- Email: [email protected]
“Chinese herbal uropathy and nephropathy”?
Correspondence
McMaster University, St Joseph’s Healthcare Hamilton, Hamilton, Ontario L8N 4A6, Canada (FEH, KP); and University of Calgary, Calgary, Alberta, Canada (RL)
of as many different diseases as any word in medicine.”3 In his translation of the fourth edition of the book, Forbes, in a footnote, insightfully went on, “As in every other case, a more correct pathology in this disease will put us in the way of a more rational practice. Instead of wasting our efforts in attempting to ward off paroxysms of a purely spasmodic nature, by measures directed to the nervous system, our attention will be directed to the removal of the real disease, the structural alteration and preternatural sensibility of the bronchial membrane.”4 Airway inflammation, remodelling, and hyper-responsiveness are not recent concepts in asthma.
1
I declare that I have no conflict of interest.
and which need to be identified to optimise treatment.5 Hence, the term asthma remains useful, provided we have an understanding of how we use the word. It needs to be maintained, but physicians and researchers need to appreciate that it describes an abnormality of function and not a specific phenotype defined as a set of observable characteristics of an individual or group. We declare that we have no conflict of interest.
*F E Hargreave, R Leigh, K Parameswaran [email protected]
2
3
4
Science Photo Library
5
The printed journal includes an image merely for illustration
For further information on the work of the RCHM, see http://www.rchm.co.uk
1416
The Lancet. A plea to abandon asthma as a disease concept. Lancet 2006; 368: 705. Scadding JG. Essentialism and nominalism in medicine: logic of diagnosis in disease terminology. Lancet 1996; 348: 594–96. Scadding JG. Definition and clinical categories of asthma. In: Clark TJH, Godfrey S, eds. Asthma. London, Chapman and Hall, 1983: 1–11. Global Initiative for Chronic Obstructive Lung Disease (GOLD), WHO, National Heart, Lung and Blood Institute (NHLBI). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda: Global Initiative for Chronic Obstructive Lung Disease, World Health Organization, National Heart, Lung and Blood Institute, 2005. http://www.guideline.gov/ summary/summary.aspx?ss=15&doc_ id=8128&nbr=4530 (accessed Oct 2, 2006). Hargreave FE, Parameswaran K. Asthma, COPD and bronchitis are just components of airway disease. Eur Respir J 2006; 2: 264–67.
May I comment from the past on your timely Editorial on asthma,1 which asks “Is it not time to step out of the [straitjacket] of a seemingly unifying name for asthma that has outlived its usefulness?” Laennec, in his grave in Doauarnez, would be pleased, for he wrote in his seminal book: “Le mot asthme signifie proprement difficulté de respirer. Il y a peu de termes dont on ait plus abusé en médecine et par lesquels on ait désigné autant de maladies différentes.”2 John Forbes translated it thus: “Asthma. The word, which properly signifies difficulty of breathing, has been as much misused, and has been made the cognomen
Peter Warren [email protected] History of Medicine/Respiratory Centre, University of Manitoba, 810 Sherbrook St, Winnipeg R3A 1R8, Canada 1 2
3 4
The Lancet. A plea to abandon asthma as a disease concept. Lancet 2006; 368: 705. Laennec RTH. De l’auscultation médiate; ou, Traité du diagnostic des maladies des poumons et du coeur, fondé principalement sur ce nouveau moyen d’exploration. Paris: Chez J-A Brosson et J-S Chande, 1819. Forbes J. A treatise on the diseases of the chest. London: T and C Underwood, 1821: 75. Forbes J. A treatise on the diseases of the chest, 4th edn. London: T and C Underwood, 1834: 90.
any aristolochic acid. We have several other concerns. First, long dan xie gan wan is used in Chinese medicine to “drain livergallbladder replete heat”.3 It is extremely unusual and doubtful that a healthy person would have taken it for 5 successive years “to enhance the liver”. Second, interstitial fibrosis is a non-specific morphological change in the kidney. It can be associated with the use of various analgesics, antimicrobial agents, non-steroidal anti-inflammatory drugs, and diuretics4 as well as with ingestion of aristolochic acid. Third, some references Laing and colleagues cite, such as the one from a newspaper, are based on supposition. Finally, the title “Chinese herbal uropathy and nephropathy” is unscientific and unfair: the nephropathy associated with aristolochic acid should no longer be related to Chinese herbal medicines because they are no longer permitted to contain it.2,5 We declare that we have no conflict of interest.
