History

In the UK, medical herbalism traces its historical traditions partly to Galen’s (a Greek physician of the 2^nd century AD) model of ‘bodily humours’ (blood, black bile, yellow bile, phlegm), their ‘temperaments’ (e.g. hot, cold, damp) and the belief that illness resulted from an imbalance in these humours. Herbs were used to correct the imbalance and were often described as, for example, ‘heating’ or ‘cooling’; a ‘cooling’ herb, such as peppermint, would be used to treat a ‘hot’ condition, such as fever. In the UK, herbalism has also drawn on other traditions, such as the use of herbs in North America after Samuel Thomson, although Thomson was himself influenced by herbalism in Europe.

Modern herbalism

Today, medical herbalism, practised by medical herbalists, draws on traditional knowledge, but, increasingly, this is interpreted and applied in a modern context. For example, herbalists use current knowledge of the causes and consequences of disease as well as some of the diagnostic tools, such as blood pressure measurement, used in conventional medicine. Also, there is an increasing emphasis on using evidence from modern randomized controlled clinical trials to support the traditional use of herbal preparations. Some other aspects of modern-day herbalism as seen by the herbalists are listed below:

Importantly, different constituents of a medicinal plant are seen as acting together in some (undefined) way that has beneficial effects. For example, the constituents may have additive effects, or interact to produce an effect greater than the total contribution of each individual constituent (known as ‘synergy’), or the effects of one constituent reduce the likelihood of adverse effects due to another constituent. Similarly, it is also believed that some combinations of different herbs interact in a beneficial way. There is some experimental (but little clinical) evidence that such interactions occur, although it cannot be assumed that this is the case for all herbs or for all combinations of herbs. Synergy is discussed in detail in Chapter 11.

Conditions treated

Medical herbalists treat a wide range of acute (e.g. infections) and, more usually, chronic conditions. Very often the chronic conditions are those that are difficult to treat, including irritable bowel syndrome, premenstrual syndrome, eczema, acne and other skin conditions, cystitis, arthritis, depression, chronic fatigue syndrome or migraine.

Herbalists’ prescriptions

A first consultation with a herbalist may last for an hour or more, during which the herbalist will explore the detailed history of the illness. Generally, a combination of several different herbs (usually four to six) is used in the treatment of a particular patient. Some examples of such combinations are given in Table 13.1, although there are no ‘typical’ prescriptions for specific conditions; as stated above, even patients with the same condition are likely to receive different prescriptions. Sometimes, a single herb may be given, for example, Vitex agnus-castus (chasteberry) for premenstrual syndrome and dysmenorrhoea. Each patient’s treatment is reviewed regularly and is likely to be changed depending on whether or not there has been a response.

Table 13.1 Examples of herbal prescriptions

Herbalists usually prescribe herbal medicines as tinctures, although sometimes more concentrated formulations (fluid extracts) are used. Where a prescription requires several herbs, tinctures and fluid extracts are blended into a mixture. Some herbalists will prepare their own stock material, others purchase it from specialist suppliers and most dispense their own herbal prescriptions. Other oral formulations (tablets, capsules) and topical preparations of herbs may also be prescribed.

Comparison of herbalism with rational phytotherapy

Herbalism contrasts with rational phytotherapy in several ways (Table 13.2). Importantly, the herbalist’s approach has not been evaluated in controlled clinical trials, whereas there are numerous controlled clinical trials of specific phytotherapeutic preparations. Another important difference is that, although many of the same medicinal plants are used in each of the two approaches, the formulations of those herbs are often very different. For example, St John’s wort (Hypericum perforatum L.) is used in both rational phytotherapy and by herbalists. However, in rational phytotherapy, the preparations used are likely to be extracts of H. perforatum herb (leaves and tops) standardized on hypericin content and formulated as tablets. By contrast, herbalists are likely to use a tincture of H. perforatum herb that is not standardized on its content of any particular constituent.

