Combining Western Herbs and Chinese Medicine

~.

Foreword H

~,

' *"

the basis of symptoms, without reference to an underlying pattern of disharmony. There was some attempt in the 19th century to take some account of the general constitution of a patient, and some attempt to classify herbs in terms of stimulants and relaxants and so on; but into the 21st century, there has been no satisfactory theory for prescribing herbs. By contrast, the theories of Chinese medicine are well established, encompassing most of human experience, spiritual, emotional, and physical. Many Western practitioners will be surprised to learn that there was a comparable theory system in the herbal medicine of the West that started with Hippocrates in the 5th century BC and was codified by Galen in the 2nd century AD. These Western theories are often remarkably similar to those of Chinese medicine: similarities are not only found in the Galenic system, but also in the later Physiomedical system of the 19th century. For example, in this system, as in Chinese medicine, strong patients are prescribed different herbs from weak patients. The present author's love of the history of herbal medicine has led him to trace its beginnings in ancient Greece and show the development of its theory and practice in the West up to the present day. He draws together the common threads of Western and Chinese tradition, and then uses this new framework of herbal theory to organize the data coming from pharmacological and clinical research. This task needed someone trained in science and skilled in both

used widely throughout the world and in many countries of the East herbal treatment from trained and qualified practitioners is readily available. Sadly, this is not always true in the West. This is a pity, for Western herbs are wonderful, and very effective. For people living in the Western world they have a great advantage over herbs from other countries: they grow here in the West. This means that the plants can be studied at first hand: the way they grow; their preferred habitat; the effect of climate on their therapeutic effectiveness. All can be observed through the changes of the seasons, often in the wild within a few miles of where one lives. They can be gathered in the wild or grown in the garden. All this helps to deepen one's understanding of the nature and action of a herb. From my own 25 years of experience of treating children, I can vouch for the fact that Western herbs can be safe and effective for the treatment of a wide range of pediatric disorders. Nor is the effectiveness of Western herbs limited to children- many of the acute and chronic conditions of adult patients respond well to Western herbs, when these are properly prescribed. So why is it that Western herbs are not more used by health practitioners? The answer lies in the recent absence of any satisfactory theory for prescribing them. For at least 200 years, the ancient Western theories of herbal medicine have been neglected, and herbs have been prescribed mainly on ERBAL MEDICINE IS

IX

Foreword

x

Chinese medicine and Western herbs, with a clear mind to put the whole thing together, and the practicality to test the theories in the clinic. It is not surprising that this has taken a long time, and I am delighted that this book has at last seen the light of day, some 20 years after work first began on the project. There have been many interesting books on herbal medicine written in the last few years, but the present book is exceptional, in containing so much new, and clinically useful

;

....".,

material. For the first time, information on how to use the herbs for different Chinese syndromes has been written down by someone who knows what they are talking about, because they have been using the herbs in clinic for many years. But the information does not stop here. There are complete prescriptions, with analysis of their composition and practical notes on their use, which makes this book stand out in a class of its own. -JULIAN SCOTT, MA, PHD, CERT.Ac. (NANJING)

Preface .. ~

was in science research, which involves two complementary activities. One is the careful gathering of data by close and detailed observation of living material. The other is the attempt to perceive underlying natural patterns within the seeming chaos of the mass of data. These natural patterns can then be represented by theoretical principles, so that the data can be organized, under-

• to classify Western herbs in terms of Chinese values for temperature, taste, actions, and organs entered

stood, and applied. When I first started to study Western herbal medicine in 1973, I was unable to fmd a framework of theoretical principles in the herbal texts then commonly available. There did not seem to be any logical system for matching herbs to disorders or for selecting herbs to form a balanced herb combi-

However, the more I investigated contemporary Western texts, the more I realized that the data they contained derived from a tradition of empirical herb use in the West reaching back over 2000 years. Therefore, I decided to include material from some of the more important materia medica of the past. As I researched the traditional Western texts, it became apparent that there had been a framework of theoretical principles in Western herbal medicine comparable to that in

M

, .....l

y ORIGINAL TRAINING

• to apply the Chinese principles of herb combination to Western herbs • to give illustrative combinations for each herb discussed

nation. In contrast, a similar combination of the close observation and the perception of natural patterns that I had found in science attracted me to Chinese acupuncture. It seemed to me that the framework of theoretical principles of Chinese medicine could also be applied to the use of Western herbs. This idea was reinforced when I started to study Chinese herbal medicine. I began to classify Western herbs in terms of Chinese values of properties, organs entered, actions, and the Chinese syndromes that they could be used to treat. Eventually, I decided to write a book with the following

China. I began to compare and contrast the Western theoretical system with that of the Chinese, and to select elements from each to produce a working synthesis. Early in the writing of this book it became obvious that there was a need to give supporting evidence for any Chinese values assigned to Western herbs. At first I drew this evidence from Western and Chinese traditional texts, but increasingly incorporated data from modern pharmacological and clinical research.

four main aims:

Gradually, the central theme of the book became the integration of theoretical principles from Western tradition, Chinese tradition, and modern pharmacology. This led to a

• to summarize the empirical data on herb use from contemporary Western texts Xl

xii

Preface

complete change in the organization of the material and a total rewrite of the text, which in turn resulted in an additional five years of writing and a book four times its original size..

However, I feel that the extra time and effort have been well worth it, and I have been fascinated by the way that the many different threads of my own past experience and interests have come together in this book.

..

Sources Evidence for statements made

• listed the temperatures and tastes for each herb in the combination so that the reader can check the supporting evidence for these values in the Research and Traditional sources sections of the materia medica chapters

Wherever possible in this book, references to source material are given tor statements made, and over 1,500 references have been cited.

• given PRACTICAL NOTES for each combination, describing its clinical use

SINGLE HERBS In the materia medica chapters of this book, references to support statements made concerning individual herbs are mainly given in the Research and Traditional sources sections.

Translations This book could not have been written in its present form without data from extensive translations from German and Chinese sources.

COMBINATIONS

GERMAN TRANSLATIONS

The materia medica chapters of this book describe and discuss over 150 different herb combinations. A few of these derive from practitioners other than myself, and for these the appropriate references are cited. However, most of the combinations in this book derive from my own experience, and it is therefore not possible to cite references to traditional texts. It is for this reason that I have:

For each herb with a materia medica chapter in this book, translations were made from the following texts in the German language whenever there was information available: Dioscorides, Lonicerus, and Tabernaemontanus. (See Source' abbreviations below for full title).

CHINESE TRANSLATIONS

• explained in detail the principles of herb combination in PART 1 of this book

Similarly, each herb chapter in the materia medica incorporates material from translation of the Chinese Herbal Medicine Dictionary (Zhong yao da ci dian), whenever data was available for a particular herb.

• given my reasoning for the construction of each individual combination according to these principles

xiii

Sources

XlV

Source~9bJiviatioris ~.

." ,"

DIOSCORIDESG Dioscorides P. Kreutterbuch (1610). Reprinted by Verlag Konrad K6lbl, Munchen, Germany

.:iJ>.-

(1960)

The majoritY of sources-bookS and journal articlesthat are referred to in this book, are specific to a particular materia medica chapter, and occur elsewhere infrequendy or not at all. However, a number of basic texts that are frequendy referred to have been assigned an abbreviation, often the names of their authors or editors. This has been done to save

ELLINGWOOD Ellingwood F. American Materia Medica, Therapeutics and Pharmacognosy. 11th edn. (1919). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1994)

cluttering the text with long repeating tides. These abbre-

ESCOP MONOGRAPHS

viations are listed below with their associated full reference. Note: The superscript G indicates that the text is in the German language. The superscript CH indicates that the text is in Chinese.

European Scientific Cooperative

on Phytotherapy: Monographs on the medicinal uses of plant drugs. European Scientific Cooperative on Phytotherapy, Exeter, United Kingdom (1997) EVANS

Evans We. Trease and Evans' Pharmacognosy, 14th

edn. WB Saunders, London, United Kingdom (1996) BENSKY AND GAMBLE Bensky D, G~ble A, Kaptchuck T. Chinese Herbal Medicine Materia Medica. Eastland Press, Seatde, Washington (1986) BHC Bradley PR (ed). British Herbal Compendium, vol I. British Herbal Medicine Association. Bournemouth. United Kingdom (1992) BHP British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983) BOTANICAL SAFETY HANDBOOK

McGuffm M, Hobbs C,

Upton R et al. American Herbal Products Association's Botanical Safety Handbook. CRC Press. Boca Raton, Florida (1997)

FELTER AND LLOYD Felter HW and Uoyd JU. King's American Dispensatory, vols.1 and 2, 18th edn. (1898). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1983) Fox Fox W. The Working Man's Model Family Botanic Guide to Health, 7th edn. William Fox, Sheffield, United Kingdom (1878) GERARD Gerard J. The Herbal or General History of Plants: The Complete 1633 Edition as Revised and Enlarged by Thomas Johnson. Dover Publications, New York, New York (1975) GERMAN COMMISSION E MONOGRAPHS

Blumenthal M

(ed). The Complete German Commission E Monographs: BRUNETON Bruneton J. Pharmacognosy: Phytochemistry Medicinal Plants, 2nd edn. Lavoisier, Paris, France (1999) CHANG AND BUT

Chang H-M, But PP-H (eds). Pharma-

cology and Applications of Chinese Materia Medica, vols. 1 and 2. World Scientific Publishing, Singapore (1986) CHINESE HERBAL MEDICINE DICTIONARyCH

Jiangsu

New Medicine Institute. Chinese Herbal Medicine Dictionary (Zhong yao da ci dian) Science and Technology Press, Shanghai, China (1975)

Therapeutic Guide to Herbal Medicines. American Botanical Council, Austin. Texas (1998) GRIEVE

Grieve M. A Modern Herbal, vols. 1 and 2. Dover

Publications, New York, New York (1971) GRIGGS

Griggs B. Green Pharmacy: The History and

Evolution of Western Herbal Medicine, 2nd edn. Healing Arts, Rochester, Vermont (1997) HILDEGARD VON BINGEN'S

Bingen's Physica. Healing Arts, Rochester, Vermont (1998)

CHRISTOPHER Christopher JR. School of Natural Healing. BiWorld, Provo, Utah (1976)

KLOSS

CRELLIN AND PHILPOTT Crellin JK, Philpott. J. A Reference Guide to Medicinal Plants. Duke University Press, Durham, North Carolina (1990)

LONICERUS G

Kloss J. Back to Eden, 5th edn. (1939). Reprinted by _

Lifeline Books, Santa Barbara, California (1975) Lonicerus A. Kreuterbuch (1679). Reprinted

by Verlag Konrad Kolbl, MUnchen, Germany (1962) LYLE

CULPEPER Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. Meyerbooks, Glenwood, Illinois (1990)

Von Bingen H. Hildegard von

Lyle TJ. Physio-Medical Therapeutics, Materia

Medica and Pharmacy. Originally published Ohio (1897). Reprinted by the National Association of Medical Herbalists of Great Britain, London, United Kingdom (1932)

~.

...

-

Sources MABEY

Mabey R (ed). The Complete New Herbal. Elm

Tree Books, London, United Kingdom (1988) MAILHEBIAU Mailhebiau P. Portraits in Oils. The C.w. Daniel Company, Saffron Walden, Cnited Kingdom (1995) MARTINDALE Reynolds EFJ (ed). Martindale: The Extra Pharmacopoeia, 31st edn. Royal Pharmaceutical Society, London, United Kingdom (1996)

•

MILLS Mills S. The Essential Book of Herbal Medicine. ArkanafPenguin Books, London, United Kingdom (1991) MILLS AND BONE Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal lvledicine. Churchill

xv

PRIEST AND PRIEST Priest AW, Priest LR. Herbal Medication. L.N. Fowler, Romford Essex, United Kingdom (1982) TABERNAEMONTANUSG Tabernaemontanus JT. Krauterbuch (1731). Reprinted by Verlag Konrad K6lbl, Munchen, Germany (1993) TIERRA Tierra M. Planetary Herbology. Lotus Press, Twin Lakes, Wisconsin (1988) TISSERAND AND BALACS Tisserand R, Balacs T. Essential Oil Safety: A guide for Health Care Professionals. Churchill Livingstone, Edinburgh, United Kingdom (1995)

Livingstone, Edinburgh, United Kingdom (2000) MOORE Moore M. Medicinal Plants of the Pacific West. Red Crane Books, Santa Fe, New Mexico (1993) PERRY .P~rry LM.~.Medicinal Plants of East and Southeast Asia. The MIT Press, Cambridge, United Kingdom (1980) POlAR AND MACKINNON Pojar J, MacKinnon A. Plants of the Pacific Northwest Coast: Washington, Oregon, British Columbia and Alaska. Lone Pine Publishing, Redmond, Washington (1994)

...

1

WEISS Weiss RF. Herbal Medicine, English edn. Beaconsfield Publishers, Beaconsfield, United Kingdom (1988) WICHTL Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn. Medpharm, Stuttgart, Germany (1994), from 2nd German edn. Wichtl M (ed) (1989) YEUNG Yeung H-C. Handbook of Chinese Herbs and Formulas vol I. Institute of Chinese Medicine, Los Angeles, California (1985)

"i'll

Terminology 1.

1

bi<.i_

L

Mandarin Chinese tones

Chinese names The following conventions have been adopted in this

book: 1. Chinese herb names EXAMPLE:

lower case with tones gul zhI

a

first tone

starts high and is held steady

a a

second tone

starts in midrange and rises

third tone

starts in lower midrange and drops down before rising

a

fourth tone

starts high and drops down sharply

2. Chinese concept names first letter capitalized, (commonly used) no tones EXAMPLE:

Chinese organs and syndromes

Qi

3. Chinese concept names lower case with tones

ENGLISH NAMES

(less commonly used) EXAMPLE:

The English names of Chinese concepts start with a capitalletter, for example, substances such as Blood, organ systems such as Heart, and syndromes such as Deficiency. For ease of indexing, organ syndromes are written with the organ stated before the type of syndrome. For example, the term Heart Deficient Qi is used throughout in this book, rather than Deficient Heart Qi.

yldu'

4. Chinese formula names lower case and italics, no tones EXAMPLE:

5. Chinese book tides EXAMPLE:

6. Chinese authors EXAMPLE:

liu wei dihuangwan only first letter of first word capitalized, no tones

Abbreviations of organ names

Huang di nei jing first letter of both elements capitalized, no tones

Bladder Gallbladder Heart Intestines

Zhang Zhong-jing

xvii

BL GB

HT IN

Terminology

xvm

Kidney Liver Lung Spleen

Stomach Uterus

KI

LR LU SP ST

UT

Intestines In referring to the use of Western herbs, this book generally uses the term Intestines to represent the combined Chinese organ systems of Large Intestines and Small Intestines, without differentiating between the two. However, in the Gentiania and Centaurium chapter, these herbs are referred to as specifically affecting the Small Intestine organ system. Uterus The term Uterus is used in this book to refer to the Chinese concept of the female reproductive system.

NONSTANDARD CHINESE SYNDROMES Some of the organ system syndromes given in this book are not standard Chinese syndromes, that is, they are not generally listed in classical Chinese texts. Examples are: • Heart Qi Irregularity • Heart Stagnant Qi • Intestines Qi Disturbance • Kidney Stagnant Qi • Kidney fear invades the Heart • Lung Stagnant Qi • Uterus Stagnant Qi I have used these terms to represent common patterns that I have observed in the clinic. Heart Qi Irregularity This syndrome represents irregularity of the Qi of the Heart, especially irregular function of the physical heart organ with predominantly physical signs, such as arrhythmia. It thus differs from Heart Spirit Disturbance, which represents disturbance of the Spirit of the Heart and may include symptoms of mental and emotional imbalance. Herbs such as Crataegus and Leonurus can be said to strengthen and stabilize Heart Qi, and thus treat the syndrome of Heart Qi Irregularity. They thus help to reduce excessive fluctuations in cardiac rhythm, blood pressure, or body temperature (see the chapters on these herbs). Heart Stagnant Qi This term refers to Stagnant Qi of the Heart, which may be associated with poor posture and lack of physical exercise, sadness and depression, frustration and difficulties in relationships,' and difficulty in expressing feelings and affection. Physical symptoms may include a sensation of fullness or obstruction in the chest, dull ache in the chest, and poor peripheral circulation. This syndrome

differs from Stagnant Blood of the Heart in that the latter syndrome is characterized by severe chest pain. Herbs such as Rosmarinus can be used to move Stagnant Qi of the Heart and thus to treat associated depression (see the chapter on this herb). Intestines Qi Disturbance This term refers to a disturbance of the rhythm of intestinal function by such factors as irregular eating habits, laxative abuse, or emotions such as Heart anxiety, Kidney fear, or Liver anger. Associated symptoms include abdominal distension, intestinal colic, borborygmus, flatulence, and irregular bowel movements. Herbs such as Lavandula and Lobelia can be used to calm the Intestines by rela.xing intestinal muscle spasms and restoring normal peristalsis (see the chapters on these herbs). Kidney Stagnant Qi In my opinion, one aspect of Kidney energy is ambition and the desire to achieve. If this energy has no suitable outlet or if it is obstructed, the syndrome of Kidney Stagnant Qi can arise with associated symptoms, such as dysmenorrhea or pain in the kidney area: Kidney Stagnant Qi can also be associated with states of chronic fear. Herbs such as Ruta can be used to move Stagnant Qi of the Kidney and thus to treat associated conditions of pain in the urinary and reproductive systems (see the chapter on this herb). Kidney fear invades the Heart In my opinion, excessive Kidney fear, whether expressed or suppressed, can disturb Heart Spirit, resulting in symptoms such as insomnia, nightmares, nervousness, palpitations, and hysteria. Herbs such as Anemone and Ruta can be used to treat these symptoms by reducing Kidney fear (see the chapters on these herbs). Lung Stagnant Qi This syndrome can be associated with poor posture and lack of physical exercise, chronic asthma or bronchitis, and the emotion of grief, whether expressed or suppressed. Herbs such as Lobelia, which can both stimulate breathing and relax bronchial spasms, can be used to move Lung Qi and relieve symptoms such as the sensation of restricted breathing with fullness in the chest (see the chapter on this herb). Uterus Stagnant Qi This term refers to the Stagnation of Qi in the female reproductive system, which may be associated with poor posture and lack of physical exercise, or with emotional constraint-whether associated with suppressed anger, depression, fear, or grief. The syndrome may be linked to conditions such as amenorrhea, dysmenorrhea with dull aching, irregular menstruation, or premenstrual syndrome with distension and soreness of the breasts. Herbs such as Leonurus or Ruta, which can move the Qi of the Uterus, can be used to treat these conditions (see the chapters on these herbs).

Introduction !'

Aims ofthis book I'·

This book has the following aims:

for beginners to perceive any pattern in the mass of data confronting them. It was hard to differentiate between herbs and thus difficult to select the most suitable herb for the specific needs of a particular patient. For example:

• to provide a clear differentiation between the different herbs presented

• Christopher listed both Achillea and Salvia for fever, nasal catarrh, digestive weakness, flatulence, liver disorders, hemorrhages. ulcers, and hair problems!

• to provide a framework of theoretical principles as a basis for herb choice and herb combination

• Grieve listed both Rosmarinus and Salvia for cough, • to initiate an integration in the use of herbs according to Western tradition. Chinese tradition, and modem

digestive weakness. kidney disorders, headache, poor memory, nervous disorders, and hair problems2

research

• the BHP listed both Lavandula and Rosmarinus for

• to give suitable herb combinations to illustrate the use of each main herb presented

headaches, migraines, myalgia, spasms, flatulent dyspepsia. and depression 3

• to emphasize the importance of safety considerations

I have therefore taken every effort in this book to bring out the unique character of each herb that makes it special and different from the others.

in herbal medicine

CLEAR DIFFERENTIATIO~ BETWEEN HERBS \.-'=-

FRAMEWORK OF THEORETICAL

Perhaps the greatest initial difficulty in studying phytotherapy is learning to differentiate between the different

PRINCIPLES

herbs. In the herbal texts that were readily available when I

At the time I began to study phytotherapy, there did not appear to be a system of theoretical principles for matching herbs to disorders within Western herbal medicine itself. The Galenic system had not been used for almost two centuries-

began to study herbal medicine, the frequency of overlapping uses between the: different herbs often made it difficult

xix

._-,,-.,,~

Introduction

xx

most modern herbalists were unaware of its existence-and the theoretical system of Chinese herbal medicine had not yet become known in the West. At that time, there were attempts to explain herb choice in terms of the paradigms of either Physiomedicalism or conventional Western medicine, neither of which was wholly satisfactory. The materia medica available in the early 1970s, such as the texts of Christopher, Grieve, or the BHP, did not include a theoretical system to explain the choice of single herbs or the logic behind herb combinations.l became determined to write a materia medica that did include such a system. Therefore, every herb that has a materia medica chapter in this book is categorized in terms of temperature, taste, actions, and the organ syndromes that it can treat. For each of these herbs, examples of combinations are given to illustrate the principles of herb combining.

INTEGRATION OF WESTERN TRADITION, CHINESE TRADITION, AND MODERN

nations, few consistently explained the logic behind their herb formulations. Some, for example, Christopher, occasionally justified their combinations in empirical terms, simply stating that a particular combination was effective. Others sometimes gave brief theoretical explanations for their combinations. For example, Shook explained his formula for nephritis and diabetes in terms of a mixture of Physiomedical and conventional medical concepts,6 and Weiss sometimes gave very brief explanations of the combinations 7 he listed in terms of conventional medicine. However, I have not seen a text in the English language, published between 1890 and 1990, in which the illustrative combinations are consistently explained in terms of a system of theoretical principles. In this book, six illustrative combinations are generally given for each of the herbs with a materia medica chapter. These combinations illustrate the principles of combination laid out in PART I of this book and show how the' effects of one herb can be enhanced or moderated by the other herbs in a combination.

RESEARCH The original aim of this book was to provide Chinese values for properties and actions for a number of commonly used Western herbs, and to use the principles of herb combination found in Chinese herbal medicine. However, as the book evolved, its central theme became the integration of Western herbal tradition, Chinese herbal tradition, and modern research, bringing together both empirical data and theoretical principles from these three sources. The categories of temperature and taste used in this book most closely follow the Chinese model, but Western herbal and modern pharmacological concepts have been incorporated. The concepts used for the herbal action categories draw equally on the Western and Chinese herbal systems, with further expansion of understanding from pharmacology and clinical research. One of the most fundamental principles in this book is that of restoring balance within the body by creating a matching balance within a herb combination. This principle is common to both the Western and Chinese traditional systems, and can greatly contribute to the safety of herbal practice, as discussed below.

COMBINATIONS TO I~LUSTRATE HERB USE '

..

Many of the 20th century materia medica of Western herbs in the English language did not include illustrative combinations for most of the herbs presented. 2•3•4•s Of those authors who regularly gave illustrative combi-

SAFETY CONSIDERATIONS IN HERBAL MEDICINE Safety considerations are essential to the practice of herbal medicine. Three chapters are devoted to safety issues in PART I of this book. In addition, relevant cautions, contraindications, and toxicological data are listed for each herb that has its own materia medica chapter. The premise of this book is that it is possible both to maximize the safety of herbal medicine and to increase the availability of beneficial herbs to the public. Safety considerations need not stifle the scope of herbal practice. Indeed, both increased safety and increased clinical effectiveness result when practitioners take greater care with the balance of temperature, tastes, and actions within a combination.

Choice ofherbs in the materia medica There is an average of 15 pages for each herb chapter in the materia medica of this book, thus limiting the number of herbs that can be treated in this degree of detail. The selection of 51 main herbs, from the several hundred that have been in common use in the West, reflects my personal background and preferences, as shown in the following three examples.

Introduction

-

...

XXI

NORTH AMERICAN HERBS

PART I

I have included several herbs native to North America, such as Asclepias, Hydrastis, Lobelia, Myrica, Phytolacca, and Zanthoxylum. These herbs represent the important contribution of the Native American people and of the Physiomedical movement to herbal therapy, and I find them to be amongst the most effective herbs available. They are well known in Britain but are still little used in Europe.

deals with the principles of herb combination in both theory and practice, and with considerations of dose and safety.

MEDITERRANEAN AROMATIC HERBS

-

,

I have also included several aromatic herbs native to the Mediterranean region, such as Lavandula, Rosmarinus, Salvia, and Thymus. These herbs from the Lamiaceae family have high essential oil content. Their aromatic constituents can affect both emotional and mental state, which has made these herbs central to the development of aromatherapy. They are little known in China. and Lavandula and Rosmarinus have been much more commonly used in Europe than in the United States. CARDIOACTIVE HERBS I have included several herbs that can be used to treat cardiac disorders such as cardiac weakness, cardiac arrhythmias, and angina pectoris. Examples are Cinchona, Convallaria, Crataegus, Leonurus, and Sarotharnnus. Two of these herbs, Cinchona and Convallaria, are on Schedule Part III of the Herbal Remedies Order 1977 of the UK, and in my opinion are not suitable for over-the-counter sales. However, they can be useful in the treatment of certain heart disorders, providing all appropriate screening, treatment precautions, and monitoring procedures are taken.

Additional herbs In addition to herbs which have their own chapter in the materia medica, the Additional herbs chapter contains a brief description of 66 further herbs that are included in the combinations discussed in this book.

PART I

PART II PART II, the materia medica, is the heart of this book. Readers are advised to study the preliminary chapter Using the materia medica, which explains how the herb chapters are organized and how they can be used to best effect.

DATA ACCESS Cross references

Herb names cross references In this book, herbs are referred to by their botanical names. Readers who wish to refer to herbs by their English, Pharmaceutical, or Mandarin names will find these in the cross references in the Appendix. However, these cross references contain only a single main page reference for each herb. More detailed page references are to be found in the Index under the herb's botanical name.

Herb combfnation cross references About 150 herb combinations are discussed in this book. The CombinationsChinese syndromes cross reference gives the main page reference for each combination, together with its associated Chinese syndromes. Herb combinations for specific disorders can be accessed using the Disorders-combinations cross reference. Index The Index has been specially designed for ease or access to four main types of data: • herbs • herb actions • disorders • Chinese syndromes

Please read the Index introduction for a detailed explanation ofhow to access these four types ofdata.

References

.How this book is organized 1. Christopher

This book has three main divisions: Herbal medicine in theory and practice • PART II Materia medica • Appendices • PART I

JR. School of Natural Healing. BiWorld, Provo. Utail

(1976)

2. Grieve M. A Modem Herbal, vols. 1 and 2. DoYU Publications, New York, New York (1971) 3. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983)

xxu

Introduction

4. Cook WH. The Physio-Medical Dispensatory, Cincinnati (1869). Reprinted by Eclectic Press. Portland, Oregon (1985)

6. Shook E. Advanced Treatise in Herbology. Enos Publishing. Banning.

5. Hohnes P. The Energetics of Western Herbs. Artemis Press. Boulder. Colorado (1989)

7. Weiss RF. Herbal Medicine. English edn. Beaconsfield Publishers,

California (1992) Beaconsfield. United Kingdom (1988)

~-.

i

Table of Contents FOREWORD PREFACE

Xl

SOURCES

xiii

Materia medica Using the materia medica

161

Achillea

165

Althaea

183

PART I:

Anemone

193

Herbal medicine in theory and practice

Angelica

TERMINOLOGY·" INTRODUCTION ...

I~

PART II:

IX

xvn

xix

History

···3

_

205

Arctium

221

Temperature

19

Arctostaphylos

233

Taste

29

Artemisia

243

57

Asclepias

263

Actions glossary

67

Berberis and Hydrastis

273

Principles of herb combination

83

Calendula

299

Practical herb combination

89

Capsella

309

Actions

-

Dose '"

Capsicum··.·

·······97

·

:

319

Safety

121

Clffilcifuga

339

Safety and the organ systems

139

Cinchona

355

Safety in clinical practice

151

Cinnamomum

371

vii

Table of Contents

VUl

387

Taraxacum

399

Thuja

Crataegus

411

Thymus

Echinacea··:·······························.··

42 5

Turnera

771

Euphrasia

439

Valeriana

781

Filipendula

447

Viburnum

795

Gentiana and Centaurium

455

Zanthoxylum

Glycyrrhiza

473

Zingiber

819

Hamamelis

493

Harpagophytum

503

Additional herbs

837

Juniperus

513

Lavandula .,

527

Leonurus

539

Commiphora Convallaria

Lobelia·····.·············

···········

···········.· .. ···

553

Myrica·····················.············· .. ····.··573

725

····

········739 · .. ·····

·· 757

:

805

Appendices GLOSSARY'"

847

HEALING CRISES ... 851 HERB PROPERTIES ...

853

Phytolacca

587

HERB NAMES ... 859

Piscidia

599

CROSS REFERENCES:

Potentilla

607

Family-botanical names

865

Rheum

619

Botanical-family names

869

Rosmarinus

635

English -botanical herb names .. ,

Ruta

651

Pharmaceutical-English herb names

Salvia

667

Botanical-Mandarin herb names

883

Sambucus

687

Mandarin-botanical herb names

885

Sarothamnus

697

Smilax································ Tanacetum

·

707

715

873

Combinations-Chinese syndromes ... Disorders-combinations ... INDEX ...

899

893

877

887

PART I:

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·Herbal Medicine in Theory and Practice

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History • History ofthe materia medica

ancient Greece and Rome, three of the most influential founders ofWestern herbal medicine can be said to be Hippocrates, Dioscorides, and Galen. Hippocrates developed a complete system of holistic therapies. These were based on a framework of medical theory developed from the new philosophies of his time. In addition, he imbued medicine with an ethical code and a deep sense of humanity. He has been said to have given medROM THE TIMES OF

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The first section discusses the development of the theoretical principles of Western medicine and their basis in early Western philosophy. The second section describes the application of these principles to the classification of herbs according to theoretical properties. The third section chronicles the development of materia medica from ancient Greece to the present day.

icine a soul. Dioscorides was the author of the first Western materia medica that was both thorough and practical.! His book was notable for its clear compilation of empirical herbal knowledge and became the most influential materia medica in Western history. The indications that Dioscorides gave for individual herbs have been copied in subsequent herbal texts

Philosophical principles and medical theories Throughout the world, the earliest forms ofherbal medicine were associated with shamanism and magic. The causative factors of disease were believed to be malevolent spirits, whether these were demons or the ghosts of ancestors. It was believed that these evil influences could be driven off by the shaman using a combination of herbs and magic. Shamanistic herbal medicine remains in use today in many cultures, but it is outside the scope of this book. About 2,500 years ago, in both China and the West, philosophers began to explain their observations of the world around them in terms of the logic of natural laws. This led to an understanding of the origins of disease based on the operation of natUral principles, rather than as a result of supernatural intervention.

right into the 20th century. Galen, in addition to his great contributions to anatomy and physiology, was responsible for producing a detailed theoretical system for classifying and using herbs according to properties and actions. The system associated with his name was used in the West for 15 centuries and provided a theoretical structure in herbal medicine similar to that used in the Chinese medicine tradition. The contributions of these and other authors'to the theory and practice of herbal medicine are discussed under three section headings below: '

• Philosophical principles and medical theories • Classification ofherbs by properties and actions

3

4

Combining Western Herbs and Chinese Medicine

In both China and the West, the natural world was explained according to philosophical principles such as: • the existence of a vital force • a duality of complementary polar forces • the operation of a number of'elements' or 'phases of change' In the West, these philosophical concepts began in ancient Greece, and the concepts that developed were incorporated into the theoretical principles of Western herbal medicine.

VITAL FORCE The most basic concept of traditional Western herbal medicine is that of a vital force or life energy that pervades all matter and sustains all the functions of the body. Healing power of life One manifestation of this vital force is the inherent ability of the body to heal itself. This concept of the vis medicatrix naturae has been attnbuted to Hippocrates of Cos, who lived about 400 Be. Hippocrates is regarded by many as the greatest Western physician of all time and the primary founder ofWestern medicine, although the writings attributed to him may be the work of a school, rather than of a single man. 2 One of the basic teachings of the Hippocratic school was that the physician should assist the body to heal itself and should use minimal treatment, avoiding such intrusive modalities as strong drugs or surgery wherever possible. Vital heat of the body The vital force was often associated with the natural heat of the body. In the 2nd century AD, Galen emphasized that this vital heat should be supported in any treatment and should not be diminished. In the 17th century, Culpeper wrote that 'we live by heat and not by cold:3

In the early 19th century, Thomson stated that 'cold or the lessening of the power of heat is the cause of all disease; that to restore heat to its natural state was the only way that health could be produced.'4 In China, the concept of cold as a main origin of disease was emphasized about the 3rd century AD by Zhang Zhong-Jing in his famous work the Shang han za bing lun.s Vitalism and mechanism During the 19th century, the philosophical basis of the sciences and medicine became increasingly mechanistic. Vitalism and mechanism were seen as irreconcilable opposites and the importance of the concept of a life energy declined in1:he new mechanistic medicine that was developing. In herbal medicine, the principle of a vital force was maintained by the North American Physiomedical practitioners, including Lyle, Thurston, and Cook.

In the last 40 years, the increasing popularity of Chinese medicine in the West, with its basis in Qi theory, has brought renewed interest in and understanding of the concept of life energy, and of the fundamental importance of supporting this force in helping the body to heal itself. Mechanism and vitalism can now be seen not as mutually exclusive concepts but as two different views of the same reality. The mechanistic understanding of biochemistry and the vitalistic understanding of life energy are both useful complementary views of reality. PAIRS OF COMPLEMENTARY OPPOSITES In China, Ym- Yang theory, the concept that all phenomena are the result of two opposing forces, may have originated about 4,000 years ago in the Shang dynasty.6 However, the first record of the application of this theory to medicine appears in the Huang di nei jing, of which some parts may have been written about 200 BC.7 The concept of a polarization of reality may have existed in the West for millennia. The principle of complementary opposing principles, such as fire and water, are basic to many cultures. Aristotle may have been one of the first to incorporate it into a new logical philosophy, just as Hippocrates was one of the first to assimilate this very ancient concept into the new medical corpus, about 400 BC. Concept of balance Both the Chinese and Western models of health and disease were based on the concept of balance, whether between two opposites, such as heat and cold, or between a greater number of principles, such as the four humors (see below). Disease was regarded as an imbalance, and herbal or other treatments were aimed at assisting the natural tendency of the body to restore its inherent balance. According to Hippocrates, health depended on a proper balance of heat and cold, and dryness and moisture. If a person had a disorder involving heat and dryness, this would be balanced with food or herbs that were cooling and moistening. This concept of polar opposites was later used by Galen asthe basis for his systematic classification of herbs according to the herbs' properties. His system of grading herbs according to degrees of heat ar:d cold and dryness and moisture remained in use until the 18th century.3 In the early 19th century in North America, the Physiomedical movement of naturopathic herbal therapy developed from the work of Thomson. Its early phase included a duality of treatment principles: stimulate and relax, which can be regarded as a crude analogy to Yin-Yang theory. Later Physiomedical authors developed a more sophisticated understanding, and in 1890 Cook wrote:

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History 'Regularity in periods of alternate labor and rest is characteristic of all vital action...the earliest departure of the tissues from under the full control of the vital force will be in the lack of ability either to relax or to contract some of the tissues as readily as in the healthy state... ' 8

In the late 19th and early 20th century, Western physiologists described the body as a system in oscillating balance with values maintained within narrow limits. This concept was later termed homeostasis, and pathologically large fluctuations in the balance were described in terms of hyperfunction or hypofunction. In modem herbal therapy, treatments aim at strengthening the natural homeostatic mechanism of the body in order to correct any hyper- or hypofunction. This can be regarded as the principles of Hippocrates or of Cook put into modern terminology.

