Medical Herbalism: A Journal for the Clinical Practitioner
Note: This publication is intended for practicing clinical professionals, and not as patient advice. If you are sick, see a medical professional.
All articles copyright 1997 by Paul Bergner
Elderberry, by Paul Bergner
Goldenseal and the Antibiotic Myth, by Paul Bergner
Case: Chronic tendinitis
Case: Lower limb venous insufficiency
Goldenseal today has a wide reputation as an "herbal antibiotic," based on scientific research and the clinical use its constituent berberine. Table 1 shows a list of organisms which berberine can kill or neutralize in the petri dish. When goldenseal is used topically, put directly onto an infected wound or ulcer, the berberine or other alkaloids may have such an effect on the microorganisms in the wound. It may have the same effect in the mouth and pharynx, and possibly on infected gut mucosa. From research such as this, it is enticing to conclude that goldenseal and other berberine-containing plants taken internally act in the body the same way that pharmaceutical antibiotics do, to kill or inhibit bacteria. However, clinical research actually indicates otherwise.
First of all, in humans, berberine is very poorly absorbed across in the small intestine (Bhide et al 1961). Four hundred milligrams of berberine sulfate, the amount contained in from about 26 capsules of goldenseal powder, causes blood levels of berberine to rise to 100 micrograms per cent. This is only about 1/200th of the levels that kill the bacteria shown in the accompanying table 13.2 (Bensky and Gamble 1986). Berberine itself thus does not act as a systemic antibiotic, and goldenseal, which contains only a small percentage of berberine cannot either, at least not due to its berberine content. Berberine is excreted through the urine in humans (Chopra et al 1932), so it could conceivably have some antibiotic effect in the concentrated urine in kidney or urinary tract infections — conditions that it was used for by American physicians of the last century.
In my experience both selling herbs at retail, and seeing patients in the clinic, not even 10% of the goldenseal use in the U.S. is clinically appropriate. When someone pops large amounts of goldenseal "for a cold," especially in its early stages, they are wasting both their money and an endangered plant. People in our culture are conditioned to think "I need an antibiotic" when they have a cold, although neither conventional nor herbal antibiotics are appropriate for such viral conditions. Table 3 shows the traditional medical uses of goldenseal. In it we find not one single reference to the use of goldenseal for colds, flu, or similar infections. Its use is limited to topical application, including douche for vaginal infections, diarrhea and dysentery (later stages) or as a bitter tonic or mucous membrane alterative. Traditional physicians used goldenseal in sub-acute and chronic mucous membrane conditions, not in acute inflammations of the same. Table 2 shows the dynamics of a mucous membrane infection. Taking goldenseal or berberine internally will not directly kill or inhibit bacteria or other infectious agents in most of these conditions, unless coming in direct contact with the infected tissue. What they will do, according to traditional herbal medicine, is excite the mucous membranes "to unusual secretion." In doing so, in the second and third stages of the pathology, the fresh and abundant mucous can soothe, clean, disinfect, and heal the tissues. Taking goldenseal too early in the process —especially in doses higher than the traditional 15 drops of tincture — can have negative effects. it may:
1) Exhaust the mucous glands, by overstimulating them, causing dry membranes. Two to three goldenseal capsules has a distinct drying effect on the membranes.
2) Inhibit the healthy inflammatory reaction, weakening the immune response, and prolonging the illness.
3)Weaken the digestive system.
A cold may seem to get better because of the drying effect, but it actually inhibits the natural defenses against whatever bug has got your patient. It may be appropriate on the third or fourth day of a cold or flu, when there is any fear of a bacterial infection setting in. At that stage, in smaller doses, goldenseal will restore a healthy flow of mucous to the stagnant membranes.
Goldenseal provides its internal benefits in small doses — 10-15 drops of a tincture or fluid extract in a glass of water —and does its work in a few days to a week. Larger doses or long duration can begin to cause side effects. Here is how the homeopath Dr. Edwin Hale described the effects of taking too much goldenseal, after many homeopathic provings in the mid-nineteenth century:
"The increased digestive power gives way to indigestion; the increased power of assimilation to deficient nutrition; and apparent strength to real debility. . . . the natural secretion [of the mucous membranes] is at first increased; then it becomes abnormal in quantity and quality. At first, clear, white, and transparent, it becomes yellow, or thick, green, and even bloody, and nearly always tenacious. . . . The distance traversed by the primary mucous flux passes from simple increase of mucous, to erosion and ulceration. Its secondary effects are exhaustion and destruction of the glandular sources of the mucous — a condition in which the mucous surface is dry, glazed, and its functions destroyed. (Hale 1875)
The digestive tract is especially susceptible to such effects, and individuals who pop goldenseal for their colds are usually injuring their stomach and intestines instead of helping their cold. This effect is consistent with the caution in traditional Chinese medicine that bitter herbs taken inappropriately or in too high a dose can injure "the spleen" — the intestinal function in Western terminology.