Table 13.2 Comparison of herbalism and rational phytotherapy

The terminology is often confusing. Herbalism is sometimes also referred to as phytotherapy, and both herbalism and rational phytotherapy are sometimes described as ‘herbal medicine’. Likewise, preparations used in rational phytotherapy and in herbalism may both be referred to as ’herbal medicines’ or ‘phytomedicines’.

In some ways, herbalism is similar to Western medicine. For example, both use drug intervention (herbs and conventional drugs, respectively) to counteract disease, although herbalism is focused on correcting disturbed function rather than treating symptoms. Both use material doses (in contrast to homoeopathy, which uses highly dilute preparations, not all of plant origin). Herbal medicine in the UK covers a wide spectrum of practice: there are traditional herbalists who refer mainly to the older traditions and philosophy, those whose view is aligned more closely with ‘modern’ rational phytotherapy, and those whose practice is somewhere between the two approaches.

Evidence of efficacy and safety

There is a significant body of clinical evidence on the potential benefits and potential risks associated with the use of specific herbal medicines (for the most important species see Part B). The vast majority of this information relates to the use of specific herbal medicines formulated as phytopharmaceuticals and used in the same manner as conventional pharmaceuticals, usually under the supervision of a physician, to treat symptoms of disease. There has been very little investigation of the efficacy and safety of herbal medicines and combinations of herbal medicines used by herbal medicine practitioners. Furthermore, the efficacy and safety of herbalism as a treatment approach has not yet been evaluated scientifically.

History

Homoeopathy was developed around 200 years ago by Samuel Hahnemann, a German physician and apothecary. His development of the principles of this controversial approach to treatment needs to be considered against the background of medical practice at the time, when the use of leeches, bloodletting, strong purgatives and emetics, and preparations containing toxic heavy metals, such as arsenic and mercury, was widespread. It is reported that Hahnemann was dissatisfied with these harsh therapeutic strategies and that this led him to give up the practice of medicine. During this period, he was stimulated to experiment with cinchona bark (which was used to treat malaria) and found that, while taking high doses of the substance, he experienced symptoms that were similar to those of malaria. Hahnemann then used this approach (which he called a ‘proving’) with healthy volunteers who were given many other substances in order to build up a ‘symptom picture’ for each substance. On the basis of his findings from these experiments, Hahnemann outlined three basic principles of (classical) homoeopathy:

Modern homoeopathy

Despite of all controversies, homeopathy has spread widely and is a very popular form of health care in many European, Asian and American countries. Hahnemann’s principles of homoeopathy still form the basis of modern homoeopathic practice, with the exception of the single remedy rule, which is ignored by many homoeopaths in favour of multiple prescribing. Today, around 1200 homoeopathic remedies are commonly used. For many of these, homoeopaths rely on Hahnemann’s provings and, therefore, guidance on which symptoms the remedies can be used to treat. Modern-day provings involving healthy volunteers are sometimes undertaken, and several have involved rigorous study design (randomized, double-blind, placebo-controlled). However, Hahnemann did not use rigorous study design, although he did specify certain criteria; for example, subjects were not permitted to have coffee during the course of a proving.

In addition to the key principles of homoeopathy outlined above, homoeopaths also claim:

In choosing a remedy for a particular patient, a homoeopath will consider the patient’s physical, mental and emotional symptoms, as well as personal characteristics, likes and dislikes. This information is then used to select the homoeopathic remedy with a ‘symptom picture’ that most closely matches that of the patient. Computerized repertories (databases of homoeopathic remedy symptom pictures) are now available which facilitate this process.

Homoeopathic remedies

Homoeopathic remedies and herbal medicines are often confused and/or deemed to be similar. The fundamental differences between the two types of preparation are:

Many of the species used for preparing homoeopathic remedies have a history of medicinal use; others are poisonous if used undiluted. Other types of material used in the preparation of homoeopathic remedies include animal, insect, biological, drug/chemical and mineral.

