Chinese Herbal Medicine: Materia Medica

Chinese Herbal Medicine: Materia Medica (CHMMM) is a popular and encyclopedic reference book on materials used in traditional Chinese medicine (TCM). As of 2020, it is in its 3^rd edition.[1] The title is a bit of a misnomer because while the book mainly includes herbal substances, it also includes animal, mineral and fungal substances.

Cover of the 3^rd edition

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Entries have sections on:

• Descriptive information
• Actions & indications
• Commentary
• Comparisons
• Traditional contraindications
• Toxicity
• Nomenclature & preparation
• Quality criteria

Notably lacking are references giving any evidence of claims. The only bibliographic entries are those used for translation.[1]^:1173-1176 A significant failing of the 3^rd edition is that it removed the "Pharmacological & Clinical Research" section from each entry that previously appeared in the 2^nd edition.[2][3] The authors' explanation for removing these sections is that:[1]^:x

“”This is a field that has exploded in recent years and deserves a multi-volume work of its own. Given our own disposition — that the practice of Chinese herbal medicine must be grounded on traditional approaches — and our limited expertise, we felt that we simply could not do justice here to the vast amount of new research that has been published.

While the authors do cite other other publications that cover these areas of knowledge (The Pharmacology of Chinese Herbs,[4] Pharmacology and Applications of Chinese Materia Medica,[5] and Chinese Materia Medica: Chemistry, Pharmacology and Applications[6]),[1]^:x the absence indicates that CHMMM is not evidence-based medicine. While safety issues are generally covered, efficacy is not — rather, the alleged efficacy of a given substance is based on largely pre-scientific Chinese herbal texts (appeal to ancient wisdom and argument from authority).

With regard to Actions & Indications sections, the authors consulted three primary sources (Chinese Herbal Medicine[7], Clinical Traditional Chinese Herbal Medicine,[8] and Chinese Herbal Medicine[9]), stating:[1]^:x

“”There is a high level of agreement on the basic actions of the herbs in modern materia medica texts, and these books were consulted for their relatively comprehensive treatment of the subject.

What the authors did not explain is the reason for this consistency was due to the Chinese Communist Party's (CCP) doctrine on Western and Chinese medicine during the mid-1950s to mid-1960s, in which Chinese medicine became standardized, resolving or glossing over the contradictory elements of the four ancient texts.[10]^:79,127,142 The authors likely did not know this because a history of TCM in communist China[10] was not published until a year after the 3^rd edition of CHMMM.

The authors' wholesale acceptance of "basic actions of the herbs in modern materia medica texts" is not a trivial issue because:

1. It completely disregards evidence-based medicine ("Western medicine" in TCM parlance) with regard to efficacy.
2. It is an arbitrary agreement imposed by CCP doctrine, which does not comport with with either the contradictions of ancient Chinese medicine or the current practice of Chinese medicine in non-CCP influenced areas, such as Singapore, Hong Kong and Taiwan.[10]^:86-87
3. The authors have been forced to recognize in some cases and sometimes inconsistently (see below) that the "traditional contraindications" sections are at least at times inadequate in the face of modern science.

"Obsolete" substances

A significant change to the 3^rd edition was the inclusion of an "Obsolete Substances" chapter, which segregated two types of substances from the main body of the book, those substances with unacceptable toxicity,[1]^:1045-1064 and those that are derived from endangered species (based on CITES Appendices I and II).[1]^:1064-1071 CITES Appendix I lists the most endangered species, banned from international trade, and CITES Appendix II lists species that are less threatened and still allowed in trade.[11] is Unfortunately, the alleged actions and indications are still described for each substance as well as methods of preparation; this could be tempting for the unscrupulous or inattentive practitioner. Also unfortunate is that because of the authors' admitted lack of expertise in pharmacology, and the removal of the pharmacology and clinical research sections, one is left wondering whether the authors had insufficient knowledge to judge whether more substances should have been added to this chapter. The unacceptably toxic substances listed in the 3^rd edition are:[1]^:1044

• Cinnabaris (cinnabar or mercury(II) sulfide, HgS)
• Papaveris pericarpium (opium poppy husk, Papaver somniferum)
• Strychni semen (Strychnos nux-vomica nut)
• Tripterygii wilfordii radix (Tripterygium wilfordii root)
• Aristolochiae fructus (Aristolochia debilis or A. contorta fruit)
• Aristolochiae manshuriensis (A. manshuriensis)
• Aristolochiae fangchi radix (A. fangchi root)
• Aristolochiae mollissimae herba (A. mollissima)
• Calomelas (mercury chloride, Hg₂Cl₂)
• Realgar (arsenic sulfide, α-As₄S₄)
• Lithargyrum (litharge or lead oxide, PbO)
• Borax (Na₂B₄O₇·10H₂O or Na₂[B₄O₅(OH)₄]·8H₂O)