One side effect of the myth that goldenseal is an antibiotic is that it might, like conventional antibiotics, disrupt the balance of normal bacteria in the intestine. This action is responsible for some of the minor or serious side effects of antibiotics. We have no evidence, either from traditional use or from scientific experiments, that either berberine or goldenseal can cause this problem. In fact, in one trial indicates the opposite.
Berberine sulfate is used clinically in Asia to treat diarrheal infections. In one double-blind placebo-controlled trial, 400 mg doses of berberine sulfate were given orally to men with E. coli<D>-induced diarrhea. The group receiving the berberine had a 48% reduction is stool volumes, and 42% of the men in the group stopped having watery stools within 24 hours, compared with 20% in the control group, who received only a placebo. The results are typical of treatment of diarrhea with berberine. This trial is frequently cited by herbal companies as "proof" that berberine-containing plants kill bacteria in the intestine, even though the authors of that trial reach the opposite conclusion. They found that pathogenic bacterial counts in the patients were unchanged (Rabbani et al 1987). Berberine in such high doses (the equivalent of about 26 capsules of goldenseal) did not appear to disrupt the pathogenic bacteria, much less the beneficial ones. I first heard about this possibility in the mid-1980s. I've been looking for a single case report of this effect ever since, and have never heard of one.
One traditional use of goldenseal is as a mucous membrane tonic. Note that it does not have to come in contact with the mucous membranes to have this effect. Hold some goldenseal in your mouth for a minute or two, and you can feel the effect on the mucous membranes in your nose and sinuses. Traditional doctors stated that goldenseal increases the secretion of the mucous membranes. At the same time, goldenseal contains astringent factors, which also counter that flow. Thus it was referred to as a mucous membrane "alterative," increasing deficient flow but decreasing excessive flow. How this happens has not been determined by science, but is thoroughly supported by the traditional uses by some of the physicians in Table 3. It is my opinion that goldenseal acts as an "antibiotic" to the mucous membranes not by killing germs directly, but by increasing the flow of healthy mucous, which contains it's own innate antibiotic factors — IgA antibodies. This effect is unnecessary in the early stages of a cold or flu, when mucous is already flowing freely.
Amin, A.H., Subbaiah, T.V., and Abbasi K.M. Berberine sulfate: antimicrobial activity, bioassay, and mode of action. Can J Microbiol<D> 1969;15:1067-1076
Bensky, D. and Gamble, H. Chinese Herbal Medicine: Materia Medica<D> Seattle, Washington: Eastland Press, 1986
Bhide, M.B., Chavan, S.R., Dutta, N.K. Absorption, distribution and extretion of berberine. Indian J Med Res<D> 1969;57:2128-2131
Chopra, R.N., Dikshit, B.B., Chowhan, J.S. Pharmacological action of berberine. Ind J Med Res<D> 1932;19:1193-1203
Choudry, V.P., Sabir, M., and Bhide, V.N. Berberine in giardiasis. Ind Pediatr<D> 1972; 9:143-146
Ghosh, A.K. Effect of berberine chloride on Leishmania donovani<D>. Ind J Med Res<D> 1983;78:407-416
Gupta, S. Use of berberine in the treatment of giardiasis. Am J Dis Child<D> 1975;129:866
Hale, E.M. Materia Medica and Special Therapeutics of the New Remedies.<D> Fourth Edition. Chicago, Illinois: 1875. Reprinted by Jain Publishers, New Delhi, 1995
Johnson, C.C., Johnson, G., et al. Toxicity of alkaloids to certain bacteria. Acta Pharm Tox.<D> 1952;8:71-78
Rabbani, G.H., Butler, T., Knight, J., et al. Randomized controlled trial of berberine sulfate therapy for diarrhea due to enterotoxigenic Escherichia coli<D> and Vibrio cholerae<D>. J Infectious Dis<D> 1987;155(5):979-984
Subbaiah, T.V., and Amin, A.H. Effect of berberine sulfate on Entamoeba histolytica<D>. Nature<D> 1967;215;527-528
"Berberis acts much like hydrastis and could be employed for many of the uses of that scarce and high-priced drug so far as the berberine effects are concerned." (Felter 1922)
Most of the research that is popularly attributed to goldenseal has actually been into its constituent berberine. A number of other plants contain berberine in medicinal quantities. One of them, coptis<D> (See MH<D>, Summer 1996, volume 8, number 2) actually contains more berberine than goldenseal. The accompanying table shows the situations where they can best be used in place of goldenseal. All these plants, like goldenseal, have a characteristic bitter flavor, and may be used as bitter tonics. Don't take berberine-containing plants during pregnancy. This caution applies to most plants containing alkaloids, including tobacco and coffee.
