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.

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

The question which must be asked at the outset and through all stages of treatment is: ‘What is the cause of disease in this individual?’ Depending on the perceived cause, treatment involving physiological enhancement and/or compensation will be directed at that cause. Using the word ‘cause’ in any medical discussion can lead ultimately to a metaphysical debate, therefore the adjective ‘perceived’ becomes an important practical qualification. As the perception and understanding of the patient’s problem improve, one gets closer to the ‘real’ cause. Often there is a chain of causal events. Here the traditional herbal approach is often to treat as many of the links in the chain as are amenable to treatment and active at the time of treatment. Perception of the cause should always be linked to a correct medical diagnosis, although, reflecting the complexity of many clinical conditions and the difficulty that even orthodox medicine has in diagnosing some presentations, a more pragmatic ‘assessment’ may be at least as useful.

Factors involved in disease causation can be divided into predisposing, excitatory and sustaining causes. A predisposing cause is any factor which renders the body more liable to disease. Such predisposing causes include stress, lowered vitality, poor diet, inherited defects and so on. Excitatory causes are the direct provoking causes of a disease, such as infection and trauma. Sustaining causes usually come into play as a result of the initiation of a disease process and hinder the resolution of the disease. In this context, inflammation can be a sustaining cause. In general, orthodox medical treatment is aimed only at excitatory and sustaining causes, at best.

As much as is possible, predisposing causes should be removed by lifestyle changes, or countered through appropriate physiological enhancement. Neutralisation of excitatory causes often requires both enhancement and compensatory mechanisms. Treatment of sustaining causes usually needs emphasis on physiological compensation to break the sustaining cycle.

An example of treating the links in a causal chain can be illustrated by the following sequence of events:

In the context of the above causal sequence, 1–4 are predisposing causes, 5 is the excitatory cause, 6 is a sustaining cause and 7 is the symptomatic expression of the disease.

The treatment approach is set out in Table 7.1.

Table 7.1 Example of a herbal treatment approach for a causal chain

While not all this may be achievable in one prescription, over time all the links in a chain might be addressed. By choosing herbs which cover several of the required actions, it may be possible to treat many or most links in the one prescription; for example, Hypericum is antiviral and a mild hypnotic, Echinacea is immunostimulant and lymphatic. Other actions might also be required if the body retraces the links in order to resolve the problem; for example, the catarrhal state may be resolved by an acute infection and this would require stimulants (in the herbal sense) and diaphoretics in addition to some of the above. If the catarrhal state were found to be more than just a sustaining cause, then it would require deeper treatment using lymphatic and expectorant herbs.

Sometimes, where there is a good understanding of the main predisposing cause and a very effective treatment, only this cause needs to be treated. For example, Ross River virus infection, which is endemic in Australia, can lead to a chronic condition with joint pain, lethargy and night sweats due to the persistence of the immune imbalance caused by the virus. Treatment with just Echinacea angustifolia root (or its combination with E. purpurea root) in sufficient doses usually resolves the condition in 6–10 weeks.

Some causes are not treatable by herbal medicine; for example, if insomnia is caused by a traumatic experience, then herbs can compensate but cannot treat or remove the cause. Causes amenable to herbal treatment are listed in Box 7.1.

Some of the causes which cannot be removed but can be compensated for by herbal treatment are listed in Box 7.2.

Often, as part of arriving at an individual treatment framework based on the above considerations, it is necessary to take into account the current medical understanding of the patient’s condition. This understanding needs to be carefully interpreted, but nonetheless the current scientific literature is yielding very useful information. For example, potential causative factors identified in autoimmune disease include chronic bacterial and/or viral infections, abnormal bowel flora, dietary allergies and chemical sensitivities. Factors identified in gastric ulceration include bacterial infection, defective sphincter function and poor mucosal resistance.