The products from endangered species are:[1]^:1044,1064

• Vesica fellea ursi (bear gallbladder): CITES Appendix I
• Manitis squama (pangolin scales, Manis pentadactyla): CITES Appendix I
• Eretmochelydis carapax (hawksbill turtle shell, Eretmochelys imbricata): CITES Appendix I
• Macacae mulattae calculus (macaque stone, Macaca mulatta): CITES Appendix II
• Tigris os (tiger bone, Panthera tigris): CITES Appendix II

Rhinoceros horn is listed separately as a substance that should no longer be used due to its endangered status.[1]^{:118-120,1064} Also, several substances were under consideration for listing in CITES Appendix II at the time of publication of the 3^rd edition:[1]^:xxxi

• Aloe (Aloe barbadensis)
• Bletillae rhizoma (Chinese ground orchid, Bletilla striata)
• Cibotti rhizoma (golden chicken fern, Cibotium barometz)
• Cistanches herba (desert-broomrape, Cistanche deserticola)
• Cremastrae/Pleiones pseudobulbus (orchids Cremastra appendiculata and Pleione spp.)
• Dendrobii herba (orchids in the Dendrobium genus)
• Euphorbiae herlioscopiea herba (sun sponge, Euphorbia helioscopia)
• Euphorbiae pekinensis radix (Peking spurge, Euphorbia pekinensis)
• Gastrodiae rhizoma (orchid Gastrodia elata)
• Ginseng radix (Panax ginseng)
• Hippocampus (sea horse, Hippocampus) (included in May of 2004[12])
• Kansui radix (Euphorbia kansui)
• Moschus (musk deer, Moschus spp.)
• Panacis quinquefolii radix (American ginseng, Panax quinquefolius)
• Picorhizae rhizoma (Picrorhiza scrophulariiflora)
• Saigae tataricae cornu (Saiga antelope, Saiga tatarica)
• Testudinis plastrum (Chinese pond turtle, Chinemys reevesii)

For some listings in the substances with unacceptable toxicity, substances are not treated uniformly. The authors clearly state that some should not be used, e.g., by stating "…should be regarded as an obsolete drug" or "…it is the editors' view that it should no longer be used" (Aristolochia manshuriensis,[1]^:1056 calomel,[1]^:1059-1060 lithargyrum,[1]^:1062 and borax[1]^:1064), though preparation information is still given in some cases.

Others do not state this — though they should because no clear evidence of efficacy and no risk-benefit analysis is given — and even give conditions for use: cinnabar,[1]^:1047 opium,[1]^:1049 nux-vomica,[1]^:1051 T. wilfordii,[1]^:1052-1053 Aristolochia debilis,[1]^:1054-1055 A. fangchi,^:1057 A. mollissimae,[1]^:1058 and arsenic sulfide.[1]^:1061

Issues with specific substances

Aristolochia species

See the main article on this topic: Aristolochia

The authors treat several species of Aristolochia differently with regard to toxicity even though the primary issue of toxicity for all species of Aristolochia is that it causes acute kidney cancer and rapid-onset cancer. This was reported conclusively by the International Agency for Research on Cancer in 2002,[13]^:118 two years before the 3^rd edition of CHMMM was published, with the first report of toxicity in 1994.[14]

For mǎ dōu líng (A. debilis or A. contorta), the authors did not state that these plants contains aristolochic acid (AA) or that the plants are carcinogenic.[1]^:1053-1054

For guān mù tōng (A. manshuriensis), the authors did not state that the plant is carcinogenic.[1]^:1055-1056

For guǎng fáng jí (A. fangchi), the authors adequately described the nature of its toxicity, but as noted above, did not definitively say that the plant should not be used.[1]^:1056-1057

For xún gǚ fēng (A. mollissima), the authors state, "This substance is toxic, due in part to its AA content, which is nephrotoxic and possibly carcinogenic."[1]^:1057-1058 The authors should have instead stated that the plant is a carcinogen, not that it is possibly a carcinogen.

Aristolochia substituents

Due to the the nature of TCM, plants with similar Chinese names are allowed to be substituted for each other. Thus all plants with mù tōng, mù xiāng fáng jí in their name may be substituted for each other, whether or not they are Aristolochia species.[13]^:69-70 It is therefore rather risky to consume such plants without there having been a chemical analysis on them to test for AA. These plants are: Stephania tetandra, Cocculus trilobus, C. orbiculatus, Clematis armandii, C. montana, Akebia quinata, A. trifoliata, Aucklandia lappa, Inula helenium, I. racemosa, and Vladimiria souliei.[13]^:69-70

For Akebia, Stephania tetandra, Cocculus, the authors warn of the substitution issue, but understate the danger of Aristolochia.[1]^{:283-284,313-317} Clematis is listed as an addendum to Akebia and has no separate mention of toxicity.[1]^:285 For Aucklandia lappa, Inula, and Vladimiria souliei, no mention of the substitution Aristolochia issue is given.[1]^:529-533