The starting point for the production of most homoeopathic remedies is a mother tincture, usually an alcohol/water extract of crude plant material, such as dried arnica flowers. The mother tincture is then diluted according to either the decimal (dilution steps of 1 in 10; denoted by D or X) or centesimal (dilution steps of 1 in 100; denoted by C or cH) scale to form homoeopathic remedies or potencies. For example, on the decimal dilution scale, a 1X (or D1) remedy is prepared by taking one part mother tincture and adding it to nine parts diluent (dilute alcohol) and succussing the resulting 1 in 10 dilution. A 2X remedy is prepared by taking one part 1X remedy and adding it to nine parts diluent and succussing the resulting dilution, which is now a dilution of 1 in 100, and so on. The centesimal scale uses the same procedure except that each step involves adding one part mother tincture to 99 parts diluent so that the first step produces a 1 in 100 dilution (1C or 1cH), the second step a 1 in 10,000 dilution (2C) and so on. The centesimal scale goes as far as M (1 in 10²⁰⁰⁰ dilution, i.e. 2000 centesimal dilution steps) and 10M (1 in 10^20,000) dilutions. These potencies are usually prepared robotically. There are also LM potencies which involve serial dilutions of 1 in 50,000 at each step.

Potencies at the lower end of the decimal (i.e. 1X, 2X,3X to around 6X) and centesimal scales (usually up to 3C) still contain reasonable quantities of starting material and, depending on the nature of the starting material, may elicit pharmacological or toxicological effects. For this reason, some homoeopathic remedies at these lower dilutions are classified as prescription-only medicines (POM) in the UK. Some examples of plant-derived homoeopathic remedies and the potencies below which they are POM include:

Potencies of 24X and 12C and above are diluted beyond Avogadro’s number; thus it is highly unlikely that even a single molecule of the original starting material is present.

Quality control needs to be carried out on the source materials, and the manufacturing process for homoeopathic preparations needs to adhere to the principles of good manufacturing practice to ensure that contamination does not occur.

Potentization

According to Hahnemann’s second principle (but in opposition to modern pharmacological principles), the more dilute the preparation, the more potent it is. So, for example, a 6X remedy is claimed to be ‘stronger’ (more potent) than a 2X remedy, and a 12C remedy more potent than a 6C remedy. Also, although 2X and 1C preparations are the same concentration, a 2X is considered to be more potent because it has undergone two steps involving succussion, whereas 1C preparations have undergone only one succussion step.

Homoeopaths have put forward several arguments in an attempt to explain how highly dilute homoeopathic remedies could work. One of the most well-known of these is the ‘memory of water’ theory. Proponents of this theory claim that the process of succussion somehow alters the solvent molecules such that they become rearranged to form ‘imprints’ of molecules of the original starting material. Research exploring this theory has drawn on the disciplines of physics and biology, and has involved investigation of the physicochemical principles of homoeopathic remedies. It has been reported for some homoeopathic remedies that their physicochemical principles are different to those of the relevant solvent alone. However, these preliminary findings have had a negligible impact on the wider scientific community.

Evidence of efficacy

Homoeopathic treatment has been investigated in over 100 clinical trials, and the results of these studies have been subject to systematic review and meta-analysis. A meta-analysis of data from 89 placebo-controlled trials of homoeopathy indicated that the effects of homoeopathy are not completely due to placebo. Restricting the analysis to high-quality trials only reduced, but did not eliminate, the effect found. However, there was insufficient evidence to demonstrate that homoeopathy is clearly efficacious in any single clinical condition (Linde et al 1997). Many trials, particularly those with negative results for homoeopathy, have been criticized by proponents of homoeopathy because participants received the same homoeopathic treatment rather than individualized treatment. So, another meta-analysis considered all placebo-controlled trials (n= 19) of ‘individualized’ homoeopathy (i.e. where patients are prescribed the remedy most appropriate for their particular symptoms and personal characteristics; Linde and Melchart 1998). The study found that individualized homoeopathy was significantly more effective than placebo, but, when the methodologically best trials only were considered, no effect over that of placebo was seen for homoeopathy. Further work has provided strong evidence that, in homoeopathy, clinical trials of better methodological quality tend to yield less positive results. There have been several high-quality trials published since Linde et al’s original meta-analysis which report negative results, and it seems likely that the original meta-analysis ‘at least overestimated the effects of homeopathic treatments’ (Linde et al 1999).