The major aim of case taking is to establish the treatment goals or treatment protocols for that individual. Even for the same medical disorder, this can vary greatly from patient to patient; for example, a patient with eczema with a history of insecticide exposure when young will be treated differently to a patient with eczema which developed after her first child. The following is a basic outline for a consultation which seeks to obtain the information needed to arrive at the treatment framework. Particular emphasis should be given to:

The main issue is that the patient should be individualised as much as possible. As part of this process of individualisation, the general morphology and constitution of the patient should also be assessed. All this can be greatly assisted by a symptom checklist. Going through the list may also show up other problems that have a connection to the presenting complaint. A good example is a female patient who complained of regular bouts of thrush. Careful questioning revealed that the thrush always followed a course of antibiotics prescribed for an infected throat. Effective preventative treatment of the infected throat saw that the patient never had a recurrence of thrush. Yet she was never specifically prescribed a treatment for this disorder.

The treatment framework or protocol sets out the aims or goals of treatment. This is mainly derived from an understanding of the perceived causes of the condition together with an assessment of the need for physiological enhancement or compensation.

Information used to arrive at the treatment framework for a particular disorder is drawn from the following sources:

For many disorders, development of the treatment framework is a relatively simple process. However, in some instances this process may become quite complex, especially in the case of chronic disorders.

The concepts that link the treatment goals or treatment framework to the choice of herbs are the actions. These are traditional herbal concepts, but scientific research also yields information about the actions of a herb. The stepwise process in linking treatment goals to choice of herbs for prescription is then suggested as follows:

To facilitate this process, the practitioner needs a clear understanding of herbs in terms of their reliable, well-established actions. Reference lists of herbs classified under each action and ranked in order of priority from the most reliable herb to the least reliable are a useful tool. For example, under the heading of immune stimulants, one might list the following herbs in this order:

This list could be annotated: for example, Echinacea spp., best at increasing phagocytic activity and early aspects of immune recognition (innate immunity), Andrographis best for acute infections, and Astragalus best in chronic states of impaired immunity and contraindicated in acute infections, and so on. (There will be an element of subjectivity in the compilation of such lists!) The interactive preparation of these lists by a group of practitioners can be a useful learning experience.

The event sequence in Western herbal therapeutics is summarised in Figure 7.1.

Figure 7.1 A summary of the event sequence in Western herbal therapeutics.

As part of this process, it can be helpful to draw up a table of treatment goals, corresponding actions and candidate herbs. Depending on the case, this might be quite elaborate, with many treatment goals expanded into even more required actions and yet even more candidate herbs. However, it is also likely that the same herb might appear more than once, indicating that this herb probably (but not necessarily always) needs to be included in the final prescription.

The following brief outline of a case can serve as an illustration of this process. Consider a female patient aged 38 who wants a second child after two miscarriages in the past 4 years. The patient also experiences difficulty conceiving, which makes her miscarriages even more traumatic. Her cycle is long at 36 to 38 days and she experiences marked premenstrual syndrome (PMS) with mastalgia, headaches, emotional lability, anxiety and depression. The patient also suffers from habitual sleep maintenance insomnia. All hormonal tests are normal, save for prolactin, which is elevated.

Table 7.2 provides an example of what might form the key treatment goals, relevant herbal actions and resultant candidate herbs for this patient. Referring to the table it can be seen that a number of herbs appear several times, in particular chaste tree and St John’s wort. These are probably the key herbs. Other herbs can be chosen according to their perceived reliability (and associated evidence), the corresponding treatment priorities and the number of times they appear in the table. For this particular case, they would also need to be selected according to their suitability in early pregnancy, should the patient successfully conceive. According to these criteria, such herbs might include passionflower, cramp bark, wild yam and false unicorn root. As Tribulus has clinical trial data for promoting fertility, it could be given priority. A case could be argued for a role for adrenal tonic, adaptogen and general tonic herbs for this patient, in which case they could also be included in the table, with stress management as the treatment goal. Patient energetics and relevant herb-drug interactions can also be taken into account to refine further the prescription.

Table 7.2 Goals, actions and herbs for the case example under discussion (see text)