What is traditional Chinese herbal medicine?

Overview

The system of herbal medicine that developed in China differs in several significant ways from European herbal medicine. The most obvious difference is that Western herbal medicine focuses on simples, or herbs taken by themselves. In contrast, traditional Chinese herbal medicine (TCHM) makes almost exclusive use of herbal combinations. Also, TCHM formulas are not designed to treat symptoms of a specific illness; rather, they are tailored specifically to the individual according to the complex principles of traditional Chinese medicine (TCM). For this reason, TCHM is potentially a deeply holistic healing approach. However, it is both more difficult to use and harder to study than its Western counterpart.

TCHM is widely used in Asian countries, both in its traditional holistic form and in a simplified disease-oriented version. There have been a few properly designed scientific trials of TCHM, but the evidence base remains highly inadequate. In addition to questions regarding effectiveness, serious safety concerns need to be resolved.

History. Chinese herbal medicine has a long historical tradition, although it is not quite as ancient as popularly believed. Ancient herbology in China focused on potions whose functions were part medicinal and part magical, and it lacked a substantial theoretical base. Sometime between the second century b.c.e. and the second century c.e., the theoretical foundations of TCM were laid, but the focus was more on acupuncture than on herbs. Only by about the twelfth century were the deeper principles of Chinese medicine fully applied to herbal treatment, forming the method known as TCHM. This was further refined and elaborated during various periods of active theorizing in the fourteenth through the nineteenth centuries. Western disease concepts entered the picture in the twentieth century, leading to further changes.

In China today, TCHM is used alongside conventional pharmaceutical treatment. Considerable attempts have been made to subject TCHM to scientific evaluation; however, most of the published Chinese studies on the subject fall far short of current scientific standards. (For example, they generally lack a placebo group.)

In neighboring Japan, a variation of the TCHM system known as Kampo has become popular, and the Japanese health ministry has approved many Kampo remedies for medical use. The scientific basis for these remedies remains incomplete, but several studies of minimally acceptable quality have been reported.

Principles of traditional Chinese herbal medicine. According to the principles of all Chinese medicine, health exists when the body is balanced and its energy is freely flowing. The term “energy” refers to qi, the life energy that is said to animate the body. The term “balance” refers to the relative factors of yin and yang, the classic Daoist opposing forces of the universe. Yin and yang find their expression in various subsidiary antagonists such as cold versus heat and dampness versus dryness.

In an ideal state, yin and yang in all their forms are perfectly balanced in every part of the body. However, external or internal factors can upset this balance, leading to disease. Chinese medical diagnosis and treatment involve identifying the factors that are out of balance and attempting to bring them back into harmony. Diagnosis is carried out by means of “listening” to the pulse (in other words, taking the pulse with extraordinary care and sensitivity), observing and palpating various parts of the body, and asking a long series of questions.

It is important to realize that diagnosis according to TCHM differs greatly from Western diagnosis. Consider two hypothetical patients with the single Western diagnosis of migraine headaches. The first might be said to have “dryness in the liver and ascending qi,” while the other might be diagnosed with “exogenous wind-cold.” Based on these differing diagnoses, entirely different remedies might be applied. In other words, there is no such thing as a TCHM remedy for migraines per se; rather, treatment must be individualized to the imbalance determined by traditional theory.

The herbal formulas used in TCHM consist of four categories of herbs: ministerial, deputy, assistant, and envoy. The ministerial herb addresses the principal pattern of the disease. Deputy herbs assist the ministerial herb or address coexisting conditions. Assistant herbs are designed to reduce the side effects of the first two classes of herbs, and envoy herbs direct the therapy to a particular part of the body. For example, in the case of “dryness in the liver and ascending qi,” an herbalist might employ a ministerial herb to reverse ascending qi, a deputy herb to exert a moistening effect, an assistant herb to prevent the stagnation of qi (qi stagnation is said to be a side effect of moistening herbs), and an envoy to carry these effects to the liver.

TCHM remedies can also be designed to fit all common causes of migraines simultaneously, mostly by multiplying the number of ingredients. Practitioners of TCHM frown upon this “one-size-fits-all” approach, but it is often popular among consumers and is easier to test scientifically.

Types of Chinese herbal remedies. To use Chinese herbal medicine in the most traditional fashion, one must visit an herbalist’s shop. There, experienced herb preparers will chop, grind, fry, and slice dried herbs according to the prescription given by an experienced herbalist. The herbalist will provide a packet of dried herbs that need to be prepared according to the instructions, which typically involve adding water, boiling for several hours in a ceramic pot, pouring off the liquid, adding more water, and repeating the process twice more. Certain herbs are supposed to be added at the end of the process, while others require extra-long preparation.

If one does not wish to carry out such a complex process, or if a classic herbal shop is not available, one may wish to move one step away from tradition and purchase a prepared Kampo formula. There are several hundred such formulas designed to match the most commonly seen forms of imbalance. Available in powder, capsule, or tablet form, they can be used much more conveniently than fully traditional herbs. Many Kampo combinations are licensed in Japan and are manufactured there on a large scale by reputable manufacturers.

The lowest level of TCHM, scarcely deserving the name, involves Chinese patent remedies, which consist most commonly of tiny brown spheres in small brown bottles. They are marketed for both classical imbalances and Western disease categories. Patent remedies are inexpensive and widely available. However, there have been so many scandals involving dangerous contaminants not listed on the label that people should avoid this form of treatment entirely.

In the West, herbal medicine is part of folk medicine. However, in China, there is a distinct tradition of Chinese folk medicine that is separate from the orthodox, rather academic TCHM approach. In this Chinese folk medicine, herbs are used more simply, somewhat in the manner of Western herbal medicine. Herbs most commonly used in this manner include Astragalus, dong quai, ginger, kudzu (Pueraria lobata), licorice, Lycium, Panax ginseng, and Schisandra.

In addition to herbs, substances that are often considered supplements are utilized in TCHM. These substances include extract of human placenta, glandular extracts, and a variety of minerals.

Uses and applications. In the traditional system of Chinese herbal medicine, herbal formulas can be used to treat virtually any condition. Some of the most common uses in China include liver disease (hepatitis and cirrhosis), sexual dysfunction in men, infertility in women, insomnia, colds and flus, menstrual pain, irregular menstruation, and menopause.

Acupuncture is often used with herbs as a supplemental treatment; in addition, extraordinarily detailed lifestyle suggestions are common. It is not unusual for a traditional practitioner to “prescribe” dinner and to counsel changes in living situation (for example, move from the basement to the first floor or face the bed south rather than north). Exercise systems such as Tai Chi and qigong may also be recommended.

Chronic hepatitis. Hepatitis is a serious problem in many Asian countries, and conventional care is lacking. For this reason, herbal remedies are widely used.

The herbal combination Shosaiko-to (Minor Bupleurum) has been approved as a treatment for chronic hepatitis by the Japanese health ministry, and it enjoys wide use in that country and elsewhere. However, a search of the literature uncovered only one large-scale, double-blind, placebo-controlled study supporting its effectiveness. In this twenty-four-week trial, the efficacy of Shosaiko-to was tested in 222 people with chronic active hepatitis using a double-blind, placebo-controlled, crossover design. Results showed that the use of Shosaiko-to significantly improved liver function measurements compared with placebo. Although these results are promising, an absence of long-term evaluation limits their meaningfulness. (Researchers followed participants for three months only.)

Other Chinese herbal remedies have been tested as adjuncts to conventional interferon treatment with promising results. However, published trials are of generally poor quality. Persons undergoing interferon therapy should not use Chinese herbal formulas (or any herbs or supplements) except under the supervision of a physician.

Combination Chinese herbal therapies have also shown some promise for the treatment of chronic hepatitis; tested formulas include Bing Gan Tang, Yi Zhu decoction, Fuzheng Jiedu Tang, and Jianpi Wenshen recipe. However, the quality of most of these studies was quite poor. The results are mixed, and overall, the evidence for these remedies remains far too weak to rely upon. Two studies failed to find Chinese herbal treatment helpful for hepatitis C. Also note that there have been numerous cases of hepatitis and other forms of liver injury caused by Chinese herbs.

Liver cirrhosis
. Shosaiko-to has also shown some promise for preventing liver cancer and liver fibrosis in people with liver cirrhosis or chronic hepatitis. However, the evidence remains marginal. For example, in a double-blind, placebo-controlled study, 260 people with cirrhosis were randomly assigned to take Shosaiko-to or placebo, along with conventional treatment. In five years of evaluation, people taking the herb appeared to be less likely to develop cancer or die, but the results just missed the ordinary cutoff for statistical significance. For the subgroup of participants without hepatitis B infection, the benefits were statistically significant at the usual cutoff point.

Irritable bowel syndrome
. In a double-blind, placebo-controlled trial, 116 people with irritable bowel syndrome (IBS) were randomly assigned to receive individualized Chinese herbal formulations, a one-size-fits-all Chinese herbal formulation, or placebo. Treatment consisted of five capsules three times daily, taken for sixteen weeks. The results showed that both forms of active treatment were superior to placebo, significantly reducing IBS symptoms. However, the individualized treatment was no more effective than the generic treatment. Similar results also were seen in another study.

Constipation. The Kampo formula known as Daio-kanzo-to is a mixture of rhubarb and licorice. In a two-week, double-blind, placebo-controlled trial, 132 people with constipation were randomly assigned to one of three groups: placebo, low-dose Daio-kanzo-to, or high-dose Daio-kanzo-to. The results indicate that the higher-dose group, but not the lower-dose group, experienced statistically significant improvements in constipation compared with placebo.

