Principles of herbal treatment

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3 Principles of herbal treatment

Chapter contents

First principles of traditional herbal treatment 

Approaches to using herbs 

Other healing strategies 

First principles of traditional herbal treatment

As any review of herbal traditions from around the world will confirm, the use of plants in medicine reflects the enormous diversity of local traditions, with much more variety than consistency. However, more consistent themes emerge in history, most clearly where local folk practices were systematised in the great written traditions, reviewed in Chapter 1.

When these traditions are examined closely, especially when they relate to human experience of illness and medicine, or to recurrent pharmaceutical forms (for example, tannin, resin, laxative, essential oil, acrid or bitter principle formulations rather than the individual remedies) and then translated into modern terminology, it is possible to identify recurrent features. These appear to encapsulate essential characteristics of the material, universal archetypes of the effects plants have on humans. They certainly reflect the therapeutic priorities of earlier ages (and should therefore be adapted before being applied to modern health needs). They are valuable, however, because they probably represent the roots of herbal therapeutics, those characteristics of the remedies that are the most reliable and potent. They also draw stark contrasts with the approaches that have emerged with the development of modern technological medicine. They are antidotes to the modern tendency to view herbs solely as milder versions of modern drugs. In essence, they should underpin any rational phytotherapy.

Note: Therapeutic insights are generally better absorbed from instruction and in practice rather than in the scientific literature and the following information arises from a breadth of sources. Notable among these is the bibliography at the end of the chapter listing authors who mostly were in contact with primary resources or leading teachers. The attempt is to distil rather than list scholastically.

Cleansing: detoxification and elimination

In much traditional practice there was an explicit or implicit assumption that, before healing could take place, noxious influences needed to be removed. In the earliest animistic traditions, pathogens could be literally demons and shamanistic practices emerged to drive them out. However, there was also a consistent, more mundane view of toxins and poisons: these needed to be removed by the body’s eliminatory functions. Disease was widely seen as a failure of elimination and the vomiting, diarrhoea, coughing, diaphoresis and diuresis of most acute diseases as evidence that the body was being driven to extraordinary eliminative measures. In Ayurvedic medicine the doshas were initially excretions and health their healthy presence; in Chinese medicine the development of chronic disease was a sign that acute eliminatory responses had failed in their primary task of keeping pathogens out and that penetration into the interior had occurred.

The task of the physician was equally clear: to support eliminatory functions as vigorously as possible compatible with the body’s vital reserves (eliminatory functions were mostly seen as taxing the body’s energies). In practice this meant robust ‘heroic’ treatments in acute disease, notably involving emetics, purgatives, powerful expectorants and, in fever management, diaphoretics. In chronic and debilitated conditions the aim was to use gentler treatments, peeling away toxic accumulations like the layers of an onion, always making sure that eliminatory measures, laxatives, diuretics, choleretics, expectorants and the more systemic lymphatics and alteratives were supported by adequate sustenance for the vital functions: rest, nourishment and the use of tonic remedies (see below).

Typically in traditional therapeutics, therefore, eliminatory measures were the first stage of treatment, to be followed increasingly by the following more adjustive and sustaining treatments.

Heating: moving the circulation

It was apparent to all humans that heat equated to vitality. The extreme absence of heat was the striking coldness of the corpse. When Samuel Thomson in North America built his therapeutics around the principle that disease was essentially a cold intrusion and that before all else remedies should heat the struggling body, he was only highlighting an almost universal instinct. In every tradition there is frequent use of heating remedies; the hot spices, or ‘pungent’ remedies, were the strongest for internal use, but there was always a raft of gentler warming remedies as well. Some were applied as aromatic digestives to failing ‘cold’ digestion, others as warming expectorants or mucolytics in treating the effects of cold and damp on the chest and respiratory system. There were warming tonics (yang tonics in traditional Chinese medicine) and a variety of remedies that brought heat to the head, reproductive system or kidneys.

All the above could be used, along with hot packs, hot baths, ‘sweat lodges’ or hot drinks in fever, which was the major indication for supportive heating. Heating remedies used in fever management are now called ‘diaphoretics’ as their main effect is to increase perspiration. Sweat was understood not only as a cooling agent but also as the prime eliminatory route in febrile disease; in this context, therefore, heating was an obvious cleansing strategy, as above.

Indications for the use of heating agents apart from fevers were easily understood. If the patient felt cold, as a whole or in the diseased part, or favoured hot food, hot drinks, hot packs or hot baths; if there was diminished vitality; if there was pallor (the nail bed or ‘quick’ was a particularly sensitive guide) or signs of cumulative cold-damp conditions like mucus or gravity-dependent oedema, then heating remedies were indicated. The fact that a headache or arthritic joint or abdominal swelling was relieved by a hot pack was as important in choosing the course of treatment as determining what pathological factor was involved.