THE ELEMENTS

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In Chinese medicine, according to the theory of the Five Elements, all natural phenomena can be described in terms of transformations between the phases of Fire, Earth, Metal, Water, and Wood. This theory may have had its origins as early as 500 BC,9 but it was first systematized by Zou Yen about the 4th century BC. Medical application of the Five Element correspondences system, linking each phase to associated organs, tissues, and emotions, are given in the Huang di nei jing, possibly written about 200 BC. However, according to Jia De-dao,lo it was not until the Song dynasty (960-1279 AD) that Five Element relationships were commonly used to explain disease processes. In ancient Greece, Empedocles, ",no lived about 450 BC, proposed that everything is composed of the four elements of fire, air, water, and earth, combined in differing proportions. According to Empedodes, these four dynamic principles underlie the transformations observed in both man and nature. The first record of the medical applications of the Greek Four Element theory is found in the writings of Hippocrates in the 5th century BC. Hippocrates linked the four elements to the four seasons and to the four humors of the body (see below). He taught that the four humors vary in strength according to the season, for example, phlegm increases in a man in the winter. because phlegm is the coldest constituent of the body and most closely akin to winter. Each season therefore has its characteristic diseases. I ~ It seems more than coincidence that the very similar theories of Four Elements and Five Elements should arise within about one century of each other in Greece and China, respectively. According to Unschuld," a philosophical impulse may have spread from an unknown source somewhere

5

between Greece and China, and may then have been modified according to the different intellectual environments of the two cultures.

Primary qualities In addition to the theory of the Four Elements-fire, air, water, and earth-both Aristotle and Hippocrates also used the concept of the four primary qualities: hot, cold, dry, and moist. I 2.13 These can be regarded as two pairs of complementary opposites: • hot and cold • dry and moist

Each element was said to incorporate a pair of primary qualities, one relating to temperature and the other relating to humidity. Fire was said to be hot and dry, air to be hot and moist. earth to be cold and dry, and water to be cold and moist. 11 In the medical system of the Hippocratic school, each element, \Yith its associated pair of primary qualities, was assigned a corresponding humor and temperament. This system of element correspondences resembles that of the Five Elements in Chinese medicine, as described in the Huang di nei jingo Elements fire air earth water

Primary qualities

Humor -'c'-Temperament·

hot and dry hot and moist cold and dry cold and moist

yellow bile blood black bile phlegm

choleric sanguine melancholic phlegmatic

The Four Humors In the Hippocratic system, it was believed that the human body was composed of four 'humors' or vital fluids: yellow bile, blood, black bile, and phlegm. Each of the Four Humors was linked to one of the Four Elements and to a pair of primary qualities, as shown in the table. Disease was thought to result from disturbance in the humoral balance. The humors were considered as partly material and partly energetic, similar to the concept of the Substances of Chinese medicine: Qi, Blood, Jing, Spirit, and Fluids. Forerunners of the modem concepts of Qi, Blood, Jing, Spirit, and Fluids can be found in the Huang di nei jing and may date back to the 2nd century BC. I ' The Four Temperaments Each of the four humors was associated with a temperament. Yellow bile was associated with the choleric temperament, blood with the sanguine temperament, black bile with the melancholic temperament, and phlegm with the phlegmatic temperament. The temperament described a person's physical constitution and psychological type. When in balance, each temperament was associated with specific positive qualities, but

6

Combining Western Herbs and Chinese Medicine

when in excess, each temperament was associated with characteristic negative qualities. For example, when in balance, the choleric temperament confers the positive qualities of warmth, activity, and courage, but when in excess, the choleric temperament results in the negative qualities of anger and irritability. The temperament assigned to a particular individual depended on the relative proportions of the four humors in the body-yellow bile, blood, black bile, and phlegm-and on the relative proportions of the primary qualities-heat, cold, dryness, and moisture. For example, in a person of the phlegmatic temperament, the dominant humor would be phlegm, and the dominant qualities would be cold and moist. This has important implications for the maintenance of health or the origin of disease. For example, if a person of the phlegmatic temperament were to consume too much food with the cold and moist qualities, the humor phlegm would become excessive. In the words of Culpeper, the person would become sleepy, dull, slow, heavy, and forgetful, with dreams of floods and water, much spitting and nasal discharge, and a slow and deep pulse. 3 The principle of treatment in such a case would be to reduce the excess of coldness and moisture by providing climate, foods, or herbs that were of the opposite qualities of hot and dry..

Importance oftemperature and humidity in the treatment In the medical system of ancient Greece and Rome, correcting imbalances of humors and temperaments involved correcting imbalances between heat and cold, as well as dryness and moisture. It was for this reason that, in the 2nd century AD, Galen classified herbs so carefully in terms of their degree of temperature, and humidity. This is discussed below in the section Classification ofherbs byproperties and actions. Importance ofhumors and temperaments in the treatment Occasionally, up to the 17th century, Western texts described the therapeutic effect of herbs in terms of correcting humoral imbalances. For example, both Gerard l5 and Culpeper wrote that Berberis could cleanse the body of choleric humors. However, I have not seen any traditional Western text that systematically listed the humors or temperaments associated with each herb. Western herbal texts from the 16th and 17th centuries continued to describe the disorders treated by herbs in terms of pathologies of heat and cold, and moisture and dryness. However, the.texts increasingly described disorders in terms of organ system imbalances rather than imbalances of humors or temperaments. For example, they used terms such as 'excessive moisture in the liver' and 'excessive cold in the stomach:

Similarly, traditional Chinese herbal texts did not generally describe herbs in terms of the Five Elements. Rather, the texts described the herbs in terms of syndromes of Substances, organ systems, and other pathologies, including Heat and Cold.

Classification ofherbs by properties and actions The theoretical approach to herb choice, in any medical paradigm, is based on assigning theoretical property values to each herb. Herbs with the appropriate property values can then be matched to specific syndromes. The evolution of Western herb classification according to temperature, humidity, and action is discussed below. Taste, as a theoretical concept, was of lesser importance in the West than in China. TEMPERATURE The polarity of fire and water was fundamental to ancient Greek philosophy, and in medicine, Hippocrates taught that health depended on a proper balance of heat and cold. Dioscorides was aware of this and sometimes described the general temperature effect of herbs.\ For example, he described Commiphora as warming. However, he did not consistently give herb temperatures in his materia medica, nor did he divide temperature into a number of grades. The systematic classification of herbs according to temperature was done by Galen of Pergamon (130-200 AD), and his model of nine degrees of temperature was influential for over 1,500 years. Galen's temperature classification Galen classified herbs according to nine temperature categories: temperate, hot in the first to the fourth degree, and cold in the first to the fourth degree. During its IS-century reign, the Galenic system went through various modifications. The description of Galenic categories given below comes from A Key to Galen's Method of Physic, written in 1651. This is included in Culpeper's Complete Herbal and English Physician Enlarged 3 and the herb examples given for each temperature category in this chapter are from A Catalogue of Simples in the New Dispensatory in that book.

Temperate These herbs correspond to the neutral category of the Chinese system (see the Temperature chapter) in that they do not have ~arming or cooling effect on the patient, and do not affect the temperature properties of other herbs in a combination to make them either hotter or colder. Temperate herbs were used in diseases lacking pathological man-

History ifestations of either heat or cold. An example is Ziziphus fruit (date).

Hot in the first degree These are herbs that just correspond to the natural heat of the body itself. They do not result in alteration to the body heat unless the body is slightly pathologically cool, in which case they help to restore the natural heat of the body. An example is Petroselinum root (parsley).

Hot in the second degree These herbs are slightly hotter than the natural temperature of the body. They were used to restore balance by their own force and strength when nature alone was unable to do so. An example is the aerial parts of Rosmarinus.

Hot in the third degree These were described as herbs sufficiently heating to inflame and cause fever if inappropriately prescribed. An example is Zingiber root.

Hot in the fourth degree These were described as herbs with the highest degree of heat, capable of causing blistering if topically applied. An example is Allium sativum (garlic).

Cold in the first degree These herbs are the least cold of the four cold categories and the least potentially damaging to the natural heat of the body. They were used to treat conditions that had only a slight degree of pathological heat, especially in children or people with weak. stomachs who it was believed were easily harmed by cold medicines. An example is Arctium leaves.

Cold in the second degree Culpeper listed the use of this category for those with a hot liver and a strong stomach. An example is Taraxacum herb.

Cold in the third degree

Culpeper did not clearly differentiate between herbs cold in the second and third degrees, that is, herbs cold in the third degree simply seem more cooling than those in the second degree in that they are used to treat hotter conditions. He described their use for the 'unbridled heat of choler' in persons with liver heat and a strong stomach. An example is Polygonum bistorta root.

7

and later writers, such as Tabernaemontanus 1i and Culpeper. For example, she classified wormwood as very hot, whilst Dioscorides listed it as warming and T~bernaemontanus listed it as warm in the fIrst degree. Galenic system during the 16th-19th centuries Whilst Culpeper used Galen's temperature system in the section A Catalogue of Simples in the New Dispensatory in his book, he did not consistently use it in the individual entries of his materia medica and often used looser terms such as warming or cooling. More systematic authors, such as Tabernaemontanus and Gerard, consistently used Galen's nine-category system. Since their texts were used as standards into the 18th century, herbal practitioners would have been familiar with Galen's system up t9 that time, even if they did not use it in its full rigor. Use of the Galenic temperature classifIcation system appears to have declined in the West during the 19th century, and no other system of classification of herbs by temperature seems to have replaced it in general use. Physiomedical and Eclectic texts There is considerable overlap between the Physiomedical and Eclectic movements, and both were derived in part from the work of Samuel Thomson (see below). The Physiomedical movement was characterized by belief in a vital force and in the restoration of health by balancing stimulation and relaxation of the body and tissues. The Eclectics were generally medical doctors who specialized in botanic medicine. In their fmal flowering in the late 19th and early 20th centuries, the Eclectic physicians made enormous advances in the detailed knowledge of individual herbs, often incorporating the new biochemical knowledge of the time. They also ma~e advances in botanical pharmacy, that is, in the extraction and processing of botanical preparations. (See Pharmacy and Pharmacognosy by lloyd in Ellingwood's text. IS) It should be noted that neither of these two groups of North American practitioners used a systematic temperature classification.

Physiomedical texts In Physiomedical theory, the fundaCold in the fourth degree Herbs in this category were used 'to stupify the senses' and used, for example, in cases of violent pain. An example is the aerial parts of Hyoscyamus niger (henbane).

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Hildegard von Bingen Not all practitioners used Galen's system. For example, Hildegard von Bingen 16 used a less structured classification, including the categories of very hot, hot, slightly hot, neither hot nor cold, cold, and very cold, which is closer to the Chinese system than to that of Galen. She tended to classify herbs as hotter than earlier writers of the Graeco-Roman era, such as Dioscorides and Galen,

mental principle of treatment was to support the natural heat of the body. Warming herbs played a greater role in treatment than cooling herbs. However, herbs that warm the body were not usually described as warming herbs but as 'stimulating' herbs. Similarly, herbs that cool were not usually described as c;oling herbs but as 'relaxing' herbs. For example, Lyle described Capsicum, Myrica, Zanthoxylum, and Zingiber not as hot herbs but as stimulant herbs, and he described Asclepias not as a cold herb but as a relaxant herb. 19

Eclectic texts Like the Physiomedicalists, the Eclectic authors Felter, lloyd, and Ellingwood did not usually describe herbs

Combining Western Herbs and Chinese Medicine

8

as warming or cooling. However, the Eclectics had a more sophisticated understanding of the multiple actions of individual herbs than the Physiomedicalists, and they considered the division of herbs into stimulants and relaxants less important. For example, the Eclectics described Capsicum as stimulant, but did not specifically classify Asclepias as relaxant. Modem texts Neither the herbal of Grieve of 1931 20 nor the BHP of 198Yl described herbs in terms of warming or cooling, and the division of herbs into stimulants and relaxants, in the Physiomedical sense, is rarely used in these texts. Later works, with a bias towards pharmacology rather than practical instructions for herb use, such as the BHC of 1992~ and the ESCOP monographs of 1996,23 do not describe herbs in terms of temperature. However, Tierra's Planetary Herbology of 1988 24 classified herbs in terms of temperature, using the Chinese temperature grades of hot, warm, slightly warm, neutral, cool. and cold. The temperature values assigned to individual herbs follow the temperature values given in Chinese texts where these are available. I have adopted the same six Chinese temperature divisions. However, in assigning temperature values for herbs discussed in this current text, I have weighed traditional Western and traditional Chinese sources, pharmacological and clinical research, and my own personal experience (see the Temperature chapter).

HUMIDITY In the medical system of Hippocrates, the concept of humidity was of fundamental importance. The four humors and their associated temperaments were each composed of a pair of primary qualities, one relating to temperature and the other relating to humidity. For example, the melancholy temperament, associated with the humor black bile, was based on the pairing of the qualities of cold and dryness. An excess of black bile would involve an excess of cold and dryness, and could be corrected by the use of herbs that were hot and moist in quality. Correcting imbalances of humors and temperaments, therefore, involved correcting an imbalance between dryness and. m()isture as well as an imbalance between heat and cold; accordingly, foods and herbs were classified according to their humidity ~ well as their temperature. It was understoodth~t' foods and herbs~oUld'change their properties deperidirig ~n their o~i~, d~gree of 'fr~~hness, and mode of preparation~For example, in the Sth century BC, Hippocrates classified barley as cold and moistening or cold and drying, depending ~ri the way in which it was prepared. II

In the 2nd century AD, Galen classified herbs according to their degree of humidity as well as their degree of temperature. In his classification, he used the categories of dry in the first, second, third, or fourth degree, and moist in the first, second, -third, or fourth degree. Whilst the classification of herbs as dry or moist remained important in the West into the 18th century, the classification of herbs into specific degrees of humidity never seem to have been regarded as important as degrees of temperature. Hildegard von Bingen generally described herbs as simply drying or moistening. Although he listed herbs according to degrees of moisture in the section A Catalogue ofSimples in the New Dispensatory, Culpeper usually omitted some of the Galenic degrees of moisture. In addition, the individual entries in his materia medica section usually simply stated whether the herb is drying or moistening. Gerard and Tabernaemontanus often classified herbs in terms of degrees of moisture, but they did so less consistently than they classified them in terms of degrees of temperature. Later authors have rarely gone beyond occasional general statements that a herb is drying or moistening. Similarly, in Chinese tradition, herbs are not divided into different grades with respect to humidity. They may, however, be described in general terms as drying or moistening.

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TASTE Dioscorides sometimes described the taste of herbs in his materia medica. For example, he described the berries of Juniperus as sweet and slightly bitter, and Commiphora resin as pungent. However, taste does not appear to have been developed as a theoretical concept in the West as it was in China (see the Taste chapter). It is only recently in the West that the taste and olfactory sensations have been associated with specific therapeutic effects, for example the bitter digestive tonic and aromatic carminative actions.

ACTIONS Since Graeco-Roman times, herbs have been classified in terms of their actions, that is, the type of therapeutic effects they have on the body. Empirical and theoretical actions The names given to actions can be roughly divided into two types: the relatively empirical and the relatively theoretical.

Empirical actions These action names simply state the desired therapeutic effect without implying the mechanism by which it is to be achieved. For example, if the patient has inadequate urination, then the required therapeutic effect isto promote urination.

History

9

Theoretical actions These action names imply a theoretical mechanism by which the effect is ac.llleved. The theoretical cephalicals pectorals cordials stomachicals hepatics splenicals nephriticals hystericals arthriticals

action mechanism is linked to the theories of etiology and pathology used by the particular medical paradigm. For example, in the Physiomedical paradigm, arthritis was often associated with accumulations of toxins in the blood. It was therefore appropriate to use a herb with the alterative action in order to clear the body of toxins and thus relieve the arthritis.

The terms 'cephalics,' 'pectorals: 'cordials,' and 'stomachics' were used in herbal medicine into the 1970s,25 and the term 'hepatics' is still in use as an action category.

Dioscorides In his materia medica, Dioscorides often described a herb in terms of its actions. The names used by Dioscorides for these therapeutic effects reflect his own nature, which was empirical rather than theoretical. The

Actions and specific organ syndromes. In both China and

words representing an action are very close to words for the associated disorder. For example, if the patient has a wound and is bleeding, the appropriate actions are to stop the bleeding and heal the wound. There is no implication of the theoretical mechanism by which the action is effected. Other therapeutic effects mentioned by Dioscorides include promote urination, induce menstruation, and increase lactation. Galen The action categories of Galen are described by Culpeper in Section III of A Key to Galen's Method ofPhysic.3 Some of these, such as 'medicines provoking urine: are like those of Dioscorides in that they simply refer to a therapeutic effect and do not imply a theoretical mechanism via which the effect is attained. Other action categories used by Galen are closely related to theoretical concepts, and their empirical use is not always clear. For example, theoretically, 'emollient' medicines were considered to soften that which is hard, to moisten that 3

which is dry, and 'to warm that which is congealed by cold: However, the exact empirical effect of the emollient action was not clear in Culpeper's account. This was due to his dis-

agreements with other authors over the theoretical definition of this action.

Actions and organs Galen was not merely a theoretician, he was a man of complex nature and many accomplishments..

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He was one of the fathers of modern anatomy and physiology, whose knowledge of anatomy came from his own dissections and whose contributions to physiology came from his own experiments. It is not surprising, therefore, that many of

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his action categories related to specific organ systems and

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parts of the body. In section II of his chapter A Key to Galen's Method of

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Physic, Culpeper described the following types of medicine that have their action on specific parts of the body:

head lungs heart stomach liver spleen kidney and bladder uterus joints

the West, actions were often linked not only to a specific organ system, but also to a specific organ system syndrome. In China, the first texts giving systematic association between actions and specific organ syndromes were those of Zhang Yuan-Su in the 12th century AD. For example; Zhang Yuan-Su wrote that Coptis (huang lian) drains Heart Fire, and Ligusticum (chuan xiong) disperses the Liver. 26 In the Galenic system described by Culpeper, actions were sometimes associated with specific organ syndromes. For example, Berberis was given to clear liver heat, Chelidonium was given to open obstructions of the liver and gallbladder, and Rosmarinus was given to clear melancholy vapors from the heart. However, individual herbs were not consistently associated with specific organ syndromes in 16th and 17th century Western materia medica. Physiomedical action categories Certain empirical actions, such as diaphoretic, diuretic, and purgative, seem to be basic to all medical systems. However, individual empirical actions were often subdivided into different types, according to their theoretical mechanisms within the particular medical paradigm. The Physiomedical authors subdivided herbal action categories according to their theory of the need to balance stimulation and relaxation. For example, Lyle described Zingiber as a stimulating diaphoretic, Asclepias as a relaxing diaphoretic, Juniperus as a stimulating diuretic, and Eupatorium purpureum as a relaxing diuretic. Eclectic action categories The later Eclectics tended to differ from the Physiomedicalists in that they were generally less influenced by the theory of relaxation and stimulation. and more influenced by recent advances in medical science. The action categories used by the Eclectics reflect their convergence with what is now called 'conventional medicine.' For example, the Eclectic doctor Ellingwood used the categories of sedatives, hypnotics, narcotics, anesthetics, ane.

Combining Western Herbs and Chinese Medicine

10

analgesics in common with the more orthodox doctors of :Us day. However, the Eclectics continued to use action categories associated with holistic practice, such as tonics and alteratives. The tonics were used to strengthen the circulatory and digestive systems, and to help the body to heal itself. The alteratives were used to cleanse the body of the toxins that were seen as the root of many disorders.

Skin

irritants caustics emmolients demulcents protectives

Stomach, liver, and digestive system

emetics antiemetics digestives hepatics astringents carminatives sialagogues antisialogogues apositics dentifrices

_4nticatarrhal action The Eclectics also emphasized the .l1l1portance of the anticatarrhal action. This was linked to :ne theory that oversecretion by the mucous membranes =auld lead to the obstruction of the ducts of the body by =atarrh (phlegm). This catarrhal obstruction could then lead -r:J dysfunction of the respiratory, digestive, hepatobiliary, u:-inary, or reproductive system. They used anticatarrhal =l~bs, such as Hydrastis and Myrica, to strengthen and tone :ne mucous membranes in order to normalize mucus secre::Ion and thus clear catarrhal states.

Antimicrobial

antizymotics deodorants parasiticides antihelmintics

Nutrition and the blood

restoratives alteratives

Miscellaneous

antidotes antagonists hemostatics styptics

~liingwoo'd's

action categories In 1919, the Eclectic practi::lOner Ellingwood listed the following main action categories, .;.argely according to organ systems:

-ervous system

sedatives' depressants excitants stimulants analeptics

::::cretory systems

cathartics diuretics renal sedatives diluents antilithics diaphoretics antihidrotics vesical tonics vesical sedatives

-"".mrt and circulatory system

~nroductive

system

~sDiratory system

cardiacs vasomotors antipyretics aphrodisiacs anaphrodisiacs emmenagogues uterine tonics uterine sedatives oxytocics abortifacients galaetagogues antigalaetagogues acting on respiratory muscles acting on lung tissue acting on mucus membranes

The list is fascinating since it reflects the state of development of herbal medicine at that time, its underlying philosophy, and its theoretical base. It can be seen from the list that many of the action categories in modern Western herbal medicine were already in place by the beginning of the 20th century. (The reader is referred to Ellingwood's text for definitions of the action categories listed.) Terms borrowed from conventional medicine Many of the Western herbal action categories that have been added later in the 20th century have been adopted from conventional medicine. Examples are: antiallergic, antianginal, antiatheromatic, antihypertensive, anti-inflammatory, antimigraine, antioxidant, and hepatoprotective. Some of these terms, for example, 'anti-inflammatory' and 'antihypertensive,' refer to an empirical general effect without specifying the theoretical mechanisms by which they are produced, in terms of the paradigm of biochemistry.

Actions in terms of biochemical mechanism However, conventional medicine often classifies medicines first according to general action group, and then according to the specific biochemical mechanism by which the action is achieved. For example, the term antihypertensive refers to the general action group of medicines used to reduce blood pressure, which can then be subdivided into such categories as:

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History • angiotensin-converting enzyme inlubitors • angiotensin receptor antagonists • beta-blockers • calcium channel blockers • potassium-sparing diuretics • thiazide diuretics • loop diuretics • selective alpha-l adrenergic blockers • antiadrenergic agents

11

inventory from Babylon, the capital city of ancient Mesapotarnia, listed 200 similar substances in the first millennium BC. 28 The early herbals of ancient Greece may have included much material from earlier Egyptian and Mesopotamian records, but only fragments of the latter have survived. This discussion of the historical development of materia medica therefore starts in ancient Greece. ANCIENT GREECE

Application to herbal medicine This system of subdividing actions according to a proposed biochemical mechanism can be applied to the individual active constituents of Western herbs in cases in which the biochemical mechanism of action is known. However, some herbs have more than one active constituent contributing to each action, each with their own biochemical me~hanism. In such cases, it is necessary to evaluate the relative contributions of the different action mechanisms. For example, two different types of chemicals contribute to the antispasmodic action of Thymus vulgaris: • the monoterpenoid phenols thymol and carvacrol • the flavonoids thymonin and cirsilineol The biochemical mechanism of action of the flavonoids may be due to inhibition of calcium ion flow, but the mechanism for the monoterpenoid phenols is not yet known (see the Thymus chapter). As more becomes known of the pharmacology of active constituents, the subdivision of herbal actions according to biochemical mechanism will become more widespread. This can be a positive step forward, providing that preoccupation with mechanistic detail does not replace the holistic approach.

History of materia medica The first great civiliz~tions developed about 3000 BC in the fertile river basins of the Nile, Tigris-Euphrates, Indus, and Huang-Ho. Information on herbs, and the herbs themselves, may have been exchanged in gradual stages via early trade routes. There may have been an exchange between Egypt and Mesopotamia, Mesopotamia and India, and possibly even between India and China. For example. the Ebers Papyrus. written in Egypt about 1500 BC referred to over 500 different substances-:-induding minerals. plants. and animal products-and co~tilils 876 formulations made from these substances. 27 Perhaps due to cultural exchange via the early trade routes, a pharmacy

In addition to his enormous output in virtually every field of knowledge, Aristotle founded a botanic garden in Athens, and wrote a text on plants. Fragments of his book have been found but are too incomplete to gain a detailed picture of this work. Aristotle's botanic garden was inherited by his disciple Theophrastus of Eresos (370-c. 285 BC) who developed the study of plant morphology to a level which w:as not substantially raised until the development of the lenses and the microscope nearly 2,000 years later. 29 His accurate and detailed observation and his insight made a great contribution to the development of scientific botany and facilitated accurate naming and description of medical herbs by later authors. The earliest Greek text on medicinal plants and their effects on the body may have been the Rhizotomikon written in the 4th century BC by Diodes of Caryatos, a disciple of Aristotle. 30 In the 1st century BC, an illustrated herbal was produced by Crataeus, the physician of King Mithridates of Pontus, but only fragments of the text have survived. 3O ANCIENT ROME Dioscorides The most famous text on herbal medicine surviving from the ancient Graeco-Roman world was the De Materia Medica of Pedanius Dioscorides in the 1st century AD. Dioscorides was a doctor traveling with the Roman armies of Emperor Nero. He brought together the existing information on medical substances and described each one in a clear, accurate, and practical manner. Dioscorides' excellent work remained the standard text until the great expansion of herbal knowledge in the 16th century. Even then, his work was regarded as authoritative and was continually quoted by later herbalists. For example, Dioscorides described the berries of Juniperus as slightly warming, astringent, sweet, and slightly bitter. and noted their use to treat stomach pain. bloating and gripes, chest diseases and cough. decreased urination, cramps, and uterine pains. About 1,500 years later. Culpeper used this description almost word for word. Even more remarkable. all of the indications of Dioscorides for

12

Combining Western Herbs and Chinese Medicine

Juniperus were repeated by the American herbalist Jethro Kloss in his text of 1939. 31 Whether American herbal practitioners know it or not, the entries for some herbs in standard American texts, such as those by Kloss and Christopher, have a basis in the material set down in the 1st century AD by Dioscorides, the founding father of Western phytotherapy. It is interesting that the first book in China with systematic descriptions of individual herbs was also written about the 1st century AD. This was the Shen nong ben cao jing, (Classic ofthe Materia Medica), written by unknown authors. Both this book and the materia medica of Dioscorides described herbs in practical terms, rather than in terms of magic. Also, both books were empirical rather than theoreti.:al. Neither book consistently classified herbs in terms of theoretical properties and linked these to therapeutic effects. This theoretical systematization began in China about 600 AD with the Yao xing ben cao (Materia Medica of Medicinal Properties), and in the West in the 2nd century AD with the work of Galen. Pliny Another Roman author who was much quoted by 16th and 17th century herbalists was Pliny the Elder (23-79 AD). His Historia Naturalis was compiled in the 1st century AD from the work of many Greek and Roman authors. This Lext perpetuated many earlier errors, and Pliny himself may .nave had no direct experience as a physician. However, his work was a great storehouse of information, and as Stearn ?oints out, it 'was of great importance in the medieval and Renaissance period as the major surviving work of Latin a..,tiquity. Many Greek concepts and plant names came to the notice of lQth century herbalists through the Latin of ":J.. )'9 _llilY· -

Pliny sometimes listed the medical uses of plants. For ~ple, Tabernaemontanus wrote that, according to Pliny,

::;entiana lutea is a good stomach remedy taken with water -v.rhen there is a fever or taken with wine when there is no :Ever. Also, Culpeper wrote that, according to Pliny, Salvia ?rocureth women's courses, and stays them from coming :lawn too fast.' However, the contribution of Pliny was more D botany; especially to botanical terminology; than to herbal :nedicine. ::'alen of Pergamon Galen has been described as 'the most .::illuential man and one of the most prolific writers in med..::al history.'32 In the 2nd century AD,he made extraordinary =::mtributions to the knowledge of anatomy and physiology, ~d wrote on the circulation of the blood, pulse diagnosis, ...nd the physiology of the brain and nervous system. In addition to his undeniable talent for observation and ==periment, Galen had a perhaps overly strong theoretical :.ent. He systematized the theories of Hippocrates -and

Aristotle, and used his very structured system to produce a very detailed classification of herbs according to theoretical properties (see the discussion on Temperature above). The application of his system profoundly influenced later materia medica. The great gift of Galen to Western herbal medicine was to provide a classification of herbs according to theoretical principles, comparable to those employed in Chinese herbal medicine (see above). Unfortunately, Galen produced a theoretical framework for herbal medicine that was perhaps overly complex and rigid, and he had a tendency to force the facts to fit this framework. If there had been an immediate successor to Galen with a more critical and flexible approach, the history of medicine and of phytotherapy may have taken a very different course.32 This was not the case, and Galen's death in 200 AD was followed by the decline of Roman civilization, culminating in the sacking of Rome by the Vandals in 455 AD. According to one author, 'in all history there is no full stop more emphatic than the death of Galen. For fifteen centuries after his death, Galen's doctrines carried almost the authority of scripture.'32 Throughout the Middle Ages in Christian Europe, from the fall of Rome to the Renaissance in the 15th century, there were no great innovations or expansions in the theory of herbal medicine.

. i¥o'"

-..:..:.

MIDDLE AGES During the Middle Ages, the shock and uncertainty following the fall of Rome and the destabilization of Western civilization may have contributed to the closed mind-set that inhibited questioning and critical investigation. The desire to preserve the doctrines of the past led to a stifling of innovation in the present. In the Christian world, to question the words of Aristotle was tantamount to questioning the authority of the Church and was strongly discouraged. The three main groups who kept herbal medicine alive in the West in the Middle Ages were the physicians of the Islamic world, the healers in the Christian monasteries, and the uneducated herbal practitioners. Islamic physicians The years following the fall of Rome up to about 1000 AD have been called the Dark Ages, and they were a nadir for the development of philosophy, science, and medicine iIi Christian Europe. However, these years saw the birth and flowering of Islamic culture. and the preservation . of Graeco-Roman science and medicine within the Islamic countries.)y·~e_.9th century. the works of Hippocrates, DioscoIides~_aIidGalen had been translated into Arabic.

Rhazes Islamic medicine was at first inspired by the teachings of the Hippocratic school, which emphasized preven-

History tion and minimally intrusive treatment. This was reflected in the writings of the Persian physician Ar-Rhazi (869-925 AD) who became known as Rhazes in the West. He wrote that 'where a cure can be obtained by diet, use no drugs, and 30 avoid complex remedies where simple ones will suffice:

Avicenna One of the most celebrated Moslem physicians was the Persian Ibn Sina (980-1037), known in the West as Avicenna. His book, the Canon of Medicine,33 was a magnificent compilation of Graeco-Roman and Islamic medicine, and became a standard text, not only in the Islamic world, but later in Christian Europe as well. Avicenna was perhaps more influenced by Galen than by Hippocrates, and like Galen, he had a tendency to favor elaborate theoretical systems. The writings of Avicenna gave such an impression of completeness and authority that, combined with his championing of Aristotle and Galen, they were readily accepted:in medieval Europe. This had the unfortunate result of ~inforcing the dogmatic adherence to the Galenic system within the Christian countries.