Allergies. In a double-blind, placebo-controlled trial, 220 people with allergic rhinitis were given either placebo or the Kampo remedy Sho-seiryu-to for two weeks. The results showed that the use of the herbal formula significantly relieved all major symptoms of allergic rhinitis compared with placebo. Based on this and other more preliminary studies, Sho-seiryu-to has been approved by the Japanese health ministry for the treatment of allergic rhinitis and allergic conjunctivitis.

Another combination herbal therapy has shown promise for allergic rhinitis. In a twelve-week, double-blind, placebo-controlled trial, fifty-eight people with allergic rhinitis were given either placebo or an eleven-herb combination remedy called Biminne. This combination therapy contains the following herbs: Rehmannia glutinosa, Scutellaria baicalensis, Polygonatum sibiricum, Ginkgo biloba, Epimedium sagittatum, Psoralea corylifolia, Schisandra chinensis, Prunus mume, Ledebouriella divaricata, Angelica dahurica, and Astragalus membranaceus.

The use of Biminne produced significant improvements in some symptoms of allergic rhinitis, while other symptoms showed a trend toward improvement that was not statistically significant. A follow-up evaluation suggested that the results persisted for one year after treatment was stopped.

Benefits also have been seen in small studies of other formulations. However, one study failed to find that the use of herbal treatments augmented the effectiveness of acupuncture for allergic rhinitis.

Osteoarthritis
. A double-blind, placebo-controlled study of ninety-six people with osteoarthritis of the knee tested the effectiveness of a mixture of three Chinese herbs (Clematis mandshurica, Trichosanthes kirilowii, and Prunella vulgaris). Participants were randomly assigned to a placebo group or one of three other groups: given either 200 milligrams (mg), 400 mg, or 600 mg of the herbal formula three times daily. After four weeks of treatment, significant improvement in arthritis symptoms was seen in all three treatment groups compared with placebo. No dose appeared conclusively superior to the others.

Muscle spasms. The Kampo remedy Shakuyaku-kanzo-to is a combination of peony root and licorice, commonly used for the treatment of muscle spasms in general. In a double-blind, placebo-controlled study, 101 people with liver cirrhosis who also suffered from severe muscular spasms at least twice per week were given either Shakuyaku-kanzo-to or placebo three times daily for two weeks. (The herb combination is not specifically aimed at liver cirrhosis. However, people with liver cirrhosis often have muscle spasms, so it made sense to try an anti-muscle-spasm formula.) The results showed significant reduction in frequency and severity of spasms among the participants using the herb, compared with those taking placebo. However, some participants using the herb developed edema (swelling caused by excess fluid) and weight gain. Researchers attributed this side effect to the licorice constituent.

Menstrual pain. In a double-blind trial of forty women with menstrual pain, the Kampo formula Toki-shakuyaku-san was compared with placebo with good results. The design of this study was interesting because researchers preselected women who, according to the principles of TCM, would be expected to respond to this Kampo treatment. Through six menstrual cycles, women using the real herbal formula experienced significantly less menstrual pain compared with those in the placebo group. Benefits took three menstrual cycles to develop.

In a 2008 review of thirty-nine randomized controlled trials involving a total of 3,475 women, researchers concluded that the use of traditional Chinese herbs shows some promise in treating menstrual pain. However, firm conclusions were not possible because of the wide variability of study design and herbs used and because of the poor quality of many of the studies.

Diabetes
. A double-blind study of more than two hundred people evaluated the effectiveness of Coptis formula (a traditional combination therapy) with or without the drug glibenclamide for the treatment of diabetes. Coptis formula appeared to significantly enhance the effectiveness of the drug; however, the herbs produced marginal benefits at best when taken alone.

Asthma. The Kampo remedy Saiboku-to has been approved by the Japanese health ministry for the treatment of asthma. However, meaningful supporting evidence appears to be limited to one small trial. In this double-blind, placebo-controlled, crossover study, thirty-three people with mild to moderate asthma received Saiboku-to or placebo three times daily for four weeks. Treatment with the herbal remedy improved symptoms of asthma to a greater extent than placebo. Additional measurements suggested that Saiboku-to works by reducing asthmatic inflammation (technically, eosinophilia). A Chinese study using a proprietary formulation also reported benefits.

Eczema
. A Chinese herbal mixture sold under the name Zemaphyte has shown promise as a treatment for eczema. This formula, based on herbs traditionally used for skin conditions, contains the following: Ledebouriella seseloides, Potentilla chinensis, Akebia clematidis, Rehmannia glutinosa, Paeonia lactiflora, Lophatherum gracile, Dictamnus dasycarpus, Tribulus terrestris, Glycyrrhiza uralensis, and Schizonepeta tenuifolia.

In paired double-blind, placebo-controlled trials carried out by one research group, Zemaphyte produced significantly better effects than placebo for both adults and children. Each study enrolled approximately forty people and used a crossover design in which all participants received the real treatment and placebo for eight weeks each. The use of the herb significantly reduced eczema symptoms compared with placebo. However, a subsequent study of similar design performed by a different research group failed to find significant benefit with Zemaphyte. The reason for this discrepancy is not clear. In a twelve-week, double-blind study, a different traditional Chinese herbal formula also failed to prove more effective than placebo for treatment of eczema.

Tension headache. A topical ointment known as Tiger Balm is a popular treatment for headaches and other conditions. Tiger Balm contains camphor, menthol, cajaput, and clove oil. A double-blind study enrolling fifty-seven people with acute tension headache compared the application of Tiger Balm to the forehead with placebo ointment and with the drug acetaminophen (Tylenol). The placebo ointment contained mint essence to make it smell similar to Tiger Balm. Real Tiger Balm proved more effective than placebo and just as effective as acetaminophen. It also acted more rapidly.

Human immunodeficiency virus infection
. Chinese herbal therapies have been investigated for the treatment of human immunodeficiency virus (HIV) infection, but the results have not been very promising. In a twelve-week, double-blind, placebo-controlled trial, thirty persons with HIV who had CD4 counts of 200 to 500 were given a Chinese herbal formula containing thirty-one herbs. The results hint that the use of the herbal combination might have improved various symptoms compared with placebo, but none of the differences were statistically significant. Participants who believed they were taking the real treatment showed significant benefit regardless of whether they were in the placebo group or the real treatment group.

In another double-blind, placebo-controlled trial, sixty-eight persons with HIV were given either placebo or a preparation of thirty-five Chinese herbs for six months. The results indicate that the use of Chinese herbs did not improve symptoms or objective measurements of HIV severity. In fact, people using the herbs reported more digestive problems than those given placebo.

Prostate cancer. For several years, the Chinese herbal combination PC-SPES underwent significant investigation as a treatment for prostate cancer, with apparently impressive results. However, subsequent investigation revealed that PC-SPES contained undisclosed pharmaceutical ingredients (principally, a form of estrogen and the strong blood thinner Coumadin) and that these ingredients were probably responsible for its benefits. The treatment has since been withdrawn.

Other uses. A large double-blind study conducted in China reported that the use of the traditional remedy Xuezhikang by people with a previous history of a heart attack could reduce the risk that they would have a subsequent severe cardiovascular problem, such as a stroke or another heart attack. Chinese herbal medicine may also be helpful for people with angina. In a small, randomized trial of sixty-six adults with stable angina, Shenshao tablets (containing ginsenosides and white peony) reduced the frequency of angina attacks.

In a small, double-blind, placebo-controlled trial, the use of the herbal combination Banxia Houpo Tang (also called Hange Koboku-to or Magnolia and Pinelliae formula) was tested for the treatment of impaired cough reflex in people who had suffered a stroke. The results indicated that the herbal combination was more effective than placebo treatment for improving the coughing response.

In a review of twenty-one studies involving almost three thousand persons, researchers concluded that Chinese herbs were as effective as commonly prescribed medications for drug withdrawal symptoms in heroin addicts. They could not draw any conclusions, however, regarding what specific herbs were most beneficial.

Various Chinese herbal formulas have been evaluated for the treatment of respiratory infections. The results of published studies appear to indicate that these formulas are more effective than standard antibiotics, but the poor design of most of these trials precludes placing much faith in their outcomes. One combination therapy called Shuang Huang Lian has better supporting evidence than most.

A double-blind study performed in Hong Kong evaluated the potential benefits in cancer chemotherapy of personalized herbal formulas designed according to the principles of TCHM. In this study, 120 people undergoing chemotherapy for early-stage breast or colon cancer were given either a personalized formula or a placebo. Researchers evaluated numerous possible effects of the treatment but found benefits in only one: the reduction of nausea. Note that even this single result is less meaningful than it may seem; it is statistically questionable to use a multiplicity of outcome measures. A review of fifteen mostly poor-quality trials with 862 participants suggested that Chinese herbal medicine might improve quality of life in persons with non-small-cell lung cancer who are undergoing chemotherapy.

One study evaluated the effectiveness of an herbal combination containing herbs commonly used for the treatment of cough, but it failed to find the treatment effective. This study has been incorrectly reported as finding the tested treatment effective; indeed, the use of the treatment did help suppress coughing, but so did the placebo treatment, and there were no significant differences between the groups.

Numerous studies have evaluated TCHM for treatment of liver cancer with generally positive results. However, study design and reporting were markedly substandard.