The authors do discuss the substituent problem, both specifically with regard to Aristolochia[1]^:xxii and more generally:[1]^:xxii

“”The pharmacological approach, with its goal of 'one name, one substance' (一名一药 yī míng yī yào) is more stringent than the traditional approach followed in clinical Chinese medicine. There the issue has been one of usage, not identification. What we refer to as 'adulterants' in this text are herbs that are commonly used interchangeably with the standard substance. For example, while Isatidis Radix (bei bun lan gen) is the standard herb for 板蓝根 bǎn lán gēn, it is interchangeable (for the most part) with Baphicacanthis cusiae Rhizoma et Radix (nán bǎn lán gēn), which is more commonly used in southern China. And because many of the herbs exported exported from China come from teh southern part of the country, and some of the less well-informed pharmacies in the West import their materials from Hong Kong without regard to product standards, Baphicanthis cusiae Rhizoma et Radix (běi bǎn lán gēn) is not infrequently dispensed instead of Isatidis Radix (bei ban lan gen) in the West. While this issue remains unresolved, we believe the pharmacological approach is the safest one.

The two problems with this statement:

1. Evidence for herbal safety is poor because most herbs have not been adequately tested for safety or efficacy. How does one know that the pharmacologically 'correct' herb is safe or whether the substituent is?
2. The author's approach to substituents is incongruous with their own statement regarding their approach to Chinese herbal medicine ("…that the practice of Chinese herbal medicine must be grounded on traditional approaches…"[1]^:x).

Xì xīn

Asarum heterotropoides and A. sieboldii (xì xīn) are in the Aristolochiaceae family, as is the Aristolochia genus. Asarum species only contain trace levels of AA,[13]^:83 but cases of aristolochic acid nephropathy due to Asarum consumption have been reported in a few incidences.[15] The authors did not report on AA,[1]^:27-30 and the report on AA nephropathy was published after the 3^rd edition of CHMMM.

Bīng láng

The authors did not give any toxicity information for betelnut (bīng láng).[1]^:1008-1010 Betelnut causes a variety of toxic effects and is a human carcinogen.[16]

References

1. Chinese Herbal Medicine: Materia Medica by Dan Bensky, Steven Clavey and Erich Stöger (2004) Eastland Press. 3^rd edition. ISBN 0939616424.
2. Chinese Herbal Medicine: Materia Medica by Dan Bensky, Andrew Gamble and Ted J. Kaptchuk (2004) Eastland Press. 2^nd edition. ISBN 0939616157.
3. "Chinese Herbal Medicine: Materia Medica, 3^rd edition" book review by Andrew Flower, The Journal of Chinese Medicine.
4. The Pharmacology of Chinese Herbs by Kee Chang Huang (1999) CRC Press. 2^nd edition. ISBN 0849316650.
5. Pharmacology and Applications of Chinese Materia Medica by Hson-Mou Chang & Paul P. H. But (2001) World Scientific. ISBN 9810236921.
6. Chinese Materia Medica: Chemistry, Pharmacology and Applications by You-Ping Zhu (1998) CRC Press ISBN 9057022850.
7. 中药学 Zhongyaoxue by 颜正华 Yan Zhenghua et al. (1991) 人民卫生出版社 Ren min wei sheng chu ban she. ISBN 711701489X
8. 中华临床中药学 Zhong hua lin chuang zhong yao xue by 雷载权 Lei Zaiquan et al. (1998) 人民卫生出版社 Ren min wei sheng chu ban she. ISBN 7117028785.
9. 中药学 Zhong yao xue by 高学敏 Gao Xuemin et al. (2000) 人民卫生出版社 Ren min wei sheng chu ban she. ISBN 7117164123.
10. Chinese Medicine in Early Communist China, 1945-1963: A Medicine of Revolution by Kim Taylor (2005). Routledge. ISBN 041534512X.
11. The CITES Appendices Convention on International Trade in Endangered Species of Wild Fauna and Flora.
12. Longsnout seahorse Convention on International Trade in Endangered Species of Wild Fauna and Flora.
13. Some Traditional Herbal Medicines, Some Mycotoxins, Naphthalene and Styrene IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 82 (2002) World Health Organization, International Agency for Research on Cancer.
14. "Urothelial malignancy in nephropathy due to Chinese herbs" by J.-P. Cosyns et al. (1994) Lancet 16;344(8916):188. doi:10.1016/s0140-6736(94)92786-3.
15. Medicinally Used Asarum Species: High-Resolution LC-MS Analysis of Aristolochic Acid Analogs and In vitro Toxicity Screening in HK-2 Cells by Johanna Michl et al. (2017) Front. Pharmacol. 8:1-9.
16. Betel-quid and Areca-nut Chewing and Some Areca-nut-derived Nitrosamines (2004) IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 85 (2002) World Health Organization, International Agency for Research on Cancer.