Safety

It is unlikely that highly dilute homoeopathic remedies can lead to serious adverse drug reactions. However, the potential for toxicity with homoeopathic remedies at low dilutions should be considered, since such preparations can still contain reasonable quantities of starting material. This view is supported by the provisions of the European directive 92/73/EEC which became law in the UK in 1994 and which provides regulations for homoeopathic medicinal products. The directive required member states to set up a simplified registration procedure based on quality and safety, but not efficacy, for homoeopathic medicinal products that met certain criteria, including:

There are isolated reports in the literature of suspected adverse effects, usually allergic reactions, following the use of homoeopathic remedies (Barnes 1998a), although a causal association has not been established. There are also isolated reports of adulterated homoeopathic remedies.

Pooled data from placebo-controlled clinical trials involving homoeopathic remedies indicate that adverse effects occur more frequently with homoeopathy than with placebo, but that adverse effects are mild and transient, and the types (e.g. headaches, tiredness, skin reactions, dizziness and diarrhoea) are similar for both homoeopathy and placebo.

History

Anthroposophical medicine is a philosophical vision of health and disease based on the work of Austrian philosopher and esoceritist Rudolf Steiner (1861–1925). Steiner’s work explored how human beings and the natural world could be described, not only in physical terms, but also in terms of soul and spirit. He called this philosophy ‘anthroposophy’. Its relevance in medicine, education and agriculture became an increasing part of Steiner’s work, and resulted in what is now known as anthroposophic medicine.

Steiner believed that consciousness could not be defined in physical terms, as in conventional medicine, and explored how human’s soul and spiritual nature relate to the health and function of the body. Nevertheless, he aimed anthroposophic medicine to be an extension, not an alternative, to conventional medicine. Steiner viewed each person as having four ‘bodies’ or ‘forces’:

And he considered the human-being to be made of three functional systems:

Modern anthroposophic medicine

Anthroposophic medicine today is still based on Steiner’s philosophy. Practitioners of anthroposophy aim to understand illness holistically in terms of how the four ‘bodies’ and the functional systems interact with each other. Diagnosis involves not only several conventional tools, such as history-taking, physical examination and laboratory investigations, but also the patient’s life story, social context and even body shape, movements, social behaviour and modes of artistic expression. Anthroposophic practitioners may use a range of therapies, including diet, therapeutic movement (eurythmy), artistic therapies and massage, as well as anthroposophic medicines, in an integrated therapeutic programme.

Anthroposophic medicine is particularly well-developed in Austria, Germany, Switzerland and The Netherlands, where there are hospitals specializing in anthroposophic medicine, as well as many general practitioners who practise an anthroposophical approach. In the UK there are only a few medically qualified practitioners who practise anthroposophic medicine.

Conditions treated

Several hospitals in Germany specializing in anthroposophic medicine provide a range of treatments that are also provided by general hospitals. Anthroposophic medicine is used as a therapeutic approach, under medical supervision, for several serious conditions, including supportive treatment in cancer. There is also a wide range of over-the-counter (OTC) medicines (both general sales list and pharmacy only) used for the symptomatic relief of conditions suitable for OTC treatment, such as indigestion, constipation, coughs, colds, sore throat, catarrh, sleeplessness, muscular pain and certain skin conditions.