When the focus of cold was clearly demarcated, then extreme heating, in the form of powerful ‘counter-irritation’, cayenne or mustard plasters, blistering croton oil or formic acid or stinging nettles, might be applied topically, with sometimes dramatic beneficial effects.

Heat in modern terms equates also to circulation: a rationale that includes improved tissue perfusion, oxygenation and metabolite removal can easily be made. A modern phytotherapist might avoid the more drastic topical heating agents and may have less need to manage fevers, but could still consider the role of heating agents in a prescription if these were indicated.

The major caution in modern times is that many patients are also debilitated, at least from the perspective of earlier, more robust times. Heating agents do not heat directly, but instead stimulate increased thermogenesis and circulatory activity. They thus require reserves of energy in the body. Someone weakened by chronic ill health may suffer if stimulated in this way. An assessment of vital reserves is essential in such treatment.

Cooling: stimulating digestion

Whereas heating was clearly ‘on the side of the angels’ in traditional healthcare, cooling was altogether a more thoughtful matter. It is, after all, perfectly possible to have hot spicy foods at every mealtime (especially in the tropics where they prompt gastric defences against enteric infections) but, with a few notable exceptions, cooling was confined to therapeutics. Cooling meant reducing vitality. The ultimate cold was death. In their simple restatement of fundamental principles, Samuel Thomson and his followers denied any prospect of cooling in healthcare and even saw something diabolical in it. Nevertheless, more considered views throughout history recognised that one can have too much, or inappropriate, heat. The obvious examples were hyperpyrexia in fevers, inflammatory diseases, hypersensitivity or allergic reactions, nervous agitation and, above all, pain. The respective treatments, febrifuges, anti-inflammatories, antiallergic remedies, sedatives, hypnotics (and narcotics) and analgesics, would all be classified as cooling in these terms. Indeed, some of the eliminatory treatments often applied for these purposes, especially the laxatives and cholagogues, were also seen as cooling. Reference to the Galenic classification (pp. 4–5) will put all this into context.

The classification of sedatives is illuminating. In former times, neurosis and anxiety, irritability and tension were aspects of heat. Children were hotter than adults and there was progressive constitutional cooling with age. Psychological explanations were not prominent and no one was told ‘it is all in the mind’. The Cartesian body–mind split had not occurred.

Clearly there was more likely to be care in prescription of cooling remedies. Although many popular treatments existed, it was more likely that professional expertise would be called for, especially in the treatment of severe pains and inflammations. Almost everything now prescribed by modern doctors would have been classified as cooling.

There was one striking exception to the cautions linking cooling to reduced vitality. As referred to in the Galenic classification, the gentlest category of cooling remedy (those ‘cold in the first degree’) did ‘qualify the heat of the stomach and cause digestion’. Digestion was widely seen as a cooling activity, marked of course by a shift of blood flow from the periphery to the core (so that excessive exercise after a big meal can lead to cramps).

The archetypal digestive stimulants were the bitters. Of all the herbal strategies in history, these are probably the most respected (the Chinese even gave them the awesome role in their five-phase classification of tonifying the Kidneys – the source of constitutional energies in their system). Bitters are universally used before and after eating as appetite stimulants (‘aperitifs’) and digestives. They were the first resort in digestive difficulties, especially when associated with heat and hepatobiliary (‘damp-heat’) disorders (bitters are also the most commonly used choleretics). Critically, they were also favourite febrifuges, apparently lowering body temperature in fever. They appeared to correct an apparent design inconsistency in the febrile response, wherein digestion is shut down, leaving undigested material as a source of new toxicity and even the original source of infection in the case of gastroenteritis. Bitters appeared to switch on digestive defences as well as bring the fever down. In many cultural traditions bitters were seen as primarily cooling (although in northern European traditions especially, some bitter remedies were classified as ‘heating’ for their stimulant properties – and possibly as a reflection of the prevailing cold environment). Unlike other cooling agents that counteracted vital functions, bitters appeared to transcend these limitations, to convert heat and vitality into nourishment. This was sometimes regarded as magical.

