungs”. 30-90 drops of tincture 2-3 times daily.

Hyssop

Yet another effective antiviral herb that is gaining more attention in modern times, it is an excellent herb for lung afflictions of the more moist / hot variety. As such, it perhaps has a role to play in the later phases of influenza and to help with recovery. Infusion is excellent, about 1 TBS / cup steeped with a lid 3 times a day.

Top 200 drugs in the US - 2008

Jón T. Njarðarson's team at the University of Cornell has put together an interesting poster listing the top 200 pharmaceuticals used last year, ranked in order of sales dollars. Ostensibly there to "educate students about how chemistry positively impacts our lives" (debatable, I guess), it is a useful list because it gives the brand names, chemical structures, and general uses of these drugs we so commonly run in to in practice. A useful quick-reference (and an alarming amount of money spent).

Hawthorn for a failing heart

Hawthorn (various Crategus species) received an endorsement in another Ernst-and-friends metareview. The review included 14 trials, and focused on hawthorn's ability to improve the maximum workload of the heart, and improve various cardiovascular markers during exercise-induced strain. The bottom line: hawthorn leaf and flower extract helps. A lot. Even if added to existing medication regimens.
Just to be clear, no new clinical research is coming out of this review. Rather, it attempts to collate existing studies and compare them using a common denominator. Further details on the data are below, but for now my opinion continues to be that hawthorn, either as a berry, a tasty jam, or as a leaf-and-flower extract (or tea), should always be considered as part of the protocol for cardiovascular weakness or imbalance. In fact, I might go further to say that most colorful berries would accomplish similar effects and that, in fact, a nice cocktail of all sorts of berry fruits is probably the best way to go for managing blood pressure, improving capillary integrity, and increasing the efficiency of the heart muscle. Eat well!

Echinacea as a common cold preventative - again

We've been over in Italy for the last few weeks, and updates here are difficult. I'll be posting some photos of wild springtime herbs soon, but for now a little tidbit that will surely make news (because it shows a negative result for an herbal intervention): another study tells us that Echinacea doesn't prevent the common cold.
90 volunteers received 3 caps pf Echinacea purpurea tops twice a day for 8 weeks, and reported 8 sick days vs. 12 for placebo. This is an 'insignificant' result. I'm not sure when the research community will figure out that this is a) an inappropriate dose and delivery system and that b) it is an inappropriate application of the herbal remedy.
Perhaps that's not the point. Perhaps media articles that say "Echinacea fails" are more enticing than actual helpful research. I just wish someone would send me the funding that researchers get for conducting these trials so I could buy more compost for my garden...

Devil's Claw and rheumatic inflammation

Devil's Claw (Harpagophytum procumbens) is native to South Africa, lives in dry soils, and produces large underground tubers that are a source of both food and medicine.
The tubers are rich in flavonoids, phytosterols, and a particular type of bitter iridoids (one of which, extensively researched, is known as harpagoside and usually serves as the 'marker compound'). It is traditionally used as a tonic for the digestion, helping to improve appetite and assimilation while also being very nourishing. It has also served as a general depurative and diuretic.
More recently interest has focused on its analgesic and anti-inflammatory qualities, with a range of human trials in the literature that expand on lots of pharmacological data (Doloteffin, the standardized aqueous extract of the whole tuber used in many trials, yields about 50mg of harpagoside per dose). Seems best for back pain, osteoarthitis, and muscular pain -- or generally, most chronic conditions involving structural inflammation.
A new study for the first time looks at Devil's Claw in chronic inflammation of autoimmune origin. It's not placebo-controlled, but rather focuses on qualitative impressions from the clinicians and the patients regarding long-term rheumatic inflammation of the knee, hip, and various other joints. Over 200 people were included in the study, though folks taking H2 and proton-pump inhibitors (two varieties of heartburn drugs) were turned away because of the potential for herb-drug interactions. Patients were followed for 8 weeks (with a mid-course checkup at week 4) and, with an eye to safety, were also evaluated through a blood analysis that looked at comprehensive blood counts and liver enzyme levels.
Bottom line: the only adverse events reported weer occasional mild GI upset. Over 50% of participants rated the results as "good" or "excellent", with assessment criteria showing a reduction in pain and stiffness, and improved joint function across the board. Additionally, no changes were seen in any blood values, showing that Devil's Claw is well-tolerated, has no liver toxicity, and works quite well for rheumatic joint pain.
A final note: the authors recorded that a majority of NSAID (aspirin, ibuprofen) users scaled back or eliminated the use of these painkillers during the study, because they no longer were necessary. They go on to point out that, since rheumatic complaints are chronic but have 'flare-ups', the Devil's Claw could be used for long-term management and the NSAIDs added only as needed. This would reduce the chance of side-effects from the medication, and improve patient well-being overall.

Sage improves memory and attention

'He that would live for aye,
Must eat Sage in May.'

The old English proverb, quoted by venerable herbalists from Gerard to Maude Grieve, refers to the virtues of the common garden sage (Salvia officinalis). This gracious aromatic herb, of a dry and warming energy, was long considered to confer immortality, a quickness of wit and eye, and protection from disease.
Previous research has shown evidence for sage's ability to enhance mood, reduce anxiety, and improve performance in healthy young volunteers (lemon balm, too), and the in-vitro research on the herb's ability to exert anti-cholinesterase activity (prolonging the activity of the neurotransmitter acetylcholine) has made it a target for research in aging and dementia. Acetylcholine is involved in transmitting signal in an area of the brain called the basal forebrain (amongst others), and there is evidence that this region of the central nervous system degrades as we age, leading to memory loss and cognitive impairment (as in Alzheimer's, for instance). Acetylcholine also provides the connection between the nervous system and musculature, and deficiencies are associated with conditions such as myasthenia gravis.
In this most recent study, 20 healthy older volunteers aged 65 to 90 were given various doses of a sage extract, and the results indicate an improvement in a variety of cognitive markers, along with a reduction in the score dropoff over the course of the day (the volunteers stayed sharper, longer). Some details:

• the extract was made with 70% alcohol, then concentrated and freeze-dried to a final weight-to-volume ratio of 7.5:1. This is pretty darn concentrated. Researchers were going for the volatile terpenes primarily (well-soluble in alcohol). They found 333mg to be the most effective dose; this is about 2.5 grams of leaf, or about 7.5 ml (1 and 1/2 tsp.) of a 1:3 tincture of sage.
• the extract was compared to placebo, in a variety of categories including word recognition and recall; vigilance; reaction time; spatial and numeric memory; and delayed picture recognition tests. Below are graphs of the changes in (a)secondary memory and (b)accuracy of attention:

So, sage is definitely worth considering in the context of other herbs such as Ginkgo and Rhodiola in helping buffer the effects of aging on otherwise healthy minds. Perhaps there is indeed some wisdom in the old Latin proverb, Cur moriatur homo cui Salvia crescit in horto? ('Why should a man die as long as sage grows in his garden?'). Or at least, why should he (or she) grow old and forgetful?