Anthroposophic medicines

Steiner believed that the sizes of different parts of plants, such as flowers, leaves and roots, are disproportionate in plants with medicinal properties. Usually, the disproportionately sized part would be used therapeutically. For example, nettle (Urtica dioica) produces an abundance of green leaves, whereas the flowers and fruit are insignificant in terms of size. Therefore, from an anthroposophic perspective, nettle leaves are deemed to have medicinal properties. However, sometimes, the whole plant, or a part of the plant other than the disproportionately sized part would be used therapeutically. In addition, in anthroposophic medicine, it is believed that the specific part of a medicinal plant relates to one of the three different ‘systems’ of the body (see above): roots relate to the ‘sense-nervous system’, flowers and fruit relate to the ‘reproductive-metabolic system’ and leaves act on the ‘rhythmic system’. Continuing to use nettle as an example, nettle leaves are used to stimulate the assimilation of iron (e.g. in anaemia), which is important in blood circulation.

Anthroposophic medicines are derived mainly from plants and minerals, such as calcium, iron and copper. Many products are combinations of herbal ingredients, and some products contain both herbal and mineral ingredients. Herbal and mineral ingredients are usually described by their Latin binomial name together with the plant part for herbs. For example:

Ingredients of anthroposophical medicines are sometimes ‘potentized’ using the X or D potency series (steps of 1 in 10 dilution) rather than the C potency series (steps of 1 in 100 dilution) (see above). Thus, an ingredient with a potency of 1X (or D1) has a concentration of 1 in 10 or 10%, a 2X potency has undergone two steps of 1 in 10 dilution so is 1 in 100 or 1%. As with homoeopathic remedies, at each dilution stage for an anthroposophical ingredient, the liquid is rhythmically succussed, which is claimed to ‘release’ the therapeutic properties of the substance. In anthroposophical medicines, ingredients are usually used at potencies below 6X (or D6). These are low dilutions, so reasonable quantities of plant constituents will be present. Thus, anthroposophical medicines containing plant-derived ingredients at dilutions below 6X can, from a pharmaceutical perspective, be considered to be herbal medicines.

Another group of products derived from the anthroposophical approach are mistletoe (Viscum album) preparations. Mistletoe is a semi-parasite, extracting water and mineral salts from the host trees. The preparations contain a specially processed fermented aqueous mistletoe extract growing on a range of host trees, such as apple (Malus domestica), pine (Pinus sp), or oak (Quercus spp.).

The three types are also available formulated with low concentrations (10^–8 g per 100 mg fresh plant extract) of certain metal salts, such as those of copper and mercury. A lectin-standardized extract, also prepared according to the anthroposophic approach, is available, although this formulation does not include metal salts. Lectin-standardized mistletoe extracts, which are distinct from anthroposophical mistletoe preparations, are also available, particularly in Germany. Mistletoe products prepared from different host trees are prescribed for patients with different types of cancer. Treatment is usually given by subcutaneous injection, although the intravenous injection route is sometimes used, and oral formulations are also available.

In the preparation of anthroposophical medicines, particular attention is paid to the source and methods of farming used in growing plant raw materials. Plant materials are grown according to the principles of biodynamic farming, which is similar to organic farming. Pharmaceutical manufacturing companies exist that are dedicated to the production of anthroposophical medicines.

History

Aromatic plants and their extracts have been used in cosmetics and perfumes and for religious purposes for thousands of years, although the link with the therapeutic use of essential oils is weak. One of the foundations of aromatherapy is attributed to Rene-Maurice Gattefosse, a French perfumer chemist, who first used the term aromatherapy in 1928 (Vickers 1996). Gattefosse burnt his hand while working in a laboratory and found that lavender oil helped the burn to heal quickly with little scarring. Jean Valnet developed Gattefosse’s ideas of the benefits of essential oils in wound healing, and used essential oils more widely in specific medical disorders. Marguerite Maury popularized the ancient uses of essential oils for health, beauty and wellbeing and so played a role in the modern renaissance of aromatherapy.