Islamic materia medica and pharmacy The Islamic physicians greatly enlarged the range of herbs used by the Greeks and Romans. They added many medicinal plants from North Africa, Arabia, and Persia, and herbs and spices brought via the trade routes from India and the Far East. They may have introduced the carminative spices Eugenia (cloves) and Myristica (nutmeg), and the purgative use of Cassia (senna) and Rheum (rhubarb). The materia medica of Ibn Baitar (died 1248) listed more than 2000 substances. About 1750 were plants, the others were animal products and minerals..l-I This expansion of the materia medica was a true contribution by the Arabian doctors. However, Islamic pharmacists began to produce increasingly complex herb combinations containing expensive and exotic ingredients and involving elaborate preparation. This highly profitable practice was continued by European apothecaries from the 12th century onwards, and such herbal treatment rapidly became beyond the reach of all but the rich (see the section on Culpeper below). Christian monasteries During the Dark Ages in Christian Europe, the monasteries were one of the few places where learning was preserved and where ordinary people could receive medical treatment. One of the duties of monastic life, laid down by Benedict of Nursia in the 6th century, was caring for the sick. Some of the monks and nuns were encouraged to study herbs and the'preparation of medicines; and to become familiar with the works of Hippocrates, Dioscorides, and Galen.30 In the 12th century, a Benedictine abbess of the Rhine-

13

land wrote one of the most important herbals of the Middle Ages. This was Hildegard von Bingen, and her main medical text is known today as Physica. 16 Her book is clearly written and contains a wealth of practical experience. Whilst she described herbs as hot or cold and moist or dry, she did not use the elaborate nine-grade classifications of Galen for degrees of heat or moisture. However, she sometimes described herbs in terms of treating imbalance of the humors or temperaments, especially of phlegm and melancholy. Uneducated herbalists So far this discussion has focused on the written tradition of Western herbal medicine. Whilst the materia medica of Dioscorides was based on empirical knowledge, the medicine practiced by followers of Galen emphasized prescribing herbs according to theoretical principles. This found its extreme manifestation in the Arabian elaborations of the Galenic system with their complex multiherb prescriptions. In the Middle Ages, most people were poor and could not read, so that Galenic medicine was beyond their reach. Unless treated in the monasteries by educated monks or nuns, the only herbal medicine available to the majority was that supplied by uneducated persons, whose knowledge of herbs came from oral tradition and personal experience. These empirical practitioners kept alive a detailed and practical knowledge of the use of single herbs, also known as 'simples: This folk knowledge may often have been recorded in writing by more literate colleagues and formed an important source for both medieval and Renaissance materia medlca. RENAISSANCE The Renaissance is the term applied to the period irl the 14th-16th centuries when there was a rebirth of the irlvestigative spirit and a questioning of religious and other dogmas in Christian Europe. As with the 5th century Be irl ancient Greece, there was an increase in intellectual activity and an advancement of science and invention, in addition to new developments in art and literature. This renewed interest irl detailed observation, objective description, and experimentation gave new life to the study of herbal medicine. In Germany, new herbals were written by Otto Brunfels (1530), Hieronymus Bock (1539), and Leonhard Fuchs (1543). What distinguished these works from those of earlier herbalists was the very detailed description of each plant and the more accurate illustrations (see Publishers Note in Gerard. 15 ) In the second half of the 15th century, some of the most famous books on herbal medicirle were published. In 1583, the Flemish author Rembert Dodoens published his second

Combining Western Herbs and Chinese Medicine

14

and larger herbal, and in 1588, Jakob Dieter of Bergzabern, under the name of Tabernaemontanus, compiled one of the greatest materia medica of all time. In England, the most popular herbal was that of John Gerard published in 1597. The text of Gerard's herbal was based on a translation into English of Dodoens herbal of 1583, and most of the illustrations were from Jakob Dieter's herbal of 1588. 17 Tabernaemontanus Jakob Dieter was a doctor and pharmacist, and a student of Hieronymus Bock. Dieter wrote what has been claimed to be the most comprehensive Western herbal: the 1,660 pages of the 1731 edition of this book, revised by Hieronymus Bauhinus, contain more than 3,000 herb studies and about 2,500 illustrations. I, This wonderful book contains very thorough descriptions of the plants, with a discussion of their many names in different languages and extraordinary detail of their practical use. It classifies the temperature and humidity of each her~ a~co_r
17

TH

AND 18

TH

CENTURIES

During these centuries in Germany, the most influential herbal text appears to have been that of Tabernaemontanus, whilst in Britain, the most popular materia medica were the Gerard-Johnson herbal of 1633 and Culpeper's herbal of 1652. However, during the 18th century in Europe, advances in the study of herbs came not so much from new materia medica, but from the advances in plant taxonomy that culminated in the system of Carl Linnaeus. In North America, the 17th and 18th centuries saw an increased use of Native American herbs by the settlers. In this time. there were the beginnings of the integration of the use of indigenous herbs and European herbs that can be seen in the North American materia medica of the later 19th century. Gerard In 1633, the Gerard herbal was revised and enlarged by Thomas Johnson. He was a more rigorous scholar than Gerard who corrected Gerard's errors and added material from his own botanical observations and from European herbals published after 1597. The Gerard-Johnson herbal described about 800 plants more than the original Gerard text, bringing the tqtal to about 2,850 plants. Like the materia medica by Tabernaemontanus, the Gerard-Johnson herbal classified herb: te!Dperature and moisture according to Galen'ssystem,:an,~,~s~~et.iInesthe herbal described the effect of the herb in t~rin.s correcting the balance of the humors and temperaments.~stnot as thorough as the work of Tabernaemontanus,the herbal is

of

nevertheless a most useful book and remained for many years the most detailed materia medica in the English language. Culpeper Nicholas Culpeper can be said to have made five great contributions to herbal medicine. Firstly, he wrote an excellent materia medica in which the properties and uses of the individual herbs were so clearly and vividly described that his book is still one of the most clinically useful texts available. Secondly, in 1651, Culpeper wrote a clear description of Galen's principles of herb prescription (A Key to Galen's Method of Physic), which appears to be the only adequate description of Galen's work on herbal medicine currently available in English. Thirdly, Culpeper is famous for simplifying and demystifying the medicine of the day. This included the translating of Latin into English. Latin had been used as a means to keep medical knowledge in the hands of the privileged few, and away from the populace. As a result of Culpeper's efforts, simple remedies could be understood and used by the ordinary people. Fourthly, Culpeper objected to the expensive and complicated herbal formulations of the day. He wanted to teach people to use herbs that grew in England and were inexpensive and readily available. He believed that English herbs '-'.' were best fitted for English bodies, and he did not include -, v. expensive foreign herbs in his materia medica. Cinnamon, cloves, nutmeg, and even pepper and ginger did not have ~~ individual entries in the materia medica section of Culpeper's book. Fifthly, through his interest in astrology, Culpeper linked each herb to a specific planet. This can sometimes be useful since it can give an understanding of the direction of energy of the herb. For example, a herb governed by the sun, such as Rosmarinus, is likely to have a warming and outward- ~ " dispersing or centrifugal energy. This is comparable to the descriptions of herbs in terms of direction of energy found in Chinese medicine. '-

Culpeper as a source for modern herbal texts Culpeper was strongly influenced by Dioscorides, to whom he often ref- _ ered. The brevity, clarity, and practicality of Dioscorides probably appealed strongly to Culpeper. Often, the wording of the herb uses in Culpeper's materia medica suggests that _ these were taken with very little alteration from Dioscorides'

text. . '. In his turn, Culpeper has had an enormous influence on __ m~y, modern herbal· texts. A Modern Herbal, written by Mary' Grieve in 1931, refers extensively to Culpeper. The classic American herbal text School of Natural Healing pub- __ lished in 1976 by John Christopher,zs included many herb

History indications that seem to have been directly lifted from Culpeper. For example, Culpeper wrote that Juniperus berries 'strengthen the brain exceedingly, help the memory, and fortify the sight by strengthening the optic nerves.' Christopher wrote that this herb 'is a strengthener of the brain, memory and optic nerve.' Many modern herbal texts in the English language, whether British or American, contain material from Culpeper's herbal, and much of this material derives from the materia medica of Dioscorides. Both practitioners and their patients owe a debt to these dedicated physicians. Linnaeus Correct plant identification is absolutely essential to safe and effective herbal medicine. This requires detailed and accurate plant description and a consistent system of plant naming. It is not always possible to be sure of the identity of plants referred to in the Graeco-Roman texts. For example, what Galen called Oxycantha appears to have been Berberis, whilst what Dioscorides called Oxycantha may have been Crataegus. Even in 16th and 17th century texts such as those by Tabernaemontanus and Gerard and Johnson, nomenclature can sometimes be confusing and identity uncertain. For example, the Gerard-Johnson herbal refered to Berberis as Spina acida or Oxycantha. The Swedish naturalist Carl Linnaeus (1707-1778) is the man associated with the introduction of a consistent system of nomenclature and identification for plants and animals. His works Species Plantarum (1753) and Genera Plantarum (1754) have been accepted by international agreement as the starting point for botanical nomenclature. Botanical names published before 1753 are termed 'pre-Linnaean' and are not recognized unless they were adopted by Linnaeus in 1753 or r later, or adopted by subsequent authors. ' North America The early settlers in North America, from the 17th century onwards, may have brought with them both oral and written herbal traditions from their countries of origin. Thus they may have had access both to European folk medicine and, via writers like Culpeper, to herbal knowledge from Graeco-Roman physicians, such as Dioscorides. They may also have brought with them European herbs in the form of seeds or ~ttings, but on arrival in America, they would come into contact with the herbs of the New World and with the herbal knowledge of the Native Americans. An early benefit of Native American herb knowledge was the use of spruce beer as a cure for scurvy, first recorded in 1652. Spruce beer was used by Captain Cook to prevent and cure scurvy in his long sea voyages in the late 18th cen-

T

r

tury.36 The early pioneers may have been living in conditions similar to those of the Native Americans themselves and

15

were too distant from towns to benefit from conventional medical assistance. As a result, they probably used a combination of European and Native American herbal medicine. However, the first American herbal, written by Samuel Stearns in 1772, rarely quoted Native American sources directly and revealed the author's ignorance of the ways in which the plants were used by the indigenous peoples. 30 It was not until the early 19th century that indigenous American herbs started to be popularized and Native American herbal knowledge to be generally acknowledged in print.

19 TH

CENTURY

The 19th century in North America was the time of the development of the Physiomedical and Eclectic movements of American herbal therapy. These movements integrated the use of both indigenous and European herbs. Thomson During the 19th century in North America, much conventional medicine consisted in giving massive doses of calomel (mercurous chloride) and draining the patient of huge amounts of blood. These crude and dangerous procedures assisted the growth of herbal medicine since this offered a less harmful and more effective alternative. Samuel Thomson (1769-1843) popularized the use of a system of naturopathic and herbal procedures, which appear to integrate the methods of Hippocrates with the practices of the Native Americans. However, whilst Thomson acknowledged and revered Hippocrates, he did not acknowledge the Native Americans as the source of much of his materia medica and methodology.30 More than a third of the 65 herbs listed by Lloyd as the main herbs used by Thomson are native to North America. 37 These include such famous American herbs as Hamamelis, Hydrastis, Lobelia, Myrica. and Zanthoxylum. The two herbs most frequently used by Thomson were Capsicum and Lobelia-the Yang and Y"m of his systemCapsicum to stimulate and Lobelia to relax. Thomson believed that all diseases are caused by cold and used: Capsicum to support the natural warmth of the body; he used a combination of Capsicum and Lobelia to manage fever. Thomson also emphasized the importance of clearing: the body of all obstructions and of all accumulated toxins. This was done by using diaphoretics and steam baths to produce sweating, and by the use of emetic and purgative herbs. Lyle The work of Thomson and his contemporaries provided the inspiration and the foundation for both the Physiomedical and Eclectic movements. In 1897, Lyle prod.uced the work Physio-Medical Therapeutics, Materia: Medica, and Pharmacy, which described the principles c£ Physiomedical treatment. It also provided an. extensive:

16

Combining Western Herbs and Chinese Medicine

materia medica in which herbs were not only described in terms of their uses but also in terms of the Physiomedical explanation of their effects on the body. For example, Myrica is described as a 'positive, diffusive, stimulating, astringent alterative and tonic... In hot infusion it gradually arouses the circulation and favors an outward flow of blood: Lyle's terminology was used by Priest and Priest in their book on Physiomedical herbal medicine written in 1982. 38 For example, they describe Myrica as 'positive diffusive stimulant-arouses circulation: In 1898, the revised edition of King's American Dispensatory was produced by Felter and Lloyd. 39 Felter and Lloyd

In my opinion, this is the greatest work on herbal medicine in the history of North America, ranking with the text of Tabernaemontanus as one of the greatest materia medica of all time. The 2,200 pages of this work integrate knowledge from five main sources. There is data derived from the mate. .ria medica of Dioscorides, from European folk medicine, from Native American tradition, from the extensive empirical testing of the herbs by the Eclectic practitiQners, and from the biochemical research of the times. A surprising amount of phytochemical and pharmacological knowledge existed in the late 19th century and was utilized by the Eclectics. For example. Stenhouse extracted the alkaloid sparteine from Sarothamnus in 1853,39 and in 1898, Felter and Lloyd described the use of sparteine to treat cardiac disorders such as cardiac weakness, arrhythmia, and cardiac edema.

20

TH

CENTURY

The Eclectic movement continued into the 20th century with the publication of such excellent materia medica as that of Ellingwood in 1919. However, following the Flexner report of 1910, the Physiomedical and Eclectic colleges were gradually driven out of business, and by 1938, they had all 30 closed. The Physiomedical and Eclectic movements greatly declined, and medicine became increasingly dominated by the new pharmaceuticals.

on Physiomedical principles and almost half the herbs taught were American. However, the American influence was not the only one on the British herbalists, and it is significant that the coat of arms of the NIMH is supported on one side by an ancient Egyptian physician and by a Native American herbalist on the other. In addition to the blending of the traditions of the Old and the New World, the Institute began to incorporate the concepts of modern Western medicine and phytopharmacology that were gaining ground in the late 19th century. All three of these influences on British phytotherapy are reflected in the BHP of 1983. British Herbal Pharmacopoeia This book was a milestone in the development of herbal medicine in Britain and was originally published in three sections between 1971 and 1974. The therapeutic sections of this work were compiled by Fletcher Hyde and can be said to represent the distilled wisdom of the senior practitioners of the NIMH. The BHP was the first scientific materia medica for trained practitioners published in Britain, superceding Grieve's text A Modern Herbal, originally published in 1931. The latter work is a useful source of information, and its historical data on individual herbs can be fascinating. However, it was written as much for the general public as for the trained practitioner, and by 1970, its biochemical information was out of date. Christopher's text Following the first installment of the BHP in 1971 in Britain, a materia medica of a very different kind was published in the United States, in 1976. This was School of Natural Healing by John Christopher, which was a text of North American naturopathic herbal medicine in the tradition of Thomson and Jethro Kloss. The BHP and Christopher's text both share the background of the Physiomedical tradition and the use of herbs indigenous to North America. However, the BHP illustrated the beginning of the trend in European phytotherapy to include increasing amounts of scientific data at the expense

The National Institute of Medical Herbalists From about 1840 onward, knowledge of American herbs and the teachings of the Physiomedicalists and Eclectics was spread in

of data on traditional use. For example, the entry for Lavandula in the BHP contained more than twice as much data on scientific aspects as on traditional therapeutics. Christopher was not interested in research data. He was a clinician and teacher who provided an invaluable wealth of

England by American lecturers such as Coffm and Beach.

practical information on the use of individual herbs. His

This knowledge was absorbed by the British herbal practitioners, who incorporated it into their practice and training.

materia medica is one of ~e very few that illustrate the actions and uses of each herb by giving a variety of combinations that include that herb. The combinations are given with practical notes on their use. Some of them are from earlier practitioners, such as Coffm. Lyle, Shook, and Nowell, but most of them may derive from Christopher himself.

In 1864, they founded the National AssoCiation of Medical Herbalists, which later became the National Institute of Medical Herbalists, the NIMH. As Mills has pointed out,4O up to the late 1970s, training for British herbalists was baSed

i

History

.~

Later texts

In the last 25 years, it can be said that there have

been three main influences on phytotherapy in the West: traditional Western herbal medicine, traditional Chinese herbal medicine, and phytopharmacological research. Some texts have concentrated on a description of the active constituents of medical plants,2z.41 or on pharmacological and clinical research. 4. 23 Others have begun to describe herbs in terms of both western and Chinese traditional medical theory.H.42 The challenge for materia medica of the immediate future ,:.1

is to utilize the positive contributions of all three paradigms.

'-'

This can broaden and deepen understanding of the individual herbs, so that they can be used more effectively and for a wider range of applications.

17

18. Ellingwood F. American Materia Medica, Therapeutics and Pharmacognosy. Hth edn. (l919). Reprinted by Eclectic Medical Publications. Sandy, Oregon (1994) 19. Lyle TJ. Physio-~!edical Therapeutics, ~!ateria Medica and Pharmacy. Originally published in Ohio (l897). Reprinted by the National Association of Medical Herbalists of Great Britain, London, United Kingdom (1932) 20. Grieve M. A Modern Herbal. vols. 1 and 2. Dover Publications, New York. New York (1971) 21. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983) 22. Bradley PR (ed). British Herbal Compendium, vol. 1. British Herbal Medicine Association, Bournemouth, United Kingdom (1992) 23. European Scientific Cooperative on Phytotherapy: Monographs on the Medicinal Uses of Plant Drugs. European Scientific Cooperative on Phytotherapy, Exeter, United Kingdom (1997) 24. Tierra M. Planetary Herbology. Lotus Press. Twin Lakes, Wisconsin (1988)

References 1. Dioscorides P. Kreutterbuch (1610). Reprinted by Verlag Konrad'K6lbl. Miinchen, Germany (1960) 2. jouanna j, Hippocrates. john Hopkins University Press, Baltimore, Maryland (1999) ,.0;1<'

3. Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. Reprinted by Meyerbooks. Glenwood, Illinois (1990) 4. Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone. Edinburgh. United Kingdom

.~

(2000) 5. Mitchell M. Feng Yeo Wiseman N (eds). Shang Han Lun: On Cold Damage. Paradigm Publications, Brookline. Massachusetts (1999) 6. Porkert M. The Theoretical Foundations of Chinese Medicine. MIT Press. Cambridge. Massachusetts (1974) 7. Unschuld PU. Medicine in China: A History of Ideas. University of California Press, Berkeley. California (1985) 8. Cook WH. The Science and Practice of Medicine. Cincinnati (1893) 9. Needham j. Science and Civilization in China. vol. 2. Cambridge University Press. Cambridge, United Kingdom (1956) 10. Kaptchuk TJ. The Web That Has No Weaver. Congdon and Wedd. New York. New York (1983)

Ii.

jones WHS (trans!). Hippocrates vol. IV. Harvard University Press, Cambridge, Massachusetts (1998)

12. Waterfield R (trans!).Aristode: Physics. Oxford University Press, New York. New York (1999) 13. Tobyn G. Culpeper's Medicine. Element Books. Rockport, Massachusetts (1997)

27. Ackerknecht EH. Therapeutics: from the Primitives to the Twentieth Century. Hafner Press, New York. New York (1973) 28. Sigerest HE. Man and Medicine. WW Norton, New York, New. New York (1932) 29. Stearn WT. Botanical Latin, 4th edn.. Timber Press, Pordand, Oregon (1992) 30. Griggs B. Green Pharmacy: The History and Evolution of Western Herbal Medicine, 2nd edn. Healing Arts, Rochester, Vermont (1997) 31. Kloss T. Back to Eden, 5th edn. (1939). Reprinted by Lifeline Books. Santa Barbara, California (1975) 32. Wingate P. The Penguin Medical Encyclopedia. Penguin Books Ltd, Middlesex, United Kingdom (1976) 33. Bakhtiar L. The Canon of Medicine (al-Qanun fi'l-tibb): Avicenna. Kazi Publications Inc. Chicago, Illinois (1999) 34. Garrison FH. History of Medicine. WB Saunders. Philadelphia, Pennsylvania (1913.1968) 35. Blunt W. The Compleat Naturalist A Life of Linnaeus. William Collins. London, United Kingdom (1971) 36. Price AG (ed). The Explorations of Captain James Cook in the Pacific. Dover Publications. New York. New York (1971) 37. Lloyd JU. The Life and Medical Discoveries of Samuel Thomson. Lloy
ro.

39. Felter H¥i, Lloyd King's American DispenS
15. Gerard J. The Herbal or General History of Plants: The Complete 1633 Edition as Revised and Enlarged by Thomas johnson. Dover Publica-

40. Mills S. The Essential Book of Herbal Medicine. ArkanaIPenguin Books. London, United Kingdom (1991)

16. Von Bingen H. Hildegard von Bingen's Physiea. Healing Arts, Rochester. Vermont (1998) 17. Tabernaemontanus JT. Krauterbuch (1731). Reprinted by Verlag Konrad Kolbl. Miinchen. Germany (1993)

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26. Bensky D, Gamble A. Chinese Herbal Medicine Materia Medica. Easdand Press, Seattle, Washington (1986)

14. Veith I (transl). The Yellow Emperor's Oassie of Internal Medicine. University of California Press. Berkeley, California (1972)

tions. New York, New York (1975)

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25. Christopher JR. S<:hool of Natural Healing. BiWorld, Provo. Utah (1976)

41. Bisset NG (ed).lkrbal Drugs and Phytopharmaceuticals. English edn. Medpharm, stuttgart, Germany (1994). from 2nd German edn. Wichti M (ed) (1989) 42. Holmes P. The Energetics of Western Herbs. Artemis Press. Boulder; Colorado (1989)

Temperature O

principles of Western and Chinese traditional medicine is the concept of the bal-

NE OF THE FUNDAMENTAL

ance of heat and cold. The etiology and pathology of disease can be discussed in terms of the imbalance of heat and cold within the body, and sYndromes can be classified in terms of degrees of heat and cold. If herbs are also classified in terms of heat and cold, then herbs can be chosen to match disorders in order to correct the temperature balance of the body and restore

Terminology In this book, the terms 'heat' and 'cold' begin with a lowercase letter unless they specifically refer to a Chinese syndrome or concept, in which case, they begin with an uppercase letter: 'Heat'and 'Cold:

Temperature classification ofherbs

health.

For over 2,000 years, herbs have been divided into different temperature categories in both China and the West. In Chinese medicine, herbs are commonly divided into the five

Temperature classification of syndromes

temperature categories hot, warm, neutral, cool, and cold. l The additional category of slightly warm is also sometimes used.

In the terminology of traditional herbal medicine, the word 'temperature' refers to the degree of heat or cold manifested by the syndrome. It does not necessarily refer to body temperature, although this factor may be included. If the condition is classified as warm or hot, this general-

Various temperature classification systems have been used in the West, the most famous being that of Galen. He divided herbs into nine temperature categories: temperate; hot in the first, second, third, and fourth degree; and cold in the first, second, third, and fourth degree (see History chapter).

ly refers to systemic or local subjective sensations of heat, raised body temperature, or local areas hot to the touch, and often redness. This condition may be associated with hyper-

This book classifies herbs as hot, warm, neutral, cool, or cold, and sometimes uses the category of slightly warm for herbs intermediate between warm and neutral. The concept

function. If the condition is classified as cool or cold, this generally refers to systemic or local subjective sensations of cold, low-

of variable temperature is also introduced to describe herbs that can have more than one temperature effect, as discussed later in this chapter.

ered body temperature, or local areas cool to the touch, and often pillor. This condition may be associated with hypo-

function.

19

Combining Western Herbs and Chinese Medicine

20

Matching herbs to syndromes

cold. Culpeper summarized the Western tradition when he

As Galen pointed out, the temperature properties of herbs do not refer to the herbs themselves but to their effect on the human body.2 Herbs are classified by temperature in order to treat syndromes of specific degrees of heat and cold. A simple system for matching herbs and syndromes is shown in the table.

'{ beseech you to take notice of this, that seeing our bodies are nourished by heat, and we live by heat, no cold medicines are friendly to the body ... children, and such people whose stomachs are weak, are easily hurt by cold medicines:!

Herb

Syndrome hot warm neutral cool cold

cold cool neutral warm hot

These correspondences seem obvious, but failure to match correctly the temperatures of herbs and syndromes is one of the most common causes of adverse effects in herbal medicine. For example, if the practitioner incorrectly diagnoses the patient's syndrome as cold when it is cool and prescribes hot herbs instead of warm ones, the treatment may produce a syndrome of heat. Alternatively, the practitioner may correctly diagnose the patient's syndrome as cool and give warm herbs, but omit to tell the patient to stop taking the warm herbs as soon as there are no longer symptoms of cold. Continued use of the warm herbs may again re~ult in overcorrection and in symptoms of heat. It is therefore most important to have a thorough understanding of the principles of balancing heat and :old.

\'\TESTERN PRINCIPLES OF BALANCING HEAT AND COLD Traditional Western systems for the temperature classiiication of herbs rest on the following four principles of tem?erature balancing: • support the vital force • support the natural power of the body to heal itself • support the heat of the body • give only the minimum treatment to restore the temperatur~ b~ance ,

.

wrote:

Give only the minimum treatment to restore the temperature balance It was considered most important to use only herbs of a temperature just sufficient to correct the temperature imbalance of the body. This was considered especially important when using cold medicines. For example, if the patient had a slightly warm condition, they would require only herbs that are cold in the first degree in terms of Galen's classification system (see the History chapter). If the practitioner were to use herbs that are cold in the second and third degree, this might damage the vital force, the heat of the body, and the natural ability of the body to heal itself. This might result in the production of a syndrome of cold more serious than the original mlld heat condition.

!!!"J

Examples for the main temperature categories /

The categories of hot, warm, slightly warm, neutral, cool, and cold are discussed in this section, and examples of the herbs in each of these categories are given. The examples used are herbs that are discussed in either the individual materia medica chapters or the Additional herbs chapter of this book. Each of the individual materia medica chapters of this book gives the reasoning for assigning the specific temperature value for the title herb in the Limitations and Traditional sources sections of the chapter.

.j

HOT HERBS The following herbs are classified as hot in this book:

Capsicum

acrid

HT. SP, ST. IN, LU

Cinnamomum (bark)

acrid, sweet. aromatic

Sp' ST, IN, LU, HT, KI, UT

.

These principles are discussed hi the History chapter; the ~:ond two are also briefly reviewed here. .

.

:"l,'"

."{

2,npport the heat of the body Western medical tradition :~eved that warmth was the essential characteristic of life, ..:.td that in the human body, heat must predominate over

Zanthoxylum acrid. aromatic, (bark) 'it..;·:': _7'"''''''''0 bitter

HT, Sp,ST,IN

zanthoxylum (berries)

acrid, aromatic. bitter

HT, Sp, ST, IN

Zingiber (dried)

acrid, aromatic

LU, Sp, ST, IN, HT, UT

Zingiber (fresh)

acrid, aromatic

LU, Sp,ST, IN, UT

._l

Temperature Hot herbs are those that can have a strong warming effect on the body and are specifically used to treat cold disorders. Hot herbs can be especially associated with the following Western actions (shown in italics and then followed by the corresponding Chinese actions):

21

Herb . Rosmarinus

aromatic. bitter.

A.Qel-t.t'i·'

Sanguinaria,

,bitter. acrid ~"···"'iJw"'·tc. vc..-..().O.. C'O' .... o/r: Schisandra sour

LU, HT, LR HT, KI, LU. LR

-uC)w~c\ac...

• metabolic stimulant • circulatory stimulant • warming diaphoretic • warming antirheumatic • counterirritant

tonify Yang of Kidney, Heart, or Spleen warm and move Qi and Blood clear Wmd Cold Damp clear Wmd Cold Damp, warm and move Qi and Blood topical irritant

Not all hot herbs have all these actions to the same degree. Also, each hot herb in the table above has its characteristic range of actions and uses. For example, a specific use of Capsicum is as a metabolic stimulant to tonify Heart Yang, and a specific use of Cinnamomum bark is to tonify Kidney Yang. Zanthoxylum is a circulatory stimulant that is specific for moving Qi and Blood to the extremities, and a specific use of fresh Zingiber is as a warming diaphoretic to clear Wind Cold. Caution Hot herbs should be used with caution since their excessive, prolonged, or inappropriate use may change a pathology of cold into a pathology of heat. Combinations with only hot herbs are rare. These herbs are usually combined with warm, neutral, variable-temperature, or even cool herbs, for a more gentle and gradual correction of the temperature imbalance. This will avoid adverse effects due to temperature overcorrection and the resulting oscillations between pathologies of cold and heat.

SymplocarPus . O:u,~ • ~O"",,,,",,,, Turnera )a~"""

HT. LR, Sp' ST, IN

acrid

LU,LR

bitter. aromatic, acrid

KI,Sp,IN

Warm herbs are those that can have a moderate warming effect on the body and that are specifically used to treat cool disorders. Warm herbs can be especially associated with the following Western actions (shown in italics and then followed by the corresponding Chinese actions):

• warming tonic • carminative • warming antispasmodic • warming expectorant

tonify Qi and Yang move Qi of Spleen and Intestines move Qi and relax spasms clear Lung Phlegm Cold

In addition, some warm herbs can act as metabolic stimulants, circulatory stimulants, or warming antirheumatics, but generally to a lesser degree than hot herbs. Each of the warm herbs listed in the table has a characteristic range of actions and uses. For example, Turnera is specific as a warming tonic for Qi and Yang of the Kidney, whilst Elettaria relaxes spasms and is specific as a carminative to move the Qi of the Spleen and Intestines. A specific use of Angelica archangelica is as a warming expectorant, whilst A. sinensis is more often used as a warming tonic for Qi and Blood.

WARM HERBS The following herbs are classified as warm in this book: Herb

Taste

Organs

bitter, acrid. aromatic

LU. Sp' ST,IN. HT

sweet., aromatic. bitter

HT, LR, SPoUT

Cinnamomum twigs

acrid, sweet, aromatic

HT, LU, BL

Citrus aur.

acrid, aromatic, bitter

LU. Sp'ST,IN

Angelica arc. Angelica sin.

Qtll<'''',

',io -

C'\

r'.-<.'o<:,c-,:f.. .

SLIGHTLY WARM HERBS The following herbs are classified as slightly warm in this book: Herb

Taste

Organs

sweet

Sp,LU

sour, sweet

HT

aromatic. 51. acrid

ST, IN, KI. LR

aromatic. 51. sour, 51. acrid

KI, BL. SP, IN. LU. LR

Lavandula A~fo;.ttl1~

aromatic, bitter, 51. acrid

HT, LR, IN

Panax gin.

sweet, 51. bitter

KI, HT, SP, LU

Petroselinum

aromatic, 51. acrid

KI, BL,IN

Astragalus

As~m20

Crataegus

Foeniculum \\1\\(''''0

Juniperus .z{,.,....'~-lO

Commiphora

bitter, acrid

HT. ST, IN. LU. UT

clettaria

aromatic, acrid

ST,IN

Ephedra

acrid, sl, bitter

LU,HT

Eupatorium per.

bitter, acrid, aromatic

LU

~en~ha pul.

aromatic

HT,IN, UT

Mynca

acrid, sour, bitter

ST, IN, LR, GB, HT, LU

'Tt;.<;;;;,.ft.(..

G.Qd.a"ff'~"'l '0

tupo.~I'-'t> c~b

-01:°/';<"'1

,

b~' . . ~t~l(l)-~·~_,t., .'~')\~~ii:'C

(n,·~~(

Sc0 oc<

Trigonella \~\'u~('i'

bitter, 51. sweet, - 51. acrid

SP,IN. LU

Combining Western Herbs and Chinese Medicine

22

Slightly warm herbs are used to treat disorders that are intermediate between neutral and cool. which have only a few mild manifestations of cold. Herbs that are classified as slightly warm may have warming tonic, carminative, warming antispasmodic, or warming expectorant actions. like the warm herbs, but with a milder warming effect. For example, Lavandula is a less warming and less stimulant antidepressant than Rosmarinus. and Juniperus is a less warming and less stimulant expectorant than Sanguinaria.

NEUTRAL HERBS The following herbs are classified as neutral in this book:

Neutral herbs are those that do not affect the temperature of the body or of the herbs with which they are combined. They are especially used to treat neutral-temperature conditions or mi..'Ced conditions of heat and cold. Combinations used to treat mixed conditions may include warm, neutral, and cool herbs. The neutral herbs form a stable 'center' in a combination, reducing the likelihood of temperature oscillations by the body. Neutral herbs can be associated with the following Western actions (shown in italics and then followed by the corresponding Chinese actions): • astringent

stabilize and bind

• anticatarrhal

no exact Chinese equivalent

• antispasmodic

move Qi and relax spasms

• emmenagogue

no exact Chinese equivalent

• diuretic

drain Damp

• neutral tonic

tonify Qi and Blood, rather than

Agrimonia

sour, 51. bitter

LU, IN. BL, UT

Agropyron

sour, 51. sweet

BL

Avena

sweet

Sp,HT, KI

Ballota

bitter, sour

ST

Capsella

sour

ST, IN, BL, UT

Caulophyllum

bitter

UT

Chamaelirium

bitter, sour

UT

Convallaria

bitter, 51. sweet

HT, KI, BL

Galium

sour, 51. bitter

KI, BL

Geranium

sour

ST,IN, UT

Glechoma

sour, bitter

LU

Hydrangea

bitter, sour

BL

Hypericum

sour, 51. sweet

HT, KI, LR

Leonurus

sour, 51. bitter

HT. UT

Lycium

sweet

LR, KI

Marrubium

bitter

LU,SP

Mitchella

51. sour

UT

Molasses

sweet, 51. bitter

SP

Panax qui.

sweet, 51. bitter

LU, ST, KI

Ae5culus

bitter, sour

SP

Parietaria

bitter

KI, BL

Althaea

sweet, 51. bitter

LU, ST, IN, BL

Passiflora

51. bitter

HT, LR

Arctium (root)

51. acrid, 51. bitter

LU, IN, KI, BL

Prunus

bitter, aromatic

LU, HT

Arctium (seeds)

acrid, 51. bitter

LU, IN, KI, BL KI, BL

YangorYm Each of the neutral herbs listed in the table has its characteristic range of actions and uses. For example, both Agrimonia and Mitchella are neutral-temperature astringents, but Agrimonia is a more general-purpose astringent, whilst Mitchella is specific for the female reproductive system. Both Convallaria and Sarothamnus are neutral herbs with cardiac tonic, antiarrhythmic, and cardiac diuretic actions. Sarothamnus differs from Convallaria in being specific for cardiac weakness with hypotension.

COOL HERBS The following herbs are classified as cool in this book: Herb

_>:-Taste

-,; 'Organs

Pseudostellaria

sweet, 51. bitter

Sp,LU, HT

Arctostaphylos

bitter, sour

Quercus

sour, bitter

IN

Bert:>eri5

bitter

LR, GB, Sp' ST, LU

UT,IN

Calendula

bitter

ST,IN LR, GB,IN

Rubus

bitter, sour

Sarothamnus

bitter

HT, Kl, BL

Chelidonium

bitter, 51. acrid

Serenoa

sweet, sl. sour

KI, BL, SP

Chrysanthemum

sweet, 51. bitter

LU,LR

Cimicifuga

acrid, 51. bitter, 51. sweet

KI, LR, UT

Cinchona

bitter

HT, SP

Urtica

acrid

LU,BL

Viburnum

51. bitter, 51. sour

UT

Vinca

sour

BL,UT

bitter, 51. acrid

LR,UT

sweet

BL

sweet

Sp,ST

',---'

Vitex Zea Ziziphus

"'f

Curcuma (rhizome) acrid, bitter

LR, GB, HT

Echinacea

acrid, bitter, 51. sweet

LU, BL

Equisetum

51. bitter, 51. sweet

BL

Temperature '--"~-.'~

·····~-':::.~_C'.7·--""·:.---~

Herb :··-:~=:-:":::;::Taste·:~--~:::::,,:::=~·.:.-::· Organs .::.:~-7:: :::~~:C::-:.:

23

COLD HERBS

The following herbs are classified as cold in this book:

bitter, acrid

lU

Filipendula

sour, bitter

ST. IN, Bl

Harpagophytum

bitter

Sp'ST

Hydrastis

bitter

S~

Iris

bitter

lR, GB,IN

Mahonia

bitter

lR, GB, Sp' ST, lU

Matricaria

sl. bitter, sl. aromatic

ST,IN, HT

Nepeta

aromatic, acrid

lU,lN, HT

Ophiopogon

sweet, sl. bitter

HT,lU, ST

Phytolacca

acrid

lU

Plantago

sour, sl. bitter

lU,lN

Polygonum

sour, sl. bitter

lU,lN

Rhamnus

bitter

IN,ST,lR

Rumex

bitter, sl. sour

LR,IN

Salvia mil.

bitter

HT,lR, UT

Sambucus

acrid, sl. bitter

LU

Sanguisorba

sour, bitter

IN, UT

• antipyretic

clear Excess Heat

Scrophularia

sl. bitter

lU

clear Damp Heat, Heat Toxin

sl. bitter

lR, KI, Bl

• strong antimicrobial

Smilax Tanacetum

bitter

lR

• anti-inflammatory

clear Damp Heat, Excess Heat

Valeriana

bitter, sweet

HT, lR, ST, IN

• sedative

Viola ado.

sour, sweet, bitter

LU,Bl

sink Heart Spirit Disturbance or Liver Hyperactive Yang

Viola tri.

sour, sweet, bitter

LU,Bl

Euphorbia

IN,lU,lR,GB,Bl,UT

Cool herbs are those that can have a moderate cooling effect on the body and are specific for treating warm disorders. Cool herbs can be especially associated with the following Western actions (shown in italics and then followed by the corresponding Chinese actions):

• antimicrobial

clear Damp Heat

• anti-inflammatory • cooling alt~rative

clear Damp Heat or Deficiency Heat clear Damp Heat or Heat Toxin

• cooling anticatarrhal

clear Phlegm and Heat

• cooling diaphoretic

clear Wmd Heat

• tranquilizer

calm Heart Spirit Disturbance or Liver Hyperactive Yang

Each of the cool herbs listed in the table has its characteristic range of actions and uses. For example, both Matricaria and Sambucus are cool herbs with anti-inflammatory and" anticatarrhal action, but the specific target area of Matricaria is the gastrointestinal system, whilst that of Sambucus is the sinuses. Both Althaea and Arctostaphylos can be used as cool anti-inflammatory herbs for the urinary system, but Althaea has demulcent action, whilst Arctostaphylos is more strongly antimicrobial.