A double-blind, placebo-controlled study of twenty-nine people with chronic fatigue syndrome found indications that the use of the Kampo remedy Hochu-ekki-to significantly improved symptoms compared with placebo. Also, the Kampo remedies Saiko-keishi-to and Shosaiko-to have been suggested for the treatment of epilepsy, but the supporting evidence is too preliminary to be relied upon. Both of these combination treatments consist of bupleurum, peony root, pinellia root, cassia bark, ginger root, jujube fruit, Asian ginseng root, Asian scullcap root, and licorice root, but the proportions are different.

Other traditional herbal combinations with some supporting evidence (often from studies of questionable quality) include Xiao-yao-san (Free and Easy Wanderer) for depression and bipolar syndrome, Mai-men-dong-tang for allergic asthma, Yi-Gan San for dementia, Bofu-tsusho-san for weight loss and diabetes, Chang Ji Tai for irritable bowel syndrome, Ondamtanggamibang (a Korean formulation) for reducing symptoms of stress, Qinzhu Liangxue for psoriasis, and red peony root for acute pancreatitis.

In one study, the herbal formula Duhuo Jisheng Wan, widely used for osteoarthritis, proved to be as effective as the standard anti-inflammatory drug diclofenac. However, the herb caused as many side effects as the drug, and it was slower to act. (It was so slow that its benefits could have been caused solely by the placebo effect.) This study did not use a placebo control group.

One double-blind, placebo-controlled study tested the remedy Hochu-ekki-to for enhancing immune response to influenza vaccine but failed to find benefit. One study quoted as showing that a Chinese herbal formula can reduce blood pressure actually failed to find any effect on blood pressure. A review of seventeen trials found that there is limited evidence to support the use of traditional Chinese herbal preparations for the common cold.

Safety Issues

There are several serious safety concerns with the use of TCHM. One concern involves the use of multiple herbs typical in this approach. In general, conventional medicine makes a point of using as few medications as possible (in theory, at least) because the greater the number of medications, the greater the risk of harm. Also, when medications are used together and harm does result, it is difficult to know what drug was at fault. From this perspective, formulas consisting of five, ten, or thirty herbs are quite worrisome.

Such combinations are actually designed for the purpose of reducing risks. According to TCHM theory, the various herbs in a formula balance and moderate each other. This theory, however, has never been put to the test, and there are reasons not to trust it. Simply put, it is very difficult to get an accurate picture of the risks of a treatment if one does not keep systematic records of adverse effects; the ancient Chinese government had no such system in place. In any case, the individualized nature of treatment would make it almost impossible to track harm. Herbalists would be expected to notice immediate, dramatic reactions to herbal formulas, and one can assume with some confidence that treatments used for thousands of years are unlikely to cause such problems in very many people who take them.

However, certain types of harm could be expected to easily elude the detection of traditional herbalists. These include safety problems that are delayed, occur relatively rarely, or are difficult to detect without scientific instruments. How would a traditional herbalist ever know, for example, if a treatment caused liver failure in 1 of every 100,000 people who used it, especially if such failure took two or more years to develop? If such a death did occur in the herbalist’s patient population, it would probably be attributed to hepatitis or some other common cause.

These factors may explain why Chinese herbal medicine traditionally uses treatments that are now recognized as potentially dangerous, such as mercury, arsenic, lead, licorice, coltsfoot, and Aristolochia clematis. Mercury, arsenic, and lead accumulate slowly in the body, and for many years their harm can only be detected by laboratory tests. Licorice (used in many herb formulas to “harmonize” the ingredients) can raise blood pressure and disturb blood chemistry. These effects were presumably undetectable to traditional practitioners unless the effects became quite severe. The herb Aristolochia can cause severe kidney damage and kidney cancer, but only rarely. Modern medical surveillance has uncovered quite a few such cases, but traditional herbology considered the herb worth using. Aristolochia contains aristolochic acid, a substance shown in animal studies to damage the kidney when taken in high enough doses. Chinese herbal products generally list Aristolochia on the label when it is present, but in some cases, Aristolochia was apparently added accidentally (it is similar in appearance to a much safer herb).

Coltsfoot (Tussilago farfara), used in Chinese cough syrups and other formulations, contains pyrrolizidine alkaloids, substances that can, over time, damage the liver. This also does not appear to have been noticed by traditional herbalists. Under modern conditions of medical surveillance, many incidents have been reported in which the use of Chinese herbs appears to have caused various forms of liver injury, including acute hepatitis, chronic hepatitis, hepatic fibrosis, and acute liver failure. Ancient herbal practitioners might not have been able to distinguish these herb-induced illnesses from the effects of infectious hepatitis, a widely prevalent condition, and thereby failed to make the connection. Even today, it appears that many cases of liver failure attributed to hepatitis have been caused by the Chinese herbs used to treat hepatitis. Other reported complications of Chinese herbal treatments include movement disorders and ovarian failure.

Another set of potential problems arises from Chinese herbal medicine not restricting itself to plant products with subtle effects. Many traditional Chinese herbal remedies are, simply put, poisons. When taken in proper doses, they may be safe for use, but dosage miscalculation or use in a particularly susceptible person may lead to serious consequences, including death. For example, in Hong Kong, poisoning caused by the herb aconite (used in numerous Chinese herbal formulas) was sufficiently widespread that public health authorities launched an information campaign to combat the problem.

Besides toxicity caused by Chinese herbs, other problems have been caused by adulteration of herbal products with unlisted ingredients. For example, the Chinese herbal formula PC-SPES, used for prostate cancer, turned out to contain three pharmaceutical drugs: diethylstilbestrol, warfarin (Coumadin), and indomethacin. This appears to have been an intentional adulteration designed somewhat along the lines of a traditional Chinese formula, with one pharmaceutical adulterant that treated prostate cancer balanced by two others to offset the side effects of the first. The combination is dangerous and has caused at least one case of severe bleeding.

In another episode, eight of eleven Chinese herbal creams sold in the United Kingdom for the treatment of eczema were found to contain strong pharmaceutical steroids. Other studies have also found steroids in eczema preparations. In addition, Chinese herbal weight-loss aids have been found to contain an unlisted chemical related to the appetite-suppressant drugs fenfluramine and phentermine (Fen-Phen).

Herbal products approved by the Japanese government have undergone meaningful safety testing and are unlikely to contain known toxins or unlisted drugs. However, this does not mean they are completely safe. For example, several case reports suggest that therapy for chronic hepatitis combining an approved herbal formula with the standard drug interferon can cause severe inflammation of the lungs. The herbal formulas Takeda Kampo Ichoyaku K-matsu, Taisho Kampo Ichoyaku, and Kanebo Kampo Ichoyaku Hused, all used to treat upset stomach, might reduce the effectiveness of the Parkinson’s disease medication levodopa.

Chen, S., et al. “Oral Chinese Herbal Medicine (CHM) as an Adjuvant Treatment During Chemotherapy for Non-Small Cell Lung Cancer.” Lung Cancer 68 (2010): 137-145.

Ernst, E. “Adulteration of Chinese Herbal Medicines with Synthetic Drugs.” Journal of Internal Medicine 252 (2002): 107-113.

Lee, M. S., et al. “Effects of a Korean Traditional Herbal Remedy on Psychoneuroendocrine Responses to Examination Stress in Medical Students.” Human Psychopharmacology 19 (2004): 537-543.

Leung, W. K., et al. “Treatment of Diarrhea-Predominant Irritable Bowel Syndrome with Traditional Chinese Herbal Medicine.” American Journal of Gastroenterology 101 (2006): 1574-1580.

Liu, T. T., et al. “A Meta-analysis of Chinese Herbal Medicine in Treatment of Managed Withdrawal from Heroin.” Cellular and Molecular Neurobiology 29 (2009): 17-25.

Matkovic, Z., V. Zivkovic, and M. Korica. “Efficacy and Safety of Astragalus membranaceus in the Treatment of Patients with Seasonal Allergic Rhinitis.” Phytotherapy Research 24 (2010): 175-181.

Mok, T., et al. “A Double-Blind Placebo-Controlled Randomized Study of Chinese Herbal Medicine as Complementary Therapy for Reduction of Chemotherapy-Induced Toxicity.” Annals of Oncology 18 (2007): 768-774.

Wang, J., Q. Y. He, and Y. L. Zhang. “Effect of Shenshao Tablet on the Quality of Life for Coronary Heart Disease Patients with Stable Angina Pectoris.” Chinese Journal of Integrative Medicine 15 (2009): 328-332.

Zhang, X., et al. “Chinese Medicinal Herbs for the Common Cold.” Cochrane Database of Systematic Reviews (2007): CD004782. Available through EBSCO DynaMed Systematic Literature Surveillance at http://www.ebscohost.com/dynamed.

How is Mayella's testimony different from her father's testimony in To Kill a Mockingbird?

In Bob Ewell's testimony, he claims that he had seen Tom Robinson "ruttin" (having sex or sexually assaulting) on Mayella. He claims that he saw Tom but was too worried about Mayella to run after him. But in Mayella's testimony, she claims that when her father found her, he was asking who had done it (who had assaulted her). So, in his testimony, he claims to have seen Tom and Mayella together. He is clear...