Modern aromatherapy

Aromatherapy is the therapeutic use of essential oils. These are obtained from plant material (e.g. roots, leaves, flowers, seeds) usually by distillation, although physical expression (using compression and pressure) is the method used to obtain some essential oils, mainly those from the skin of citrus fruits. Some of the key aspects of the use of essential oils in aromatherapy are described below:

Conditions treated

Aromatherapy is widely used as an approach to relieving stress, and many essential oils are claimed to be ‘relaxing’. Many aromatherapists also claim that essential oils can be used in the treatment of a wide range of conditions. Often, many different properties and indications are listed for each essential oil, and conditions range from those that are relatively minor to those considered serious. For example, indications for peppermint leaf oil (Mentha × piperita) listed by one text include flatulence, ringworm, skin rashes, cystitis, indigestion, nausea, gastritis and sciatica, as well as migraine, hepatitis, jaundice, cirrhosis, bronchial asthma and impotence (Price & Price 1995). Many users self-administer essential oils either as a beauty treatment, as an aid to relaxation, or to treat specific ailments, many of which may not be suitable for self-treatment. Aromatherapy is also used in a variety of conventional healthcare settings, such as in palliative care, intensive care units, mental health units and in specialized units caring for patients with HIV/AIDS, physical disabilities and severe learning disabilities.

On a first appointment and before treating a client, an aromatherapist will take a case history, including gathering details of the client’s medical history, lifestyle, diet and moods/emotions. Information gathered during the consultation is used to select essential oils thought to be appropriate for the individual concerned. The most common method used by aromatherapists for the application of essential oils is by massage, where drops of (usually) two to three essential oils are diluted in a vegetable carrier (or base) oil, such as grapeseed oil, jojoba oil, wheatgerm oil, sweet almond oil or sesame oil. The resulting ‘blend’ is then applied either during a full-body massage or localized massage. Other methods of applying essential oils used by aromatherapists or in self-treatment include:

Some practitioners advocate the oral administration of essential oils, described as ‘aromatology’. However, essential oils should never be taken internally without medical supervision. Some aromatherapists also suggest that essential oils can be administered vaginally (e.g. via tampons or a douche) or rectally, but administration by these routes may cause mucosal membrane irritation and is not recommended.

Essential oils

Typically, an essential oil contains around 100 or more chemical constituents, mostly present at concentrations below 1%, although some constituents are present at much lower concentrations. Some essential oils contain one or two major constituents, and the therapeutic and toxicological properties of the oil can largely be attributed to those constituent(s). However, other constituents present at low concentrations can be important. The composition of an essential oil will vary according to the plant’s environment and growing conditions, the plant part used and on methods of harvesting, extraction and storage. The major constituents of an essential oil can also vary in different chemotypes of the same species of plant. The constituents of essential oils are largely volatile compounds which are sensitive to the effects of light, heat, air and moisture and should, therefore, be stored in a cool place in tightly closed, darkened bottles. Even when stored correctly, the composition of essential oils can change during storage, so qualitative and quantitative analyses relate only to the composition of the oil at the time of testing. There is also the possibility of adulteration and contamination occurring during processing. Gross adulteration can be detected using established analytical techniques such as gas chromatography–mass spectrometry (GC-MS).

Essential oils should be referred to by the Latin binomial name of the plant species from which a particular oil is derived. The plant part used should be specified and, sometimes, further specification is necessary to define the chemotype of a particular plant; for example, Thymus vulgaris CT thymol describes a chemotype of a species of thyme that has thymol as a major chemical constituent (Clarke 2002).

Efficacy and safety

Essential oils are believed to act both by exerting pharmacological effects following absorption into the circulation and via the effects of their odour on the olfactory system. There is evidence that essential oils are absorbed into the circulation after topical application (i.e. massage) and after inhalation, although amounts entering the circulation are likely to be very small (Vickers 1996).

Certain essential oils have been shown to have pharmacological effects in animal models and in in vitro studies, but there is little good-quality clinical research investigating the effects of essential oils and aromatherapy as practised by aromatherapists. Most of the clinical trials that have been conducted do not show that massage with essential oils is significantly better than massage with carrier oil alone (Barnes 1998b). There is evidence that tea tree oil applied topically is effective in the treatment of certain skin infections, but these studies have not tested aromatherapy as practised by aromatherapists.