Anemone

bitter

HT,KI

Asclepias

bitter

LU

Baptisia

bitter

LU

Humulus

bitter

HT,lR,lN

Piscidia

bitter

HT,lR

Pulsatilla

bitter

IN, ST, LR

Cold herbs are those that can have a strong cooling effect on the body and are specific for treating hot disorders. Cold herbs can be especially assoCiated with the following Western actions (shown in italics and then followed by the corresponding Chinese actions):

Cold herbs may have antimicrobial, anti-inflammatory, and alterative actions, like the cool herbs, but they can have a stronger cooling and sedating effect on the body. Caution Cold herbs should be used with caution or they may depress metabolism and reduce the ability of the body to heal itself. Combinations with only cold herbs are rare, and these herbs are usually combined with some warm herbs to moderate their potential ill "effects.

Variable temperature Variable herb temperature is a concept that can help to resolve some of the apparent contradictions regarding herb temperature, can broaden and deepen understanding of the mechanism of herb action, and can contribute to both greater flexibility and greater precision in herb combining. The majority of herbs have one main temperature effect, for example, Asclepias is cold, Cinnamomum bark is hot, and Agrimonia is neutral. However, some herbs can have a range of potential temperature effects, just as they can have a range of potential actions. Which of the potential temperature effects manifests in a specific situation depends on the condition of the patient and on the temperatures of the other herbs in the

24

Combining Western Herbs and Chinese Medicine

combination. These herbs are referred to in this book as

• one active constituent may have variable-temperature

variable-temperature herbs.

effects • different active constituents may have different temperature effects

Example Achillea millefolium is classified in this book as a warm-cool variable-temperature herb, that is, it can have a range of potential temperature effects that include warm, neutral, and cool.

Warm

Achillea can act as a warming diaphoretic if the patient has a cool condition, such as influenza with chills associated with Wind Cold, especially if Achillea is combined with warming diaphoretics, such as Zingiber.

One active constituent may have variable-tempera~e effects For example, Gentiana is classified as a variabletemperature herb with a temperature range of neutral-cool. The bitter secoiridoids in Gentiana may be responsible for both potential temperature effects of this herb: the neutral, bitter digestive tonic action and the cool anti-inflammatory action. Which of these two potential secoiridoid actions manifest itself will depend on the syndromes of the patient.

Neutral Achillea can act as a neutral bitter tonic if the patient has a neutral condition, such as weak digestion without signs of either heat or cold associated with Spleen Deficient Qi, especially if Achillea is combined with neutral, bitter digestive tonics, such as Marrubium.

Cool Achillea can act as a cooling diaphoretic if the patient has a warm condition, such as influenza with fever associated with Wmd Heat, especially if Achillea is combined with cooling diaphoretics, such as Sambucus.

DETERMINANTS OF TEMPERATURE

If a combination contains variable-temperature herbs, their effective temperature will be determined by the state of the patient and by the other herbs in the combination. For example, as shown below, in the combination Achillea: influenza + sore throat, the overall temperature of the combination is cool. This is because the variable-temperature herbs, Achillea and Mentha, can both have a cooling effect in the context of a Wind Heat condition, especially when they are combined with a cooling herb, such as Sambucus. -- .-. -

Herb

,-:-~ .. ~J:,:"",""-f.:.;10;~';'~~ ~':."I'!~''''f~:·;.'?'(·-~ t;;I:·~~:-

.. Daily.. dose,:". rerrifjernture .. -... '- .

. - '.",.,. ,-'"

Achillea Mentha pip. Sambucus

.

-

6g 3g 3g

.

-,'

...~

".""".'

warm-cool warm-cool cool

.;

---- .!~'.-

•

--7-~.~ "~;'c'-

Taste '

"-

acrid, bitter acrid. aromatic acrid, 51. bitter

MECHANISM OF

Different active constituents may have different temperature effects In the case of Achillea, it may be that the sesquiterpene lactones are responsible for the cooling antiinflammatory action and that monoterpenoids, such as camphor, are responsible for the warming diaphoretic action.

VARIABLE TEMPERATURE AND HOMEOSTASIS In addition to their ability to treat conditions involving mixed signs of heat and cold, some variable-temperature herbs can have a normalizing effect specifically on body temperature. If the patient'$ body temperature is pathologically low or high, these herbs can have a warming or cooling effect, respectively, and help to normalize body temperature. Thus, they can be said to assist in the body's homeostasis. For example, Lobelia has been found to be effective both in cases of extreme coldness and in high fever. Whether this homeostatic effect is due to the alkaloid constituent lobeline, or whether different constituents are responsible for separate warming and cooling effects is not known. Salvia officinalis is another herb that can be used to alter body temperature. It can be used as a warming herb for headaches or muscle aches associated with sensations of cold, and it can be used as a cooling herb for menopausal hot flashes. Salvia has a complex biochemistry, and the mechanism of its warming and cooling effects is not yet known.

VARIABLE-TEMPERATURE HERBS

VARIABLE TEMPERATURE The phenomenon of variable. t~mperature must have its basis in the biochemistry ofplant.a~,tive constituents. However, there is insufficient data .at present to go beyond speculation. Two of the factors that may contribute to variable temperature are:

The table below shows herbs that have been classified in this book as having variable temperature. Each of the herbs marked with an asterisk"" has a separate chapter in the materia medica of this book in which the reasoning behind the variable-temperature status is discussed in the Traditional sources section.

Temperature

Warm-cool Achillea*

acrid. bitter

LU. SP,HT. UT

Artemisia abs. *

bitter. aromatic.

LR.SP,UT

Artemisia vul. *

aromatic. bitter

LR. SP, UT

Hyssopus

acrid. aromatic

LU,HT

Lobelia *

acrid

LU, IN. HT. UT

Mentha pip.

acrid. aromatic

LU, ST, IN, LR

Ruta*

bitter. aromatic

KI. LR. HT. UT

Salvia off. *

aromatic, acrid

LU. HT, LR, UT

Thuja*

acrid. aromatic. bitter

LU, HT. BL, UT

Thymus*

aromatic

LU, BL. HT. UT

Centaurium*

bitter

SP, ST. 51, LR, GB

Euphrasia*

acrid. sour. bitter

LU

Gentiana*

bitter

SP, ST. 51. LR, GB

Neutral-cool

sweet

ST, IN, LU, KI. HT

Hamamelis*

sour. sl. bitter

SP, IN

Populus

bitter, sour

Sp, ST, IN. LR. BL

Potentilla*

sour. bitter

IN

Rheum*

bitter. sour

IN.ST, LR. HT

Taraxacum*

bitter

KI, BL. LR. GB, ST. IN

Glycyrrhiza*

Cool-cold

25

in lower doses, Rheum can act as a bitter digestive tonic to treat weak digestion and poor appetite associated with Spleen Deficient Qi. In this situation, it can have a moderate cooling action, if any. At higher doses, Rheum can have a strong cooling effect, for example, for a patient with severe gastritis associated with Stomach and Liver Heat.

Differences of opinion on herb temperature No perfect system for the classification of herbs by temperature has been devised. There have been differences of opinion on the temperature classification of specific herbs not only in different countries and in different centuries, but also between different authorities in the same time and place. This range of opinion can be found in both Western and Chinese herbal medicine.

WESTERN HERBAL MEDICINE For example, the temperature values given for Artemisia absinthium (wormwood) in different Western texts range from very hot to hot in the first degree:

Three main groups of variable-temperature herbs are discussed in this book: • warm-cool • neutral-cool • cool-cold Warm-cool These herbs can have either a warming or cooling effect, depending on the patient's condition. They may also have a neutral-temperature effect when they are used to treat conditions without signs of either heat or cold. In this case, they do not change the temperature balance of ,. ',~.

the patient. The example of Achill~a is given above. Neutral-cool These herbs can have either a neutral-temperature effect or a cooling effect depending on the patient's condition. For example, Glycyrrhiza can have a cooling antiinflammatory action if the patient has a hot condition, such as gastritis associated with Stomach Heat. However, if the patient has a neutral condition, such as exhaustion without signs of heat or cold associated with Kidney Deficient Qi, Glycyrrhiza can have a neutral-temperature effect. Cool-cold These herbs can have either a moderately cooling or strongly cooling effect, depending on the patient's condition and the dose in which they are used. For example.

.. - ~-,'--. :":(.

--;··~~~;~;)~·r:;r"f.r;"-;.~'_

Author

Assigned temperature

von Bingen 3

very hot

Gerard'

hot in the second degree

Tabernaemontanus S

hot in the first degree

CHINESE HERBAL MEDICINE Students reading a basic text on Chinese herbal medicine that is published in the West may see only one temperature listed for a specific herb. What they may not know is that such Western texts are brief summaries of much more detailed texts in the Chinese language, which may give not merely a consensus of opinion on the temperature of each herb. but a range of opinion from different classical texts. For example. for Angelica pubescens (du hu6), the range of opinion on its temperature from the Chinese sources summarized in the Chinese Herbal Medicine Dictionarl includes warm, slightly warm. neutral. and slightly cool.

EXPLANATION The differences of opinion on the temperature classification of a herb may be due to one or more of the following fucto~:

~

26

Combining Western Herbs and Chinese Medicine

• different traditions of use • a single herb contains both warming and cooling constituents • chemical differences in different samples of the same herb • differences in human populations Different traditions of use Different temperature values for the same herb may arise even when there are no appreciable chemical differences between different populations of the same species. The different values are simply due to different traditions of use for the same herb. For example, in the Western tradition, Commiphora has been used as a warming carminative for weak digestion with signs of cold. In the Chinese tradition, this herb (mb y1lO) has been used as a neutral-temperature herb for epigastric and abdominal pain. A single herb contains both warming and coo14lg constituents Some herbs contain some constituents with potentially cooling effect and other constituents with potentially warming effect. For example, some varieties of Achillea millefolium contain both potentially warming camphor and potentially cooling sesquiterpene lactones, and thus can have a variable-temperature effect. This may be one of the reasons why in the past Achillea has been classified in the West sometimes as slightly hot and sometimes as cold in the first degree (see the Achillea chapter). Chemical differences in different samples of the same herb These chemical differences may arise from a number of factors, including: • genetic differences in populations of the same species • different methods of cultivation • different methods of preparation

Genetic differences in populations ofthe same species In some cases, chemical differences between different herb populations of the same species may account for the difference of opinion on the temperature of the same herb. For example, Valeriana officinalis has been considered cooling by some herbal practitioners in Europe and warming by some practitioners in the USA. This difference of opinion may be linked to known chemical differences between the different geographical populations of this herb, associated with variations in chromosome number (see the Valeriana chapter).

grown with artificial light in a greenhouse and harvested before maturity. The first Salvia sample may tend to be more warming (see the Salvia chapter).

Different methods of preparation Use of the fresh or dried herb, variation in the time and temperature of storage, and differences in the method of preparation can make significant chemical differences between samples of the same species. For example, both fresh ZingIber (shengjiang) and dried Zingiber (gan jiang) can be classified as hot in Chinese medicine, but the dried herb is considered more warming to the Interior. There are real chemical differences between fresh and dried ginger that underlie this difference in temperature effects (see the Zingiber chapter). As another example, the temperature of Panax ginseng can vary considerably with the country of origin and the method of processing. Ginseng cured in rock candy-white ginseng (bcii shenF--can be used to treat Qi and rm Deficiency and can be classified as cooling. Ginseng cured by steaming-red ginseng (h6ng shen}-can be used to treat Qi and Yang Deficiency and can be classified as warming.

Caution Failure to make these temperature distinctions between different preparations of the same herb can result in adverse effects for the patient. Differences in human populations The perceived temperature effect of a herb may vary with differences in the physiology and pathology of human populations that result from differences in genetics, climate, and life-style. For example, until relatively recently, the bulk of the population in China lived in the countryside, did much physical work, lived in unheated housing, ate small amounts of home-grown food with little meat, and had relatively little medication. Such rural populations tend to have more syndromes of Deficiency and Cold. In contrast, the bulk of the population in some Western countries is urban, does very little physical exercise, lives on junk food with potentially harmful additives, and takes prolonged multiple medication. Such urban populations tend to have more syndromes of Stagnation, Deficiency Heat, and Retained Pathogen. The temperature effect of herbs on the body is likely to be different in these two populations. For example, in the urban population Panax ginseng is more likely to produce adverse effects involving Heat.

Different methods of cultivation There may he important chemical differences in samples of a single herb species due to differences in methods of cUltivation and time of harvesting. For example, a sample of Salvia officinalis grown in its natural habitat in a warm, dry climate and harvested at maturity will have a greater amount of monoterpenoids and a different chemical spectrum than a sample of the same species

References 1. Bensky D, Gamble A. Chinese Herbal Medicine Materia Medica. -Eastland Press, Seattle, Washington (1986)

~'"

-

-

Temperature 2. Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. Meyerbooks. Glenwood. Illinois (1990) 3. Von Bingen H. Hildegard von Bingen's Physica. Healing Arts, Rochester. Vermont (1998) 4. Gerard J. The Herbal or General History of Plants: The Complete 1633 Edition as Revised and Enlarged by Thomas Johnson. Dover Publi-

'_L

,

r I

27

cations, New York, New York (1975) 5. Tabernaemontanus IT. Krauterbuch (1731). Reprinted by Verlag Konrad Kolbl,Munchen. Germany (1993) 6. Jiangsu New Medicine Institute. Chinese Herbal Medicine Dictionary (Zhong yao da ci dian) Science and Technology Press, Shanghai. China (1975)

...

Taste Taste as a herbal property This refers to a theoretical system for classifying herbs according to the type of effect they have on the body. Herbs can then be selected according to the taste property to correct specific types of imbalance. For example, according to Chinese herbal theory, sweet herbs often have tonic action so that they are often selected to treat Deficiency patterns.

Concepts oftaste

...

This chapter introduces a new approach to the theory of taste, drawing on concepts from Chinese medicine, Western herbal tradition, and modern biochemistry. This movement towards an integrated approach can increase theoretical understanding and widen the clinical application of the taste concept in herbal therapy. It can also help to resolve some of

The importance of experience It is very valuable for practitioners of herbal medicine to taste and take the herbs that they use. In this way, they can compare and contrast the theoretical taste properties of each herb used with its tastes in the mouth and with its effects on their own bodies. For each herb with an individual materia medica chapter in this book, its tastes in the mouth and its taste properties are discussed separately in the section on Traditional

the apparent contradictions between the Chinese and \Vestern concepts of taste.

TASTE IN THE MOUTH AND TASTE AS A PROPERTY There are two overlapping concepts of taste: taste in the mouth and taste as a herbal property. Over the centuries, the different tastes that substances have in the mouth have been associated with different herbal effects.

sources.

Taste in the mouth

The classification of herbs in terms of taste can facilitate herb choice in two main ways:

IMPORTANCE OF THE TASTE PROPERTY

This relates to taste as a sensation-to

what the herb actually tastes like in the mouth and on the tongue. This subjective experience has a foundation in physiology and biochemistry. There may be individual variations in the quality and intensity of the taste experience, and there may be cultural differences relating to differences in linguis-

• by providing a simple overview of herbal groups • by acting as a sophisticated method for the mutual balancing of herbs in a combination

tic concepts or patterns ofnutrition. However, there is a general consensus of experience and most people experience quinine as bitter, honey as sweet, cayenne as acrid, and ,", lemons as sour.

29

Overview Dividing herbs according to their taste properties gives the practitioner about five herb groups to choose from when assessing a situation. This is a more manageable number of groups for getting a preliminary overview than

-,

Combining Western Herbs and Chinese Medicine

30

the 20 to 30 action categories, and it is not as restrictive as would be the two choices offered by the Yin-Yang division. For a more detailed classification, each taste can be subdivided into action categories, as discussed in the individual taste sections below. Balance At the basic level of herb combination, herbs can be selected according to their action categories to match the patients syndromes. In addition to this, at a more sophisticated level of herb combination, taste properties can be used . to optimize the balance between the herbs in the combination. This is discussed in the Balancing the tastes section in this chapter, which contains a table of the 20 main taste combinations that can be used in the clinic. It is also discussed in the Taste section of the Principles of herb combination chapter.

CHINESE AND WESTERN CONCEPTS OF TASTE

sidered to be a taste, but in this book, I have used it as such (see discussion in the Aromatic section), I have not included the salty taste property of Chinese medicine since I fmd this taste to be rare in the Western herbs that I use in clinical practice. I have included the astringent property with the sour taste property since there is such a close overlap between the two. Finally, the Chinese category of bland is not used as a taste property in this book.

CHANGING CONCEPTS OF TASTE Concepts of taste property are currently in the process of change and expansion due to input from three different sources: Chinese herbal tradition, Western herbal tradition, and modern biochemistry. Each of these three systems can make valuable contributions to the understanding of taste, and each has its limitations or blind spots. It is important to keep an open mind in order to see beyond the limitations of each system if a useful integration is to be achieved in the future.

This section very briefly introduces the Chinese and Western concepts of taste and the taste classification used in this book. These are discussed in greater detail in the sections on the individual tastes. Chinese herbal tradition In Chinese medicine, there are two main taste classifications; one is associated with Chinese herbal tradition, and the other is associated with Five Element theory. In both classifications, there are five main taste properties: bitter, sweet, acrid, sour, and salty. However, the effects associated with each of the five tastes are not necessarily identical in the herbal and the Five Element models. For example, in the herbal model, bitter is often associated with clearing Heat and Damp, whereas in the Five Element model, it is associated with tonifying the Heart. Also, in the herbal model, the additional properties of aromatic, astringent, and bland are often used together with the five tastes. Western herbal tradition In the West, the Galenic system described each herb in terms of its temperature (whether warming or cooling) and moisture (whether drying or moistening), and the body parts on which the herb acts. However, in this system, there was less emphasis on the taste property than in Chinese herbal medicine. More recently in Western herbal medicine, individual taste sensations have been associated with specific herbal effects, for example, bitter with the digestive tonic action and aromatic with the . , . '. carminative action. ........ . . ,:

",

This book The five taste properties used in this book are bitter, sweet, sour, acrid, and aromatic. I am aware that in Chinese medicine, the aromatic property is not strictly con-

Chinese herbal tradition The Chinese herbal system of taste properties gives a framework of clear, simple concepts for classifying herbs and matching them to syndromes. Perhaps most importantly, it contributes a system of matching herbs with each other according to taste to produce a balanced combination. The limitation of the Chinese system is that it has remained relatively static for a long time, without further evolution of its concepts. As in the history of the Galenic system in the West, respect for the authority of tradition may have reduced rigorous critical investigation and discussion, and slowed the evolution of ideas. Western practitioners are reevaluating the concepts of traditional Western phytotherapy in the light of the theories of Chinese medicine. Perhaps it is time for Chinese practitioners to reevaluate the concepts of taste in view of ideas from Western herbal tradition and from modern biochemistry. This would be especially valuable in the case of the aromatic, bitter, and sweet properties. Western herbal tradition In the West, from the time of Galen to Culpeper, concepts of taste were not as clearly developed or as well organized as in China. However, Western herbal therapy has more recently made major contributions in this area with respect to understanding and utilization of the bitter and aromatic concepts. This is discussed in the individual sections on these tastes. Biochemistry and taste On the one hand, the concepts of taste from Chinese and Western herbal tradition can contribute to the application of phytopharmacology to clinical

r."

Taste practice. On the other hand, concepts and detailed information from phytochemistry and phytopharmacology can help to give breadth and depth to the understanding of taste. Contribution of taste to biochemistry There is a vast number of individual active herb constituents. 'Whilst these can be organized into major chemical groups, such as phenols and steroids, there is as yet no clear and simple system in phytopharmacology to match individual constituents, or even major chemical groups, to the syndromes of the patient. The structured framework of the taste concept can be used to give some organization to the apparent chaos of the biochemical data. To the degree that active constituents can be classified in terms of taste, they can be linked to herb actions and thus to the treatment of specific syndromes. For example, if a constituent is bitter, it may have one or more of the potential actions associated with this taste, for example,

it may function as a digestive tonic. Contribution of biochemistry to taste Research on active constituents and their pharmacological effects have demonstrated new practical uses for phytochemicals with a specific taste. For example, some chemicals with the sweet taste have been shown to have immunoregulatory effect. In addition, each t:tste can be subdivided into groups according to its chemical type and pharmacological effect. For example, sweet phytochemicals can be divided into the

following groups:

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• nutrient carbohydrates • demulcent mucopolysaccharides • immunopolysaccharides • adaptogenic triterpenoid saponins The contribution of new practical uses and a system of subdivision of the taste types can lead to a more profound understanding of taste and a wider clinical application of each taste group.

Bitter The bitter taste sensation follows stimulation of the bitter taste receptors on the tongue. Substances differ in the intensity of the bitter sensation they evoke and are sometimes given bitterness values. For example, the most abundant bitter secoiridoid in Gentiana root is gentiopicroside with a bitterness value of about 12,000. However, the most important bitter component in Gentiana root is amarogentin, which, although only present in tiny amounts, nonetheless has a bitterness value of 58,000,000 (see the Gentiana chapter).

31 CHINESE HERBAL TRADITION According to the Five Element theory, the bitter taste tonifies the Heart. However, most of the herbs classified as bitter in modern Chinese materia medica are not listed as tonifying the Heart, and in the herbal tradition, bitter is more associated with reducing Excess conditions. For e.xampIe, it can be associated with the following actions: l • drains Damp • clears Heat • drains downward • purges stools • clears Lung Phlegm Drains Damp In some circumstances, the bitter property can be associated with draining Damp regardless of whether the Damp is associated with Heat or Cold. 2 It should be noted that not all herbs that drain Damp and promote urination are classified as bitter; some are sweet, like Zea (yu mi xu), or sweet and bland, like Poria (m ling). Clears Heat In some circumstances, the bitter property can be associated with clearing Heat from the organ systems, whether Heat from Stomach or Heart, or Damp Heat from Liver or Bladder. Many herbs that are listed as clearing Wind Heat, Summer Heat, Heat, Heat in the Blood, Damp Heat. or Heat Toxin are classified as bitter. For example, Coptis (huang Han) can cool the Blood, clear Heat Toxin, clear Heat in the Heart or Stomach, and clear Damp Heat in the Intestines. However, not all herbs that clear Heat do have the bitter property. Gypsum (shi gao) is sweet and acrid, Lophatherum (dan zhli ye) is sweet and bland, and Calcitum . (han shui shi) is acrid and salty. Drains downward In some circumstances, the bitter property can be associated with the tendency to move Qi downwards as in the following actions: • redirects Lung Qi to treat cough, for example, Prunus armeniaca (xlng ren) • redirects Intestines Qi to treat constipation, for example, Rheum (cia huang) • drains Heart Heat out through the unne, for example, Akebia (mil tong) Purges stools Whilst most herbs listed as bitter are not purgatives. most herbs in the laxative, purgative, and cathartic categories of Chinese medicine are classified as bitter. Most of these bitter herbs that move stool are cold or cool and are especially appropriate for constipation due to Heat, for example, Rheum, Cassia (fan xie ye), and Aloe (1ti hul).

Combining Westet:n Herbs and Chinese Medicine

32

Clears Lung Phlegm In some circumstances, the bitter property can be associated with dissolving Phlegm and relieving cough. Prunus armeniaca is an example of a warm, bitter antitussive, and Euphorbia (ze qI) is an example of a cool, bitter, and acrid expectorant. Bitter herbs that clear Phlegm are often also acrid (see the Acrid section in this chapter).

Summary of Chinese tradition Whilst the Five Element theory proposes a tonic action for the bitter taste, the herbal tradition emphasizes its reducing: downward-moving, and drying effects. \NESTERN HERBAL TRADITION In the last century of Western herbal tradition, the bitter taste has been associated with the following actions: • bitter digestive tonic • bitter general tonic • bitter cholagogue and hepatic Bitter digestive tonic In the Western tradition, bitter herbs have been used to treat the lack of appetite and digestive weakness.3.4·5.6 More recendy, it has been suggested that bitter herbs may help to treat malabsorption, gastrointestinal infection, and food allergies (see the Biochemical perspective section below). Bitter general tonic The general tonic effect of the bitter herbs may largely depend on their digestive tonic action. In terms of Chinese medicine, it can be said that some bitter constituents can tonify and move the Qi of the Spleen, Stomach, and Intestines, and thus indirectly help to tonify Qi and Blood. In the Western tradition, bitter herbs have been used to treat exhaustion, anemia, weight loss, and associated muscular weakness and mus~ular atrophy.3.4.5.6 It has recendy been suggested that bitter herbs may help to strengthen the immune system.7 Bitter cholagogue and hepatic Bitter herbs have a tradition of use in the West to strengthen the secretion and flow of bile, and to treat disorders of the liver and gallbladder.3.4. 5.6. 7 Expressing this Western use in terms of Chinese medicine, it can be said that some bitter herbs can tonify and move the Qi of the Liver and Gallbladder. ,Other actions of bitter herbs The main emphasis in the use of bitterherbs in the,West has been on ~eir general tonic, digestive tonic, cholagogue, and hepatic actions. However, herbs with the bitter taste are found in other Western action groups, especially the following:

• antimicrobial, antipyretic, and anti-inflammatory • cardiotonic • tranquilizer These are discussed in the section Combining the Western and Chinese perspectives below. BIOCHEMICAL PERSPECTIVE Bitter herbs, or more precisely, bitter constituents, can be said to have three main levels of activity: • general bitter effects • effects shared by members of a particular chemical group • effects specific to an individual chemical General bitter effects All substances that stimulate the bitter taste receptors at the back of the tongue may set off a cascade of events in the gastrointestinal and hepatobiliary systems. These may include stimulation of appetite, flow of saliva, flow of digestive secretions from the stomach, intestines, and pancreas, and stimulation of the secretion and flow of bile (see the Research section in the chapters on Artemisia and Gentiana). Increase in bile flow may then have a laxative effect. This subject has been reviewed by Mills and Bone/ who noted that reduced gastric secretion can lead to abnormal bowel flora, malabsorption of nutrients, and an increased tendency to enteric infection. By increasing gastric secretion, bitter herbs may thus help to treat these conditions. In addition, reduced gastric secretion may lead to the inadequate breakdown of polypeptides. This may result in an increase in potential antigens and an increase in allergic responses related to foods. By increasing gastric secretion, bitter herbs may therefore help in the prevention and treatment of food allergies. It was also suggested that bitter herbs may assist in the normalization of blood sugar levels and the stimulation of the immune function. Effects shared by members of a particular chemical group In addition to the general bitter effect, each substance may then have additional effects characteristic of the chemical group to which it belongs. For example, the quinoline alkaloid group, to which quinine and quinidine belong, can have antimalarial and cardioregulatory effects. Many different chemical groups can produce the bitter taste sensation. For example, each of the following groups contains some substances with the bitter taste: monoterpenoids, sesquiterpenoids; sesquiterpene lactones, diterpenoids, triterpenoids, iridoids, flavonoids, and alkaloids. This great variety of chemical types may explain why bitter herbs can have such a wide range of actions.

-,...

Taste Effects specific to an individual chemical Each bitter substance may have effects that are specific to its unique individual structure. For example, within the quinoline alkaloid group, quinidine is a stronger antimalarial than quinine and has more risk of cardiotoxicity (see the Cinchona chapter).

lvlultiple effects of a single bitter chemical It is interesting that some bitter chemicals can have most of the actions that have been associated with bitter herbs above. For example, the alkaloid berberine, present in Berberis and Hydrastis, has been reported to have choloretic, hepatic, antimicrobial, anti-inflammatory, cardiotonic, and respiratory effects. It would be interesting to determine if a specific chemical structure can be associated with this range of actions and if this structure can also stimulate the bitter taste receptors.

33

General tonic exhaustion anemia weight loss muscular weakness muscular atrophy weak immune system Digestive tonic lack of appetite digestive weakness malabsorption gastrointestinal infection food allergies

Hepatobillary tonic

COMBINING WESTERN AND CHINESE PERSPECTIVES The Western emphasis on tonification and the Chinese herbal emphasis on reducing and cooling seem to be irreconcilable opposites, but they can be regarded as just the two

depression epigastric and abdominal distension nausea intolerance of fatty foods reCOliery from habitual overeating recovery from substance abuse recovery from prolonged medication gallstones constipation

Antimicrobial infections such as: recurring respiratory infections acute bacillary dysentery urogenital infections boils AntI-Inflammatory inflammatory disorders such as: gastritis colitis cystitis arthr,itis Antipyretic disorders with fever such as: acute influenza acute tonsillitis mononucleosis malaria some chronic fatigue syndromes

ends ofa spectrum ofbitter actions. -·-tonifies Qi.~.:~b~esQi ... clears H~at

.

';,'--

T~e

~

..

':--.''; ~-..,~"':":~--'-~

action of moving Qi acts as the bridge between tonifying

Qi and clearing Heat. Stagnant Qi can be associated with Deficient Qi, as in exhaustion and depression, or it can be associated with accumulation of Heat and Damp, as in recurring diarrhea with sensations of heat. In more complex conditions, Stagnant Qi can occur with patterns of both Deficiency and Heat, as in some cases of weak digestion with chronic gastrointestinal inflammation. Bitter herbs, depending on their temperature, can be used in all of these situations. Six potential bitter actions The table below shows six of the main potential actions of bitter herbs, together with some of their associated uses. These six actions can be divided into two groups as follows:

• tonic actions:

general, digestive, and hepatobiliary tonic

• cooling actions: r:'

antimicrobial, antiinflammatory, and antipyretic

The tonic actions are associated with tonifying Qi and moving Qi, and the cooling actions are associated with clearing Heat and moving Qi.

Which of these actions manifests in a particular situation will depend on the state ofthe patient, on the other herbs in the combination, and on the temperature ofthe bitter herbs. Use of bitters for hepatobiliary stagnation In Chinese medicine, the syndrome of Stagnation of Liver Qi can have many manifestations and ramifications. These include depression, nausea, indigestion with epigastric and abdominal distension or discomfort, gallstones,.constipation, intolerance of fatty foods, and recovery from substance abuse or prolonged multimedication. By moving Liver Qi, bitter herbs can therefore assist in the treatment of a wide range of conditions. (See the Research sections in the Berberis and Gentiana chapters for hepatobiliary effects of bitter active constituents.) Western use of bitter herbs to treat hot conditions It is interesting to note Culpeper's use of the bitter herb Berberis to cleanse the body of 'choleric humors' (associated with anger), to clear heat from the liver and .from the blood, and to treat jaundice, itching skin disorders, boils, and fever. 8 Also, Lonicerus wrote that Berberis is good for headache if it is a result of heat and acidity from gallbladder disease. 9 In Chinese medicine terms, this would be equivalent to clearing Heat or Damp Heat from the Liver-Gallbladder, clearing the resulting Blood Heat or Damp Heat from the skin, and reducing Liver Hyperactive Yang associated with Liver-Gallbladder Qi Stagnation.

Combining Western Herbs and Chinese Medicine

34

Antimicrobial. antipyretic. and anti-inflammatory actions

strong downward effect on it, and they are cool or cold in

In Chinese herbal tradition. the main emphasis for the bitter herbs is on clearing Heat and Damp. In terms of Western herbal medicine. this translates into the antimicrobial. antiinflammatory. and antipyretic actions. It is not stated in Western tradition that bitter herbs are specific for infections, inflammations, and fever. However, bitter herbs have been used just as much for these disorders as they have been used for general debility, atonic digestion, and hepatobiliary weakness. (See the Research sections in the Berberis and Gentiana chapters for antimicrobial. antipyretic, and antiinflammatory actions of bitter active constituents.)

temperature. Additional actions of bitter herbs Two further actions associated in the Chinese herbal tradition with the downward~moving aspect of the bitter taste have been noted above: purgative and antitussive actions.

Purgative In China, the bitter taste is also associated with .the purgative action, that is. to direct Intestines Qi downward and move the stool. Whilst most of the purgative herbs used in the West have a bitter taste. such as Rhamnus and Rheum, these actions are not generally regarded as specific to the bitter taste.

Alterative action of bitters In my opinion, certain bitter herbs have the capacity to treat recurring fever by their alterative action of clearing toxins from the body or, in Chinese medicine terms, by clearing Retained Pathogens. The three bitter effects of tonifying Qi, moving Qi. and clearing Heat can combine to do the following:

• tonifies Qi

• moves Qi

helps to strengthen the natural ability of the body to clear pathogens from the system and to prevent further infection helps to clear pockets of Stagnation with accumulation of pathogens and toxins that may act as foci for recurring infections

• clears Heat can allow the Qi and Ym to rebuild to speed convalescence This is discussed in the Cinchona chapter in the section

Possible mechanism ofantipyretic effects. Bitters herbs and the Heart There are two very different groups of bitter herbs with effects on the Heart: one group has tonic action, and the other has a calming. reducing, and cooling action.

Tonics The bitter taste is said to tonify the Heart in the Chinese Five Element tradition, and there is a minor tradition in Western herbal therapy that states that the heart can be strengthened by bitter herbs. Some of the cardiotonic herbs used in the West have a bitter taste, such as Cinchona. Convallaria. Leonurus, and Sarothamnus, but other cardiotonic herbs, such as Crataegus, are not appreciably bitter. These cardiotonic bitter herbs can be said to tonify and stabilize Heart Qi, and ijiost of them are more or less neutral in temperature. Tranquilizers Most Western herbs that have a strong tranquilizing action also have the bitter taste, for example, Anemone, Gelsemium, Humulus, Piscidia, and Valeriana. These herbs can be said to calm the Heart Spirit by having a

Antitussive Two other actions associated with the bitter taste in the Chinese herbal tradition are the antitussive action, that is. directing Lung Qi downward, and the expectorant action, that is, clearing Lung Phlegm. In the West, whilst some herbs with antitussive and expectorant action have a bitter taste, such as Marrubium, these actions are not linked specifically to the bitter taste.