In Bob Ewell's testimony, he claims that he had seen Tom Robinson "ruttin" (having sex or sexually assaulting) on Mayella. He claims that he saw Tom but was too worried about Mayella to run after him. But in Mayella's testimony, she claims that when her father found her, he was asking who had done it (who had assaulted her). So, in his testimony, he claims to have seen Tom and Mayella together. He is clear about this. But Mayella says that Bob immediately started asking who had "done it." This is perhaps the biggest difference in their stories about what had happened. This is a red flag indicating that one of them (or both) is lying. 

Mayella's testimony tells us (the readers) and the jury more about her home life.We also learn more about her relationship with Tom. When Atticus questions her, she first says that she's never asked Tom for help before. Then she says she might have asked him for help before. Mayella gets flustered and continues to contradict herself. She says Tom didn't hit her, then she says he did. Her testimony is more inconsistent than Bob's. She is more emotional and this is because of the pressure she feels to lie for her father in front of the entire town. 

What are treponema? |

Natural Habitat and Features

The name Treponema was derived from the Greek words trepein and nema, meaning “turning thread.” Like other spirochetes, treponemes have two or more periplasmic flagella, each attached to opposite ends of the protoplasmic cylinder and unattached at the other end. They extend about two-thirds of the way along the cylinder. The membrane cell wall of the cylinder is rigid, while the complex outer sheath is flexible. When the flagella rotate in the space between the sheath and the cylinder, the entire organism rotates in the opposite direction, allowing for motility.

Because the diameters of these bacteria are usually less than 0.3 micrometers
(m), they are difficult to visualize with a Gram’s stain. However, most can be
visualized using dark-field or phase-contrast microscopy. They grow best at pH 7.2
to 7.4 and at temperatures between 86° and 99° Fahrenheit (30° and 37° Celsius).
Treponemes have very small genomes, with approximately 1.14 million base pairs and
fewer than 1,100 genes. Because of their small genomes, they have limited
metabolism and depend on their hosts for many necessary compounds, including fatty
acids and most amino acids that treponemes are unable to make. They are difficult
to grow in culture because of their extensive nutritional requirements. Some, like
pallidum, have never been successfully grown in culture;
others can be co-cultured only in the presence of other cultured cells; and some,
whose complex nutritional requirements have been determined, can be grown in
normal culture.

Although immunity does develop after some treponemal infections, that immunity is strain specific; no Treponema vaccine has been developed.

The taxonomy of the genus has changed in the twenty-first century. The four
main human pathogens, pallidum,
carateum, endemicum, and
pertenue, have all been reclassified as subspecies of
pallidum, although the original designations, especially
carateum, still appear in the literature. These pathogens were
combined because, morphologically and genetically, almost no difference exists
among these organisms. All are flattened spirochetes that cause a three-phase
infection in humans. Stage one shows a small sore or chancre at the site of
infection. It usually appears days or weeks after initial contact; during this
stage the spirochetes are multiplying. Stage two occurs a few weeks to several
months later; during this stage the bacteria disseminate and lesions
appear on various parts of the body. Stage three occurs after the bacteria have
become fully disseminated, which may take many years, and is the most serious;
many lesions present both internally and externally.

The treatment of choice is penicillin and a single dose is usually
enough to wipe out the organisms in stages one and two. Other antibiotics,
such as tetracycline, chloramphenicol, erythromycin, and azithromycin, have been
used, but none seem as effective as penicillin in treating human primary and
secondary
infections. The tertiary stage requires prolonged and
sometimes more diverse antibiotic therapy.

Pallidum naturally infects only humans, and humans serve as the
only living reservoir for the bacteria. Pallidum, a thin
spirochete with a diameter of less than 1.5 m, is so sensitive to environmental
stress that it rarely survives more than a few seconds away from its human host.
Pallidum pallidum causes syphilis, the most severe of the treponemal infections. Infections are
usually contracted through sexual contact with an infected partner. Congenital
syphilis can occur when the bacterium crosses the placental barrier or infects the
fetus as it passes through the birth canal of an infected woman. The tertiary
stage of syphilis occurs in about one-half of all untreated cases. Lesions can
occur on the central nervous system and the circulatory system, leading to
paralysis and death.

Pallidum pertenue causes yaws and
pallidum carateum causes pinta. Both
are transmitted through skin-to-skin contact and are most common in children in
tropical and subtropical countries. Yaws is found in tropical regions worldwide
and, in its tertiary stage, can lead to disfiguring lesions on the bones. Pinta is
more common in Central America and South America and, even in its tertiary stages,
involves only the skin.

Pallidum endemicum is the cause of bejel. This disease is most common in the Mediterranean region and Saharan Africa. The bacterium is usually transmitted through mouth-to-mouth contact but is sturdy enough to remain viable on eating utensils and can be transmitted by sharing utensils with an infected person. The primary and secondary stages are usually found in the mouth, while the disseminated tertiary stage leads to bone lesions.

Denticola, mucosum, and vincentii are three of the many treponemes that cause periodontal disease. Other Treponema spp. seem to be commensal in human oral and genital tissue without being pathogenic, unless the host is debilitated. Some Treponema spp. are pathogenic in other animals (for example, hyodysenteriae in pigs and paraluiscuniculi in rabbits). Bryantii and saccharophilum, found in the rumen of cows, are important in the complete breakdown of cellulose, although neither is cellulolytic itself. In termite guts, both primitia and azotonutricium are needed for the utilization of wood as food. Azotonutricium is the only known Treponema spp. that can fix atmospheric nitrogen.

Antal, George M., Sheila A. Lukehart, and Andre Z. Meheus. “The Endemic Treponematoses.” Microbes and Infection 4 (2002): 83-94. This article describes the main endemic treponeme infections in humans: yaws, pinta, and bejel.

Krieg, Noel R., et al., eds. Bergey’s Manual of Systematic Bacteriology. 2d ed. New York: Springer, 2010. Volume 4 of this multivolume work describes the Spirochaetes in detail.

Madigan, Michael T., and John M. Martinko. Brock Biology of Microorganisms. 12th ed. Upper Saddle River, N.J.: Pearson/Prentice Hall, 2010. This text outlines many common bacteria and describes their natural history, pathogenicity, and other characteristics.

What is Hashimoto's thyroiditis? |

Causes and Symptoms

Hashimoto’s thyroiditis is a common type of hypothyroidism. The cause and etiology of this disorder is not fully understood; however, it is thought to have an autoimmune origin, in which abnormal blood antibodies and white blood cells, called lymphocytes, infiltrate and attack thyroid cells. The combative interplay between the lymphocytes and the thyroid may lead to a complete absence of thyroid cells. A family history of thyroid disease is commonly traced.

The highest incidence of the disease is observed in young or middle-aged women, but it may occur at any age. The onset is very slow, and the disease may progress for many months or years before it is fully detected. The symptoms may vary, but the condition is usually characterized by a mild pressure on the thyroid gland. In some cases, a firm, slightly irregular, and sometimes tender goiter
(enlarged thyroid gland) may develop in the neck region. In more severe cases, the disease may cause symptoms related to low thyroid function (hypothyroidism), such as fatigue, weight gain, intolerance to cold, constipation, and hair loss.

The symptomatology of Hashimoto’s thyroiditis may resemble other medical conditions. Therefore, in addition to a full medical examination, the diagnostic procedure must also include blood tests to determine the levels of thyroid hormone and thyroid antibodies. If a patient has developed the classic symptoms that accompany Hashimoto’s thyroiditis but has a normal blood test, then a biopsy in which a needle is inserted into the thyroid and some cells are removed may be performed to confirm the diagnosis.

Treatment and Therapy

Though a specific treatment is not yet available, the hypothyroidism resulting from Hashimoto’s thyroiditis can be treated with hormones. Medical practitioners opt to commence hormone therapy, in the form of thyroxine, as soon as a diagnosis is made, even if thyroid function is normal at the time. The hormone therapy is expected to shrink any goiter that has developed. If there is no response, then surgery may be required. The prognosis for a full recovery is usually good because the disease remains dormant or stable for many years.

Bibliography:

Bayliss, R. I. S., and W. M. Tunbridge. Thyroid Disease: The Facts. 4th ed. New York: Oxford University Press, 2008.

Burman, Kenneth D., and Derek LeRoith, eds. Thyroid Function and Disease. Philadelphia: Saunders/Elsevier, 2007.

"Chronic Thyroiditis (Hashimoto's Disease). Medline Plus, June 4, 2012.

"Hashimoto's Disease." National Endocrine and Metabolic Diseases Information Service, April 6, 2012.

"Hypothyroidism." Health Library, March 15, 2013.

Kronenberg, Henry M., et al., eds. Williams Textbook of Endocrinology. 11th ed. Philadelphia: Saunders/Elsevier, 2008.

Shannon, Joyce Brennfleck, ed. Thyroid Disorders Sourcebook: Basic Consumer Health Information About Disorders of the Thyroid and Parathyroid Glands. Detroit, Mich.: Omnigraphics, 2005.

Wood, Lawrence C., David S. Cooper, and E. Chester Ridgway. Your Thyroid: A Home Reference. 4th rev. ed. New York: Ballantine Books, 2005.

What is malabsorption? |

Causes and Symptoms

The nutritive components of food—carbohydrates, protein, fats, vitamins, and minerals—must be digested in the gastrointestinal tract and absorbed into the circulatory system to be of use to the body. Malabsorption of these nutrients is caused by specific defects in any one of the many separate processes involved in the digestion and absorption of food. It is also the result of general impairment of the structure or function of the gastrointestinal tract.

