Understanding Herbal Remedies
Recently, I was reminded of an interesting case that illustrates that even with excellent clinical skills and sophisticated testing, we must remain humble and recognize that certain patient problems may remain unsolved despite our best efforts. In addition, physicians must continually keep apprised of new information and be prepared for the ever-changing challenges of modern medicine.
Mr. J is an 82-year-old Chinese-speaking gentleman who reports being in good health his whole life. He walks daily, tends to his own personal needs, and enjoys visits from his children and grandchildren. He has never been to a physician since coming to the United States over a decade ago and reports taking no medications. Over the past two weeks, however, he noted increasing pain throughout his entire body that grew in intensity until it hurt just to get dressed. Noting a change in his usual routine, his daughter decided to bring him into the emergency room for an evaluation. His story was retold through an interpreter. His physical examination revealed limited range of motion in his ankles, knees, and wrists. His joints were not “hot,” and no effusion could be elicited. The rest of his physical exam was unremarkable; his vital signs were within normal limits.
Of note, his white blood cell count was slightly elevated at 10,500, with a predominance of polymorphonuclear cells. His erythrocyte sedimentation rate was 40, and his C-reactive protein was 10 times normal. His liver function tests were of concern only for an aspartate aminotransferase that was 1.5 times normal, with no other abnormalities identified. Although the initial impression was of a septic polyarthritis, cultures were negative and no effusion was noted in sufficient quantity to tap. Bone scan and indium scans were negative as well. An initial trial of empiric antibiotic therapy had no effect on his pain, and after three days both the infectious disease and rheumatology consultants were confident that this was not due to an infectious etiology. He was repeatedly cultured and tested without any leads. Gout and pseudogout were also considered not likely, as were other common arthritic problems.
Over the next two days, the pain began subsiding and the laboratory findings were returning to normal. Unfortunately, no definite diagnosis was made and all physicians involved in his care remained puzzled. Was this some strange viral illness or something else? “Tincture of time” appeared to be the cure. Further questioning of family members, however, revealed that Mr. J had recently been taking a natural herbal remedy he received from a Chinese herbalist—he refused to allow his daughter to bring these to us and dismissed our concern that these may be in fact the cause of his problem. He had not been taking these herbs since his arrival in the hospital and was feeling better and hopefully on the road to his usual self. What else could we think? We all believed that he would resume taking these herbs after returning home, despite our warning him otherwise; only if his pain resumed would Koch’s postulates be met and the link confirmed. Only time would tell.
This case illustrates a bigger problem than whether some herb or combination of herbs was the cause of Mr. J’s discomfort. Clearly, in this case there still were many other possible etiologies. The established medical profession knows very little about home remedies, methods of “natural healing,” and medicinal herbs, despite the fact that these have been used for centuries throughout the world and with greater frequency in the United States in recent years. What are their benefits, potential risks, and side effects? We have seen the evidence for and against using Ginkgo biloba, black cohosh, echinacea, and other herbs that are more commonly used in the West, but many other available “natural” products remain mysterious and not well understood. Naturopathic medicine is a growing profession and now is taught throughout the country in schools located in Arizona, Oregon, California, and Connecticut. There is even an online course available for those interested in receiving a “specialized degree” in this area.
There is currently no regulation regarding what can be sold in the name of a “natural remedy,” as these other nutritional products do not fall under FDA regulatory standards. As physicians and health professionals, we must ensure that our histories are complete and that we ask the right questions. I for one have obtained various references and texts dealing with natural medicine and other complementary therapies that until recently were not part of my knowledge base. I continue to learn and hopefully better prepare myself for future patient encounters. I suggest you do the same. I remain concerned, however, about the myriad of herbs and medicinals that are at times impossible to identify and, even if known, remain poorly understood by modern standards. The better we can accept that our patients may be using these, the better we can prepare for and hopefully understand their side effects and toxicities as well as appreciate their potential benefits.
Send comments to Dr. Gambert at firstname.lastname@example.org.