DIRECTION OF ENERGY OF BITTER HERBS The effect of a bitter herb on the direction of energy movement depends on its specific actions and the organs it affects. Stomach and Intestines In the Western view, bitter substances can stimulate the bitter taste receptors, thus increas- - • ing gastrointestinal and hepatobiliary secretions. This can be described as a tonic effect that can assist in the normalization of the natural downward movement in the stomach and intestines. This is a different emphasis from the downward movement proposed by the Chinese herbal tradition. which can involve purgative and diuretic actions, with an overall reducing effect on the body. Liver and Gallbladder Stimulation of hepatobiliary function can be said to include dispersal of Liver Stagnant Qi. This movement is not limited to the downward direction since it can have upward, downward. and horizontal components. Some bitter constituents, for example, the bitter constituents of Piscidia, can reduce the disturbed upward movement of Liver Yang, to treat headaches and migraines. Heat clearance In the West, bitter herbs are commonly used as antimicrobials, anti-inflammatories, and antipyretics, and these actions can be related to the action of clearing Heat in Chinese -medicine. However, these Western actions are not necessarily associated with the clearance of Heat by downward movement via the stools and urine, as proposed for the bitter taste in the Chinese herbal tradition.

Taste Heart In the Chinese Five Element tradition, the bitter taste is said to tonify the Heart, but no specific effect on the direction of energy movement is proposed. The same is true of the Western concept of the cardiotonic effect of bitters. However, the bitter herbs with tranquilizing action can be described as having a downward-directing effect on the pathological upward movement of Heart Spirit or Liver Yang.

Summary Bitter herbs, or more specifically bitter constituents, may help to normalize the natural downward movement in the stomach and intestines, and help to spread Liver Qi. They may also have one or more of the following effects, depending on their specific chemical structure: • nondirectional antimicrobial, antipyretic, and antiinflammatory actions • nondirectional cardiotonic action • downward-directing tranquilizing action • downward-directing diuretic or purgative action

TEMPERATURE OF BITTER HERBS In itself, the bitter property tends to be either neutral, as in some of the digestive tonics, cardiotonics, and tranquilizers; or cooling, as in some of the antimicrobials, antipyretics, anti-inflammatories, and sedatives. Warm bitter herbs generally have bitter combined with acrid, for example, Myrica and Sanguinaria. The wide variation in temperature among Western herbs with the bitter taste, from warm to cold, is illustrated by the following examples: Temperature warm

neutral

Examples Myrica for patterns of Deficiency, Stagnation, and Cold, such as exhaustion and depression with sensations of cold Marrubium for patterns of Deficiency and Stagnation, with or without Heat or of Cold, such as a weak cough with sensations of obstruction in the chest

neutral~ool

Gentiana for patterns of Deficiency and Stagnation with some Heat. such as weak digestion with gastroenteritis

cool

Berberis for patterns of Stagnation and Heat with or without some Deficiency, such as cholecystitis with sensations of heat

cold

Asclepias for patterns of Excess Heat. with or without Stagnation, and in the absence of DefIciency. such as acute respiratory infections with fever

CAUTIONS Chinese herbal tradition

It must be clearly understood

35 that in the Chinese herbal tradition, cautions and contraindications for bitter herbs depend on their temperature, rather than on the bitter quality itself.

Cool or cold bitter herbs Chinese contraindications for Cold Deficient patterns of the Spleen and Stomach, especially with diarrhea, are related to the temperature, rather than to the bitter property itself. Cool or cold bitter herbs are contraindicated or to be used with caution for Cold Deficient conditions of the Spleen and Stomach, especially with loose stools or diarrhea. However, sweet cold herbs may be similarly contraindicated for Cold Deficient patterns of the Spleen and Stomach since it is not the taste but the cold temperature that is damaging to the Spleen. Warm 'or hot bitter herbs In contrast to cooling bitter herbs, warming bitter herbs may be indicated for Cold Deficient patterns of the Spleen and Stomach. For example, Evodia (wti zhii yti) is indicated for diarrhea from Cold Deficient Spleen and Kidneys. Warm bitter herbs are generally contraindicated for Heat patterns, especially Deficiency Heat associated with Deficient Ym. Western herbal tradition Some texts contraindicate certain bitter herbs in cases of gastric ulceration or hyperacidity due to the possibility that they may increase the secretion of gastric acid and aggravate these conditions. However there is evidence to suggest that these herbs can reduce rather than increase the potential for gastric irritation (see the Toxicology section in the Gentiana chapter).

Sour In the mouth, the sour taste and the astringent effect can be differentiated as follows:

• sour taste • astringent effect

'sharp: acid taste oflemon juice or vinegar puckering or drying effect on the mouth and tongue

The sour taste is not necessarily accompanied by a puckering effect, nor is the astringent effect necessarily accompanied by a 'sharp' taste.

CHINESE HERBAL TRADITION In the Five Element tradition, the sour taste is said to tonify the Liver. In the Chinese herbal tradition, the concepts of sour (suan) and astringent (se) are very close. Most of the herbs in the astringent action group are classified as sour, although there are exceptions, and the main manifestation of the sour taste is the astringent action.

36

Combining Western Herbs and Chinese Medicine

Astringency is associated with firming and stabilizing the Qi to hold things in their proper place. This includes not only the prevention of leakage of fluids and of organ prolapse, but also the stabilization of the organ functions, including their mental and emotional aspects. By firming and stabilizing the Qi, the astringent action can counteract three related pathologies: • Deficiency of the holding function of Qi • Excessive dispersal of Qi • Qi not holding Spirit firm Deficiency of the holding function of Qi This is Deficiency of a very specific function of Qi-not the warming, moving, or activating aspect-but the special function of holding things firm and stable and in their proper place. If this function of Qi becomes weakened, then there may be leakage of fluids through cell walls, leakage of blood from capillaries, loss of sweat through the pores, leakage of urine or stool through atonic sphincters, and the prolapse of organs. Excessive dispersal of Qi If the condensing and concentrating function of Qi is weak, there may be an excessive, dispersing, outward movement leading to loss of energy from the body and to a diffusive and scattering effect on the Qi. If the Defensive Qi becomes less dense and more diffuse, it is easier for pathogens to enter the body, resulting in chronic or recurring illnesses. If the Qi of the Kidney becomes more diffuse or scattered, mental concentration becomes more difficult, and it may become more difficult to focus the will to get things done. Qi not holding Spirit firm Weakness in the capacity of Qi to hold the Spirit firm and stable may result in the disturbed upward movement of energy in the body, with symptoms such as mental or emotional instability, anxiety, insomnia, and palpitations. Schisandra is an example of a herb that can be used to counteract all three of these pathologies since it can:

• reduce excessive dispersal ofQi to treat excessive sweating and reduce the side effects of dispersing herbs, such as Ephedra

• strengthen the holdingfunction of Qi to treat urinary frequency, diarrhea, and vaginal discharge

• strengthen the holdingfunction ofQi to firm and stabilize Heart Spirit to treat insomnia and palpitations

,WESTERN HERBAL TRADITION . , Sour taste There does not appear to have been a clear concept of the sour taste in the West comparable to that of Chinese medicine. However, Gerard 10 described the juice of

the lemon as 'sharp' and stated that it 'cutteth, divideth, and maketh thin, gross, tough, and slimy humors? Lemon juice has been used in Western folk medicine to cleanse the liver and to treat liver and gallbladder disorders. In Britain, greasy fish and chips are usually drenched with vinegar, and this can be associated with the sour taste assisting the liver to deal with this intake of oily food. 11

Astringent action Lonicerus and Tabernaemontanus used the term 'ziehen zusammen' (to draw together) to describe herbs, such as Achillea, that are used to stop hemorrhages and the leakage of stool, sperm, or vaginal discharge. Christopher described astringents as 'herbs that influence the vital contractility of cell walls, condense the tissues, make them denser and firmer, and arrest discharges.' The emphasis in the West is on what can be called the material aspects of astringency, that is, on preventing the leakage of the fluids and holding the organs in their proper place. Western astringent herbs are therefore used internally to treat disorders, such as diarrhea, bleeding, discharges, urinary incontinence, and organ prolapse, and locally to treat varicose veins, hemorrhoids, wounds, and ulcers. Western herbal therapy does not appear to possess a concept comparable to the Chinese idea of the energetic aspect of astringency in terms of firming the energies of organ systems and stabilizing the mind and emotions.

BIOCHEMICAL PERSPECTIVE Sour taste The sour taste sensation may result from the stimulation of the sour taste receptors by hydrogen ions. Sour-tasting compounds are often carboxylic acids, such as acetic acid (as in vinegar), citric acid (as in lemon juice), and oxalic acid (as in Rumex). Tannin astringents Local astringent effects, and the puckering sensation produced by many astringents on the mouth and tongue, are most commonly associated with tannins (see the Potentilla chapter).

Bioavailability of tannins This topic has recently been reviewed/ and in the present state of knowledge, it appears that intact tannin molecules have poor bioavailability. This is perhaps fortunate since intact hydrolyzable tannins in the blood have been reported to be hepatotoxic. However, the bowel flora breaks down tannins into smaller phenol molecules that can be absorbed through the gut wall into the blood and can have antioxidant effects in the body. Therefore, whilst tannins can have local astringent and antihemorrhagic effects on the mucosa of the mouth, stomach, or intestines, there is currently no evidence to indicate that they can produce these effects at sites remote from the

Taste

37

gut. It is therefore necessary to verify traditional claims for tannin-containing herbs that they can treat disorders such as hemoptysis, menorrhagia, or urinary incontinence. It is possible that the products of tannin breakdown in the gut may contribute to astringent and antihemorrhagic effects at sites remote from the gut, but this has yet to be demonstrated.

Relatively material aspect This refers to the relatively more

Nontannin-containing astringents Substances other than tannins may have local astringent or antihemorrhagic ef-

nins.

fects, as for example in the following herbs:

Relatively energetic aspect This refers to the relatively more

• Calendula

antihemorrhagic and vulnerary actions may be due to resinous constituents

• Capsella

antihemorrhagic action may be due to

• Capsicum • Commiphora

a peptide antihemorrhagic action may be due to the amide capsaicin antihemorrhagic and vulnerary actions may be 9,ue to both resinous and polysaccharide constituents

Equisetum and Hydrastis also have astringent or antihemorrhagic actions, and have not been reported as containing appreciable quantities of tannins. Astringent mechanisms Three possible components of the astringent mechanism can be summarized as follows. 1. Tannins or other chemicals may have local effects on the gut mucosa, following oral administration, or on the surface of the body, following topical application. 2. Substances may be absorbed through the gut wall and travel in the bloodstream to target tissues remote from the gut. 3. Substances may first strengthen the function of the organ systems, resulting in indirect astringent effects. For example, in terms of Chinese medicine, Schisandra may reduce diarrhea by first firming Kidney Qi, or Astragalus may treat diarrhea by first tonifying the Qi and Yang of the Spleen. However, there is as yet no data linking astringency to the systemic effects of plant constituents.

COMBINING WESTERN AND CHINESE PERSPECTIVES The discussion below links elements from Chinese medicine and Western herbal tradition. 1\vo aspects of astringency Sour herbs can be said to manifest two main aspects of astringency, the relatively material and the relatively energetic.

material manifestations of astringency, such as reduction of leakage of fluids and treatment of organ prolapse. In the West, astringent herbs are used to treat these more material aspects. Most Western astringent herbs can be classified as sour, such as Geranium and Vinca, or sour and bitter, such as Polygonurn and Sanguisorba, and most of them contain tan-

energetic manifestations of astringency, that is, stabilizing organ functions, especially their mental and emotional aspects, to treat such disorders as palpitations and dreamdisturbed sleep. Western contribution The contribution of the Western herbal tradition lies not so much in theoretical concepts of astringency, but in the development of the use of a wide range of astringent herbs. For example, Myrica can be used as a warming, anticatarrhal astringent to treat diarrhea with mucus in the stools and sensations of cold. Polygonurn bistorta can be used as a cooling, demulcent, anti-inflammatory astringent to treat diarrhea with intestinal inflammation and sensations of heat. Up to the present, there have been few research studies on the mechanism of astringency, and of these studies, most have focused on the tannins. In the future, research studies may reveal a variety of astringent mechanisms, involving both local and systemic astringent effects. Chinese contribution The specific contribution of Chinese medicine is in regard to the relatively energetic aspects of astringency, especially the use of sour astringent herbs in the treatment of mental and emotional disorders. In terms of Chinese medicine, if the Qi does not perform its function of firming and stabilizing the energies of the organ systems, their normal rhythm and direction of movement may become disturbed, as in the irregular upward movement of Heart Spirit Disturbance. Cardioregu1ators and nervines The Chinese concepts of the energetic aspects of astringency can be applied to the Western action concepts of cardioregulators and nervines. Herbs with these actions can be used to strengthen and stabilize the function of the coronary and nervous systems, respectively. In some of these herbs: the sour astringent property may contnbute to the stabilizing effect

.

Cardioregulator . In terms of Western herbal medicine, a cardioregu1a~r ca:n be defined as a herb that by strengthening the heart can stabilize i~ function and treat conditions such as arrhythmia. labile blood pressure, and fluctuations in energy and. body temperature. In terms of Chinese medi-

38

Combining Western Herbs and Chinese Medicine

cine, a cardioregulator can be said to tonify Heart Qi, and, by doing so, firm and stabilize Heart Qi to treat the syndrome of Heart Qi Irregularity. The two main cardioregulatory herbs listed in this book are Crataegus and Leonurus. Both have a sour taste in the mouth and are ascribed the sour astringent taste property in this book. They can be said to have astringency with respect to the specific function of firming and stabilizing Heart Qi. A cardioregulator can be said to treat problems of the coronary system (Heart Qi Irregularity), rather than the nervous system or the mind and emotions (Heart Spirit Disturbance), and Crataegus is a good example of this. However, in addition to tonifying and stabilizing Heart Qi, Leonurus can also calm Heart Spirit Disturbance. It can thus be used to treat anxiety in addition to cardiac weakness and arrhythmia.

Nervines These can be defined as herbs that tonify and stabilize the nervous system. They can be used to treat depression and emotional instability, especially when these are . associated with physical, emotional, and mental exhaustion. In terms of Chinese medicine, nervines can be said to tonify the Qi or Y'm of the Kidney, and the Qi, Y'm, or Blood of the Heart, and to firm and stabilize Heart Spirit. Some nervine herbs have a sour taste in the mouth and can be assigned the sour astringent taste property, for example, Hypericum and Schisandra. In my opinion, both these herbs can firm and stabilize Kidney Qi. This can reduce the diffusing, dispersing, and disturbing effect of fear on the Kidney itself, and lessen the disturbing effect of fear on the Heart. They can also firm and stabilize Heart Spirit, and can thus be used in combinations for enuresis and dream-disturbed sleep associated with fearfulness and anxiety. DIRECTION OF ENERGY The astringent property can be said to hold things firm, stable, and in their proper place. It can be seen as a passive effect of maintenance, rather than an active effect that moves energy in a particular direction. It can, thus, control excessive outward movement of energy and fluids, but it does not in itself produce an active inward (centripetal) movement of energy. It can also control the excessive disturbed upward movement of energy, but it does not actively direct energy downward.

TEMPERATURE The,~~tionof Qi t? hold things firm and in their proper place is not, in itself, associated with either warming or cooling effects. Most of the astringent herbs that have been classifiedin this book as only sour or slightly sour are neutral in temperature, for example, Capsella and Geranium.

Herbs classified as having both the sour and bitter tastes are also mainly neutral, for example, Agrimonia and Quercus. Some .herbs with both the sour and bitter tastes are listed as neutral-cool or cool, and this may be associated with the anti-inflammatory bitter constituents, as in Filipendula and Hamamelis. Sour astringent herbs that are warming, such as Myrica and Schisandra, are not common, and the warming effect of both these herbs may be due to the acrid constituents.

CAUTIONS Chinese herbal tradition Astringent herbs are contraindicated for Exterior conditions that are not fully cleared since astringents will reduce the outward dispersive movement needed to clear Exterior pathogens through the body surface. This includes skin rashes that are in the process of expressing. In apparent contradiction to this, Schisandra has been used for allergic skin disorders. However, I do not generally use Schisandra in the acute stage of allergic skin disorders associated with Wmd Heat. I use Schisandra in the chronic or remission phase associated with Kidney Deficient Qi. For example, in this book, Schisandra is not included in the combination Arctium: recurring urticaria: acute phase, but it is included in Arctium: recurring urticaria: remission phase. Astringent herbs are also contraindicated in Chinese medicine for Interior Stagnation since they may reduce the dispersing, moving effect required to clear the Stagnation. Warm astringents, such as Schisandra, are especially to be avoided in cases of Interior Stagnation with Heat. Western herbal tradition Astringent herbs are contraindicated when it is necessary to allow toxins to clear from the body via sweat, urine, stools, or discharge. Also, there are specific cautions to be used for astringent herbs with a high tannin content (see the Toxicology section in the Potentilla chapter).

Sweet In the Chinese herbal tradition, the sweet taste is associated with the taste that rice gives in the mouth on chewing; it is not associated with the intensely sweet sensation of sugar, as in the West. This cultural difference explains why some Chinese herbs that are listed as having the sweet property do not taste sweet to Westerners. For example, PanaX ginseng is listed as sweet and slightly bitter in property. However, to most Western people, brought up on massive amounts of sweet foods and candies, the taste in the mouth is primarily bitter, and not all Westerners can detect a sweet taste.

Taste CHINESE HERBAL TRADITION Five Element tradition In this tradition, the sweet taste is said to tonify the Spleen and is linked with Earth. This element can act as the center reference point to which other things are linked and around which they have their movement, giving them stability and balance. The material solidity and weight of the Earth element can be associated with a dampening of excessive movement away from the central position and, therefore with a moderation of extremes. Earth and the sweet taste can also be associated with nourishment, especially of the material aspect of Qi. Herbal tradition In this tradition, the following effects have been associated with the sweet taste property:! • tonic • moistening • antispasmodic ,.; '" • harmonizing of emotions • harmonizing of other herbs • moderation of other herbs

Tonic In Chinese medicine, the sweet taste is associated mainly with the ability to tonify Qi, Blood, ¥m, or Yang. It is especially associated with the nourishing function of Oi. that is, the capacity to increase the solid substance of the body. A good example of a herb with this effect is Ziziphus fruit (da zao). Moistening Closely associated with the nourishing action of the sweet taste is its moistening effect-the ability to tonify Fluids. For example, Pseudostellaria (tai z1 shen) and Ophiopogon (mai men dong) are used for their moistening effect.\2

Antispasmodic Some herbs with the sweet taste can reduce muscle spasms and alleviate pain. This is said to be due to the sweet taste nourishing the rm of the tendons and thus relaxing the muscles. l Glycyrrhiza is such a herb. Angelica sinensis (dang gui) can also relieve pain, and this may result partly from its ability to tonify the Blood. nourish the muscles. and relieve spasms. However, the analgesic effects of this herb may be primarily due to the ability of its acrid constituents to move Blood Stagnation.

Harmonizing ofemotions According to Yang, the moderate

stTeet

taste gives it the ability to harmonize the quality of the emotions and reduce stress, and Lilium brownii (bcii he) and Rehrilannia (shu dl huang) can be used to do this.\ (See the discussion'In the Combining the Western and Chinese perspectives section below.) ,

,'~

.,'

.-

Harmonizing of other herbs Some sweet substances can act

39 as a stabilizing central focus for the other herbs in a combination and can bring together and harmonize their different effects. Glycyrrhiza (gan cao) is the most common example of this.

Moderation of other herbs Substances with the sweet taste can moderate the effects of other herbs. For example, Glycyrrhiza can moderate the harsh effects of other herbs, such as the burning sensation of acrid Capsicum on the mucus membranes. Sweet herbs can moderate the speed and intensity of the effects of other herbs, making their effects less rapid and violent and more moderate and longer lasting. 1 For example, the sweet herb Serenoa can be used to moderate the Yang tonic action of Panax ginseng and Turnera. As a result, the body can incorporate this Yang energy ina smooth and steady fashion, rather than in a short burst that may result in imbalance and side effects.

WESTERN HERBAL TRADITION The theory of taste properties was not as well developed in the West as in China. In addition, the sweet taste was not associated directly with elaborate theoretical concepts. The fruits of Ficus carica, the fig, and Ziziphus jujube, the date, are examples of sweet herbs that were used from ancient times in the West. Both of these fruit were used for their nutritive action and as demulcents to treat respiratory disorders. 1J Althaea and Ulmus are examples of sweet herbs that are currently used in the West for their demulcent and nutritive action. 5,14

BIOCHEMICAL PERSPECTIVE Herbs that are classified as sweet in this book generally contain one or more of the following four types of constituent: • nutritive constituents • mucopolysaccharides • immunopolysaccharides • adaptogens Nutritive constituents The nutritive aspect of the sweet tonic action goes beyond simply supplying sweet nutrients in the form of sugars and starches. It also involves strengthening the natural ability of the body to make Qi and Blood and form tissue. This may involve herb constituents, such as minerals and vitamins, that may act as cofactors and facilitate the anabolic processes of the body. For example, Ziziphus fruit contains calcium, phosphorus, and iron, and the vitamins A, Bz, and C. in addition to sugars and starches.

Combining Western Herbs and Chinese Medicine

40

Mucopolysaccharides Demulcent herbs contain abundant mucopolysaccharides that can form a slippery gel and have a soothing and protective effect on inflamed mucus membranes. Althaea. Plantago major, and Viola are examples of herbs with demulcent action based on mucopolysaccharides, and these herbs can be used for conditions involving inflammation, soreness, and dryness of the respiratory mucosa. (See the Althaea chapter.) Immunopolysaccharides Polysaccharides from the following herbs have been reported to have an immunomodulatory effect: Althaea, Angelica, Calendula. Echinacea, Thuja, and Viburnum (see the chapters on these herbs). This can be regarded as a specific aspect of the Qi tonic action, related to the concept of tonifying Defensive Qi. There is some debate as to the effectiveness of the socalled immunopolysaccharides in vivo. However, it may be that these constituents help herbs, such as Echinacea or Thuja, to increase the resistance of the body to infection. Adaptogens This term refers to herbs or herb constituents that can enhance endurance and strengthen the natural ability of the body to adapt to environmental shocks and stresses. This is a specific aspect of the Qi tonic action that enables the body to maintain homeostasis even under adverse conditions. The active constituents that are responsible for the adaptogenic effect are often triterpenoid saponins. These chemicals can have multiple effects on the body and can strengthen the ability of the following systems to adapt to stresses: • Kidney (nervous and endocrine systems) • Heart (cardiovascular system) • Liver (hepatoprotective system) Examples of sweet tonic herbs with adaptogenic action based on triterpenoid saponins are Astragalus (astragalosides), Glycyrrhiza (glycyrrhizin), and Panax ginseng (ginsenosides). COMBINING WESTERN AND CHINESE PERSPECTIVES The discussion below combines elements from Chinese medicine, Western herbal tradition, and biochemistry, and is • organized under the following headings: • tonic • demulcent • stabilization of the emotions ":~" , • moderation of other herbs Tonic The main effect associated with the sweet taste is the tonic action. However, the tonic action of the sweet taste is

different in nature from the tonic action of the bitter or acrid tastes. Unlike the acrid and bitter tastes, the sweet taste is not associated with increasing movement and dispersing Qi Stagnation. The tonic action of the sweet taste is especially associated with strengthening the material aspect of Qi. Sweet tonics aid the formation of Blood, Yin, and Fluids, and some sweet tonics, such as Serenoa and Ziziphus, can be used to assist in weight gain. Some sweet tonics can strengthen the ability to adapt to environmental stresses and the ability to resist infection. However, these herbs are more for maintaining the stability of the homeostatic mechanism and the integrity of the body's defense system. They do not necessarily tonify Yang in the sense of increasing warmth and movement. Many of the herbs in the Yang tonic group that do strengthen these aspects are either not sweet or have taste properties in addition to sweet, such as acrid and bitter. Demulcent In the Chinese tradition, some sweet tonic herbs are said to help to generate Fluids and thus have a moistening effect, for example, Ophiopogon. Such herbs can be used to treat conditions involving dryness, soreness, and inflammation of the mucous membranes. In the Western tradition, demulcent herbs, such as Althaea, are used for similar conditions, but their effect has been explained in terms of supplying mucilage to the body, rather than by increasing the generation or secretion of Fluids. It is possible that some herbs may have both mucilagesupplying and Fluid-generating effects, or that these two effects are part of the same phenomenon. For example, Althaea is listed as a demulcent in the West and Ophiopogon as a Fluid tonic in China, but both herbs can be used to treat dryness and inflammation of the respiratory mucosa with dry cough and thick sputum that is difficult to expectorate. Stabilization of the emotions The sweet taste can be associated with the Earth element. The damp, heavy, static nature of the sweet taste can be utilized to reduce excessive or disturbed movement of energy, and to stabilize, balance, and harmonize the flow of the emotions. For example, the calming nature of Valeriana may be partly due to the heavy nature of its sweet property, which helps to weigh down the disturbed upward movement of Heart Spirit or Liver Yang that can be associated with anxiety or anger, respectively. I often combine Valeriana with the sweet herb Glycyrrhiza to emphasize this function of the sweet taste. ), . As another example, Cra~~egus h,as a cardioregulatory action that enabl~s it to stabilize"fluctuations in Heart Qi resulting in arrhythmia, energy fluctuations, or emotional lability. I consider the cardioregulatory action of Crataegus to be due paitly to its sour property that can firm Heart Qi

Taste and partly to its sweet property that emphasizes stability around a center point by dampening movement toward the extremes. Moderation of other herbs In a similar way, sweet herbs can moderate the extremes of other herbs in a combination and provide a stable central pivot for their actions. For example, if the patient has both anxiety and depression associated with Deficiency, the following combination could be used: Herb

Ratio

Temperature

Taste

Lavandula Passiflora Hypericum Avena Serenoa Rosmarinus Zingiber

1 1 1 1 0.5 0.5 0.5

51. warm neutral neutral neutral neutral warm hot

aromatic, bitter 51. bitter sour, 51. sweet sweet sweet, 51. sour aromatic, bitter, acrid acrid, aromatic

Th~ sweet taste ofAvena, Hypericum, and Serenoa forms the stable central point of this combination. Lavandula and Passiflora have a calming action to treat anxiety, and Rosmarinus and Zingiber have a stimulant action to treat depression. The sweet herbs will moderate movement toward the extremes of anxiety or depression, reducing any tendency to overcorrection by Lavandula and Passiflora on the one hand or Rosmarinus and Zingiber on the other.

DIRECTION OF ENERGY OF SWEET HERBS In terms of the Five Elements, the sweet taste maintains the movement of energy stable around the center, and dampens movement toward the extremes. It can be said to weigh down excessive or disturbed upward movement, and to reduce excessive outward dispersing movement of energy. However, in high doses, some of the sweet adaptogenic herbs, such as Astragalus, Glycyrrhiza, and Panax ginseng can aggravate or produce excessive or disturbed upward movement of Heart Spirit or Liver Yang. For example, in excessive doses and in susceptible persons, Glycyrrhiza can aggravate hypertension. At high doses, the adaptogenic action becomes a Yang tonic effect with increased upward movement, overriding the heavy nature of the sweet property that tends to control this effect.

TEMPERATURE OF SWEET HERBS In itself, the sweet taste can be associated with the neutral temperature and can be used to stabilize fluctuations in the temperature of the body. Some sweet herbs are classified as cool, but these usually also have the bitter taste in its anti-inflammatory aspect, for example, Althaea, Ophiopogon, and Viola. Herbs with the sweet taste that are classified as warm or hot usually also have the acrid taste, for example, Cinnamomum.

41 CAUTIONS General cautions In Chinese medicine, sweet herbs are avoided or used with caution in the following patterns: • Exterior Excess • Interior Stagnation • Damp • Phlegm Manifestations of the last three patterns include sensations of heaviness, feelings of lethargy and depression, mental heaviness and dullness, digestive stagnation, loss of appetite, nausea, bloating, weight gain, and catarrhal conditions. Specific cautions There are specific cautions and contraindications for different types of sweet herbs. For example,

• Astragalus can have warming and drying effect and so should be used with caution in cases ofYin Deficiency with Heat signs

• Ophiopogon is a sweet herb that is moistening and cooling and is therefore inappropriate for patterns of Deficiency with Cold and Damp

• Panax ginseng is a sweet herb with a stimulating and upward movement effect on the energy and is therefore to be avoided in cases of Heart Spirit Disturbance or Liver Hyperactive Yang

Acrid In the mouth and on the tongue, the acrid or pungent taste can be associated with a range of related sensations, including the severe burning of Capsicum, the prickling of Lobelia, and the tingling of Echinacea or Zanthoxylum. The acrid taste is sometimes referred to as pungent or spicy.

CHINESE HERBAL TRADITION According to the Five Element tradition, the acrid taste tonities the Lung. In the Chinese herbal tradition, the characteristic function of the acrid property is moving and dispersing. It can move Stagnation of Qi and Blood and disperse pathological factors associated with the Stagnation, such as Exterior Wmd, Toxin, or Retained Pathogen. The acrid property can promote Fluid metabolism and help to move and disperse accumulation of Damp or Phlegm.

The acrid property is not necessarily warming. Cool, acrid herbs can be used to disperse Heat, and warming, acrid herbs can be used to disperse Cold.

42

Combining Western Herbs and Chinese Medicine

Three well-known acrid categories In the Chinese herbal tradition, the acrid taste is commonly associated with the following three herb categories: • cool, acrid herbs that clear Exterior Wind Heat • warm, acrid herbs that clear Exterior Wind Cold • acrid herbs that warm the Interior Action groups containing acrid herbs Acrid herbs are not just found in the three well-known categories mentioned above, they are also found in other Chinese action categories. A more complete list is as follows: • clear Heat • clear Wind Heat • clear Wind Cold • clear Wind Damp • transform Phlegm and stop cough • open the Orifices • transform Dam~ i ~ . • regulate the Qi • move the Blood • warm the Interior • tonify Yang • external application Clear Heat In Chinese medicine, the acrid taste occurs in action categories where it might not be expected, for example, the action categories of herbs that clear Heat (drain Fire) and clear Heat Toxin. In these cold. acrid herbs, the moving and dispersing functions of the acrid property are important to assist in the complete clearance of Heat from the body to prevent the possibility of some Heat lingering in the body as a Retained Pathogen. The acrid and cooling properties combine to move Stagnation of Qi and disperse the associated accumulation of Heat and Toxin. l For example. in Chinese medicine, Prunella (xia kii dlO) is a cold, acrid herb that can clear Liver Heat with hypertension and headache, and also disperse Phlegm Heat to treat neck lumps and goiter. Houttuynia (yU xing dio) is a cold acrid herb that can clear Heat Toxin and treat swellings and abscesses. and can clear Lung Phlegm Heat to treat lung abscess or cough. Clear Wmd Heat Herbs with this action can be said to assist in the dispersing function of the Lung, move Stagnation in the surface channels, and disperse Wind Heat and Retained Pathogen. The acrid and cooling properties combine to move Stagnation of Qi and disperse the Wind Heat. Some acrid, cooling diaphoretics are also bitter, and the bitter property may assist the acrid in clearing Heat. For example, in Chinese medicine, Arctium seeds (niu bang ZI) can be used for acute urticaria with feverishness and sore throat.

Clear Wmd Cold Herbs with this action are commonly used in acute respiratory or other infections when chills are dominant to fever and there is pain and sensations of cold in the head, neck, or body. The warming and acrid properties combine to disperse Stagnation, Wmd, and Cold from the surface channels, and often increase or regulate sweating. For example, in Chinese medicine, Angelica dahurica (bai zhi) can be used for acute common cold with headache, sinus congestion, and sensations of cold; and fresh Zingiber (sheng jiang) can be used for acute influenza with chills and cough with copious sputum. Clear Wmd Damp The function of the acrid property in these herbs is to move Stagnation of Qi and Blood in the channels of the muscles, tendons, and joints, and to disperse the Wind and Damp associated with the Stagnation. These acrid herbs can thus be used to treat pain or restriction of movement associated with inflammation of the muscles, tendons, and joints. Some are warming, acrid herbs to disperse Wind Damp Cold, for example, Angelica pubescens (dli huo), and others are cooling, acrid herbs to disperse Wmd Damp Heat, for example, Gentiana macrophylla (qin jiao). li'ansform Phlegm and stop cough A specific aspect of the moving and dispersing function of the acrid taste is to dissolve and disperse Phlegm. l One application of this is to treat wheezing and cough. Once again, the acrid property can be used to treat patterns of either Heat or Cold:

• Pinellia (ban xia) has both the warming and acrid properties that can be used to treat cough associated with Lung Phlegm Cold

• Euphorbia helioscopia (ze qi) has both the cooling and acrid properties that can be used to treat cough or wheezing associated with Lung Phlegm Heat Open the orifices Another application of the capacity of the acrid taste to dissolve and disperse Phlegm is its ability to clear so-called insubstantial Phlegm from the channels. This can assist the aromatic property to open the orifices and revive the Spirit. Aromatic and acrid herbs have been used in Chinese medicine to treat severe acute conditions such as febrile delirium or coma from cerebrovascular accidents, for example, Secretio Moschus (she xiang). Some of these herbs have also been used to treat chronic conditions such as dizziness, deafness, mental dullness, poor memory, or disorientation, for example, Acorus (sm chang pu). li'ansform Damp In Chinese medicine, the herbs in the transform Damp group are most commonly associated with the aromatic property; but they are also acrid in taste, and nearly all are warm in temperature. These herbs are used to revive the Spleen, move Stagnation in the Spleen and Stomach, and transform Damp.

{ .. i

Taste The dispersing and moving functions of the acrid taste complement the lightening and penetrating functions of the aromatic property. Together they can counteract the heavy, deadening characteristics of Damp that can be associated with stagnation, accumulation, and obstruction. For example, Atractylodes lancea (cang zhu) is a warm, acrid, aromatic herb that can treat disorders associated with Spleen Damp, for example, loss of appetite, nausea, epigastric distension, and diarrhea. This herb is especially useful to treat Damp patterns because its aromatic property can transform Damp, its bitter taste can drain Damp downwards, and its dispersing acrid taste can assist both of these processes.