Malabsorption leads to poor growth when it affects the uptake of any essential nutrient, which is one that must be obtained from the diet. It may cause diarrhea if one of the more abundant constituents of food is not absorbed; carbohydrate malabsorption will usually lead to a watery diarrhea, while protein and fat malabsorption will cause a foul-smelling diarrhea that is dark or whitish, respectively. Diarrhea itself may reduce the absorption of nutrients.

Cystic fibrosis
is one of the most common causes of malabsorption in children. The mucus accompanying this disease is secreted into the gastrointestinal tract; it is largely indigestible and can obstruct the passage of nutrients.

Treatment and Therapy

Treatment for malabsorption depends entirely on its cause. In the case of bacterial infections that affect intestinal function, treatment with appropriate antibiotics will return this function to normal. In celiac sprue, an intolerance to the gluten found in wheat and other grains that alters the absorptive surface of the intestines, the removal of gluten from the diet restores normal activity. Some specific defects can be cured by the elimination or replacement of the dietary constituent that is not well digested or absorbed. Incidence of celiac disease rose during the first decade of the twenty-first century. In other cases, no curative treatment is known, as with cystic fibrosis.

Perspective and Prospects

In 1825, William Beaumont, a US Army surgeon, was the first to study human digestion in the stomach. Since then, the processes of digestion and absorption have become well understood, as have many of the causes of acquired and inherited malabsorption. Effective treatment has been developed in all but the most intractable cases. It is hoped that progress in understanding the genetic basis for inherited malabsorption will lead to earlier and definitive identification of affected individuals and eventually to suitable therapies.

Bibliography

Bonci, Leslie. American Dietetic Association Guide to Better Digestion. New York: Wiley, 2003.

Christian, Janet L., and Janet L. Greger. Nutrition for Living. 4th ed. Redwood City, Calif.: Benjamin/Cummings, 1994.

Green, Peter H. R. Celiac Disease: A Hidden Epidemic. Rev. ed. New York: William Morrow, 2010.

Jackson, Gordon, and Philip Whitfield. Digestion: Fueling the System. New York: Torstar Books, 1984.

Janowitz, Henry D. Indigestion: Living Better with Upper Intestinal Problems, from Heartburn to Ulcers and Gallstones. New York: Oxford University Press, 1994.

Mayo Clinic. Mayo Clinic on Digestive Health: Enjoy Better Digestion with Answers to More than Twelve Common Conditions. 2d ed. Rochester, Minn.: Author, 2004.

Peikin, Steven R. Gastrointestinal Health. Rev. ed. New York: Quill, 2001.

Sharon, Michael. Complete Nutrition: How to Live in Total Health. London: Prion, 2001.

Wilson, Hannah M. Diarrhea: Causes, Types, and Treatments. New York: Nova Science, 2010.

Wu George Y., Nathan Selsky, and Jane M. Grant-Kels. Atlas of Dermatological Manifestations of Gastrointestinal Disease. New York: Springer, 2013.

What is skin? |

Structure and Functions

The anatomy of the skin consists of two major parts: the outer epidermis and the underlying dermis. The epidermis is composed of a particular kind of tissue called stratified squamous epithelium. Epithelium consists of cells that are packed together very tightly, a feature that is very important to an organ that must cover and protect the rest of the body. It is called squamous, which comes from the Latin word for "scale," because its cells are flat and fit together like scales or tiles. The word “stratified” describes the dozens of layers of cells that are piled up to create the epidermis. These cells form four or sometimes five strata, each with their own characteristics and roles to perform.

The stratum basale, or basal layer, lies on a thin piece of tissue called the basement membrane, which is next to the dermis. The basal layer cells divide continuously throughout life, supplying new cells called keratinocytes for all the layers above the basal layer. About one-fourth of the stratum basale cells are called melanocytes, because they produce the pigment melanin. As the keratinocytes are pushed up, they acquire a spiny shape; for this reason, the layer above the basal layer is called the stratum spinosum. While in the spiny layer, the upward-moving cells begin to produce the protein fibers that will eventually become waterproof keratin. As the spiny cells are moved further upward, they begin to flatten out. The layer that they form at this point is called the stratum granulosum, because the keratin being formed is visible here, under the microscope, as large clumps or granules. Langerhans cells, which are very important in immunity and protection from disease, are also found in the granular layer. Only in thick skin, such as that found on the palms of the hands and the soles of the feet, do some of the migrating cells form a transparent layer of dead cells full of a shiny substance called eleidin. The shininess of this fourth layer earned it the name stratum lucidum.

The outermost part of the epidermis, the stratum corneum, is what most people think of as “the skin”—dead, dry cells that are completely waterproof because they are packed with keratin. The twenty-five layers of corneum cells form an efficient barrier to water loss and to the entrance of microorganisms. The epidermis has no blood vessels. The living, reproducing basal-layer cells must be nourished by nutrients passed from blood vessels in the dermis. Nerve endings that pick up the sensations of touch and pain extend upward into the epidermis, while those that sense pressure, heat, and cold extend only into the dermis.

Directly beneath the epidermis’s basement membrane is the dermis. The dermis extends in a wavy or vertical tonguelike fashion into the epidermis to anchor it. The top of the dermis, which is called the papillary layer, thus forms ridges that account for one’s fingerprints and toe prints. There are small blood vessels and fibers scattered throughout the papillary layer. The larger, lower part of the dermis is called the reticular layer. This thicker dermal layer has many more elastic and collagen fibers than does the papillary layer, and it is the location of oil glands, sweat glands, fat cells, hair follicles, and large blood vessels.

Directly under the skin, which is often called the cutis, is the jellylike, fat-filled subcutaneous layer. This packaging material provides heat insulation and energy storage, and it serves to attach the skin to the muscles and organs below.

The anatomy of the skin makes it able to perform a variety of functions. All these roles have one major purpose: to enable the skin to maintain homeostasis—that is, to keep the body relatively stable inside, in spite of constantly changing conditions outside.

The intact skin acts as a barrier to invasion by the multitude of microorganisms that come into contact with its surface. The waterproof keratin in the epidermis prevents all substances that are able to dissolve in water from entering the body through the skin. The presence of the pigment melanin enables the skin to absorb harmful radiation from the sun safely, up to a point. Too much exposure to the sun causes sunburn, drying of the skin, a loss of elasticity, and wrinkling. More important, every sunburn increases the risk of skin cancer. Inheritance determines the amount of melanin
possessed; although all races have the same number of melanocytes, people of different races differ greatly in the amount of melanin that their cells produce. The more melanin present, the darker the skin. The absence of a certain gene prevents melanin synthesis, a condition called albinism; people (or animals) with this condition, called albinos, have very pale skin and hair. Skin color also varies because of the yellow pigment called carotene, which is found in the upper layers of the epidermis, and because of the red blood that is visible through the dermis of light-skinned people.

A very important function of skin is its role in temperature regulation. The body rids itself of excess heat by sweating. Excess heat passes from blood vessels into sweat glands, which conduct heat and perspiration to the surface. A large amount of heat can be lost as the sweat evaporates, thus maintaining normal body temperature. At other times, skin conserves heat by tightening blood vessels and reducing sweat secretion. Simultaneously, shivering, which is the involuntary contraction of skeletal muscles, releases internal heat to counteract excessive heat loss from the body. Only certain sweat glands—namely, those in the armpit and groin—produce the type of sweat that gives rise to an odor.

The waterproof quality of the skin prevents most substances from being absorbed through it into the body. Among the materials that can be absorbed are oxygen; vitamins A, D, E, and K; steroids such as cortisone cream; and poisons such as insecticides.

The skin is able to produce a form of vitamin D that becomes active and useful to the body after passing through the kidneys. This synthesis requires a small amount of sunshine—far less than that necessary to cause a sunburn. If the skin does not produce enough vitamin D to enable the body to use calcium correctly, then vitamin D is needed in the diet.

Two very specialized accessory structures of the skin have their own particular functions. One of these skin derivatives is the pili, or hair. Except for the palms, soles, lips, and eyelids, the entire body contains hair. Each hair consists of a hair shaft that grows beyond the skin surface and a hair root lying inside a hair follicle. The follicle itself consists of epidermis that has grown downward into the dermis. Each hair follicle has an associated sebaceous gland that produces sebum, an oily substance, to lubricate the hair. Scalp hair protects the scalp from overexposure to the sun and from cold weather; eyelashes and tiny hairs inside the nose and ear canals help keep foreign material from entering.

The other important skin accessory is the nails. Each nail consists of a nail plate attached to a nail bed. Nails contain modified, highly keratinized cells from the stratum corneum. The basal cells that reproduce to make the nails grow lie under the cuticle at the base of the nail. Nails help to protect fingers and toes and enable humans to pick up tiny objects more efficiently.

Disorders and Diseases

The complex anatomy of the skin allows for the development of many possible defects and diseases. Three disorders that modern medical science attempts to understand and alleviate are psoriasis, cancer, and the many varieties of contact dermatitis.

Psoriasis, one of the most common of all skin conditions, is said to afflict about 3 percent of the American population. It commonly runs in families and affects both sexes equally. It may develop in childhood or old age but typically appears in the second or third decade of life. It most frequently occurs as scaly patches, or plaques, on the elbows, knees, and scalp but may appear on the back, belly, buttocks, and legs. Many people with psoriasis experience itching; some do not.