*Alicia Grant, Bo-Ying Ma, Han Yuan Chen [email protected] 21 Upeer Mulgrave Road, Cheam SM2 7AY, UK 1
“Chinese herbal uropathy and nephropathy”? In their Case Report (July 22, p 338), Chris Laing and colleagues1 relate the development of cancer and renal failure to having taken long dan xie gan wan without showing that the patient had aristolochicacid-related DNA adducts in the tissues.2 Aristolochic acid containing herbs was banned worldwide as an ingredient in Chinese medicines in 2001. The case report did not present any evidence that the long dan xie gan wan taken by the patient contained
2
3
4
5
Laing C, Hamour S, Sheaff M, Miller R, Woolfson R. Chinese herbal uropathy and nephropathy. Lancet 2006; 368: 338. Cosyns JP. Aristolochic acid and ‘Chinese herbs nephropathy’: a review of the evidence to date. Drug Saf 2003; 26: 33–48. Flaw B. 160 essential Chinese herbal patent medicines, 1st edn. Boulder, CO: Blue Poppy Press, 1999: 53. Davison AM, Cameron JS, Grünfeld J-P, Kerr DNS, Ritz E, Winearls CG, eds. Oxford textbook of clinical nephrology, 2nd edn. Oxford: Oxford Medical Publications, 1998: 1638. Chen HY, Ma B-Y, Grant A. Time to abandon the term “Chinese herbs nephropathy”. Kidney Int 2001; 60: 2039–40.
We read with concern the Case Report by Chris Laing and colleagues (July 22, p 338).1 Such cases are appalling and only emphasise the urgent need for regulation of Chinese herbal medicine. The Register of Chinese Herbal Medicine (RCHM) was set up nearly www.thelancet.com Vol 368 October 21, 2006
McMaster University, St Joseph’s Healthcare Hamilton, Hamilton, Ontario L8N 4A6, Canada (FEH, KP); and University of Calgary, Calgary, Alberta, Canada (RL)
of as many different diseases as any word in medicine.”3 In his translation of the fourth edition of the book, Forbes, in a footnote, insightfully went on, “As in every other case, a more correct pathology in this disease will put us in the way of a more rational practice. Instead of wasting our efforts in attempting to ward off paroxysms of a purely spasmodic nature, by measures directed to the nervous system, our attention will be directed to the removal of the real disease, the structural alteration and preternatural sensibility of the bronchial membrane.”4 Airway inflammation, remodelling, and hyper-responsiveness are not recent concepts in asthma.
1
I declare that I have no conflict of interest.
and which need to be identified to optimise treatment.5 Hence, the term asthma remains useful, provided we have an understanding of how we use the word. It needs to be maintained, but physicians and researchers need to appreciate that it describes an abnormality of function and not a specific phenotype defined as a set of observable characteristics of an individual or group. We declare that we have no conflict of interest.
*F E Hargreave, R Leigh, K Parameswaran [email protected]
2
3
4
Science Photo Library
5
The printed journal includes an image merely for illustration
For further information on the work of the RCHM, see http://www.rchm.co.uk
1416
The Lancet. A plea to abandon asthma as a disease concept. Lancet 2006; 368: 705. Scadding JG. Essentialism and nominalism in medicine: logic of diagnosis in disease terminology. Lancet 1996; 348: 594–96. Scadding JG. Definition and clinical categories of asthma. In: Clark TJH, Godfrey S, eds. Asthma. London, Chapman and Hall, 1983: 1–11. Global Initiative for Chronic Obstructive Lung Disease (GOLD), WHO, National Heart, Lung and Blood Institute (NHLBI). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda: Global Initiative for Chronic Obstructive Lung Disease, World Health Organization, National Heart, Lung and Blood Institute, 2005. http://www.guideline.gov/ summary/summary.aspx?ss=15&doc_ id=8128&nbr=4530 (accessed Oct 2, 2006). Hargreave FE, Parameswaran K. Asthma, COPD and bronchitis are just components of airway disease. Eur Respir J 2006; 2: 264–67.