Rumors are circulating in scientific and regulatory circles that berberine may be toxic. In 1996, the committee of the European Union that regulates drugs placed Barberry (Berberis vulgaris<D>) in a table of Herbal Drugs with Serious Risks without any Accepted Benefit because it contains berberine. This recommendation is so out of line with the long traditional use of barberry and other berberine-containing herbs that it must be taken with a grain of salt. The "serious risks" may refer to animal trials or human incidents using large amounts of isolated berberine. The lack of "accepted benefit" may be simply because these plants have not been studied in formal clinical trials, as is common with most medicinal plants. I was able to find only a single report of potential adverse effects of berberis species, berberine-containing plants, or berberine itself in a computer search of the MEDLINE and TOXLINE databases of the U.S. National Library of Medicine. This was a study in China that showed that berberine sulfate is inappropriate for the treatment of newborn infants with prenatal jaundice (Chan 1993). I assume this is not a risk for the general public or for contemporary herbalists or general practice physicians, because such an infant will be hospitalized in this country. It does support traditional cautions about using berberine-containing plants in pregnancy, however.
In a recent review of potentially hepatotoxic herbs, two French physicians state only that barberry has been "suggested" as potentially hepatotoxic, with no specific clinical evidence. He cites Vulto and De Smet (1988) as a source, but states that no case has been confirmed, and that the problem, if there is one, is rare (Larrey and Pageaux 1995). Another trial showed that a berberis species from India protected<D> the liver from damage by the drug acetaminophen (Gilani and Janbaz 1992).
This quote at the beginning of this article doesn't come from a modern-day herb conservationist, but from Dr. Harvey Felter in 1922. In his time, goldenseal had already become scarce due to overharvesting in areas of the country. The situation now, seventy five years later, is much worse, and barberry, as a substitute is just as effective. The table below shows some traditional uses of barberry. A tincture is usually taken. For external applications, sores in the mouth, or eye problems, make a tea, and, in the case of the eyes, dilute it (20 drops of the tea in a pint of water.). Contemporary researchers have used berberine successfully to treat eye infections. According to Felter, who was familiar with such treatments, barberry is more effective for this than the isolated berberine alkaloid (Felter and Lloyd 1898).
Traditional uses of barberry
Mouth sores, ulcers
Ellingwood classifies Oregon grape not as a goldenseal substitute, but as an echinacea substitute. He calls it an antiseptic alterative.<D> Historically it has been used, like echinacea, for "bad blood," although it does not have the high reputation that echinacea does for this. It is probably not an immune-stimulant. Felter, on the other hand, did consider it a goldenseal substitute and said of it:
"Like goldenseal, Berberis aquifolium<D> is an excellent peptic bitter and tonic to the gastric function, and is, therefore, a drug of much value in atonic dyspepsia, with hepatic torpor. Upon the mucosa its effects are like those of goldenseal, controlling catarrhal outpouring and erosion of tissue." (Felter 1922)
His older medical terminology may be translated to say that Oregon grape is effective in digestive complaints that require a bitter tonic, sluggish liver complaints, and chronic mucous membrane problems. If we put these two doctors' opinions together, Oregon grape alone could take the place of the echinacea-goldenseal preparations so common now in health food stores. Oregon grape is especially famous as a treatment for chronic skin conditions.
Mahonia (Berberis) aquifolium
Yerba de Sangre
(Source: Moore 1993)
Northwest herbalist Howie Brounstein has used Oregon grape as a substitute for echinacea and goldenseal, and his experienceverifies the opinion of the Eclectic physicians that it is a worthy replacement for either. He has used it for intestinal and other bacterial infections for more than ten years. He considers it in cases that might otherwise call for a broad-spectrum antibiotic, although he does not consider Oregon grape to be an antibiotic itself. Brounstein uses internal doses of the tincture in doses of forty-five to sixty drops three or four times a day. If it is going to work, he says, there should be marked improvement within twenty-four hours. His observations are recorded as follows:.
Antibiotic resistant ear infections: Every case I have treated has cleared up. I Usually add mullein flower oil externally to the ear.
Bacterial infection moving inward: Excellent results
Abscessed tooth: Excellent results
Colds: Much better than Echinacea for the common cold. If echinacea is the light cavalry, Berberis is the heavy artillery.
Bronchitis Good results
Bladder infections Mixed results, I generally use other herbs first and move to Berberis in more stubborn cases.