Human epidermis cells usually take about twenty-eight days to move from the stratum basale, where they are produced, to the top of the stratum corneum, where bathing removes them. This means that the cycle of normal epidermal cells in transit through the skin is accomplished in a month or more, allowing the cells time to mature. In psoriasis patients, this transit period is as short as four days. The reproducing basal cells divide five to ten times too rapidly, and the epidermis thickens enormously, but in patches. The skin cells of psoriasis patients are so abnormal that the patients’ immune systems form antibodies that attack and destroy them, further damaging the ruptured, scaly surface. There is a notable tendency for psoriatic lesions or sores to form at sites of childhood injuries such as sunburns, scratches, scrapes, and areas where chickenpox was particularly widespread. These lesions often become pus-filled abscesses that contain enormous numbers of white blood cells. The epidermal cells no longer die at the stratum granulosum, and even the granules themselves are lost. The outermost corneum layer, which is usually
dead, dry, and protective, is full of living but abnormally functioning cells. In the dermis below, large, dilated, thin-walled blood vessels appear, and the epidermis directly above them is disproportionately thin. Scratching or picking at the plaques causes bleeding.

The exact cause of psoriasis is not yet known. Genetic factors play a role in its development, since one-third of all patients have a family member who is also afflicted. In addition to the physical discomfort and damage to self-esteem caused by this very obvious skin condition, it can lead to heat loss, fever, severe arthritis, heart failure, and even death.

The many forms of skin cancer can also cause great disfigurement and even death. Two frequently observed types are basal cell carcinoma and malignant melanoma
. Basal cell cancers, which may begin in the hair follicle epithelium, are the most common skin cancers, accounting for almost 70 percent of all cases. Fortunately, they are also the most easily treated. They are most often found where sunlight strikes the hardest, on the neck, scalp, face, and shoulders. Basal cell cancers often start as small bumps but grow wider and more elevated, usually with a cavity in the center. Although their surface is shiny and filled with tiny blood vessels, their color may still be like that of normal skin. If left untreated, basal cell carcinomas may develop a crust or an ulcer that cannot heal. Although they seldom metastasize, shifting or spreading through the bloodstream to another part of the body, they often do great damage to the tissues and structures directly under them. Those that grow near ears and eyes can cause loss of function of those organs.

In almost all cases, the appearance of basal cell carcinomas is directly related to sun exposure. A few seem to be related to previous scars, burns, tattoos, or exposure to arsenic. It is important to be aware of the warning signs of basal cell carcinomas. Some can be felt as well as seen as reddish or dotted lumps; others look like open sores caused by scratches or insect bites that do not heal. Because these cancers, which often grow for two years before detection, have such varied appearances, they can be diagnosed accurately only by biopsy.

The most dangerous skin cancers are the malignant melanomas. They begin in the pigmented cells called melanocytes but usually and quite rapidly invade deeper tissue. Severe sunburns early in life seem to be their usual cause. Many start as small dark brown growths similar to moles, although they may become white, blue, or reddish and irregular in shape as they grow. Often they will bleed if rubbed. People who have acquired one hundred or more moles by young adulthood are considered genetically predisposed toward these dangerous melanomas; such people should use sunscreens every day all year long. It should be noted that half of all melanomas arise from apparently normal skin that has no moles. The malignant melanomas are much more dangerous than the basal cell carcinomas because they tend to release cancerous cells into the bloodstream that latch onto and grow into numerous internal organs.

Seldom life-threatening, contact dermatitis can still be very uncomfortable for a patient. Dermatitis is an inflammation of the skin that usually is a result of an allergic reaction and may include redness, swelling, blistering, crusting, and scaling among its symptoms. In all its many varieties, it probably forms the bulk of a dermatologist’s practice. Contact dermatitis results from coming into contact with a causing substance, such as poison ivy, poison oak, or poison sumac. The sap from these plants contains urushiol, a substance to which 70 percent of all people are allergic.

Large numbers of people are allergic
to the metal nickel and can develop inflammations from wearing nickel rings, watches, earrings, or other jewelry. Nickel zippers and clothing snaps, eyeglass frames and sewing needles, and even coins can cause a reaction.

The chemicals in permanent hair dyes cause terrible swelling and itching of the face and neck in some people. Oddly, the scalp under the dyed hair is often unaffected. When dermatitis seems to result from hair dyes, it is often because the affected person has simultaneously been using certain sunscreens, the pain reliever benzocaine, or one of many other common medicines.

The chemical potassium dichromate is found in many detergents. People who experience dermatitis caused by detergent use should avoid other chromate-containing products as well. These include inks, paints, bleaches, and spackling, to name only a few.

Other people contract dermatitis caused by a formaldehyde allergy. Permanent-press clothing and sheets are made wrinkle-proof by the use of a formaldehyde-based substance. Individuals with a formaldehyde allergy must also avoid many paper products, cosmetics, and disinfectants that contain formaldehyde derivatives.

Susceptibility to contact dermatitis from rubber products is widespread. Surprisingly, it often appears long after the exposure and is most common in manufacturing workers.

In modern society, with its heavy reliance on over-the-counter drugs, cleaning products of all kinds, deodorants and cosmetics, insecticides and weed-killers, and innumerable other chemical products, the potential causes of contact dermatitis will probably continue to multiply.

Perspective and Prospects

Research in dermatology both borrows from and sheds light upon many other branches of medical science: immunology, endocrinology, biochemistry, surgery, and oncology are just a few.

Diseases of the skin can reveal the presence of many otherwise unseen internal disease conditions. Shiny, thin, reddish-yellow patches on the shins may be a sign of diabetes. Prediabetics are also susceptible to repeated yeast and fungal infections of the skin and have poor wound-healing ability.

Too little thyroid hormone causes coarse hair; thickened, dry, cool skin; and rough plaques on the shins. Too much thyroid hormone causes thin hair, excessive sweating, and, surprisingly, identical rough plaques on the shins.

Abnormally dark skin can be a sign of drug side effects, the presence of heavy metals, poor adrenal gland output, or pituitary tumors. Skin may also darken from excess iron intake or, very noticeably, from a widespread malignant melanoma.

Various bowel diseases may also cause skin conditions. The small intestine defect involving a flattened, malfunctioning lining can produce severely itchy blisters on the limbs and the back. Ulcers in the large intestine often produce deep, dirty-looking skin ulcers.

The presence of cancer in the breast, bowel, or lungs may precipitate thousands of external wartlike growths or flat, waxy-surfaced growths. Similarly, the gradual appearance, usually on the legs of the elderly, of fishlike skin may reveal the early presence of cancer of the lymph glands.

Alcoholism reveals itself in spider telangiectasia, webs of dilated capillaries on the skin surface. The presence of hepatitis, a serious viral infection of the liver, is indicated by the yellowing of the skin known as jaundice.

Two other links among dermatology, immunology, and oncology are the search for a vaccine against skin cancer and a new treatment called photopheresis. Since the late 1960s, there has been an ongoing attempt to develop a vaccine to prevent a recurrence of malignant melanoma. This is a particularly important pursuit because those who have survived one case of melanoma have a high risk of developing future ones.

Photopheresis involves having patients take a drug called psoralen. Two hours later, their blood is drawn and exposed to ultraviolet light. The interaction between the psoralen and the light destroys abnormal white blood cells, after which the blood is returned to the body. Since 1987, photopheresis has been used to treat a cancer of the immune system that begins in the skin. Researchers hope eventually to use psoralen to treat arthritis and lupus, and to prevent the rejection of organ transplants.

For many years, drugs for internal conditions could be administered only orally or by injection. In both methods, the circulating amount may be too high to be safe immediately after it is given and too low to be effective as the hours go by. Dermatologists have greatly advanced medical science by developing transdermal patches. These patches enable a steady supply of a drug to enter the bloodstream by absorption through the skin. By the end of the twentieth century, patches had been developed to treat angina, high blood pressure, motion sickness, menopausal symptoms, and nicotine addiction. Their applications continued to expand in the early twenty-first century, with treatments from opioids and hormones to antidepressants and medications for attention deficit hyperactivity disorder being delivered transdermally.

One of the greatest traumas skin can suffer is a widespread burn. Although surgeons have had great success in transplanting many internal organs, they are unable to permanently transplant skin from another person. In 1981, they developed a marvelous technique to produce artificial skin. It uses animal skin protein seeded with a few skin cells taken from the patient. From this small patch, a large enough piece of skin can be grown to cover the wounds until the patient's own healing skin gradually replaces it.

From the earliest simple salves for skin rashes to the great discoveries of transdermal patches and artificial skin, dermatologists have done and continue to do their share in advancing medical science.

Bibliography

Goodman, Thomas, and Stephanie Young. Smart Face. Englewood Cliffs, N.J.: Prentice Hall, 1988.

Jacknin, Jeanette. Smart Medicine for Your Skin. New York: Putnam, 2001.

Lamberg, Lynne. Skin Disorders. Philadelphia: Chelsea House, 2001.

Lees, Mark. Skin Care: Beyond the Basics. 4th ed. Clifton Park, N.Y.: Delmar Learning, 2012.

Mackie, Rona M. Clinical Dermatology. 5th ed. New York: Oxford University Press, 2003.

Siegel, Mary-Ellen. Safe in the Sun. New York: Walker, 1995.

"Skin Conditions." Skinsight, 2013.

"Skin Disorders Center." Health Library, 2013.

Turkington, Carol, and Jeffrey S. Dover. The Encyclopedia of Skin and Skin Disorders. 3d ed. New York: Facts On File, 2007.