The modern phytotherapist in effect competes in cooling remedies with modern orthodox medicine. Technology has produced the most powerful analgesics, sedatives and anti-inflammatory and antiallergic drugs (although many are still derived from natural sources). Phytotherapy may score in two ways: first, by producing a more gentle and sustained and perhaps even a longer lasting alternative (treating an inflammatory disease with cleansing remedies, for example) and second, by having recourse to the cooling digestives to transform a hot condition in the most constructive way. The phytotherapist might also be sensitive to the risks of excessive cooling; especially when vital reserves are low (there is a well-signed risk of provoking latent kidney inflammations).

Bitters and other cooling herbs and other strategies (such as cooling drinks, baths and cold packs) could be considered by the phytotherapist when the patient, whatever the diagnosis, favours cool applications or is thirsty, abhors heat, has a reddened complexion, is excessively animated or distressed, has a dry and possibly red tongue and/or coloured tongue coating. Any sign of liver difficulties (particularly with fatty food or alcohol) or a history of hepatobiliary problems or digestive troubles strongly indicates bitter remedies. When so appropriate, they are one of the best tactics available.

Tonification: supporting nourishment and repair

So far all the foregoing strategies make demands on the patient’s reserves. In more robust times (i.e. when not being robust seriously compromised one’s chances of survival) and in the treatment of acute disease, this was not a major issue. However, it quickly becomes one when there is diminished vitality. It can be argued that traditional practitioners would see most modern clinical indications as marked by degrees of debility. The low-grade viral or fungal infections, the persistent catarrhal state, recurrent headaches or migraines, allergies, skin and arthritic disease and other chronic inflammatory diseases, stress problems and anxiety neuroses and cancer are all marked by a failure to cope or adequately to defend. One perspective on this development is that modern medicine has so effectively neutered the acute disease, especially in the too frequent use of antibiotics and anti-inflammatories, that most people in developed countries have never had to muster their defences. Life is also much easier in these societies and there is generally less rigorous testing of physiological functions.

Whatever the reason, the modern phytotherapist will need to ensure that there are adequate vital supports in their prescriptions. In large part this involves mobilising the principles of convalescence – rest, exercises and diet (see below) – but in herbal terms the remedies to use are the ‘tonics’.

Tonics have been poorly defined, with different meanings in different contexts. In this text they are taken to refer to remedies with substantially supportive reputations. Some are also classified as adaptogens, i.e. they appear to encourage the body to better adaptability under stress (so reflecting the concept elaborated by Hans Selye as the general adaptation syndrome, as a marker of health and vitality in the face of stresses). On one hand remedies used as tonics overlap wholly with foods: different parts of the oat, wheat, barley, rye, asparagus and artichoke, for example, have been used as both foods and medicines. In modern times dietary supplements like evening primrose oil and grape seed have further blurred the distinction. Other tonics are more dynamic, notably some of those used in Chinese medicine, particularly the yang tonics like Trigonella (fenugreek) and Eucommia and the qi tonics like Panax ginseng (asiatic ginseng): these move beyond the simply sustaining towards their own contraindications in the very debilitated.

Within this spectrum there is a vast range of remedies which are used in modern phytotherapy because they appear to support some aspect or other of body function: Silybum (St Mary’s thistle) and Taraxacum (dandelion root) for the liver and hepatobiliary functions, Crataegus (hawthorn) for the cardiovascular system, Plantago lanceolata (ribwort) for the upper respiratory system, Verbascum (mullein) and Inula (elecampane) for the chest, Hypericum (St John’s wort), Withania and Turnera (damiana) for nervous with hormonal symptoms, Foeniculum (sweet fennel), Cardamomum (cardamom) for the digestion, Linum (linseed), Plantago psyllium (psyllium seed) and Mentha (peppermint) for the bowel, Echinacea, Picrorrhiza and Astragalus for the immune defences, Vitex agnus-castus for the female reproductive system, Serenoa repens (saw palmetto) for the prostate, and many more in this and other herbal traditions. In earlier times tonification was often the final stage of a course of herbal treatment. The phytotherapist most often has to start a prescription with at least some tonic element.

Approaches to using herbs

Instant treatments: trigger-point phytotherapy

Herbal medicine has developed the reputation in modern times of being an innocuous alternative to conventional drug treatment. It is often thought that if the remedies work at all, it can only be after weeks or months. The French term médecine douce sums up a modern European view of herbal medicine; that it is ‘soft’ and above all safe, free from the side effects of modern chemical drugs.

This is not how herbal medicines were developed. Before ambulances and hospital casualty wards, men and women had to turn to the remedies they had available, sometimes for life-and-death emergencies. Until a few hundred years ago there were few other options than to use plant products. These were often administered in heroic doses and judged on their ability to produce dramatic results. In most people’s daily lives there was little room for sentiment or for the modern romantic view of natural medicine maintaining holistic health and balance. The imperative was simple and urgent: ‘Will this measure work, and work soon? If not, I do not want to waste time in trying it’.