This plant contains a number of alkaloids besides the more famous berberine. These alkaloids, some of which are found in other berberine-containing plants, may contribute to the sort of broad-spectrum effects that Brounstein notes.
Yerba Mansa is a traditional Southwest herb which is growing in popularity as a goldenseal substitute, primarily on the authority and advice of Southwest herbalist Michael Moore (Moore 1989). It is one of the most-often prescribed herbs at our clinic in Boulder, Colorado. Moore, is well-known not only for his scholarship of the herbal scientific literature, but for knowledge of traditional plant use and hands-on knowledge the plants he writes about. His three volumes are among the most important herbal texts in American history. He didn't come up with the idea of using yerba mansa as a goldenseal substitute out of thin air. You may not have heard of this herb, but don't underrate it because it is not as famous as goldenseal. To the traditional residents of the desert areas where it grows, local residents consider it among the "royalty" of the local herbs.
Yerba mansa is very different from goldenseal. It contains no berberine or other related alkaloids, and it not a bitter tonic. It is hot and acrid, with a warming sensation, and is astringent. It may replace goldenseal as a mucous membrane tonic, when bitter tonics are contraindicated and the membranes are congested.
The Eclectics were aware of its properties, but generally only those in the Western states used it extensively. It was introduced into Eclectic use by Dr. W.H. George of California in 1877 — about the same time as echinacea — and remained in use by that profession until its decline in the 1930s. The homeopathic school also used it (Boericke 1927). The chief Eclectic indication was as a mucous membrane remedy, when there is full stuffy sensation in the head and throat, cough with expectoration, or mucous discharges from the bowels or urinary tract.
mucous membrane tonic
urinary organ tonic
The above herbs all either contain constituents in common with goldenseal, or have been used for similar conditions. The Eclectics described several of them as goldenseal substitutes more than seventy-five years ago. I don't personally use them in the place of goldenseal in all conditions, however.
Try this experiment: Take some goldenseal and several of its substitutes: I've done this with barberry, Oregon grape root, and yerba mansa, and various mixtures of them, as tinctures. Take a dose, say a dropperfull of the tincture or the powdered herb in a little water, and hold it in your mouth. When I take the goldenseal, within a minute I can feel secretions moving in my nasal mucous membranes. In a short time, I can feel stimulation in my intestines and urinary tract membranes. I've never felt this with the goldenseal substitutes, although a combination of Oregon grape root and yerba mansa comes closest. The goldenseal does not have to come in contact with these membranes to have the effect.
For this reason, I still use goldenseal in conditions where a cold, flu, or bronchitis seems to be going deeper into the system, or becoming complicated by a bacterial infection. In one case, a client with a chronic dry bronchitis had been coughing up only slight amounts of clear phlegm for several weeks. Then the discharges turned to yellow and green — a sign of the onset of bacterial infection and the threat of pneumonia. A combination of goldenseal and echinacea returned the phlegm to its normal clear color within twelve hours. Goldenseal is simply the most effective and fastest remedy for such a condition. I've consulted with two herbalists who were suffering from a similar condition four or five days into a cold. Each of these Southwest herbalists had tried yerba mansa for the condition, without noticeable effect. When they used goldenseal, the got rapid results.
Boericke, W. Pocket Manual of Homeopathic Materia Medica<D> New Delhi: Jain Publishers, 1922. Reprint edition,1984
Chan, E. Displacement of bilirubin from albumin by berberine. Biol Neonate<D> 1993;63(4):201-8
Felter H.W. and Lloyd J.U. King's American Dispensatory<D> Cincinnati, Ohio, 1898. Reprinted 1983. Portland, Oregon: Eclectic Medical Publications
Felter, H.W. The Eclectic Materia Medica, Phrmacology, and Therapeutics<D>. Cincinnati, Ohio, 1922. Reprinted 1985. Portland, Oregon: Eclectic Medical Publications
Gilani A.H. and Janbaz K.H. Prevention of acetaminophen-induced liver damage by Berberis aristata leaves. Biochem Soc Trans;<D> 1992;20(4):347
Larrey, D. and Pageaux, G.P. Herbs and mushrooms that are toxic to the liver Seminars in Liver Disease<D> 1995;15(3)183-188
Moore, M. Medicinal Plants of the Desert and Canyon West<D>, Santa Fe: Museum of New Mexico Press, 1989
Moore, M. Medicinal Plants of the Pacific West<D> Santa Fe: Red Crane Books, 1993
Vulto A.G. and De Smet P.A.G.M. Drugs used in non-orthodox medicine. In: Dukes, M.G.N. Meyler's side effects of drugs<D> 11th ed. Amsterdam: Elsevier, 1988
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