I

.~

Regulate the Qi Due to the moving and dispersing function of the acrid taste, many herbs in the regulates the Qi action category have the acrid property. Most of these herbs are acrid and warm. For example, the mature peel of Citrus reticulata (chen pi) can move Stagnation of Spleen and Stomach Qi to treat nausea with epigastric and abdominal distension. Move the Blood Many of the herbs in this action category have the acrid property, which helps them to disperse and move Blood Stagnation. Most of the acrid herbs that move the Blood are warming. An example is Ligusticum (chuan xiong), which can be used for pain in the chest, sides, or lower abdomen. However, some of the acrid herbs that move the Blood are cooling, for example, the tuber of Curcuma longa (yil jIn), which can be used for chest pain associated with Heart Stagnant Blood and Heart Phlegm Heat. Warm the Interior The acrid and warming properties tend to accentuate each other. The acrid property is moving and dispersing, and the warming property is activating and moving, and can loosen Stagnation, especially that due to Cold. The two properties can combine to produce a rapid, stimulating, and dispersing effect. Most herbs that warm the Interior also warm the Middle Burner and are specific for clearing Cold from the Spleen and Stomach. For example, dried Zingiber (gan jiang) can be used to treat vomiting, epigastric pain, or abdominal pain, when these are accompanied by sensations of cold. A few of the herbs that warm the Interior can warm and strengthen the Kidney. For example, Cinnamomum bark (roil gul) is an acrid herb that can be used for weak back, urinary frequency, and impotence with sensations of cold. These herbs may also warm and strengthen the Yang of the Heart. Tonify the Yang Some~f the herbs' iIi the tonifi~~.th~' Yang group are warming and acrid. However, these herbs are usually also sweet, bitter, or salty. In itself, the acrid taste may be quickly and temporarily stimulating, but it usually needs

43 other properties to add the slow tonic component. For example, the slower, heavier, nourishing characteristics of the sweet taste can provide a good balance to the quick, moving, and dispersing aspects of the acrid taste. For example, Eucommia (dil zhong) has both the acrid and sweet properties. The sweet taste tonifies chronic Deficiency of the ~idney and Liver, and strengthens the sinews and bones to treat weakness in the lower back and legs. The moving and dispersing function of the acrid taste assists circulation of Qi and Blood in these areas to complement the sweet tonic function. External application Many of the substances in this category have the acrid property, and some of these substances are acrid and hot, for example, camphor (zhang nilo). This herb is applied topically in sprains and trauma to reduce pain and swelling associated with Blood stasis. WESTERN HERBAL TRADITION The acrid taste has not been developed as a well-defined theoretical concept in the West as it has in China, and there is not such a clear association of specific actions with the acrid taste. The main action associated with the acrid taste in the West is the circulatory stimulant action. However, there is a wide range of Western action categories that contain herbs with the acrid taste. These are discussed in the Combining the Western and Chinese perspectives section below. Circulatory stimulants These can be defined as herbs that can stimulate or tonify heart function, improve circulation, and warm the body. Some, for example, Capsicum, can specifically increase coronary circulation; some, for example, Zanthoxylum, can specifically increase peripheral circulation; and others for example, fresh Zingiber, are specific for warming the surface of the body. BIOCHEMICAL PERSPECTIVE The acrid taste sensation is not associated with a specific type of taste receptor on the tongue. It is a more general effect, following stimulation of sensory nerve fibers in the mouth or tongue. This may be similar to the counterirritant and local analgesic effect of some acrid substances on the skin. As with the bitter taste, the acrid taste is not limited to one type of chemical. Substances with the acrid taste can be found in various groups of plant constituents, for example, monoterpenoids, phenols, amides, and isothiocyanates. However, the bitter taste sensation on the tongue is followed by a specific sequence of physiological events, but no such sequence is yet known for the acrid taste. This may be partly due to the lack of a specific taste receptor for acrid.

44

Combining Western Herbs and Chinese Medicine

As noted previously, the pharmacological effects associated with the sweet taste can be divided into different groups, each group of effects associated with a different type of chemical. For example the adaptogenic tonic function of the sweet taste can be associated mainly with triterpenoid saponins. This detailed differentiation is not yet possible for the acrid taste. Actions of acrid constituents reported by research Some of the Western actions listed in the table below as associated with the acrid taste have been reported for specific acrid constituents. However, in herbs with multiple tastes, it can be very difficult to decide which pharmacological effects can be attributed to each taste. This is especially so when a single constituent possesses more than one taste, for example, camphor can be classified as both acrid and aromatic. Capsicum is thus a useful herb for study since acrid appears to be its only appreciable taste. Both Capsicum and its main pungent constituent, the amide capsaicin, have been reported to have antimicrobial, circulatory stimulant, digestive tonic, adrenal tonic, and topical irritant and analgesic effects (see the Capsicum chapter). Zingiber is a more complex herb to study since it can be hard to separate the acrid and aromatic effects, and because it has a number of different types of pungent constituents. The following effects have been reported for Zingiber's pungent constituents, the gingerols and shogaols: cardiotonic, thermogenic (warming), digestive stimulant, antispasmodic, antiemetic, antidiarrheal, and antitussive (see the Zingiber chapter).

COMBINING WESTERN AND CHINESE PERSPECTIVES The table below shows a range of Western actions that can be associated with the acrid property along with their nearest equivalent Chinese action concept. Understanding the role of the acrid property in these different action groups gives a deeper appreciation of the nature of the acrid concept. Each action is discussed below in terms of the different aspects of the acrid property, of which the most fundamental are moving and dispersing.

• antimicrobial, alterative

clear Heat

• cooling diaphoretic

clear Wind Heat

• warming diaphoretic

clear Wind Cold

• antirheumatic, antiarthritic

clear Wind Damp

• anticatarrhal, expectorant, antitussive

transform Phlegm and stop cough

.. -~

• resuscitant. anticonvulsant

open the Orifices

• carminative

transform Damp, regulate the Qi

• antispasmodic. analgesic

move the Blood

• circulatory stimulant

warm the Interior

• tonic

tonify the Yang

• counterirritant

external application

Antimicrobial and alterative (clear Heat) In Chinese medicine, in some circumstances, the moving and dispersing functions of the acrid property can result in a cooling effect by clearing Heat of various kinds. This can apply to some Western acrid herbs in the following action categories:

LOBELIA antipyretic

clear Excess Interior Heat and Wind Heat

CAPSICUM anti-inflammatory

clear Heat associated with Interior Stagnation

THUJA antimicrobial

clear Damp Heat and Heat Toxin

PHYTOLACCA alterative

clear Damp Heat. Heat Toxin. and Retained Pathogen

Some antimicrobial and alterative acrid herbs are classified as warming, such as Capsicum and Thuja, others as cooling, such as Phytolacca, and others as variable-temperature herbs, such as Lobelia. In each case, it is the moving and dispersing functions of the acrid property that results in the clearance of Heat Diaphoretic (clear Exterior Wmd) Western herbs with the diaphoretic action, that is, inducing or increasing perspiration, can be divided into cooling diaphoretics and warming diaphoretics.

Cooling diaphoretic In herbs with this action, for example, Nepeta, the dispersing function of the acrid property can be said to assist clearance of Wind Heat. In some cooling diaphoretics, the Heat-clearing function of the bitter property assists the acrid dispersing function to remove Heat from the system. Such acrid and bitter diaphoretic herbs often also have the alterative action of clearing Retained Pathogen from the surface of the body, for example, Achillea. Warming diaphoretic Herbs that have the warming diaphoreticaction often also have the circulatory stimulant

Taste action, for example, fresh Zingiber. Both these actions are associated with the warming, stimulating, moving, and dispersing aspects of the acrid property. In the diaphoretic action, these acrid functions are active more at the surface of the body, and in the circulatory stimulant action, more in the interior. Antirheumatic and antiarthritic (clear Wmd Damp) In herbs with these actions, the moving and dispersing functions of the acrid property can be said to clear Wind and Damp, and associated Stagnation, from the channels of the muscles and joints. In some Western herbs with these actions, for example, Arctium and Phytolacca, the dispersing aspect of the acrid property can have a cooling effect by dispersing Heat. In other Western herbs with these actions, for example, Myrica and Zanthoxylum, the acrid property is combined with a warming, circulatory stimulant effect. Anticatarrhal, expectorant, and antitussive (transform Phlegm and stop cough) In Chinese medicine, the moving and dispersing functions of the acrid property can be associated with the functions of penetrating, dissolving, and dispersing Phlegm. These acrid functions can contribute to the Western anticatarrhal, expectorant, or antitussive actions. Anticatarrhals reduce excessive secretion and accumulation of mucus by the mucous membranes, wherever these may be in the body, but do not necessarily initiate the cough reflex. Expectorants have the more specific function of promoting the coughing up of phlegm, and antitussives can reduce excessive coughing. There is no exact equivalent of the anticatarrhal action in Chinese medicine. It is not the same as the action transforming Damp since the anticatarrhal action does not necessarily depend on stimulating the Spleen, but rather on a local effect on the mucous membranes. However, there may be some overlap between the two actions. In the Western herbal tradition, Sambucus is an example of a cooling acrid anticatarrhal that can be used for sinusitis, and Euphorbia hirta is a cooling acrid expectorant that can be used for bronchitis. Angelica archangelica can act as a warming acrid expectorant for cough with watery sputum or as a warming anticatarrhal for sinusitis. Lobelia is an example of an acrid antitussive herb that can be used for hot or cold conditions. . Resuscitant and anticonvulsant (open the orifices) In Chinese herbal medicine terms, the acrid functions of penetrating, dissolving, and dispersing Phlegm from the channels can complement the functions of the aromatic property of transforming Phlegm, opening the orifices, and reviving the Spirit.

In Western tradition, the acrid herbs Lobelia and Symplocarpus were components of the Antispasmodic tincture beloved of the Physiomedical and Eclectic practitioners. This combination, or Lobelia as a single herb, were given for fainting and for loss of consciousness associated with asphyxia, drowning, concussion, or apoplexy. They were also given for infantile convulsions, epilepsy, and febrile delirium. These acrid herbs can be said to combine the actions of dearing Phlegm and opening the orifices with extinguishing Wind and stopping tremors. Carminative (transform Damp and/or regulate the Qi) Herbs with this action are usually warming and are usually not only aromatic but also acrid. These tWo properties combine to regulate Qi, move Food Stagnation, and, in some cases, transform Damp and Phlegm. The digestive stimulant aspect of the carminative action may be more due to the acrid property, and the smooth muscle relaxant aspect may be more associated with the aromatic property. For example, Elettaria is a warming, acrid, aromatic herb that can be used for loss of appetite, flatulence, and intestinal colic, and can be said to regulate Qi and relax spasms. Angelica archangelica and Juniperus are aromatic and acrid herbs that can regulate Qi and, in addition, transform Damp. They can be used to treat loss of appetite and flatulence with sensations of heaviness in the limbs and body. Antispasmodic and analgesic (move the Blood) Some Western herbs that possess only the acrid taste, such as Capsicum and Lobelia, can be used as antispasmodics and analgesics both when taken internally and when used as external applications. This can be related to the acrid function of moving Qi and Blood and dispersing local areas of Blood stasis. For example, both Capsicum and Lobelia can be used for angina pectoris, postnatal pain, or local trauma. Circulatory stimulant (warm the Interior) In herbs with this action, the stimulating and moving aspects of the acrid property are associated with a strong warmirig effect. Such herbs stimulate the cardiovascular system and warm the body. This group contains the hottest herbs used internally in the West and includes Capsicum, Cinnamomum, Sanguinaria, Zanthoxylum, and Zingiber. It is interesting that Capsicum, the hottest of these herbs, has 1;leen used to equalize the distribution of heat in the body, to reduce fever or to treat certain patterns ofhypertension with sensations of heatin the head and upper body (see the Capsicum chapter). Redistribution or clearance of Heat can be associated with the dispersing function of the acrid property.

46

Combining Western Herbs and Chinese Medicine

The circulatory stimulant category has no exact equivalent in Chinese medicine, the closest category being that of herbs that warm the Interior. However, the· emphasis for most of these herbs is on warming the Spleen and improving digestion, rather than warming the Heart and improving circulation. A few of the herbs in the action category of moving the Blood can be described as circulatory stimulants in terms of Western tradition, for example, Commiphora (mb yao). However, circulatory stimulants have the specific function of strengthening coronary or peripheral circulation and warming the body. Herbs in the category of moving the Blood do not necessarily do this. Rather, they have the function of relieving pain due to Blood Stagnation, wherever it may be in the body and regardless of whether it is associated with Cold or Heat. Tonic (tonify Yang) When combined with the warming property, the acrid property is normally associated only with rapid stimulating, moving, and dispersing effects. Warming acrid herbs that also have a more gradual tonic action usually also have an additional taste. such as sweet or bitter. For example, Cinnamomum is warming, acrid, and sweet. and Turnera is warming, acrid, and bitter. However, Capsicum is a good example of a warming acrid herb that has only the acrid taste property but can have a more long-lasting tonic action in addition to its rapid stimulant effects. Counterirritant (external application) It may be that one aspect of the acrid property is its capacity to irritate the tissue and thereby initiate the natural local healing process. This can stimulate local circulation of Qi and Blood in the tissues and reduce pain and swelling due to blood stasis. Capsicum and Lobelia are examples of acrid counterirritants used in the West as topical applications for sprains and injuries.

DIRECTION OF ENERGY The function of the acrid taste is moving and dispersing and its direction of movement is outward. The acrid property is light and moving, and therefore likely to accentuate the upward movement of other light and moving energies. such as Heart Spirit and Liver Yang. It can counteract the heavy, dulling, downward effect of Damp. Acrid and wiU'lning The outward dispersing movement is accentuated if the acrid herb. is also warming. However. different acrid, warming herbs can vary greatly in their effects, as shown by. the difference between-Ephedra and Capsicum. '..,' '.'". .'0-' .• .

Ephedra This is an example of a warming. acrid herb with such a strong dispersing effect that there is the potential of loss of energy through the body surface and of depletion of

Lung and Kidney Qi. Ephedra can also accentuate irregular .: upward movement of energy and aggravate Heart Spirit Disturbance or Liver Hyperactive Yang, resulting in hypertension with sensations of heat in the upper body.

":c=:

Capsicum This is a powerful warming acrid herb with a very different effect on the movement of energy from Ephedra. Although it can have a strong dispersing effect. Capsicum does not accentuate disturbed upward movement. In fact. it tends to equalize the circulation of Qi and Blood throughout the body, so that it can be used to treat certain forms of hypertension with heat in the head and face.

TEMPERATURE Especially in the West, the acrid taste is often associated with the warming property. Certainly the moving dispersing nature of acrid is more comparable to the nature of the warming property than it is that to the nature of the cooling property. However: acrid resembles bitter in that neither of these tastes is necessarily linked to any particular temperature. Although acrid is perhaps more often associated with the warming property and bitter with the cooling, both tastes can be associated with any of the temperature categories. from hot to cold.

CAUTIONS General cautions The key function of acrid is moving and dispersing. Therefore, herbs with a strong dispersing effect of the type that can result in depletion or disturbance of energy, for example, Ephedra, are contraindicated or to be used with caution in cases with severe Deficiency of Qi or Disturbance of Spirit. However, this does not necessarily apply to acrid herbs that have a strong dispersing effect but are less likely to lead to depletion. For example, Achillea can have an acrid dispersing effect, but this is balanced by both tonic and astringent actions. . Specific cautions The specific indications of an acrid herb will depend on its temperature, its tastes, other than acrid, and its specific actions. For example, a hot acrid herb such as Capsicum would generally be contraindicated for peptic ulcers with Stomach Heat, and a cool acrid herb such as Echinacea should be used with caution for exhaustion with Deficiency and Cold in the Spleen, Stomach, and Intestines.

/.

.·Aromatic

. In the case. of the aromatic property. the sense of taste overlaps with the sense of smell. Aromatic substances are generally partially volatile at room temperature. and any

Taste effect they may have on the body may be partly via stimulation of taste receptors and partly via stimulation of olfactory receptors.

CHINESE HERBAL TRADITION The Five Element taste correspondences did not include aromatic, and in the Chinese herbal tradition, the aromatic property (xiang) was not strictly regarded as a taste.

47 substances can be used either to revive consciousness and treat coma, or to calm febrile delirium and help to reduce spasms and convulsions. Again, most of these aromatic substances also have the acrid property, which may contribute to the capacity to penetrate Phlegm. Some are warming, for example, Liquidambar resin (sii. he :dang), and others are cooling, for example, ox gallstone (nili huang).

Herbs that regulate the Qi Some of the herbs in this categoFunctions of the aromatic property The aromatic property is similar to the acrid in that it has moving and dispersing functions. However, to a greater degree than acrid, the aromatic property is considered to be lightening, penetrating, awakening, and reviving. The aromatic property is especially used when the Spleen fails to digest the food and metabolize Fluids properly, resulting in the accumulation of Damp and Phlegm. The aromatic property can:

• awaken the Spleen to transform Damp • penetrate the turbidity of Damp • lighten the effect of the heaviness of Damp on the body and the mind

• revive the Heart Spirit and open the orifices Actions associated with the aromatic property In Chinese herbal medicine, two groups of herbs are specifically associated with the aromatic property: • aromatic herbs that transform Damp • aromatic substances that open the orifices In addition, there are aromatic herbs in the category of herbs that regulate the Qi.

Aromatic herbs that transform Damp The aromatic property of these herbs awakens the Spleen to transform Damp, penetrates the turbidity of Damp, and lightens the effect of the heaviness of Damp on the digestive system and the body in general. These herbs are used to treat loss of appetite, nausea, vomiting, abdominal distension, and diarrhea when these are associated with indications of Damp, such as lethargy and sensations of heaviness and dullness in head, body, and limbs. The aromatic herbs in this group are also acrid and most of them are warm. fhese three properties combine to move Stagnation and to disperse Damp and Cold, as in, for example, Agastache (hub xiang) and Eupatorium fortunei (pei lcin).

Aromatic substances that open the orifices The aromatic property of these substances is said to penetrate the turbid Phlegm that is clouding and obstructing the sensory orifices and to revive the Heart Spirit. Phlegm can have either a dulling or a disturbing effect on the mind. Therefore, these

ry have the aromatic property and can move Stagnant Qi in the Spleen, Stomach, or Intestines to treat such complaints as belching, nausea, vomiting, and epigastric or abdominal distension and pain. A good example is the mature peel of Citrus reticulata (chen pi). Regulating Qi and transforming Damp are two actions that can have similar effects. The difference between the two is that Qi regulators are specific for intestinal spasms and pain linked to Stagnation of Qi, whilst herbs that transform Damp are specific for abdominal distension and diarrhea with lethargy and sensations of heaviness linked to Damp. The action of regulating the Qi is more connected to the moving, relaxing, and calming aspects of the aromatic property, and the action of transforming Damp is more related to awakening the Spleen and penetrating and lightening Damp. Clarifying terminology Herbs that are aromatic in smell and in property are not always classified as aromatic in the materia medica of Chinese herbs. Rather, an examination of these texts reveals that these herbs are treated as follows: 1. Some herbs are not classified as aromatic in the list of

properties for their materia medica entry, but are included in the chapter relating to aromatic herbs that transform Damp and/or the chapter relating to aromatic substances that open the orifices. For example, Agastache (huQ xiang) and Eupatorium fortunei (pei hin) are included in the Aromatic Herbs that Transform Dampness chapter in Bensky and Gamble, but are both listed only as acrid in the text of Yeung. 2. Some herbs are not classified as aromatic in the list of properties for their materia medica entry and are not included in the two 'aromatic' chapters, but are described as aromatic elsewhere in the text. For example, camphor (zhang nao) is listed only as acrid in Bensky and Gamble, and in Yeung, but is described in both books as an aromatic herb to open the orifices. 3. Some herbs are not classified as aromatic in the list of properties for their materia medica entry and are not included in the two 'aromatic' chapters. In addition, they are not described as aromatic in the text, but nevertheless, they have a strong aroma and have actions that can

Combining Western Herbs and Chinese Medicine

48

be linked to the aromatic property, for example, Angelica dahurica (bai zhI) and Ligusticum (chuan xiong). One recent text by a Chinese author has listed these herbs as aromatic in property.l

WESTERN HERBAL TRADITION Fragrant herbs are found especially in three main Western action categories: • carminatives • tranquilizers • antidepressants Carminatives Culpeper wrote that one of the herb properties that strengthens the stomach and assists digestion is the aromatic property. Carminatives can be defined as aromatic herbs that aid digestion, excite peristalsis, promote the expulsion of gas from tlle gastrointestinal tract, and relieve the pain caused by flatuleilce:These herbs are aromatic because of their relatively high content of volatile oils. Examples are: Elettaria and Pimpinella. Tranquilizers Many of the herbs used in the West to treat insomnia, calm anxiety, and relax nervous and muscular tension are rich in aromatic oils. Many of these herbs are from the family Lamiaceae, for example, Hyssopus, Lavandula, Melissa, Mentha pulegium, Nepeta, Rosmarinus, Salvia, and Thymus. Culpeper recommended Lavandula, for example, for'tremblings and passions of the heart: and Tabernaemontanus listed it for palpitations. Antidepressants Aromatic herbs have a long tradition of use for treating melancholy and lowness of mood. For example, Culpeper described the following herbs for these conditions:

• Melissa

causes the heart to become merry and drives away troublesome cares and thoughts from the mind that arise from melancholy • Rosmarinus can drive melancholy'vapours' from the heart and refresh the spirits and make them lively and active • Salvia can quicken the senses and treat lethargy in those persons who are dull and heavy of spirit

WESTERN AROMATHERAPY

and permeate the body, bringing a wonderful sense of light- .-ening and well-being. The subject feels temporarily raised above the darkness and heaviness of the clouds to where the sun is shining and the atmosphere is clear and peaceful. The tension and cares of daily life seem to fall away, allowing the soul to expand. Lonicerus and Tabernaemontanus used Lavandula, Rosmarinus, and other aromatic herbs as steam inhalations or as steam baths to treat both internal and external ailments. Culpeper described the use of two or three drops of the oil extracted from Lavandula or Rosmarinus to be taken internally or applied to the temples and nostrils. He used these oils for the physical, emotional. and mental conditions for which he recommended these herbs. He warned that these aromatic oils should be used with caution and in small amounts since their nature is very quick, piercing, and subtle. The traditions of using aromatic herbs for emotional and mental disorders. and of us~g concentrated ()~s have existed for a long time in Western herbal medicine. In recent years, aromather~py has developed and expanded these traditions, and the interest in the medical use of aromatherapy has given impetus to the isolation of individual aromatic constituents and to the study of their pharmacological effects.

BIOCHEMICAL PERSPECTIVE Aromatic substances may have their pharmacological effects by stimulating both the olfactory receptors in the nasal membranes and the taste receptors on the tongue. In addition, they may stimulate receptors in interior tissues of the body, following absorption through the nose, mouth, gut, or skin. Whilst there appear to be several different types of olfactory receptors, each sensitive to a different group of odors, there do not appear to be taste receptors that are specific for aromatic substances. However, aromatic compounds can have one or more of the main tastes, especially acrid or bitter. Three levels of the aromatic effect As with bitter compounds, aromatic constituents can be said to have three main levels of activity: • effects shared by aromatic compounds in general • effects shared by members of a particular chemical group _. effects specific to individual chemicals

'F~r ih6us~ds-ofyears;in all Cultures, the inhalation ~f

Effects shared by aromatic compounds in general For example,

fragrances has been used to change mood and state of consciousness. As a subjective experience, the fragrance of an aromatic substance can change the nature of the air itself

those aromatic substances whose scent is generally experienced as fragrant and pleasing generally have the common effect of lifting and lightening a person's mood. This effect

---

Taste may follow stimulation of a variety of types of olfactory receptors and may be mediated by the limbic system.

Effects shared by members of a particular chemical group An aromatic substance may have additional effects that are characteristic of its chemical type. This may be either by stimulation by a specific type of olfactory receptor, following inhalation of a volatile substance, or by chemical reaction within the body, following oral administration. For example, the monoterpenoid ketones, such as camphor and pulegone, may be especially linked to calming or antidepressant effects, whilst the monoterpenoid phenols, such as carvacrol and thymol, may be especially associated with the antimicrobial action. However, whilst there has been considerable speculation suggesting that each of the different groups of monoterpenoids has a different spectrum of characteristic pharmacological effects, it should be pointed out that there is very little research data to support such a clear differentiation. Effects specific to individual chemicals There can be considerable differences in pharmacological effect between monoterpenoids in the same chemical group, for example, within the monoterpenoid ketone group: • fenchone is an antitussive • valerone is a sedative • camphor can be a stimulant

COMBINING WESTERN AND CHINESE PERSPECTIVES Definition of aromatic

An aromatic herb can now be

defined in the following terms: • it is fragrant and has a relatively high essential oil content • it has one or more of the following energetic effects: dispersing, lightening, moving, opening • it has one or more of the following actions: carminative, tranquilizer, antidepressant, resuscitant Carminative There is considerable overlap between the Western concept of carminative and the Chinese concepts of aromatic herbs that transform Damp and herbs that regulate the Qi of the Spleen, Stomach, and Intestines. These concepts all deal with the treatment of digestive disorders, especially those concerned with epigastric or abdominal distension and discomfort.

I I

Carminatives and Damp The Western concept of carminative does not emphasize the clearance of Damp. However, certain aromatic herbs used in the West as carminatives can

49 be used to stimulate the Spleen and to clear Damp and Phlegm from the body. Two good examples are Angelica archangelica and Juniperus. both of which are drying in nature. These herbs can be used not only to treat flatulence and intestinal colic, but also to assist in the treatment of edema, obesity, general catarrhal conditions, and rheumatism associated with Exterior and Interior Damp and Cold.

Normalizing effect of carminatives on the gut In terms of Chinese medicine, the carminative action can be associated with the regulation of the Qi in the Spleen, Stomach, and Intestines. In terms of Western physiology, carminatives can be said to have a normalizing effect on the muscle of the gut. They can both relax intestinal spasms to normalize muscle tone and stimulate the gut to normalize peristalsis. They do not have an antispasmodic effect to the point of flaccidity, nor do they stimulate peristalsis to the point of producing spasms and pain. In fact~ carminatives can be given to counteract the griping caused by purgatives. For example, the essential oil of Cinnamomum cassia has been reported both to increase gastrointestinal secretion and to stimulate digestive action, and also to relieve intestinal spasms (see the Cinnamomum chapter). Carminative and tranquilizer effects Some aromatic herbs and herb constituents can have both an antispasmodic action on the smooth muscle of the gut and a tranquilizing effect on the central nervous system. For example, Lavandula can be used for intestinal colic and anxiety. Also, the aromatic constituents of Cinnamomum can relieve intestinal spasms and have. sedative and anticonvulsant effects. It is not yet possible to separate the mechanisms of these antispasmodic and tranquilizer effects. Tranquilizer Aromatic herbs, such as Lavandula, Mentha pulegium, and Salvia, can be used to treat both anxiety and insomnia as well as headaches and migraine. In terms of Chinese medicine, they can be said to calm Heart Spirit and Liver Yang and thus control disturbed upward movement of theQi. The mechanism of these effects can give an insight into the nature of the aromatic property. It does not control the upward movement by firming the Qi, as do sour herbs, nor by weighing it down by its heavy nature, as do sweet herbs, nor by having a sedative action on consciousness, as do some bitter constituents. Rather, by its calming and lightening nature, the aromatic property can gently relax internal tensions, and by its moving and dispersing nature, the aromatic property can dissipate the pressure of constrained energy that may contribute to the disturbed upward movement.

\

50

Combining Western Herbs and Chinese Nledicine

Antidepressant Aromatic herbs, such as Lavandula, Mentha piperita, Rosmarinus, and Thymus, can be used to treat melancholy and lowness of mood. In terms of Chinese medicine, these herbs can be said to treat depression associated with Stagnation of the Heart, Liver, or Lung Qi. They may also have a tonic effect on the Heart or Spleen that may assist in the treatment of depression associated with Deficiency, but the antidepressant effect of the aromatic property is not so much linked to this tonic effect. Rather, the aromatic property has its effect on depression by lightening heaviness, lifting mood, relaxing constraint, and calming the mental and emotional disturbance that may be associated with depression.

Aromatic and acrid The antidepressant effect of the aromatic property is different from that of the acrid. Acrid is more Yang, dynamic, stimulating, and especially more moving. It can stimulat~ the Heart to increase the driving force to move Blood through the vessels and penetrate stasis of the Qi and Blood. A good example of an acrid antidepressant is provided by Capsicum. Aromatic is more Ym, relaxing, calming' and especially, more lightening. Lavandula is a good example of an aromatic herb that can relieve depression by its lightening, relaxing, and gently dispersing effects. Normalizing the effect ofaromatics on the mind and emotions Just as aromatic herbs can have a combination of relaxant and stimulant effects on the gut, thus, normalizing its function, so they can have a combination of relaxant and stimulant effects on the central nervous system and the emotions. In fact, it is in the nature of the aromatic property to have this dual effect. The calming and relaxing nature of the aromatic property can help to treat emotional disturbance, and its lightening and dispersing nature can help to treat depression, especially when the depression is associated with either Stagnation or Disturbance of energy. Resuscitant The use of aromatic herbs as resuscitants is not common in the West, and most Western resuscitant herbs have the acrid property, for example, Lobelia and Capsicum. However, the use of aromatic herbs in the treatment of chronic emotional and mental imbalance is one of the great contributions of Western herbal medicine. In contrast, in Chinese medicine, aromatic substances are used as resuscitants to treat acute conditions of dulling of consciousness, such as apoplectic coma, or are used for acute conditions of disturbance of consciousness, such as febrile delirium or convulsions. There does not appear to be a strong Chinese tradition of using the aromatic property to treat chronic mental and emotional imbalance. Acorus (shi chang pu) is an aromatic herb that can be

\

-_ .. _-~==-.\

used for chronic forgetfulness, mental dullness, or disorientation associated with Phlegm obstructing the sensory orifices and dulling the Spirit. However, its capacity to penetrate Phlegm may be as much due to its acrid taste as to its aromatic property.

DIRECTION OF ENERGY As discussed above, both the acrid and aromatic properties have a moving, dispersing nature and an outward effect on the direction of energy movement. However, acrid is more strongly dynamic in moving Qi and Blood through the vessels and in penetrating Blood stasis or obstruction by Phlegm. Strong acrid herbs, such as Ephedra, can cause excessive outward movement so that energy is lost through the body surface, or it can cause disturbed upward movement. Aromatic herbs have a gentler moving and dispersing effect, and a more relaxing and calming effect. As a result, they can be used to reduce disturbed upward movement. They are characterized by their lighte~ing effect on the body so that they can form a natural counter to treat heaviness of mood and the effects of excessive Damp.

TEMPERATURE Aromatic herbs are mainly warm in temperature, and many of these are also acrid. The few Western aromatic herbs that are cool, such as Matricaria or Nepeta, are also to some degree bitter, and the bitter constituents may contribute to the cooling property. A number of herbs with the aromatic property are listed as variable-temperature herbs in this book and classified as warm-cool, for example, Mentha piperita. This herb is used in both Chinese and Western tradition as a cooling diaphoretic to clear Wind Heat, and this effect is associated with its acrid property. In addition, it has been used in the West since the time of Dioscoridesl 3 as a warming carminative for cold conditions of the stomach, and this effect is associated with its aromatic property. This use has continued, especially in the Spanish-speaking world, for example, in South America 14 and the Philippines. 15

::

CAUTIONS In Chinese medicine, aromatic substances that open the orifices are considered to be scattering in nature and have the potential of draining the source Qi 12. In my opinion, this does not apply to aromatic herbs used in the West as carminatives, tranquilizers, or antidepressants, such as Lavandula, Mentha, Rosmarinus, Salvia, or Thymus.

'-.l

Taste If aromatic herbs are also acrid and warming, they should be avoided in cases of Excess or Deficiency Heat unless the aromatic herbs are combined with other properties. Aromatic herbs that are warming and drying, such as Angelica archangelica, should be avoided in cases of Yin Deficiency and Dryness unless they are moderated by moistening herbs, such as Althaea or Glycyrrhiza.

51 'Effectof.taste;,cont.'·'" ......----.-- ..--------...-----.----~.::=_..::_=.:. Aromatic • lightening effect counteracts heaviness of mood or the dulling, heavy, downward effect of Damp • dispersing, relaxing, and calming effect clears constraint and stagnation, and reduces disturbed upward movement.

TEMPERATURE

Comparison summary In this summary, the following features of the taste properties are compared in table format • direction of energy • temperature • contraindications

A particular taste is not necessarily linked to a particular temperature. This is especially true of the bitter and acrid tastes. Although many bitter herbs are cooling and many acrid herbs are warming, both these taste properties can be associated with temperatures ranging from hot to cold. It depends on the individual herb. For example, Evodia (wti zhii yIi) is a hot herb with the bitter taste, and Prunella (xia kii cao) is a cold herb with the acrid taste.

DIRECTION OF ENERGY The effect of the different taste properties on the direction of energy movement is summarized in the table below. It can be seen that some tastes may have a variety of different effects. Which effect manifests in a particular situation depends on the state of the patient and on the specific chemical structure of the constituent(s) responsible for the taste.

,',

.;....

, ::.<:~-~:~=,._~~

Bitter • range from hot to cold • mainly neutral or cooling - neutral, as in some of the digestive tonics, cardiotonics, and tranquilizers

- cooling, as in some of the antimicrobials, antipyretics, anti-inflammatories, and sedatives

Effect of taste on the direction of energy movement"

Sour/astringent

Bitter • nondirectional antimicrobial, antipyretic, and antiinflammatory action • nondirectional cardiotonic action • spreads Liver Qi • normalizes the natural downward movement in the stomach and intestines • downward-directing tranquilizing action • downward-directing diuretic or purgative action

Sourjastrlngent .........-

• warm bitter herbs generally also have the acrid taste

• holds things firm, stable, and in their proper place, thus, controlling excessive outward or upward movement of energy and fluids

Sweet • maintains the movement of energy stable around the central point of balance and dampens movement toward the extremes

• mainly neutral • if the herb has both sour and bitter tastes, then it is mainly neutral or cooling • if the herb has both sour and acrid tastes, then it is mainly warming Sweet • mainly neutral • if the herb has both sweet and bitter tastes, then it is mainly neutral or cooling • if the herb has both sweet and acrid tastes, then it is mainly warming Acrid • ranges from hot to cold • most are warming, some are variable-temperature (warm-cool), and some are cooling Aromatic

• weighs down excessive or disturbed upward movement

• mainly warm in temperature and these are usually aromatic and acrid

• reduces excessive outward dispersing movement of energy

• the few that are cool are aromatic and bitter

Acrid

.

• increases movement of Qi and Blood through the vessels • disperses energy outward • accentuates upward movement of other light and moving energies, such as Heart Spirit and liver Yang • counteracts the heavy, dulling, downward effect of Damp

CAUTIONS It is important to remember that cautions or contraindications for a particular taste may depend more on the temperature of a particular herb with that taste, than on the taste property itself.

52

Combining Western Herbs and Chinese Medicine In some cases the contraindications for one taste can be overcome by utilizing the moderating effects of another taste property; this topic is dealt with in the next section.