All this should not be surprising. The notion that people used somehow to be less interested in efficacy or had less wit in seeking out and recommending the best strategies available would be more extraordinary. There is no doubt that the measures actually adopted in the past, often by ordinary people, did work dramatically when needed.

It is of course unlikely that while modern emergency facilities are available anyone would choose to adopt the traditional alternatives, which were often uncomfortable, crude and imprecise. What may be more interesting is to consider the many ways in which these traditional herbal techniques were applied to lesser problems. In having to learn how to survive illnesses, early practitioners appear to have gained considerable insight into the way the body behaves.

One of the tactics adopted was the use of remedies for provocation. The heroic techniques of emesis and catharsis were merely the most dramatic of the approaches used: the bitter digestives and cholagogues, circulatory stimulants, topical rubefacients and expectorants are more gentle examples of remedies that nudge the body towards hopefully useful activity. All these effects are short term, even immediate, as are the measures adopted for symptom relief: the demulcents, carminatives and spasmolytics. These categories of activity link closely to categories of plant constituents (see Chapter 2) and recur again and again in human history. They now may make a persuasive case for modern herbal therapeutics.

Long-term repair

As we have seen, in modern times herbal medicine has come to be seen as gentle, almost innocuous, most suitable for long-term therapy. Patients often expect herbs to take a long time to work. This perspective, however, says more for the conditions being treated than for the herbs themselves. Chronic diseases cannot be corrected quickly. An informal rule of thumb used by some practitioners is to allow 3 months’ treatment for a problem of a year’s standing and a month for every further year (or a week’s treatment for every month in problems of shorter duration). Such formulae can of course only be approximate, but at least they are indicative. They also imply that real correction of chronic disease is possible. This may be unattainable in conditions that are too far established but there are many pleasant surprises in herbal practice and most patients may gain some long-term benefits.

In general, herbal treatment for chronic conditions uses relatively smaller doses, less robust remedies and more tonics.

Other healing strategies

Convalescence

It is ironic that at the very time that healthcare has to deal with so much chronic and debilitating disease it has abandoned the best strategic approach inherited from tradition. In the past it was taken for granted that any illness would require a decent period of recovery after it had passed, a period of recuperation, of convalescence, without which recurrence was possible or likely. For the really debilitating diseases convalescent care was the primary treatment, reaching its apogee in the many European sanatoria for tuberculosis patients.

Convalescence fell out of favour as powerful modern drugs emerged. It appeared that penicillin and the steroid anti-inflammatories produced so dramatic a resolution of the old killer diseases, including tuberculosis, that all the time spent convalescing was no longer necessary. Then, as healthcare provision became generally more effective and public expectations increased, pressure on hospital facilities led to shorter stays, whilst the increasing angst of the modern working rhythm has conspired to ensure that most people now could not consider time off to convalesce after a bout of flu. That this means they are more likely to get another bout the next year is a cruel irony.

A good convalescence is a marvellous thing. It rounds off an illness and gives it meaning; it makes the sufferer stronger for having had the illness. In a way no vaccination could do, it arms and strengthens the immune defences and provides real protection against recurrence, possibly forever. It is probably the only strategy that will allow real recovery from debilitating disease, fatigue syndromes, recurrent infections and states of compromised immunity. It is the therapeutic recognition that healing, like the growth of children, is almost inevitable but that it needs to be allowed to proceed. Convalescence needs time, one of the hardest commodities now to find.

There are four essential features of convalescence, in general agreed through history, though with many cultural embellishments.

Rest

This is by far the most important element. It should include maximum sleep, as physiologically this is the body’s time for repair. In the early stages of vigorous convalescence almost constant sleep should be encouraged (as in the former ‘sleep clinics’). Thereafter it should be promoted as much as possible. Rest also means less activity: if work has to be done it should be in brief bouts, switching frequently between different activities (‘change is as good as a rest’). Patients should be encouraged to pace themselves, to go to bed early, sleep late and not to volunteer for any work that is not absolutely necessary. As much as anything rest becomes a mental priority: all other considerations are secondary. That hour of more sleep is more important than a film on TV, a late-night conversation or night out.