May I comment from the past on your timely Editorial on asthma,1 which asks “Is it not time to step out of the [straitjacket] of a seemingly unifying name for asthma that has outlived its usefulness?” Laennec, in his grave in Doauarnez, would be pleased, for he wrote in his seminal book: “Le mot asthme signifie proprement difficulté de respirer. Il y a peu de termes dont on ait plus abusé en médecine et par lesquels on ait désigné autant de maladies différentes.”2 John Forbes translated it thus: “Asthma. The word, which properly signifies difficulty of breathing, has been as much misused, and has been made the cognomen
Peter Warren [email protected] History of Medicine/Respiratory Centre, University of Manitoba, 810 Sherbrook St, Winnipeg R3A 1R8, Canada 1 2
3 4
The Lancet. A plea to abandon asthma as a disease concept. Lancet 2006; 368: 705. Laennec RTH. De l’auscultation médiate; ou, Traité du diagnostic des maladies des poumons et du coeur, fondé principalement sur ce nouveau moyen d’exploration. Paris: Chez J-A Brosson et J-S Chande, 1819. Forbes J. A treatise on the diseases of the chest. London: T and C Underwood, 1821: 75. Forbes J. A treatise on the diseases of the chest, 4th edn. London: T and C Underwood, 1834: 90.
any aristolochic acid. We have several other concerns. First, long dan xie gan wan is used in Chinese medicine to “drain livergallbladder replete heat”.3 It is extremely unusual and doubtful that a healthy person would have taken it for 5 successive years “to enhance the liver”. Second, interstitial fibrosis is a non-specific morphological change in the kidney. It can be associated with the use of various analgesics, antimicrobial agents, non-steroidal anti-inflammatory drugs, and diuretics4 as well as with ingestion of aristolochic acid. Third, some references Laing and colleagues cite, such as the one from a newspaper, are based on supposition. Finally, the title “Chinese herbal uropathy and nephropathy” is unscientific and unfair: the nephropathy associated with aristolochic acid should no longer be related to Chinese herbal medicines because they are no longer permitted to contain it.2,5 We declare that we have no conflict of interest.
*Alicia Grant, Bo-Ying Ma, Han Yuan Chen [email protected] 21 Upeer Mulgrave Road, Cheam SM2 7AY, UK 1
“Chinese herbal uropathy and nephropathy”? In their Case Report (July 22, p 338), Chris Laing and colleagues1 relate the development of cancer and renal failure to having taken long dan xie gan wan without showing that the patient had aristolochicacid-related DNA adducts in the tissues.2 Aristolochic acid containing herbs was banned worldwide as an ingredient in Chinese medicines in 2001. The case report did not present any evidence that the long dan xie gan wan taken by the patient contained
2
3
4
5
Laing C, Hamour S, Sheaff M, Miller R, Woolfson R. Chinese herbal uropathy and nephropathy. Lancet 2006; 368: 338. Cosyns JP. Aristolochic acid and ‘Chinese herbs nephropathy’: a review of the evidence to date. Drug Saf 2003; 26: 33–48. Flaw B. 160 essential Chinese herbal patent medicines, 1st edn. Boulder, CO: Blue Poppy Press, 1999: 53. Davison AM, Cameron JS, Grünfeld J-P, Kerr DNS, Ritz E, Winearls CG, eds. Oxford textbook of clinical nephrology, 2nd edn. Oxford: Oxford Medical Publications, 1998: 1638. Chen HY, Ma B-Y, Grant A. Time to abandon the term “Chinese herbs nephropathy”. Kidney Int 2001; 60: 2039–40.
We read with concern the Case Report by Chris Laing and colleagues (July 22, p 338).1 Such cases are appalling and only emphasise the urgent need for regulation of Chinese herbal medicine. The Register of Chinese Herbal Medicine (RCHM) was set up nearly www.thelancet.com Vol 368 October 21, 2006