Bitter • warm or hot bitter herbs are generally contraindicated for Heat patterns • cool or cold bitter herbs are generally contraindicated for Cold Deficient patterns of the Spleen and Stomach, especially with diarrhea • some texts contraindicate certain bitter herbs for gastric ulceration or hyperacidity since they may increase the gastric acid secretion, but see the discussion in the Toxicology section of the Gentiana chapter

Sour/astringent • Exterior conditions that are not fully cleared, including skin rashes that are in the process of expressing • during a treatment to clear toxins from the body via sweat, urine, stools, or discharge • Interior Stagnation, including Stagnation with Damp, and, in the case of warm astringents, Interior Stagnation with Heat • long-term use of herbs with high tannin content; see the Toxicology section in the Potentilla chapter

Sweet • Exterior Excess • Interior Stagnation • Damp • Phlegm • therefore, to be used with caution in cases of sensations of heaviness, feelings of lethargy and depression, mental heaviness and dullness, digestive stagnation, loss of appetite, nausea, bloating, weight gain, and catarrhal conditions

Acrid • herbs with a strong dispersing effect, of the type that can result in depletion or disturbance of energy, such as Ephedra, are contraindicated in cases with severe Deficiency of Qi or Disturbance of Spirit

Aromatic • aromatic substances that open the orifices are considered to be scattering in nature and have the potential to drain the source Qi • aromatic herbs that are also acrid and warming should be used with caution in cases of Excess or Deficiency Heat • aromatic herbs that are warming and drying should be used with caution in cases of Yin Deficiency and Dryness

TASTE + COMBINATION

+ sour/astringent (support)

Balancing the tastes Each taste has its specific range of uses and its specific disadvantages. Tastes can be combined so that one taste can support the beneficial effects of another to maximize the clinical effectiveness or moderate the potential adverse effects of another to minimize side effects. As an example of support, the warming and moving aspects of the acrid taste can support the digestive tonic aspect of the bitter taste. As an example of moderation, the aromatic function to revive the Spleen and transform Damp can moderate the potential adverse effect of sweet tonics to produce Stagnation and Damp. Optimizing the balance of the taste properties can be an important part of creating effective herb combinations. An example of taste balancing is given in the Taste section in the chapter Principles ofherb combination. In balancing the tastes, it is possible either to pick one herb with both the required tastes or to pick two herbs, each with one of the required tastes. For example, if bitter and acrid are required to stimulate digestion, either Rosmarinus can be selected, which has both tastes, or bitter Gentiana can be combined with a suitable amount of acrid Capsicum.

:-,

'I 1 ,-,.,1

f:"l

. I

-~ """""

._~

Note The term support is used here in a general sense to indicate the strengthening of the effect of one action by another. Support could be by the specific processes of either complementarity or emphasis, but this differentiation is not made in this section. Complementarity and emphasis are described in the Principles ofherb combination chapter. ~-.

BALANCING TASTES TABLE For each taste, shown in upper case in a gray bar in the left-hand column, a description of its support or moderation by each of the other four tastes is given with a herb example. The Taste aspect column lists which specific aspect of the main taste is being supported or moderated. For example, for the bitter taste, this column shows whether it is the digestive tonic, tranquilizer, and cardiotonic, hepatobiliary, or purgative aspect that is under discussion.

TASTE ASPECT

DESCRIPTION

HERB EXAMPLES

bitter digestive tonic

the sour/astringent property can enhance the digestive tonic aspect of bitter by maintaining the Integrity of the gut wall

bitter Gentiana combines with sour astringent Agrimonia to treat weak digestion with malabsorption