Weedon, David. Weedon's Skin Pathology. 3d ed. New York: Churchill Livingstone/Elsevier, 2010.

What are addiction medications? |

Introduction

Addiction is a brain disease. Once a person becomes addicted, changes typically occur in the body and the brain that make these systems function differently than before the development of the addiction. The functional (and perhaps structural) changes to the brain that occur with addiction can sometimes be treated with medications that allow the brain to function normally in the absence of the drug.

Medications are available for the treatment of opiate, alcohol, and cocaine use disorders and for nicotine use. Each of these medications will be considered individually here. No medication exists for the treatment of methamphetamine addiction, but about one-half dozen are being studied.

Many of the medications used in the treatment of addiction are used “off-label.” In other words, the medications are used for addiction even though they have been approved by the US Food and Drug Administration
(FDA) to treat other disorders, such as depression, muscle spasms, insomnia, and nausea. Only those medications currently legal to use in the United States (including those used off-label) are presented here. When available, both the clinical name and the more commonly used name will be included. The common name will appear in parentheses.

Many of the medications discussed fall under one of three categories: antagonist, full agonist, or partial agonist. An antagonist is a substance that binds to receptor cells so tightly that it will block any other substance from binding to that cell. Antagonists also bind to the cell without stimulating the cell or otherwise causing a response. Examples of antagonists include naltrexone and ondansetron.

A full agonist is similar to an antagonist in that it completely binds to a receptor cell. Unlike antagonists, however, full agonists will activate that receptor site. Examples of full agonists include morphine and topiramate (a gamma-aminobutyric acid, or GABA, agonist).

Partial agonists, like agonists, bind to receptor cells and activate them, but they cannot bind fully, so the receptor is only partially activated. Examples of partial agonists include varenicline and buprenorphine.

Medications are wonderful tools in the treatment of both physical and mental illnesses and disorders. It should be noted, however, that patients receiving medication also should receive psychosocial treatment.

Medications for Alcohol Addiction

Alcohol is a central nervous system depressant. It works by interfering with communication between nerve cells and by interacting with the receptors on some cells. Alcohol suppresses excitatory nerve pathway activity (for example, glutamine) and increases inhibitory nerve pathway activity (for example, GABA). Thus, alcohol lowers inhibitions, which is why it is often found to be a significant factor in violent and sexually motivated crimes. Medications used (or under study) to treat alcohol use disorders include baclofen, campral (Acamprosate), disulfiram (Antabuse), naltrexone (ReVia or Vivitrol), ondansetron (Zofran), and topiramate (Topamax).

Baclofen
. Baclofen treats muscle tightness and cramping or spasms that are often associated with spinal cord injury, spinal cord disease, or multiple sclerosis. The drug is a derivative of GABA and works with alcohol dependence by decreasing withdrawal symptoms and cravings. These effects are achieved by inhibiting the activation of the receptors in the brain that become stimulated during withdrawal.

Campral. The FDA approved campral for the treatment of alcohol use disorder in 2004. Before this time, campral was used widely across Europe in the treatment of alcohol use disorders. Campral works by stimulating GABA receptors and thereby reducing the negative symptoms a person may experience when attempting to abstain from alcohol.

Disulfiram. Disulfiram has been used to treat alcohol use disorders since the 1950s. Originally thought to work well as a treatment for parasites, experts began to notice that persons who took the medication and who also drank alcohol became ill. The medication disrupts the metabolism of alcohol, resulting in a hangover type of physical illness. The physical effects caused by disulfiram in persons also ingesting alcohol include headache, flushing nausea, dizziness, and vomiting.

Naltrexone
. Naltrexone is an antagonist; it binds to the mu (µ) opioid receptors in the brain, but it does not stimulate them. This is important because naltrexone is used to treat addictions but does so without causing euphoria, like some addiction medications. Naltrexone is available in two different administrations: oral and injection.

The oral version of naltrexone, ReVia, was approved for the treatment of alcohol use disorders in 1995. However, because it must be taken daily, its effectiveness varies for those who are not medication compliant or not committed to treatment. In addition, side effects may be substantial because the medication levels vary throughout the day. The injection form of naltrexone, Vivitrol, was approved in 2006. Vivitrol is a long acting, once-a-month, injection that works the same way as ReVia, but it has fewer side effects and better medication compliance.

Ondansetron. Ondansetron is an antiemetic that reduces the nausea and vomiting that often accompany chemotherapy treatment. Ondansetron is a serotonin receptor antagonist and works by reducing the activity of the vagus nerve, thereby blocking the sensation of the need to vomit. This medication also has been studied as a treatment for other disorders, including alcohol use disorder, and although it is not approved for this, it can be prescribed off-label.

Topiramate. Topiramate treats epilepsy; however, research also indicates that it may be useful as a treatment for alcohol, cocaine, and nicotine dependence. Topiramate is a glutamate antagonist and a GABA agonist. It works by blocking the glutamate receptors and by increasing the effects of GABA, which help to calm over-excited nerve cells. Topiramate has been shown useful in the treatment of alcohol dependence. Topiramate has a number of side effects, including weight loss, impaired memory and concentration, numbness and tingling of extremities (although this side effect is transient), and the development of kidney stones.

Medications for Cocaine Addiction

Cocaine
is a stimulant of the central nervous system derived from the coca plant (not to be confused with the cocoa plant, which is used for chocolate). Cocaine is a serotonin-norepinephrine-dopamine reuptake inhibitor, which means that cocaine can increase alertness, euphoria, energy, motor activity, and feelings of competence. However, it also can result in anxiety, paranoia, restlessness, delusions, hallucinations, and tachycardia. Medications used (or under study) to treat cocaine use disorders include baclofen, disulfiram, gabapentin (Gabitrol), and modafinil (Provigil), and the dietary supplement N-acetylcysteine (NAC).

Baclofen. Baclofen, which is used to treat muscle spasticity (found in persons with multiple sclerosis), also has been studied as a potential treatment for cocaine addiction. Baclofen is said to work by decreasing the effects of dopamine in the brain and, thereby, reducing cocaine-induced euphoria.

Disulfiram. Disulfiram, which is used to treat alcohol use disorders, also has been studied as a treatment for cocaine disorders. In one study conducted at Yale University, disulfiram was found to work well in decreasing cocaine use. Similar to its effect with alcohol users, the study showed that is caused cocaine users to become physically ill. This research has since been replicated.

Gabapentin. Gabapentin is an anticonvulsant medication used to treat seizure disorders, depression, and pain. The medication also has been studied as a treatment for cocaine use disorders. The medication works by making cravings less intense and by lessening the severity of any relapse to cocaine use. Because of these positive effects, however, some doctors are hesitant to prescribe gabapentin for cocaine use disorders; it is believed that the medication will reinforce cocaine use rather than discourage it.

Modafinil. Modafinil is FDA approved for the treatment of narcolepsy and other sleep disorders. It also has been studied in the treatment of cocaine use disorders. However, findings have proven inconclusive.

N-acetylcysteine. N-acetylcysteine is an over-the-counter herbal supplement with purported antioxidant effects. It has been used to treat everything from carbon monoxide poisoning to acetaminophen overdose. Its effectiveness in treating cocaine use disorders has not been determined.

Medications for Methamphetamine Addiction

Methamphetamine
is a synthetic drug. Although chemically similar to amphetamine, its effects are much longer lasting. Methamphetamine is a central nervous system stimulant with euphoric effects similar to those found with cocaine. Methamphetamine works by increasing the release of dopamine in the brain. No approved medications are on the market to treat methamphetamine addiction, and no medication is used off-label to treat methamphetamine addiction. However, a few drugs are under study, including paroxetine (Paxil), ondansetron, and gabapentin.

Paroxetine. Paroxetine is indicated for the treatment of mood disorders (depression and anxiety) and obsessive-compulsive disorder and panic disorder. It also is under study for the treatment of methamphetamine abuse.

Ondansetron. Ondansetron, used to treat alcohol use disorders, is FDA approved as an antinausea drug that may work to block specific binding sites for the neurotransmitter serotonin. Some preliminary studies have indicated that ondansetron may block the effects of methamphetamine.

Gabapentin. Gabapentin, in addition to being a potential medication for the treatment of cocaine use disorders, also may be a viable option for the treatment of methamphetamine use disorders.

Medications for Nicotine Addiction

Nicotine is a stimulant found in tobacco and tobacco products. The American Heart Association reports that nicotine dependence is one of the most difficult addictions to break. Some medications, including bupropion (Wellbutrin) and varenicline (Chantix), and other products, such as nicotine replacements, are available to assist persons addicted to nicotine. The use of bupropion and varenicline in nicotine addiction treatment, however, has been linked to serious side effects, including depression and suicidal ideation. Nicotine replacement products (such as patches and gum) provide the user with nicotine, but they do not have the harmful carcinogens that accompany many of the delivery systems (such as smoking or tobacco chewing).

Bupropion
. Bupropion is a well-known antidepressant that has been used in the treatment of nicotine dependence. The drug works by reducing the urge to smoke.

Varenicline. Varenicline is a nicotine receptor partial agonist. It works by decreasing the cravings for nicotine and by decreasing the pleasurable effects of nicotine consumption.

Medications for Opiate Addiction

Opiates are narcotic analgesics (painkillers) that are derived from the poppy plant and from several artificial means. Opiates work by binding to specific receptors in the brain. Because the human body creates its own form of opiate, the brain has specific receptors created just for this substance. The receptors where opiates bind typically control movement, digestion, mood, the experience of pain, and, most problematic, body temperature and respiration.

