A systematic approach to herbal prescribing

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7 A systematic approach to herbal prescribing

Chapter contents

Introduction 

Therapeutic strategy 

Treating the perceived causes 

The critical role of case taking 

The treatment framework 

The actions 

Introduction

In order to appreciate a key element of the approach behind Western herbal therapeutics, we must assume that a normally functioning human body is free from disease and capable of resisting disease. Therefore, a deeper understanding of the cause and treatment of disease should also come from a consideration of physiology, the normal functioning of the body, as well as pathology and pathophysiology. An excessive focus on pathology will lead to a medical system which is interventionist and directed towards compensating for the physiological deficiencies and imbalances that arise in disease (physiological compensation), without seeking a greater understanding of how they arose in the first place. Such a basic strategy will lead to a superficial and short-term approach to treatment. This is increasingly the orthodox medical system we have today. While it is very useful for advanced pathologies and life-threatening states, it is incomplete, and especially inadequate in the treatment of many chronic diseases.

In contrast, most traditional medical systems, which are partially or completely based on herbal medicine, concern themselves more with the underlying physiological imbalances that led to and sustain the disease. As such, they are more focused on physiology than pathology. The treatment is aimed at physiological support or enhancement, rather than just compensating for the chemical deficiencies or excesses resulting from an abnormal physiology. Physiological compensation often requires the constant presence of the medicine to achieve the desired effect, whereas physiological support can, in time, lead to a permanent correction of an abnormal body chemistry.

One group of herbalists in the 19th century recognised these considerations and, in an attempt to translate traditional herbal thinking into more modern concepts, named their discipline ‘physiomedicalism’. Obviously, other traditional herbal practitioners did not and could not express their understanding of physiology in terms of modern scientific theories, but this does not detract from the value or elegance of their comprehension of the healthy functioning of the human body.

One example of physiological support versus physiological compensation can be seen in the treatment of bacterial infections. The traditional herbal approach is to support immunity and to fine tune the normal physiological responses to infection such as fever. In contrast, the conventional approach is to suppress the fever and kill the bacteria with antibiotics, thereby compensating for weakened or overloaded bodily defences. The latter approach has life-saving value but will not prevent infections from recurring. The traditional herbal approach may see a higher rate of failure in acute situations, although this is debatable, but could lead to improved immunity and possibly a reduced rate of recurrent infections. Clearly, an important complementary role for traditional herbal medicine can be argued from this and other examples.

Western herbal medicine is also not opposed to employing physiological compensation when needed, although the approach is far less interventionist than that possible with modern drugs. It recognises that a disease process can often create a vicious cycle and that only direct intervention to break that cycle can restore health in some instances. At a pragmatic level, interventionist treatment gives quicker relief of symptoms, which encourages the patient to persist with the treatment. Sometimes, the very concepts treated might require an interventionist approach because they are orthodox concepts, for example, hypertension and high serum cholesterol. This is not to say that a more traditional herbal approach cannot be of assistance as well.

Therapeutic strategy

The treatment strategy that should inform prescribing in modern Western herbal medicine therefore arises from a consideration of both physiological enhancement and physiological compensation.

Physiological enhancement

General strategy

In general, the goal of physiological enhancement is to create a state of active, robust health. This is more than just the absence of overt disease, although such a positive state of body and mind would be free of disease and capable of resisting disease. It is the optimum state of body chemistry and body energy. The term ‘energy’ in this context is more than just physical or chemical energy and reflects a subjective quality of good health. All traditional health systems without exception conclude that the obvious extra energy in good health signifies the presence of a vital force that integrates the normal physiological functioning of the body and maintains homeostasis. This controversial concept, ‘vitality’, represents a fundamental difference between traditional and orthodox medical systems.

The general treatment goals of physiological enhancement can be elaborated as follows:

• Optimise body chemistry by improving nutrition and enhancing detoxification. This applies not just to the body as a whole but to every cell, organ and system within the body.

• Optimise body energy by raising vitality. Improved vitality automatically follows from optimised body chemistry. But it can also be specifically encouraged using tonics, which make more energy available, and adaptogens, which optimise the capacity to cope with stressors of all kinds, thereby helping to conserve vitality.

As noted above, an important general goal of physiological enhancement is the stimulation of detoxification. This is particularly required for problems where toxin overload is significant, as may be the case in chronic fatigue syndrome, autoimmune disease and cancer, for example. Detoxification is traditionally achieved by both stimulating detoxification processes with depuratives, immunostimulants and liver herbs and stimulating elimination with diaphoretics, diuretics, lymphatics, laxatives and expectorants.

Specific strategies

With the exception of ‘whole-body’ medicines such as the tonics and adaptogens, the general goals of physiological enhancement are achieved by enhancing the function of individual systems, organs or even tissues and cells. Such enhancement often involves the correction of imbalances. Deficient function in one physiological compartment can lead to overstimulated function in another, which in turn can create a deficiency elsewhere. For this reason the specific treatment is sometimes not aimed at the problem site: for example, in constipation caused by deficient liver function, liver function would be enhanced instead of, or in conjunction with, enhancing bowel function. In another example, an excess of female hormones causing a menstrual problem may again be treated by enhancing liver detoxification processes, since the liver is the organ which breaks down these hormones. Rather than directly manipulating ovarian secretions, it may also be treated by optimising the inputs to the pituitary, which controls ovarian function.

From the brief examples above it becomes apparent that fundamental to the specific strategy of physiological enhancement is the individualisation of the patient. If the concept of a vital force is the first pillar of traditional herbal medicine, the treatment of the patient as an individual is the second. This is in direct contrast to current medical science, since double blind, placebo-controlled clinical trials only examine the effect of a treatment in a group of patients (the more the better, for statistical power) rather than individuals.

Where appropriate, specific physiological enhancement might involve the regulation or boosting of digestive function, immunity, circulation, respiratory function and hormone output. It may also involve the enhancement of specific organs such as the liver, kidneys, ovaries and so on. The focus may be on specific tissues, for example, the exocrine cells of the pancreas. Specific functions of organs may also be supported, for example, the bile secretion from the liver or the detoxification enzyme systems in the liver. In all cases, this must be assessed on an individual basis and periodically reviewed.

Physiological compensation

Sometimes an overstimulated function needs to be directly controlled, or deficiencies need to be compensated, because the pathological process has gone too far. In other cases, a vicious cycle needs to be broken or the patient needs relief from uncomfortable or debilitating symptoms. These are circumstances where physiological compensation is appropriate. Actions which begin with ‘anti’ usually denote a role in physiological compensation, for example, anti-inflammatory, antiviral, antispasmodic, antiseptic, antiallergic and so on. Sedative and hypnotic actions also involve compensatory mechanisms and there are many other examples. Many of the ‘specific’ herbs come into this category. Experience has shown that these herbs work well for particular disease states, for example, Tanacetum parthenium

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