Exercise

This is the flipside and necessary adjunct to rest, the equivalent to ‘turning the engine over’, to prevent congestion and stagnation. Essentially the body needs to be taken to aerobic exercise (defined for these purposes as any activity producing a pulse rate of between approximately 60–80% of 220 minus one’s age, e.g. 108–144 for a 40-year-old) at least briefly each day. Using the pulse rate to set exercise levels has the advantage of being self-adjusting: the very debilitated will reach high pulse rates with minimal activity. Nevertheless, caution is required. The debilitated will have very little stamina and even a minute may be too long. If exercise is followed by more fatigue, it is too much. Rather, one should build up to being able to undertake aerobic activity for up to 15 minutes each day. The main benefit of the aerobic mode is that it quickly dissipates sympathetic-adrenergic effects on the body (‘adrenaline’), constantly generated during the day in response to perceived stressors, and the enemy of convalescence. Timing one’s exercise for the evening will encourage better sleep that night.

Diet

The principle of the convalescent diet is that it should simply nourish. It should not stimulate or impose demands. Subject to individual dispositions, a convalescent diet is based on vegetables, especially root vegetables, cereals and pulses (if tolerated), fish and eggs, as the most easily assimilated protein sources, and chicken and other fowl if acceptable (chicken stock and soup remain one of the most universal and puzzling convalescent recommendations of history!). There should be no stimulants, caffeine, nicotine, alcohol or sugar, little dairy food and a minimum of convenience foods and food additives. Patients should thus be encouraged to take a simple peasant diet, sharing also with the peasant a simple respect for the food, taking time over it, building their daily rhythm around it.

Medication

It is obviously important to maintain treatment during convalescence: herbal or conventional. However, there is also a key contribution to the measures above in herbal traditions. It was accepted that rest, exercise and diet alone might not be sufficient to bring about recovery. A range of herbal remedies have been directed to facilitating the process, to drive recovery. Many of these are the tonics listed earlier. If recovery is from febrile disease, sustaining warming remedies like Achillea (yarrow), Angelica archangelica (common angelica), Cinnamonum zeylanicum (Ceylon cinnamon), Cardamomum (cardamom) or Foeniculum (sweet fennel) might be indicated. Recovery from low-grade assault on the immune system, chronic viral or fungal infections, conditions marked by swollen lymph glands, persistent sore throats or catarrhal states would need Echinacea, Picrorrhiza or Baptisia tinctoria (wild indigo). Digestion is often in need of support, whether from cooling bitters or warming aromatic digestives. Cleansing should be managed, above all, by gentle eliminatives.

For the phytotherapist convalescence is often the main strategy in making headway in chronic debilitated conditions such as a fatigue syndrome or persistent low-grade infections. Often these problems start with an infection early in life – a glandular fever or infectious mononucleosis, perhaps. The phytotherapist might suggest to the patient that the task is to go back and complete the convalescence from the original illness. The remedies available are probably uniquely appropriate to the job.

Nutrition: helping to convert foods into nourishment

The revival in holistic and traditional healthcare rightly highlights the importance of good diet. It can also be argued that in an age of processed foods and widespread adulteration of the environment, additional foods and food supplements are sometimes essential. Most phytotherapists will attend to these matters as an intrinsic part of their treatment. This text is not the place to rehearse this complex matter but it is the place to explore the phytotherapist’s particular perspective on dietary therapy.

One could start with a principle, literally a fundamental principle (‘fundament’ comes from the Latin for stomach). New-wave dietetics has been associated with the dictum that ‘You are what you eat’. This pop simplicity might be derided but it reflects much of what inspires nutritional therapy. A phytotherapist, on the other hand, grounded in the affairs and rude robustness of the digestive tract and liver, might respond: ‘No, you are what you assimilate’. To almost every popular dietary measure it is possible to add a functional modifier or a caveat.

Is there any real point giving extra vitamins, minerals or other food supplements if they are not being well absorbed or utilised, or are being excessively metabolised? What is the point of eliminating potential dietary allergens if the gut is in hypersensitivity mode (when one simultaneously reduces vital dietary variety and creates new allergens)? If there is abdominal bloating or flatulence after eating a food, improving digestive performance might be better than removing the food. Correcting bowel environment by attending to biliary or gastric functions may be more useful in containing Candida outbreaks than drastic eliminations of starches and yeasts.

The phytotherapist would want to answer such questions satisfactorily before embarking on extra dietary measures. Referral to the sections on treating digestive, bowel and liver problems and the section on acupharmacology (p. 187) should provide a rich range of tactics to modify digestive performance and modulate dietary measures. Appropriate use of eliminative or heating remedies may provide additional influence on dietary metabolism. Phytotherapy provides unique opportunities to convert food into useful nourishment. It gives dietary therapy much added value.

Bibliography

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