Opiate use disorders vary and can include addiction to heroin and painkillers (such as vicodin and oxycodone). Medications used to treat opiate use disorders include buprenorphine, methadone, and naltrexone.

The FDA approved buprenorphine in 2002 as a treatment for opiate use disorders. The drug works by binding to the same receptors as opiates, but because it is a partial agonist it does not completely fill the receptor; therefore, little euphoria is achieved when taken as prescribed. A doctor prescribes buprenorphine, and induction (introduction of buprenorphine into the system) can be done in a doctor’s office rather than at a substance abuse treatment facility. The effects of buprenorphine can last up to three days, so unlike the common drug methadone, daily doses are not required.

There are two different formulations of buprenorphine: Subutex and Suboxone. Subutex contains only buprenorphine and is the formulation used during the first few days of induction. Suboxone includes both buprenorphine and naloxone. Naloxone is a powerful substance that blocks the effects of opiates and is often used to treat opiate overdose. When combined with buprenorphine, it greatly reduces the abuse potential of this medication.

Methadone
. Methadone, perhaps the best-known medication to treat opiate use disorders, is a synthetic opiate and a narcotic pain reliever similar to morphine. It has been used in the treatment of opiate addiction since the 1960s. Methadone is a full mu (µ) opioid agonist and works by binding to this receptor and by preventing other opiates from binding to that same receptor. However, methadone, if given in the incorrect dosage or through certain routes, can result in euphoria similar to that of illicit opiates.

Withdrawal from methadone can take several weeks to several months and has been described as more difficult to withdraw from than other opiates. Methadone is taken orally and is typically taken daily.

Naltrexone. Naltrexone, in addition to treating alcohol use disorders, also has been shown to be effective in the treatment of opiate use disorders. When used for opiate use disorders, naltrexone works as it does for alcohol: It binds tightly to the mu (µ) opioid receptors and prevents any other drug from binding to those same receptors. The binding action reduces cravings for the substance and also prevents the high that is normally experienced from opiate use. Because naltrexone is an antagonist, it is powerful enough to push the opiates out of the receptors to bind to them. This is important because naltrexone will place a patient into precipitated withdrawal from opiates if the patient has not abstained from opiates before receiving naltrexone.

There are two ways to administer naltrexone: orally (ReVia) and through an intramuscular injection (Vivitrol). Both forms are FDA approved for the treatment of opiate use disorders.

Bibliography

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According to Scout, what does a jury do when they've found a defendant guilty, and is exactly what Tom's jury does?

Being the daughter of an attorney provides Scout with insight about how court proceedings, procedures, and policies work because her father discusses those things at home sometimes. Scout is also very intelligent and observant; so she picks up on the little things, such as the mannerisms of a jury. At the end of chapter 21, the jury is done deliberating and makes its way back into the courtroom. Everyone is very anxious to find out...

Being the daughter of an attorney provides Scout with insight about how court proceedings, procedures, and policies work because her father discusses those things at home sometimes. Scout is also very intelligent and observant; so she picks up on the little things, such as the mannerisms of a jury. At the end of chapter 21, the jury is done deliberating and makes its way back into the courtroom. Everyone is very anxious to find out if Tom Robinson will be acquitted or convicted. Based on Atticus's strong defense, which smashed the prosecution's allegations to pieces, there are high hopes that Tom could actually go free. Scout's description of the moments surrounding the reading of the verdict is as follows:

"I saw something only a lawyer's child could be expected to see, could be expected to watch for, and it was like watching Atticus walk into the street, raise a rifle to his shoulder and pull the trigger, but watching all the time knowing that the gun was empty.

"A jury never looks at a defendant it has convicted, and when this jury came in, not one of them looked at Tom Robinson" (211).

Scout notices that the jury doesn't look at Tom because they know the news they have for him is bad.

What is the relationship between bipolar disorder and addiction?

Background

The coexistence of bipolar disorder and addiction is the rule rather than the exception. As many as 60 percent of people with bipolar disorder also will abuse an addictive substance during their lifetime, according to the National Alliance on Mental Illness.

The person in the manic phase of bipolar disorder may turn to alcohol or drugs to try to stabilize their condition. An addiction to alcohol or drugs might come about because the person is trying to slow down his or her thought processes long enough to get some rest. Addiction may be the result of, and not the reason for, the manic phase of the illness.

In the depressive stage of the illness, a person is vulnerable to addiction because he or she is looking for something that will help with feelings of hopelessness, isolation, and worthlessness. Alcohol or drugs may be considered a type of anesthetic to help the person escape from these kinds of feelings.

Causes

Persons with bipolar disorder are subject to overwhelming forces that are largely beyond their conscious control, which explains why so many persons with the disorder turn to drugs and alcohol for support and relief. Often, persons with bipolar disorder will use alcohol or drugs to numb their painful and difficult symptoms and to help them cope with their intense feelings. This can lead to a pattern of abuse that can quickly spiral into dependency and addiction.

People suffering with bipolar disorder are three to seven times more likely than others to abuse alcohol or drugs, such as sleeping pills and stimulants (including cocaine and methamphetamines). Drugs and alcohol are abused to increase the natural high of the mania and to self-medicate during depressive episodes.

Symptoms

Bipolar disorder is characterized by drastic mood swings—extreme highs and devastating lows. Some of the symptoms exhibited during manic episodes include an extremely elated, happy mood or an extremely irritable, angry, unpleasant mood; increased physical and mental activity and energy; racing and uncontrolled thoughts; increased talking (speech more rapid than normal); ambitious, often grandiose plans; inflated self-esteem; risk taking; and impulsive activity such as spending sprees; sexual indiscretion; and decreased sleep without experiencing fatigue.

Symptoms of depressive episodes include loss of energy; prolonged sadness; decreased energy and activity; restlessness and irritability; inability to concentrate or make decisions; increased worry and anxiety; less interest or participation in, and less enjoyment of, activities normally enjoyed; feelings of guilt and hopelessness; change in appetite; change in sleep patterns; and thoughts of suicide.

People with bipolar disorder often have difficulty in the workplace. Many of their symptoms can interfere with their ability to show up for work, to do their job, and to interact productively with others.

The consequences of addiction for persons with bipolar disorder are many and include taking drugs or consuming alcohol to regulate, stabilize, or improve their mood. Drugs and alcohol can provide temporary symptom relief, but in time, they worsen the symptoms, resulting in ever-increasing drug or alcohol use. Alcohol and drugs can reduce the effectiveness of bipolar medications and can reduce compliance for bipolar treatment. Stimulant drugs, such as cocaine or methamphetamines, can induce mania and then deep depression, exacerbating symptoms. Withdrawal symptoms can worsen depression.

Screening and Diagnosis

A diagnosis for substance abuse that occurs in persons with bipolar disorder is known as a dual diagnosis. In such cases, the substance abuse can occur during both the manic and the depressive phases.

No diagnostic laboratory tests exist for bipolar disorder. Thus diagnosis occurs through standardized diagnostic criteria to rate and evaluate the person’s behavior.

Treatment and Therapy

Treatment for addiction includes psychiatric care and medication. Because bipolar disorder and alcohol and drug addiction often appear together, the symptoms of each disorder overlap, making it difficult to recognize the coexistence of both. The two conditions must be treated in tandem, making dual diagnosis critical to the recovery process.

Effective in treating co-occurring disorders is a residential substance abuse treatment program. This treatment typically includes individual and group counseling, cognitive-behavior therapy, dialectical behavior therapy, twelve-step programs, and other mental health services. Research has shown that the most effective treatment combines supportive psychotherapy and the use of a mood-stabilizer (either lithium, carbamazepine, or divalproex/valproic acid), often with an antipsychotic medication. No research exists to show that any form of psychotherapy is an effective substitute for medication.

Prevention

The best recoveries are achieved when individuals with bipolar disorder get effective treatment and faithfully follow that treatment for a lifetime. The patient should regularly see a supportive physician who is knowledgeable about the psychiatric management of this disorder, should learn what symptoms predict the return of this illness and what additional “rescue” medication can be taken, and should learn to trust the warnings given by family and friends when they see early signs of relapse.

Bibliography

Bacciardi, Silvia, et al. "Drug (Heroin) Addiction, Bipolar Spectrum, and Impulse Control Disorders." Heroin Addiction and Related Clinical Problems 15.2 (2013): 29–36. Print.

Basco, M. R., and A. J. Rush. Cognitive-Behavior Therapy for Bipolar Disorder. 2nd ed. New York: Guilford, 2007. Print.

Goodwin, F. K., and K. R. Jamison. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. 2nd ed. New York: Oxford UP, 2007. Print.

Johnson, C., et al. “Convergent Genome-Wide Association Results for Bipolar Disorder and Substance Dependence.” American Journal of Medical Genetics B: Neuropsychiatric Genetics 150.2 (2009): 182–90. Print.

Mondimore, Francis Mark. "Alcoholism and Drug Abuse." Bipolar Disorder: A Guide for Patients and Families. 3rd ed. Baltimore: Johns Hopkins UP, 2014. 174–92. Print.

Perkinson, Robert R., Arthur E. Jongsma, and Timothy J. Bruce. "Bipolar Disorder." The Addiction Treatment Planner. 5th ed. Hoboken: Wiley, 2014. 90–103. Print.