Data regarding the safety of essential oils as used in aromatherapy are limited. Few adverse effects associated with aromatherapy treatment have been reported; most reports relate to cases of contact dermatitis in patients or aromatherapists. Minor transient adverse effects, such as drowsiness, headache and nausea, can occur after aromatherapy treatment. The increasing use of essential oils during pregnancy and labour is of concern. Because of uncertainties about the safety of essential oils during these periods, general advice is that the use of essential oils should be avoided during pregnancy, particularly during the first trimester. The use of certain essential oils should also be avoided by patients with epilepsy.

History

Bach flower remedies were developed by Dr Edward Bach (1886–1936), a physician and homoeopath. Bach believed that negative states of mind caused physical illness, and his approach to maintaining health was focused on the patient’s psychological state. His theory was that by treating patients’ emotional and mental responses to their illness, physical symptoms would then be relieved. He identified 38 negative psychological states (e.g. jealousy, hopelessness, guilt, indecision) and sought natural remedies that could be used to ‘correct’ these negative states of mind. It is claimed that to do this Bach visited the countryside, concentrated on these specific emotional states and was intuitively drawn towards particular wild flowers that he believed could relieve them.

Modern flower remedy therapy

Flower remedies of various types are widely available for self-selection and self-treatment. In addition some individuals undertake training to become a flower-remedy practitioner; this includes some healthcare professionals, such as some general practitioners, who use flower remedies alongside their day-to-day conventional medical practice.

Flower remedies

Bach developed 38 flower remedies, 37 of which are based on single wild flowers and tree blossoms, and one (rock water) which is made from natural spring water. He intended each remedy to be used for a specific emotional or mental state. Some examples are:

Bach also developed a preparation termed Rescue Remedy, which is a combination of five of the other remedies: impatiens (Impatiens glandulifera), star of Bethlehem (Ornithogalum umbellatum), cherry plum (Prunus cerasifera), rock rose (Helianthemum nummularium) and clematis (Clematis vitalba). Bach recommended this preparation to be used in difficult and demanding situations, such as shock, terror, bereavement.

Bach flower remedies are prepared from mother tinctures which are themselves made from plant material and natural spring water using either an infusion (‘sun’) method or a ‘boiling’ method (Kayne 2002). The infusion method is used to prepare mother tinctures for 20 of the Bach remedies: flower heads from the appropriate plant are added to a glass vessel containing natural spring water and are left to stand in direct sunlight for several hours, after which the flowers are discarded and the infused spring water retained. The boiling method involves the addition of plant material to natural spring water, which is then boiled for 30 minutes, cooled and strained. With both methods, the resulting solution is diluted with an equivalent volume of alcohol (brandy) to make the mother tincture. Flower remedies are then prepared by adding two drops of the appropriate mother tincture to 30 ml of grape alcohol. It is claimed that the resulting solution is equivalent to a 1 in 100,000 dilution. This is the same dilution as a 5X potency in homoeopathy, but preparation of flower remedies does not involve serial dilution and succussion. Thus, in material terms, flower remedies and 5X potencies can be considered equal, although from a homoeopathic perspective they are not.

Flower remedies are usually taken orally (2–4 drops added to a cold drink and sipped), although, in some cases, drops are placed directly under the tongue and even on the wrist or temples. Rescue Remedy is also available as a cream for external use.

Efficacy and safety

Although there are many anecdotal reports of the benefits of flower remedies, there is a lack of both experimental and clinical research into their reputed effects (Barnes 1998c) and while this form of self-treatment is very popular, it remains highly controversial.

Flower remedies are widely claimed to be completely free from adverse effects. Adverse effects are unlikely to occur, given that the preparations contain only highly dilute material. However, as flower remedies contain alcohol, they may be unsuitable for some individuals. Excessive use of a flower remedy could be of concern if an individual was relying on self-treatment with flower remedies for conditions such as anxiety or depression, for which medical treatment and other professional support may be required.