Taste TASTE + COMBINATION

TASTE ASPECT

DESCRIPTlON

53 HERB EXAMPLES , '.'-'."':"=::-:::!

•

~~~4'!':

BITTER, CaNT. bitter tranquilizer

the sour/astringent property can support the tranquilizer aspect of bitter by firming the energy of the Heart to stabilize the emotions

bitter Passiflora combines with sour astringent Schisandra to treat difficulty in concentration with fearful anxiety

bitter cardiotonic

the sweet property can support the cardiotonic aspect of bitter by nourishing the Heart

bitter Convallaria combines with sweet Glycyrrhiza to treat exhaustion from cardiac weakness

bitter tranquilizer

the heaviness of the sweet property can support the tranquilizer aspect of bitter by weighing down irregular upward movement of energy

bitter Valeriana combines with sweet Glycyrrhiza to treat anxiety, restlessness, and headache

bitter digestive tonic

the sweet property can reduce gastric irritation from excessive secretion of gastric acid resulting from gastric stimulation by bitter herbs

bitter Cinchona combines with sweet demulcent Althaea to reduce the possibility of gastric irritation

bitter digestive tonic

the acrid property can support the digestive tonic aspect of bitter by warming and moving the Qi of the Spleen, Stomach, and Intestines

bitter Gentiana combines with acrid Capsicum to treat weak digestion with sensation of cold in the epigastrium

bitter hepatobiliary anti-inflammatory

the warming acrid properties can moderate potential adverse effects of the cooling bitter properties on the Spleen

cooling bitter Berberis combines with warming acrid Zingiber to reduce the possibility of impaired digestion and absorption

bitter tranquilizer

the aromatic property can complement the tranquilizer aspect of bitter by its lightening, dispersing, relaxing, and calming functions

bitter Anemone combines with aromatic Mentha pulegium to treat anxiety and headache with feelings of desperation

bitter purgative

the relaxing function of the aromatic property can moderate the potential purgative aspect of bitter to produce intestinal spasms

bitter Rheum can be combined with aromatic Foeniculum to reduce the possibility of intestinal colic

reduce leakage of fluids

the cooling and bitter properties can support the sour astringent property in cases of leakage associated with Heat

neutral astringent Quercus can be combined with cool bitter Hydrastis to treat diarrhea with sensations of buming on defecation

stabilize emotions

the sweet property can nourish the Heart and weigh down disturbed upward movement of energy to support the stabilization of emotions by sour

sour Hypericum combines with sweet Avena to treat nervous exhaustion with emotional lability

reduce leakage of fluids

the demulcent sweet property can moderate the potentially irritating effect of tannin-containing astringents on the gut wall

sour Potentilla combines with sweet demulcent Althaea to treat diarrhea with colitis

(support)

reduce leakage of fluids

the warming and acrid properties can support the sour astringent property in cases of leakage associated with Cold

sour Geranium combines with acrid Myrica to treat diarrhea with sensations of cold in the abdomen

+ aromatic

stabilize emotions

the calming and relaxing functions of the aromatic property can support the sour astringent function to firm and stabilize the Heart Spirit

sour Hypericum combines with aromatic Mentha pulegium to treat daytime anxiety and enuresis with nocturnal terrors

+ sour/astringent (support)

+ sweet (support)

(moderate)

+ acrid (support)

(moderate)

+ aromatic (support)

(moderate)

SOUR. + bitter (support)

+ sweet (support)

(moderate)

+ acrid

--

I

r

(support)

54

Combining Western Herbs and Chinese Medicine

TASTE + COMBINATION

TASTE ASPECT

DESCRIPTION

HERB EXAMPLES

sweet nutrient tonic

the digestive tonic aspect of bitter can supPOrt the uptake and utilization of the sweet tonic, thus enhancing the tonification of Qi and Blood

sweet nutrient molasses combines with bitter Gentiana to treat poor appetite with weight loss and anemia

sweet demulcent

the anti-inflammatory and antimicrobial aspects of bitter can complement the sweet demulcent action

sweet demulcent Althaea combines with bitter Arctostaphylos to treat cystitis with infection and burning sensation on urination

sweet demulcent

the wound healing and hemostatic effects of astringency can complement the sweet demulcent anti-inflammatory effect

sweet demulcent Althaea combines with sour Capsella to treat peptic ulceration with bleeding

sweet adaptogenic

the warming, moving, acrid effects complement the sweet adaptogenic effects to treat hypofunction while maintaining homeostasis

sweet Panax ginseng combines with acrid Cinnamomum bark to treat reduced stamina with sensations of cold

sweet immunoregulator

the dispersing acrid function of clearing Retained Pathogens complements the immuneregulatory aspect of sweet to strengthen Defensive Qi

sweet Echinacea combines with acrid Achillea to treat recurring respiratory conditions with fever

sweet nutrient tonic

the moving nature of acrid can moderate the tendency of sweet to produce digestive stagnation

sweet Serenoa combines with acrid Capsicum to treat debility with poor appetite, lethargy, abdominal sensations of fullness and cold

sweet nutrient tonic

the aromatic function to revive the Spleen and transform Damp can moderate the tendency of sweet to produce fat and mucus

sweet Ziziphus fruit combines with aromatic Citrus to treat debility in persons with tendency to weight gain and chronic sinusitis

acrid diaphoretic

the cooling and bitter properties can help the dispersing nature of acrid to clear Wind Heat from the body surface

acrid Sambucus combines with bitter Achillea to treat influenza with fever

(support)

acrid circulatory stimulant

the sour function of tonifying the liver can support the acrid function of moving Stagnation and dispersing Damp and Phlegm

acrid Zanthoxylum combines with sour Myrica to treat sluggish liver function with lethargy and sensations of heavi· ness and cold

(moderate)

acrid diaphoretic

the sour astringent property to hold fluids and energy in the body can moderate the excessive loss of energy by the dispersing function of acrid

acrid Ephedra combines with astringent Schisandra to reduce possible excessive sweating and weakening of Defensive Qi

acrid metabolic stimulant

the steadying, slowing aspects of the sweet property can convert the rapid, stimulant effect of acrid to a more moderate and sus· talned tonic action

acrid Cinnamomum bark combines with sweet Serenoa to treat exhaustion with emaciation and sensations of cold

acrid stimulant antidepressant

the gentle dispersing, calming, and relaxing nature of the aromatic property can moderate the rapid, stimulant, acrid antidepressant effect

acrid and stimulant Rosmarinus combines with more aromatic and calming Lavandula to treat depression with nervous tension

SWEET

+ bitter (support)

(support)

+ sour (support)

+ acrid (support)

(moderate)

+ aromatic (moderate)

ACRID

+ bitter (support)

+ sour

+ sweet (moderate)

+ aromatic (moderate)

_t:.-,

Taste TASTE + COMBINATION

55

TASTE ASPECT

DESCRIPTION

HERB EXAMPLES

aromatic carminative

bitter stimulates secretion of gastrointestinal enzymes and bile to complement the aromatic stimulation of appetite and peristalsis

aromatic Mentha piperita combines with bitter Gentiana to treat weak digestion with loss of appetite. abdominal distension and flatulence

aromatic antidepressant

the sour astringent function of firming and stabilizing the emotions complements and moderates the moving. lightening, and antidepressant functions of the aromatic property

sour astringent Schisandra combines with aromatic Lavandula to treat emotional lability with depression and emotional constraint

aromatic tranquilizer

the tonic aspect of sweet can nourish the Heart and Liver. thus helping to calm the Spirit and Yang, and complement the relaxing aspect of aromatic

aromatic Lavandula combines with sweet Ziziphus to treat nervous headache associated with Deficient Qi and Blood

aromatic anticatarrtlal

acrid can penetrate and move the Phlegm and complement the aromatic function of transforming Damp and Phlegm

aromatic Thymus combines with acrid Thuja to treat catarrhal obstruction of the respiratory and urogenital system

AROMATIC

+ bitter (support)

+ sour (moderate)

+ sweet (support)

+ acrid (support)

References .....

1. Yang Yi-fan. Chinese Herbal Medicines. Churchill Livingstone, Edinburgh, United Kingdom (2002)

9. Lonicerus A. Kreuterbuch (1679). Reprinted by Verlag Konrad K6lbl, Munchen, Germany (1962)

2. Yeung H-C. Handbook of Chinese Herbs and Formul~s, vol. 1. Institute of Chinese Medicine, Los Angeles, California (1985)

10. Gerard J. The Herbal or General History of Plants: The Complete 1633 Edition as Revised and Enlarged by Thomas Johnson. Dover Publications, New York. New York (1975)

3. Felter HW, lloyd JU. King's American Dispensatory, vols. I and 2, 18th edn. (1898). Reprinted by Eclectic Medical Publications. Sandy. Oregon (1983) 4. Ellingwood F. American Materia Medica. Therapeutics and Pharmacognosy, 11th edn. (1919). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1994) 5. Christopher JR. School of Natural Healing. BiWorld, Provo, Utah (1976) 6. Weiss RF. Herbal Medicine, English edn. Beaconsfield Publishers. Beaconsfield, United Kingdom (1988) 7. Mills S. Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone, Edinburgh, United Kingdom (2000) 8. Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. Meyerbooks, Glenwood. Illinois (1990)

11. Tabernaemontanus IT. Krauterbuch (1731). Reprinted by Verlag Konrad K6lbl, Miinchen, Germany (1993) 12. Bensky D, Gamble A. Chinese Herbal Medicine Materia Medica. Eastland Press, Seart!.e, Washington (1986) 13. Grieve M. A Mod= Herbal, vols. 1 and 2. Dover Publications. New York, New York (1971) 14. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983) 15. Dioscorides P. Kreutterbuch (1610). Reprinted by Verlag Konrad K61bl. Munchen, Germany (1960) 16. Bejar E et al (eds). Herbs of Southern Ecuador. LH PreSS, Spring Valley, California (2001) 17. Pardo de Tavera TH. Plantas Medicinales de Philipinas. Ayala Foundation, Makati City. Phillipines (2000)

.-~.

Actions· herb can be defined as the types of therapeutic effects it has on the body. This is in contrast to the uses or indications of a herb, which refer to the disorders it can be used to treat. An indication refers to a practical result, whilst an action refers to the process by which that

T

to tonify the intestines and move the stool, and a herb with a tonic laxative action can be chosen, such as Turnera • constipation with dryness principles of treatment are to moisten the intestines and move the stool, and a herb with a moistening laxative action can be chosen, such as Linum (flaxseeds) • constipation with excessive heat principles of treatment are to clear the heat and move the stool, and a herb with a cooling purgative action can be chosen, such as Rheum

HE ACTIONS OF A

result is achieved.

Action concept

,

1-

Actions can be regarded as the bridge between theory and practice. They link the theoretical concepts of etiology, pathology, syndrome classification, principles of treatment, and principles of herb choice with the practical end resultthe treatment of a particular disorder.

ACTIONS REFLECT THE MEDICAL PARADIGM

EXAMPLE If a patient has constipation, for example, the simplest approach would be to bypass the action concept and pick any herb that has constipation as one of its indications. However, the problem with this simplistic approach is that constipation, like most other disorders, may have a variety of etiologies and pathologies and may be associated with various different syndromes. In the theory of traditional Western phytotherapy, for example, constipation may be associated with weakness, dryness, or excessive heat in the intestines and in the body as a whole. The principles of treatment and the herb action . chosen will depend on the specific syndrome as follows:

i

• constipation with weakness principles of treatment are

57

The names of some action categories simply refer to a practical therapeutic effect without implying the mechanism by which this effect is achieved and without linking the action to the theoretical concepts of the medical paradigm. For example, the word 'diuretic' simply refers to the therapeutic effect of increasing urination. However, the names of many action categories reflect the underlying philosophy and theoretical principles of the medical paradigm to which they belong. Often, general categories, such as diuretic, diaphoretic, and tonie, are divided into more specific subcategories. In each of these, the action name is preceded by a qualifying word that implies the action mechanism and links the action concept to the theories of the specific paradigm. Thi~ is shown in the following examples, in which the qualifyIDg word has been put in italics:

Combining Western Herbs and Chinese Medicine

58

• in conventional medicine, the general category of diuretics is divided into such categories as osmotic diuretics or thiazide diuretics, according to the proposed physiological or biochemical mechanism • in Western Physiomedical tradition, the general category of diaphoretics is divided into stimulating diaphoretics and relaxing diaphoretics, according to the Physiomedical theory of stimulation and relaxation • in Chinese herbal tradition, the general category of tonics is divided into Qi tonics, Blood tonics, Yin tonics, and Yang tonics, according to Chinese theories of Qi and Blood and Yin and Yang ACTIONS, PROPERTIES, AND ORGAN SYNDROMES Actions and properties In the herbal traditions, some action categories have names that do not include reference to either temperature or taste, as in the action names 'purgative' or 'drain Damp: However, other action categories have names that link the concepts of action, temperature, and taste, as in the term 'warming acrid herbs that release the Exterior:

from the liver or the Chinese action concept of tonifying Spleen Qi. The evolution of action concepts that refer to organ systems or specific organ syndromes is briefly discussed in the History chapter.

Classification ofherbs by action Herbs can be organized into groups according to their action. The table below shows some of the main action groups from Western herbal medicine, together with their approximate Chinese action equivalent. However, there is never a complete equivalence between the action categories of different paradigms. For example, there is no exact Chinese equivalent of the Western anticatarrhal action category, and there is no exact Western equivalent of the Chinese transform Damp action category. The equivalents shown in the table are only approximations, and the reader is· referred to the Action glossary chapter for a more detailed discussion of Western and Chinese equiva-

Actions and organ syndromes In the herbal traditions, some action categories refer to therapeutic effects on a particular organ system, for example, the action categories of circulatory stimulant and digestive tonic. Other action categories refer to the treatment of a specific organ syndrome, for example, the old Western action concept of clearing heat

Diaphoretic

.

lents. How the modern herbal action categories evolved in the West, from the time of Dioscorides in the 1st century AD to the present day, is discussed in the History chapter. ACTIONS AS A CRITERION OF HERB CHOICE Herbs are described and classified by their actions so that the appropriate herbs can be selected to treat a specific

clear the surface disperse Wind Cold disperse Wind Heat

Zingiber (fresh) Sambucus

Antirheumatic, antiarthritic

disperse Wind Damp

Angelica archangelica

Antipyretic, etc.

clear Heat clear Heat clear Damp Heat and Heat Toxins clear Heat and Damp Heat clear Damp Heat and Heat Toxins

Asclepias Baptisia Filipendula Taraxacum (root)

laxative, purgative

drain Downwards

Rheum

Diuretic

drain Damp

Parietaria

Carminative

transform Damp or regulate Qi

warming diaphoretic cooling diaphoretic

antipyretic antimicrobial anti-inflammatory alterative

transform Damp regulate the Qi of the Stomach and Intestines

Expectorant, etc. expectorant antitussive anticatarrhal

transform Phlegm and stop cough transform Phlegm stop cough no exact Chinese equivalent

Juniperus Citrus aurimtium

Euphorbia hirta Prunus serotina Hydrastis

-" Actions

59

Antispasmodic antiasthmatic

regulate Q; regulate Lung Qi

Ephedra

Analgesic antianginal

move the Blood move Heart Blood and relieve pain

Crataegus

Emmenagogue tonic emmenagogue hormonal emmenagogue stimulant/antispasmodic emmenagogue

tonity and regulate the Uterus* tonify the Uterus regulate Uver Qi move Uterus Qi and Blood

Chamaelirium Vitex Leonurus

Circulatory stimulant

warm the Interior

Capsicum

Tonic general tonic

tonitying herbs tonify Qi tonify Blood tonify Yin and Auids tonify Yang • tonify Spleen and Stomach Qi tonify Heart Qi

Glycyrrhiza molasses Althaea Turnera Gentiana Convallaria

Astringent antidiarrheal antihemorrhagic

stabilize and bind, stop bleeding stabilize and bind stop bleeding

Geranium Vinca

Nervlneand sedative nervine tranquilizer, sedative

calm the Spirit nourish the Spirit settle and calm the Spirit

Avena Valeriana

Anticonvulsant, etc. antispasmodic, anticonvulsant antimigraine agent

extinguish Wind and stop tremors extinguish Wind and stops tremors calm Uver Yang

Lobelia Tanacetum

Resuscitant, anticonvulsant

(aromatic substances that) open the orifices

Acorus

Antihelmlntic

expel parasites

Artemisia absinthium

Topical

external use

Calendula

moistening and demulcent tonic antidepressant, aphrodisiac digestive tonic cardiotonic

* The action category of herbs that tonify and regulate the Uterus is not standard to Chinese convention and has only been inserted in the table to give a Chinese approximation to the corresponding Western action.

condition. However, actions are not the sole criterion of herb choice. The chapter Principles of herb combination describes how herbs are combined according to considerations of action, temperature, taste, and organ syndromes.

Working with actions The following basic concepts are fundamental to working with herb actions in the clinic: • range of potential actions • normalizing actions • action groups . • primary and secondary actions

RANGE OF POTENTIAL ACTIONS Usually, herbs do not have just one action. Rather, they have a range of potential actions. For example, Achillea can

have nine or more different actions, among them the antipyretic, anticatarrhal, alterative, bitter digestive tonic, and diaphoretic actions (see the discussion in the Achillea chapter). Which of these actions manifest in a particular situation may depend on the patient's condition. For example, the antipyretic action is absent or minimal unless there is a fever.

NORMALIZING ACTIONS Some individual herbs can have two actions that are apparently opposite in their effects. For example, Lobelia can have a stimulant or relaxant action on the smooth muscles of the bronchi, intestines, or uterus, depending on the initial state of the patient (see the detailed discussion in the Lobelia chapter). Rather than descnbe such herbs as either stimulant or relaxant, it might be more accurate to descnbe them as having a normalizing or regulatory action. Other examples are Crataegus, which can normalize either hyper- or hypo-

-

Combining Western Herbs and Chinese Medicine

60

.

/~I

:r:~~t,

tension, and Lavandula, which can have either a calming or an antidepressant action. depending on the patient's state.

ACTION GROUPS

the herb or herbs with that action can be used in higher __ ~ o.,£'';;;: doses than herbs with secondary actions. For example, in the combinations discussed in this book, nerbs with the desired primary actions are often used at t\-vice the dose of herbs with secondary actions, assuming that the herbs are of equal potency (see the section Factors affecting dose in the Dose

.-_.~-

VYhen a herb has more than one action. some of these actions may work together in groups to meet the needs of the situation. For example. Achillea can be used to treat recurring fever, in which case the diaphoretic action can work together with the antipyretic and alterative actions. The diaphoretic action increases sweating and can clear Wmd Heat from the Exterior, the antipyretic action can help to clear Excess or Deficiency Heat from the Interior, and the alterative action can clear Retained Pathogen from the body to prevent recurrence of febrile episodes. (These action groups are discussed in greater detail in the Achillea chapter.)

chapter).

Action contraindications There are situations in which specific herb actions are contraindicated or need to be applied with caution. Whether or not an action is contraindicated in a particular situation depends not only on the action itself, but also on the specific characteristics of the individual herb. These characteristics include the strength of the action for the particular herb, and the properties of temperature and taste.

PRiMARY AND SECONDARY ACTIONS Four factors determine which actions are of primary and which of secondary importance in any given situation: • the herb itself • the context of a specific patient's condition • the context of a specific herb combination • the dose The herb itself If a herb has multiple actions, some of these are usually regarded as more important than others. In the case of Achillea, for example, the diaphoretic action is generally regarded as of primary importance and the bitter digestive tonic action is regarded as secondary. Therefore, Achillea is more commonly used to treat respiratory infections with fever and chills than it is to treat digestive weakness. The context of a specific patient's condition The state of the patient's health plays an important role in determining which actions of a particular herb are dominant. For example, if Achillea is used in a case in which digestive weakness is severe and feverishness only mild, the bitter digestive tonic action is likely to be of primary importance and the diaphoretic action of secondary importance. The context of a specific herb combination VVhich actions are dominant for a particular herb depends upon the herbs with which it is combined. For example, the bitter digestive tonic action of Achillea is generally regarded as secondary. However, if Achillea is combined with other herbs for which

this action is prim;u-y, such as~i#}}~e~~~~thi~;~~d Gentiana, the bitter digestive tonic action. of. Achillea can - fi' . - ' , ' become of primary importance. Dose

If an action is required to be of primary importance,

STRENGTH An action may not be contraindicated in itself, but only when it is particularly strong. For example, Iris has mild purgative action and is appropriate for constipation in weak patients, whilst Cassia fruit (senna) has much stronger purgative action, and may in some circumstances be contraindicated for weak patients.

TEMPERATURE If a specific action category is required in a particular case, it is important to match the temperature value of a herb with this action to the temperature requirements of the patient. For example, tonics are generally appropriate to treat conditions of Deficiency, but a warming tonic is generally contraindicated for hot patterns, such as Deficient Yin with Deficiency Heat. This situation requires a cooling tonic. However, a warming tonic may, in certain cases, be used in a mixed temperature situation, if it is used in relatively small amounts, and its warming effects are balanced and moderated by the other herbs in the combination (see

Temperature chapter). TASTE If a specific action category has been selected. it may be necessary to match the taste value of a herb with this action to the requirements of the patient and to the taste balance requirements of the herb combination. For example, a sweet tonic may be contraindicated in a case of digestive weakness and general debility if this occurs

.. '

,":~.,..

,..."lI~"

-:,.2~

Actions

61

the potential adverse effects of another herb to minimize side effects.

with obesity, lethargy, and abdominal distension from Spleen Qi Deficiency with Qi Stagnation, Damp, and Phlegm. In this situation, a tonic herb with acrid, aromatic, and bitter taste properties would be more appropriate. However, a sweet tonic may be appropriate in some cases of this kind, if it is used in relatively small amounts, and if its potential for aggravating Qi Stagnation and accumulation of Damp and Phlegm is balanced and moderated by the other herbs in the combination (see Taste chapter).

Support For example, the circulatory stimulant action can support the diaphoretic action, resulting in increased perspiration. Either a herb with both these actions, such as Zingiber, can be chosen, or a herb with diaphoretic action, such as Achillea, can be combined with a herb with circulatory stimulant action, such as Capsicum.

Note The term 'support' is used here in a general sense to indicate the strengthening of the effect of one action by another herb. Support could be by the specific processes of either complementarity or emphasis, but this differentiation is not made in this section. Complementarity and emphasis are described in the chapter on Principles of herb combina-

MINIMIZING POTENTIAL SIDE EFFECTS In many cases, the potential side effects of a particular action can be avoided or reduced by the moderating effect of another action. For each action listed in the Balancing actions table below, an example is given of a second action that can moderate the side effects of the first action. This information can be great value in the clinic.

tion. Moderation For example, the antispasmodic action can moderate the tendency of the purgative action to produce intestinal spasms as a side effect. For example, Rheum can be combined with Foeniculum so that the purgative action of Rheum is moderated by the antispasmodic action of Foeniculum.

Balancing actions in a herb combination Some actions usefully complement each other's effects, whilst other actions work in opposition. In designing a balanced herb combination, actions can be combined so that one action can support the beneficial effects of another action to maximize their clinical effectiveness or moderate

BALANCING ACTIONS TABLE For each action shown in the left-hand column, a description of its support or moderation by additional actions is given with a herb example.

~

Action

Additional actions .. .

Description...'..

Herb example

anticatarrhal

assists in the clearance of toxins by reducing excessive accumulation of mucus

Hydrastis

circulatory stimulant

assists in the clearance of toxins by increasing circulation and clearing obstructions

Myrica

detoxicant

reduces adverse effects of accumulated toxins released by alteratives

Glycyrrhiza

demulcent

soothes inflammation due to accumulated toxins released by alteratives

Viola

'

Alterative (support)

.....

~-

(moderate)

Analgesic (support)

(moderate)

.....................................•.•................................................................ antispasmodic

reduces muscle spasms that are contributing to the pain or resulting from it

Viburnum

tranquilizer

calms nervous tension that is aggravating pain or resulting from it

Anemone

nervine tonic

treats the mental and physical exhaustion associated with chronic pain

Avena

circulatory stimulant

moderates the potential depressing effect of a sedative analgesic action on metabolism

Rosmarinus

62

1,

Combining Western Herbs and Chinese Medicine

Antiarthritic (support)

(moderate)

Anticatarrhal (support)

(moderate)

Antidepressant (support)

(moderate)

Antihypertensive (support)

(moderate)

diaphoretic

treats the effects of exposure to wind and damp, eliminates toxins from the body in the sweat

Zingiber

cirCUlatory stimulant

increases circulation and clears obstruction, stimulates clearance of toxins

Zanthoxylum

anti-inflammatory, analgesic, antipyretic

relieves pain and swelling, treats acute febrile episodes

Populus

alterative

clears toxins from the joints and assists in the detoxification of the liver, reducing inflammation

Taraxacum

tonic

treats the anemia resulting from gastric irritation by antiinflammatory drugs

Gentiana

detoxicant

assists in the detoxification, reducing inflammation from toxins released by antiarthritics

. Glycyrrhiza

............................................................................................................................................................................................................. stimulates local circulation, reduces local inflammation, reduces mucus accumulation

Capsicum

circUlatory stimulant

stimulates circulation, thereby stimulating clearance of toxins and obstructing phlegm

Zanthoxylum

carminative

stimulates the digestion, reduces the formation of phlegm

Angelica arc.

alterative

clears toxins and pathogens that are causing excessive mucus secretion

Thuja

demulcent

moderates the tendency of some anticatarrhals to dry the mucus membranes

Polygonum

. ',' counterirritant

...•...............•..•..•...............................•.............................................. circulatory stimulant

supports the antidepressant effect by stimulating the heart and circulation

Capsicum

tonic

makes the stimulant antidepressant effect more gradual, stable, and sustained

Serenoa

tranquilizer

moderates potential for overstimulation

Passiflora

........................•....•.•..•.•......•............................................................ antiatheromatic, antilipidemic

assists in the treatment of hypertension due to hyperlipidemia and atheroma

Commiphora

tranquilizer, sedative

assists in the treatment of hypertension associated with nervous tension

Valeriana

antispasmodic, anticonvulsant

assists in the treatment of hypertension associated with muscular spasms or apoplexy

Lobelia

antimigraine

treats the hypertension associated with headaches or migraines

Lavandula

nervine

treats the hypertension associated with physical and' nervous debility

Viscum

cardioregulator' ,. , .

normalizes blood pressure, reducing the possibility of hypotension or blood pressure oscillations

Crataegus

circulatory stimulant

normalizes blood pressure, reducing the possibility of hypotension from sedative antihypertensives

Capsicum

Actions

63

Anti-inflammatory (support)

(moderate)

antiallergic

assists in the treatment of inflammatory disorders with an allergic component

Ephedra

antimicrobial

assists in the treatment of inflammatory disorders with infection

Arctostaphylos

astringent

assists in the healing of inflamed mucosa. reduces discharge or bleeding from the inflammation

Hamamelis

demulcent

moistens and soothes dry, inflamed mucosa

Althaea

analgesic

assists in the treatment of pain associated with inflammatory disorders

Salix

tonic

assists in the treatment of inflammation associated with systemic weakness

Glycyrrhiza

warming carminative

moderates potential weakening effects on digestive system of anti-inflammatory herbs with cooling effect

Zingiber

......•............................... •............. .................................................. ~~

Antispasmodic (support)

(moderate)

tranquilizer. sedative

treats spasms associated with nervous tension or fear

Anemone

nervine tonic

treats mental and physical exhaustion due to chronic pain

Avena

circulatory stimulant

moderates potential depressing effect on metabolism of antispasmodic herbs with sedative action

Rosmarinus

........................................................................................................ Antitussive (support)

(moderate)

Astringent (support)

(moderate)

expectorant

facilitates the expectoration to relieve nonproductive cough with sticky mucus

Marrubium

anticatarrhal

reduces the excessive secretion and accumulation of mucus

Thymus

demulcent

moistens and soothes inflamed mucosa, thereby facilitating expectoration

Viola

antispasmodic

reduces excessive bronchial spasms that may inhibit expectoration

tranquilizer

calming effect supports an antitussive action. especially in nervous coughs

Prunus

circulatory stimulant

moderates the dulling of consciousness from sedative antitussives

Zingiber

carminative

moderates digestive stagnation and increased mucus due to moistening demulcent antitussives

Pimpinella

. Lobelia

......................................................................................................... . Achillea

tonic

normalizes cell permeability and increases muscle tone to reduce leakage and prolapse

anti-inflammatory

reduces discharge by reducing inflammation

Hydrastis

anticatarrhal

reduces discharge by reducing excessive mucus secretion

Myrica

antimicrobial alterative

reduces discharge and treats diarrhea by destroying microorganisms and clearing toxins

Berberis

demulcent

reduces potential irritant effect of tannin astringents

Althaea

Combining Western Herbs and Chinese Medicine

64

Bitter digestive (support)

(moderate)

Carminative (support)

(moderate)

circulatory stimulant

stimulates and speeds digestion. especially if there is Stagnation of Qi from Cold

Capsicum

astringent

can normalize gut permeability to complement stimulation of the digestion by bitters

Agrimonia

demulcent

moderates any potential irritant effect from stimulation of gastric acid secretion by bitters

Althaea

......••.•...•.....................•...............•••......•.............•............................. cirCUlatory stimulant

supports a stimulant effect on digestion and peristalsis. reduces Stagnation of Qi from Cold

Capsicum

bitter digestive

supports the stimulation of the appetite and peristalsis

Rosmarinus

antispasmodic

supports a relaxing effect on gut spasms

Lobelia

moistening sweet tonic

moderates any potential drying effect from anticatarrhal or diuretic carminatives

Glycyrrhiza

....•...........•.•................................... ..........................................• Circulatory stimulant (support)

cardiotonic

provides a gradual and sustained energy increase to complement the stimulation of the circulation

Cinchona

(moderate)

demulcent

counteracts the tendency of some acrid circulatory stimulants to irritate the gastric mucosa

Glycyrrhiza

Demulcent

• • • • • • • • • • • • " . " . " . " . " •• " . " . " •• " .""" fit" " """"""

analgesic anti-inflammatory

complements the anti-inflammatory action of demulcents

Filipendula

(moderate)

carminative

counteracts the digestive stagnation and increased mucus from sweet, moistening demulcents

Citrus

(support)

(moderate)

Diuretic (support)

(moderate)

.

a""" """"."" """ " " """. """,,"" """"""""""""""""""""."""""""""" •• "

(support)

Diaphoretic

~

'""""""""""""""""""" """""""""""" " " """""""."""" , "" "" """" "

..

.

"" " " ",," "" ",,"" ""

circulatory stimulant

stimulates peripheral circulation, supports diaphoresis and the clearance of toxins

Capsicum

anticatarrhal

reduces excessive secretion and accumulation of mucus in respiratory infections

Sambucus

antipyretic

reduces fever and lowers the body temperature

Nepeta

alterative

eliminates toxins from the body in the sweat

Achillea

tonic

strengthens the immune system to clear lingering pathogens and to resist further infection

Echinacea

astringent

moderates excessive sweating to avoid weakening the body

Salvia off.

••.••...•.•.••......•.•.•••.•...•.•..................................................................... circulatory stimulant

can stimulate the urinary sy&tem, clear obstruction, and accentuate the diuretic effect

Zingiber

tonic

can tonify the urinary system and strengthen the diuretic effect

Panax gin.

mineral supplement

moderates the effect of mineral loss as a result of diuresis

Taraxacum

Actions

65

Emmenagogue (support)

(moderate)

bioavailability enhancer

can act as a 'carrier' or 'messenger' and enhance the bioavailability of other herbs

Zingiber

circulatory stimulant

can support the use of emmenagogues for conditions with sensations of abdominal cold

Capsicum

tonic

assists in the treatment of reproductive weakness associated with atrophy or hypofunction

Serenoa

stimulant

assists in the treatment of lack of sexual interest associated with depression

Tumera

antispasmodic

assists in the treatment of uterine spasms

Viburnum

tranquilizer

assists in the,treatment of gynecological disorders associated with nervous tension

Saivia off.

astringent

moderates potential excessive bleeding from stimulant emmenagogues

Vinca

.............................. r

_

..

Expectorant (support)

(moderate)

circulatory stimulant

stimulates bronchial circulation and supports the movement ' and clearance of mucus

Sanguinaria

anticatarmal

reduces the excessive secretion and accumulation of mucus

Thuja

demulcent

moistens and soothes inflamed mucosa, thereby facilitating expectoration

Glycyrrhiza

antispasmodic

reduces excessive bronchial spasms that may inhibit expectoration

Lobelia

antiemetic

moderates potential nausea from stimulant expectorants, such as Lobelia

Zingiber

............................................................................................................................................................................................................ Hepatic and cholagogue

circulatory stimulant

improves the circulation in the liver, enhancing clearance of toxins

Capsicum

antioxidant

can contribute to both hepatoprotective and antilipidemic effects

Artemisia, spp.

antispasmodic

assists in the treatment of spasms and pain of the biliary system

Chelidonium

anti-inflammatory alterative

treats hepatobiliary inflammatory conditions associated with accumulation of toxins

Berberis

detoxicant

can assist in the protection against toxins released by the action of alterative hepatics

Glycyrrhiza

(support)

(moderate)

Purgative (support)

(moderate)

........•............................................................................................... cholagogue

increases the secretion of bile, which has a laxative action

Iris

circulatory stimulant

supports the stimulant action of purgatives on atonic bowel

capsicum

tranquilizer

reduces nervous tension that may be contributing to intestinal spasms and obstruction

Valeriana

carminative

moderates potential intestinal colic due to p'urgatives

Foeniculum

demulcent

moderates potential irritation of the intestinal mucosa due to purgatives

Glycyrrhiza

--~--K~L

Combining Western Herbs and Chinese Medicine

66

Sweet tonic (support)

(moderate)

Tranqulllzer (support)

(moderate)

bitter digestive tonic

assists in the absorption of sweet tonics by stimulating the digestive and hepatic function -

Gentiana

circulatory stimulant

stimulates digestion and speeds the assimilation and delivery of nutrients to the cells

Capsicum

carminative

reduces digestive stagnation and sensations of heaviness due to the sweet tonics

Elettaria

............................................................................................................................................................................. nervine

strengthens and stabilizes the nervous system to complement the tranquilizer effect

Avena

cardioregulator

strengthens and stabilizes the cardiovascular system to complement the tranquilizer effect

Crataegus

antidepressant

complements the tranquilizer effect for patients with both depression and anxiety

Thymus

circulatory stimulant

moderates any potential dulling of consciousness from stronger tranquilizers

Rosmarinus

-

Actions glossary Western herbal a.ction ca~egories .discussed in this glossary, the followmg details are given

OR EACH OF THE

P

where appropriate: • synonyms (within parentheses) • defmition and uses • herb examples • types (subcategories) • Chinese equivalent • differentiation from other categories

necessarily strengthen the adaptive capacity. Adaptogens are a subdivision of tonics with the specific quality of strengthening the ability to adapt to stress. Alteratives (blood purifiers and depurants) These are herbs that can clear toxins fro.m the body by increasing the processes of elimination and detoxification. They are used for disorders involving the accumulation of toxins, for example, acute sepsis, arthritis, recurring infections, skin disorders, and the sequelae of chemo- or radiotherapy. They can also be used to assist in detoxification programs for alcohol, drugs, or prolonged medication. For example,

Adaptogens See also Tonics. These are herbs that can enhance the ability of the body to adapt to chemical, physical, emotional, or mental stress. These herbs can enhance the strength and speed of performance under stress, and enhance the speed at which the body returns to normal function after stress. Examples include Astragalus, Eleutherococcus, Panax ginseng, Schisandra, and Withania.

• Achillea

can assist in the clearance of toxins through the skin by diaphoresis

• Phytolacca

can assist in the clearance of toxins from the lymph system

• Taraxacum

can assist in the clearance of toxins via its diuretic and laxative actions

Chinese equivalent There is no exact equivalent to the al-

Chinese equivalent The adaptogenic action can be said to

terative action in Chinese medicine. Perhaps the nearest equivalent action categories are clear Retained Heat, clear Damp Heat, and clear Heat Toxins. It should be noted that the concept of toxins as a main cause of disease, involving cleansing as a major treatment principle, is stronger in Western herbal tradition than in Chinese medicine.

be a subdivision of the Qi tonic action. One of the most important functions of Qi is the capacity for a rapid and appropriate adaptation to environmental stimuli, with rapid subsequent return to the balance between Ym and Yang.

Adaptogens, stimulants, and tonics Stimulants rapidly in-

Analeptics See also Stimulants. Once known as restoratives or resuscitants, these are sub-

crease the activity of the body, but their long-term use may result in depletion or destabilization. Tonics gradually and cumulatively increase the strength of the body but do not

stances that can restore consciousness following fainting or

,

67

Combining Western Herbs and Chinese Medicine

68

coma. In conventional medicine, analeptics that stimulate the central nervous system have been used to counteract the effect oflarge doses of narcotics. In the Western herbal tradition, Lobelia has a tradition of use as a resuscitant to treat the loss of consciousness from fainting, apoplexy, or concussion. It was used either as a single herb or in combinations such as the Antispasmodic tincture (see the Lobelia chapter).

Chinese equivalent The action category of aromatic substances that open the orifices is used to clear Phlegm from the sensory orifices and revive Heart Spirit, and to treat such disorders as apoplectic coma and febrile delirium. Analgesics (anodynes) These are substances that reduce the conscious perception of pain. Three main types are: • anti-inflammatory analgesics • narcotic analgesics • tranquilizing analgesics

Anti-inflammatory analgesics These can relieve pain by reducing inflammation, generally without dulling consciousness. They may also have an antipyretic action. One group used in conventional medicine is the nonsteroidal anti-inflammatories (NSAIDs), which includes the salicylates. Filipendula. Populus. Salix, and Viola are examples of herbs with the anti-inflammatory analgesic action; they contain compounds that can be converted in the body to salicylic acid.

Narcotic analgesics The narcotic analgesics reduce pain but may also produce dullness or drowsiness. One group used for severe pain in conventional medicine is the opiates. such as codeine and morphine. None of the herbs discussed in this book have a narcotic analgesic action.

Tranquilizing analgesics Some substances can assist in the treatment of pain because of their tranquilizing or sedative action, especially when the pain is linked to muscle spasms associated with nervous tension. Tranquilizers calm without necessarily dulling consciousness. Sedatives calm and may also have a dulling effect on consciousness, but not so severe a dulling effect as narcotic analgesics. Piscidia and Valeriana are examples of herbs that can have antispasmodic and analgesic effects in addition to their tranquilizing"action. At high doses. these herbs may have some sedatiVe'effects.' Analgesics and anesthetics ArialgesicS relieve pam;Without necessarily'removing all sensation or'dulling consCiousness. Anesthetics abolish sensation in a specific area (local anesthetics) or in the whole body (general anesthetics).

Chinese equivalent Herbs with the analgesic action can be found in the move the Blood action category. especially when the pain is associated with Blood stasis from trauma or internal causes. Analgesics are also found in the regulate Qi category. but in this case, pain is linked to Qi Stagnation. which may be associated with muscle spasms. such as intestinal colic. Anodynes

See Analgesics.

Antacids See also Antiulcer agents. In conventional medicine. antacids are substances that are used to treat peptic ulceration by neutralizing the hydrochloric acid in the gastric secretions. In Western herbal tradition, the term antacid has been used rather vaguely, to include antiulcer herbs for which a gastric acid neutralization mechanism has not been demonstrated or which indeed have their antiulcer effect by a different route, such as demulcent or anti-inflammatory actions.. The term antacid is therefore not used in this book and the more general term of antiulcer is preferred. There is no exact equivalent action category to antacid in traditional Chinese medicine. Antiabortives These are herbs that have a tradition of use during pregnancy of reducing the risk of miscarriage. Examples are Mitchella, Rubus, and Viburnum.

Chinese equivalent In Chinese medicine. herbs with a tradition of antiabortive action are found in various action categories. For example. Artemisia argyi (al ye) is in the category of herbs that stop bleeding. and Dipsacus (xu duao) is in the group of herbs that tonifyYang. Antianginals These are herbs that have a tradition of use of relieving chest pain due to heart disease. Examples are Capsicum, Convallaria. Crataegus. and Leonurus.

Chinese equivalent In Chinese medicine, herbs with this action are found mainly in the move the Blood category. Their specific action is to move Heart Blood. Antiarrhythmics See also Cardiotonics and Cardioregulators. These are herbs that have a tradition of use of treating cardiac arrhythmia. Examples are Cinchona. Convallaria, Crataegus, Leonurus, and Sarothamnus.

Chinese equivalent In Chinese medicine, herbs with this action are found in various action categories. including toni'fy Qi. tonify Blood, tonify rm, stabilize and bind. and calm the Spirit. Antiarthritics These are herbs that can relieve inflammation, stiffness. and pain of the joints. The term antirheumatic is an older. less specific term referring to herbs that relieve

-

Actions glossary inflammation, stiffness, and pain of the muscles and/or joints. Antiarthritics can be used for such disorders as rheumatoid arthritis, osteoarthritis, psoriatic arthritis, and gout. Antirheumatics can be used for these disorders. In addition, they can be used for myalgias, such as those occurring in muscular rheumatism associated with exposure to wind, cold, and damp, or in chronic fatigue and fibromyalgia syndromes. Examples of herbs that can be used to treat inflammation, stiffness, and pain of the muscles and/or joints are Angelica archangelica, Filipendula, Harpagophytum, Populus, Salix, and Zanthoxylum.

Types of antiarthritics The table shows examples of different types of antiarthritics.

ZING1BER diaphoretic antiarthritic

clear Wind. Cold-, Damp

ZANTHOXYLUM circulatory stimulant antiarthritic warm and move Qi and Blood POPULUS antipyretic antiarthritic

clear Heat. clear Wind Heat

HARPAGOPHYTUM anti-inflammatory antiarthritic

clear Damp Heat

ARCTIUM alterative antiarthritic

clear Heat Toxin

Chinese equivalent In terms of Chinese medicine, herbs with the antiarthritic and antirheumatic actions are especially found in the clear Wind Damp action category. They are also found in the categories shown in the table above. Antiasthmatics These are antispasmodic herbs that are specific for treating the bronchial spasms of asthma. Examples are Ephedra and Lobelia.

Chinese equivalent In Chinese medicine, herbs with this action are found mainly in the category of herbs that relieve cough and wheezing, and also in the regulate Qi and release the Exterior categories. Antiatheromatics See also Antilipidernics. These herbs can help to prevent the formation of atheroma, or they can help to disperse an existing atheroma. Examples are Angelica sinensis, Commiphora, Crataegus, and Salvia miltiorrhiza.

Chinese equivalent In terms of Chinese medicine, such herbs can be said to clear Phlegm accumulation and obstruction from the arteries and to move the Blood. Herbs with this action are found in the move the Blood and tonify the Blood categories.

69

Antibacterials See Antimicrobials. Antibiotics

See Antimicrobials.

Anticatarrhals These are herbs that can reduce excessive mucus secretion or mucus accumulation. They can therefore clear mucus obstruction in the ducts and passages of the body, and indirectly help to reduce inflammation and infection. They can be used, for example, for nasopharyngeal catarrh, phlegmy cough, asthma with bronchitis, some cases of conjunctivitis or otitis media, diarrhea with mucus in the stools, urinary infections with cloudy urine, and some cases of prostatitis or salpingitis. Examples include Achillea, Angelica archangelica, Echinacea, Euphrasia, Hydrastis, Myrica, Plantago Ianceolata, Sambucus, Sanguinaria, and Thuja.

Chinese equivalent There is no exact Chinese equivalent of the anticatarrhal action. This reflects the special emphasis that Western herbal tradition of the last century has placed on the concept of phlegm blocking the secretory ducts and passages of the body and producing potential sites of inflammation and infection. There is some overlap between the anticatarrhal effect and the action of transform Damp. The latter is mainly used to treat digestive disorders such as nausea or abdominal distension when these occur with a sensation of heaviness in the limbs or body. These symptoms are similar to those of chronic catarrhal gastric and intestinal catarrh, as described by the Eclectic practitioners. However, the anticatarrhal action specifically refers to the capacity to reduce secretion by the mucous membranes lining the ducts of the body. Also, anticatarrhals are not necessarily aromatic herbs that transform Damp and Phlegmthey may be acrid or bitter in taste-and they do not necessarily have a drying effect. Anticatarrhal, expectorant, and antitussive Anticatarrhals do not necessarily promote the cough reflex, as do expectorants, or reduce the cough reflex, as do antitussives. Anticoagulants See under Antithrombotics. Anticonvulsants These are herbs that can assist in the treatment of convulsions, for example, febrile convulsions or epilepsy. They may also assist in the treatment of tremors and spasms of the skeletal muscles. sudden loss of consciousness, hemiplegia, facial paralysis, aphasia, and other signs of cerebrovascular accident. Examples of Western herbs with a tradition of use of assisting in the treatment of convulsions are Cimicifuga, Lobelia, Scutellaria, and Valeriana.

Combining Western Herbs and Chinese Medicine

70

Chinese equivalent These herbs can be said to calm Liver Wind and Liver Hyperactive Yang. They may also calm Heart Spirit and clear Phlegm from the sensory orifices. They are mainly found in the categories of herbs that extinguish Wind and stop tremors, calm the Spirit, and open the orifices.

Chinese equivalent In terms of Chinese medicine, the equivalent group is that of herbs that expell'arasites. Antihemorrhagics

See Astringents.

Antihyperlipidemics

See Antilipidemics.

Anticonvulsants, resuscitants, and antispasmodics Resuscitants can be used to restore consciousness following fainting or coma, but both resuscitants and antispasmodics do not necessarily reduce convulsions. However, there is overlap between the three action categories, and some herbs can produce all three effects, for example, Lobelia. Antidepressants See also Stimulants. These are herbs that can be used to treat lowness of mood, whether it is associated with bipolar states, premenstrual or postnatal depression, seasonal affective disorder, the side effects of medication or drugs, or illnesses such as chronic fatigue synch:ome. The following herbs are specific for depression, although, as shown in the list, they are effective as a result of differing actions: • Avena, Hypericum • Panax ginseng • Turnera • Capsicum • Rosmarinus

nervine adaptogen, stimulant stimulant circulatory stimulant hepatic

Antihypertensives (hypotensives)

These are herbs that

can help to reduce high blood pressure. The antihypertensive effect may involve antilipidemic, antiatheromatic, antithrombotic, cardioregulatory, vasodilatory, tranquilizing, or sedative actions.

Types ofantihypertensives The table shows examples of different types of antihypertensives. •. w ....~.

.. - .<~

. ' ••. ~.'. •

Chinese action _"

RHEUM alterative antihypertensive

clear Heart and Liver Heat, clear Heat Toxins

CRATAEGUS antiatheromatic antihypertensive move Blood. clear Heart Phlegm VALERIANA sedative antihypertensive

calm Heart Spirit and Liver Yang

Chinese equivalent There is no exact equivalent of this category in Chinese medicine. Herbs with antidepressant effect are found in the categories of herbs that tonify Qi, tonify Yang, and calm the Spirit.

LOBELIA anticonvulsant antihyperter.sive

extinguish Wind and stop tremors

VISCUM nervine antihypertensive

tonify

Kidn~y

and Liver Qi

Antiemetics These are herbs that help to prevent, reduce, or stop nausea and vomiting, including travel sickness and vomiting during pregnancy. Examples are Ballota, Matricaria, Mentha, and Zingiber.

Chinese equivalent There is no exact Chinese equivalent of

Chinese equivalent These herbs are said to calm Rebellious

found in various action categories. Some are shown in the

Stomach Qi and are mainly found in the action categories of herbs that transform Dampness, regulate Qi, and relieve food Stagnation.

table, and additional categories include herbs that clear the

Antifungals

See Antimicrobials.

the antihypertensive action, and herbs with this effect can be

Exterior and herbs that tonify Yang. Anti-inflammatories These are herbs that can reduce inflammation either in the body as a whole or in specific organ

Antigalactagogues (galactophygics) These are herbs that have a tradition of use of decreasing lactation. An example is Salvia officinalis.

systems or tissues. They can be used to treat inflammatory

Antihelmintics (vermifuges) These herbs are, used for infestation by intestinal worms (helminths), such as tapeworms (cestodes) or roundworms (nematodes). Examples are Artemisia absinthium and Dryopteris felix-mas. The latter herb can have side effects in high doses, and there may be local restrictions on its use.

Examples are Althaea, Berberis, Echinacea, Euphrasia, Fili-

disorders such as rhinitis, sinusitis, gastritis, enteritis, colitis, cystitis, salpingitis, vaginitis, arthritis, and dermatitis. pendula, Glycyrrhiza, Hamamelis, Harpagophytum, Hydras- tis, Matricaria, Populus, Salix, Symphytum, and Viola.

Types of anti-inflammatories The table shows examples of different types of anti-inflammatories.

Actions glossary

ECHINACEA antiallergic anti-inflammatory

clear Wind Heat

FILIPENDULA analgesic anti-inflammatory

clear Heat

BERBERIS antimicrobial anti-inflammatory

clear Heat Toxin

HAMAMELIS astringent anti-inflammatory

ALTHAEA demulcent anti-inflammatory

71

Antimicrobials (antibiotics, antiseptics) These are herbs that can treat infection by inhibiting the growth of microorganisms. They include herbs that have antiviral (some), antibacterial (many), antifungal (some), or antiprotozoal (some) actions. antiviral antibacterial antifungal antiprotozoal

• Echinacea • Arctostaphylos • Calendula • Cinchona

stabilize and bind

tonity Yin and Fluids, clear Heat

Chinese equivalent There is no exact Chinese equivalent of the anti-inflammatory action, and, as shown in the table, herbs with this effect can be found in various Chinese action categories. Antilipidemics (antihyperlipidemics)

See also Anti-

atheromatics. These herbs can reduce hyperlipidemia, that is, raised lipid levels in the plasma, whether of triglycerides or cholesterol. Research studies have reported antilipidemic action for Achillea, Angelica sinensis, Capsicum, Cinnamomum bark, Commiphora, Crataegus, Glycyrrhiza, Rheum, Salvia miltiorrhiza, and Zingiber (see the chapters on these herbs).

Chinese equivalent Herbs with antimicrobial action can be found especially in the clear Heat, clear Damp Heat, clear Heat Toxin, clear Wind Heat, and clear Wind Cold action categories. Antimigraine agents These are herbs that can be used for the treatment of headache or migraine. The term 'antimigraine agents' is used in conventional medicine rather than in the Western herbal tradition. Headaches or migraines can be associated with many factors, including exposure to cold wind, trauma, sinus obstruction, nervous tension, and hypertension.

1Ypes of antimigraine agents The table shows examples of different types of antimigraine herbs. . Western action

Chinese action

ANGELICA ARC.

Chinese equivalent There is no exact Chinese equivalent of the antilipidemic action, but herbs with this effect can be found in various Chinese action categories, including cool and transform Phlegm Heat, warm and transform Phlegm Cold, drain downward (purgative), relieve food stagnation, move the Blood, warm the Interior, tonify Qi, and tonify Blood.

F

Antilipidemic and antiatheromatic The antilipidernic action may help to prevent atheroma, but not all herbs with the antilipidemic action are necessarilyantiatheromatic. Antilithics These are herbs that can help to dissolve or discharge biliary or urinary gravel or stones. Examples are: • Berberis, Chelidonium, Taraxacum • Hydrangea, Parietaria, and Zea

cholelithiasis urinary stones

Demulcent, anti-inflammatory, anticatarrhal, alterative, and antispasmodic actions may all contribute to the antilithic effect.

Chinese equivalent Antilithics are mainly found in the action category of herbs that drain Damp, but a few are also found in the relieve food Stagnation, move the Blood, and tonify Yang categories.

anticatarrhal antimigraine

clear Phlegm (in the head)

BERBERIS hepatic antimigraine

move Liver Qi, clear Liver Heat

SCUTELLARIA anticonvulsant antimigraine

extinguish Wind and stop tremors

PASSIFLORA tranquilizing antimigraine

calm Heart Spirit and Liver Yang

VISCUM nervine antimigraine

tonity Kidney and Liver Qi

Chinese equivalent There is no exact Chinese equivalent of the antimigraine action. As shown in the table, herbs that treat headache and migraine are found in various categories. Antineoplastics

See Antitumor agents.

Antioxidants This term has been adopted from modern research literature and refers to substances that can neutralize harmful oxygen-bound free radicals produced by disease, drugs, or toxic chemicals. Many herbs have been reported to have an antioxidant action, including Cinnamomum, Glycyrrhiza, Rosmarinus, and Zingiber.

Chinese equivalent There is no exact equivalent of this action in Chinese medicine, and herbs with antioxidant

Combining Western Herbs and Chinese Medicine

72

effect are found in various Chinese action categories, including the warm the Interior and tonify Qi categories. Antiparasitics These are herbs that prevent or destroy parasites. The term antiparasitic lacks specificity, and more specific terms, such as antihelmintic, are often preferred. See Antipyretics.

Antiperiodics

Antiplatelet agents Antiprotozoals

carminative

LEONURUS antispasmodic emmenagogue

See Antimicrobials.

Chinese equivalent Herbs with antipyretic action can be found especially in the clear Heat, clear Damp Heat, clear Heat Toxin, clear Wind Heat, and clear Wind Cold action categories. See Antimicrobials.

Antispasmodics (spasmolytics, relaxants) The term 'antispasmodic' sometimes refers to herbs that relax: spasms in the smooth muscle of the viscera. A broader defmition is the relief of spasms in smooth, cardiac, or striated muscle. Which definition is used depends on the author of the specific text.

Normalizing action Some antispasmodics do not simply relax: smooth muscle spasms, but have a normalizing effect on the degree of contraction and on contraction rhythms of smooth muscle. For example, carminatives can both relax: intestinal spasms to normalize muscle tone and stimulate the gut to normalize peristalsis. They do not have an antispasmodic effect to the point of flaccidity, nor do they stimulate peristalsis to .the point of producing spasms and pain (see the Lobelia chapter)..

Types of antispasmodics The table shows examples of different types of antispasmodics. .

antianginal

LOBELIA anticonvulsant antispasmodic VALERIANA sedative antispasmodic

move the Blood (in the Uterus) •

relieve cough and WheeZing

move Heart Blood

extinguish Wind and stop tremors calm Heart Spirit

Chinese equivalent There is no exact Chinese equivalent of the antispasmodic action, but herbs with this action can be found in the Chinese categories shown in the table.

-~.

Antithrombotics These are herbs that can prevent the formation of blood clots (thrombi). There is a number of related action categories that have been used in conventional Western medicine: these can reduce platelet aggregation, thus reducing blood coagulation and the formation of clots • anticoagulants these can reduce blood clotting, not necessarily by inhibiting platelet aggregation, but by other mechanisms such as the inhibition of the activity of thrombin • thrombolytics these can disperse clots once they are formed, in contrast to an antithrombotic that prevents their formation

• antiplatelet agents

Achillea and Crataegus have traditions of use of assisting _ in the treatment of cerebral and coronary thrombosis, respectively. According to research studies, the following herbs have been reported to have antiplatelet effect: Angelica _ sinensis, Berberis, Capsicum, Cirmamomum bark, Commiphora, Hydrastis, Leonurus heterophyllus, Rheum, Salvia miltiorrhiza, Zanthoxylum, and Zingiber (see the chapters on these herbs).

Normalizing effects on blood coagulation The anticoagulant and antihemorrhagic effects appear to be opposite. However, some herbs and their constituents, for example, Capsicum and its main active constituent capsaicin, can have either anticoagulant or antihemorrhagic,e,ffects, depending on the st~te of the patient. S~ch he~b's:app~ to h~ve,a' normalizing effect on blood coagulation. ,

EPHEDRA antiasthmatic

regUlate Qi

HAMAMELIS

See Antithrombotics.

Antipyretics (febrifuges) These are herbs that reduce fever and lower body temperature. Examples are Achillea, Asclepias, Artemisia absinthium, Berberis, Cinchona, Salvia, and Zingiber. Antiperiodics are a subdivision of antipyretics. They can prevent the periodic recurrence of fever or diseases, such as malaria. Examples are Berberis and Cinchona. The antipyretic action of lowering fever and reducing body temperature may be produced via a direct effect on the central temperature-lowering mechanism of the body. However, in some herbs with antipyretic effect; the diaphoretic, antimicrobial, or alterative actions may also help to lower the body temperature.

Antiseptics

ELmARIA

,.

Chinese equivalent There is no exact Chinese equivalent of

Actions glossary the antithrombotic action, and herbs with this action can be found in various Chinese categories, including move the Blood, warm the Interior, and tonify Blood. Antitumor agents (antineoplastics) In this book, the antitumor action refers to a herb with a tradition of use of retarding the development of benign or malignant growths. In conventional medical terminology, this would include a variety of the following overlapping action categories:

• eytotoxics • antimitotics • antimetabolites

damage or destroy cells inhibit cell division and growth interfere with cell metabolic reactions by combining with the enzymes responsible for them

In Western herbal tradition, the main action associated with the antitumor effect is the alterative action. Most of the herbs listed as antitumor agents also have an alterative action, for examplti,'Arctium, Phytolacca, Thuja, and Viola.

Chinese equivalent There is no exact equivalent of the anti-

-

tumor action in Chinese medicine. Some of the herbs recently used in China to treat cancer are in the clear Heat Toxin group, which interestingly is the nearest equivalent to the Western alterative action. Other herbs with antitumor effect are found in the cool and transform Phlegm Heat and move the Blood categories. Antitussives These are herbs that can relieve coughing, whether by calming the central nervous system, influencing the coughing reflex, soothing inflammation of respiratory mucosa, reducing excessive mucus secretion, or by other mechanisms. Antitussives can be used for whooping cough, chronic dry cough, or nervous cough, depending on the additional actions of the particular herb. Examples are Althaea, Glycyrrhiza, Lobelia, Prunus, Thymus, and Viola.

,

~­

..

I !

Types of antitussives The table shows examples of different types of antitussives.

~-

ANGELICA ARC.

anticatarrtlal antitussive

r r T

ALTHAEA demulcent antitussive

no exact equivalent tonify Yin and Auids. clear . Heat

LOBELIA

antispasmodic antitussive

regulate Qi

PRUNUS

tranquilizing antitussive

.calm Heart Spirit

. "',:'

Chinese equivalent Antitussive herbs are found especially in the Chinese category of herbs that transform Phlegm and stop cough. They are also found in the categories shown in the table. Antiulcer agents See also Antacids. These are herbs that can be used in the prevention and treatment of peptic ulcers. They may reduce secretion of gastric acid or have a protective or anti-inflammatory effect on the mucosa. Herbs with a tradition of use in the West of treating peptic ulcers include Althaea, Calendula, Filipendula, Glycyrrhiza, Hydrastis, Syrnphytum, and Ulmus.

Chinese equivalent There is no exact equivalent of this category in Chinese medicine, but herbs with antiulcer action can be found in the categories of herbs that stop bleeding as well as herbs that stabilize and bind. Antivirals Anxiolytics Aperients

See Antimicrobials. See Tranquilizers. See Laxatives.

Aphrodisiacs These are herbs with the reputation of increasing sexual desire and sexual performance. Examples are Panax ginseng, Serenoa, and Turnera.

Chinese equivalent In Chinese medicine, herbs with aphrodisiac action are found mainly in the tonify Yang action category, although Panax ginseng is in the category of herbs that tonifyQi. Aromatic digestives

See Carminatives.

Astringents The word astringent is derived from the Latin 'stringere: to bind. When astringents, especially tannins, are in contact with mucous membranes or with wounds on the surface of the body, they can bind with proteins in both the mucus and the surface cells. This can result in shrinkage and in reduction of membrane permeability. This process can help to reduce excessive loss of fluids from the body, whether the fluids are in the form of sweat, mucus secretions, blood, urine, or feces. Astringents can be used for excessive sweating, rhinitis, sinusitis, diarrhea, urinary frequency or incontinence, and for discharges from the reproductive system. When the astringent action reduces bleeding, the herbs are termed antihemorrhagics or hemostatics and can be used for disorders such as epistaxis, hematemesis, hemoptysis, hematuria, and menorrhagia. Examples are Agrirnonia, Alchemilla, Capsella, Cinnamomum, Geranium, Hydrastis, Myrica, Polygonum, Potentina, Quercus, Sanguisorba, and Schisandra.

1Jpes of astringents The table shows examples of different

CAPSICUM

counterirritant antitussive

73

no exact equivalent ;';.'.

types of astringents.

"\

Combining Western Herbs and Chinese i\1edicine

74

-_"~f-w~~~rri~6tlC:ri~;~{;/tT":-~h~1~~chiri:~~tfn~~~~~:~~ -

_.

-) -

..

. ..,

Blood cleansers

See Alteratives.

Blood purifiers

See Alteratives.

....

""., ii' "£* G .Jb+;,¥..... ~-. ..• ~-....

----

H.~

ACHILLEA anticatarrhal astringent

no exact equivalent

ARCTOSTAPHYLOS antimicrobial astringent

clear Heat

POLYGONUM demulcent astringent

tonify Yin and Auids. clear Heat

CINNAMOMUM BARK tonic astringent

tonify Spleen and Kidney Yang

Chinese equivalent Astringent herbs are found especially in the Chinese category of herbs that stabilize and bind, and in the categories shown in the table. Antihemorrhagics are found especially in the category of herbs that stop bleeding. Herbs that firm and stabilize the Spirit The astringent action usually refers to the reduction in the loss of physical material, specifically fluids. However, the concep! of astring~nt action can be extended to include the concept of firming energy that is overly dispersed, scattered, or disturbed, especially that of the Heart and Kidney. This aspect of astringency can be used to treat insomnia, anxiety, palpitations, and scattered thinking. This topic is discussed in the section on Sour in the Taste chapter. Bitter digestive tonics These are herbs with a marked bitter taste in the mouth. The bitter constituents can stimulate the bitter receptors on the tongue, causing a cascade of events, involving stimulation of appetite, gastrointestinal digestive secretion, bile secretion, and peristalsis. Bitter digestive tonics can increase the efficiency of digestion, absorption, and assimilation. They can, therefore, be used to treat anorexia and loss of appetite, atonic digestion, malnourishment associated with impaired digestion and absorption, food allergies and intolerance, and impaired digestion with gastrointestinal inflammation. This topic is discussed in the Bitter section in the Taste chapter. Examples are Artemisia absinthium, Centaurium, Cinchona, Gentiana, and Populus.

Chinese equivalent There is no comparable theory, proposing bitters as digestive tonics, in Chinese medicine. The bitter digestive tonic action can be said to involve tonifying and moving the Qi of the Spleen, Stomach, Intestines, Liver, and Gallbladder. Bitters See also Bitter digestive tonics. This term refers t~ bitter tasting herbs and is sometimes . . used as a synonym for bitter digestive tonics. The term 'bitters' is ge~~rally a~oided in this book'sinte many different actions can be associate with the bitter taste, and the more specific term 'bitter digestive tonics' is preferred.

Cardiac diuretics

See Cardiotonics and Diuretics.

Cardioregulators See also Tranquilizers. Cardiotonics can be defined as herbs that can strengthen .--'-'.~ heart function and treat cardiac weakness with exhaustion. I use the term 'cardioregulators' for herbs that not only strengthen the heart, but by doing so, stabilize its function and treat conditions involving arrhythmias or fluctuations in blood pressure, body temperature, energy, and mood. Some cardioregulators have a normalizing effect on the heart, and can be used to treat both hyper- and hypofunction. Examples are Crataegus and Leonurus.

Chinese equivalent There is no exactly equivalent Chinese action category. Like the cardiotonics, the cardioregulators can tonify Heart Qi. By doing this, they can stabilize Heart Qi irregularity. Like the antiarrhythmics,_ ~ey. can be use~_ for cardiac arrhythmias, but in addition, they have the further effect of treating hyper- or hypoactivity of heart function, or of reducing oscillations between extremes ofYm and Yang. I therefore use them for conditions such as bipolar syndrome, emotional lability, the temperature fluctuations of menopause, or the energy fluctuations of some cases of chronic fatigue. Cardiotonics These are herbs that can strengthen heart function and can be used to treat disorders associated with cardiac weakness, such as exhaustion, hypotension, arrhythmias, and edema. Examples are Capsicum, Cinchona, Convallaria, Crataegus, Leonurus, Panax ginseng, and Sarothamnus.

Chinese equivalent There is no exactly equivalent Chinese action category, but cardiotonics can be said to tonify Heart Qi. Cardiotonics with antiarrhythmic action may also stabilize Heart Qi Irregularity (see Syndromes), and cardiotonics with diuretic action may tonify both Heart and Kidney Qi. Capsicum is an example of a herb that can give both shortterm stimulation to Heart Yang and long-term tonification to Heart Qi. Carminatives (aromatic digestives) These are aromatic herbs that can aid digestion, stimulate peristalsis, promote the expulsion of gas from the gastrointestinal tract, and relieve the pain due to flatulence. These herbs are aromatic due to their relatively high content of volatile oils. The normalizing effect of carminatives on gut muscle tone and motility has been described under Antispasmodics above. Examples are Angelica archangelica, Cinnamomum bark, Citrus, Elettaria, Foeniculum, Juniperus, Lavandula, Rosmarinus, and Zingiber.

"

Actions glossary Chinese equivalent There is no exact Chinese equivalent to the carminative action. The closest are those herbs in the regulate Qi action category that rela.x: and move the Qi of the St~mach and Intestines. There is overlap between the uses of carminatives and herbs that transform Damp, but the carminatives are not necessarily associated with Damp disorders. This topic is discussed in the Aromatic section in the Taste chapter. Cathartics

75

the normal body processes to reduce inflammation and infection. Counterirritants can be used as gargles or mouthwashes for such complaints as chronic laryngitis or gum disorders. They can be applied topically as poultices, plasters, oils, or liniments for disorders such as osteoarthritis, myalgias, sprains, or unbroken chilblains. Examples are Brassica nigra seeds (black mustard), Capsicum, Lobelia, Sanguinaria, and the fresh leaves ofUrtica (stinging nettle).

See under Laxatives.

Chinese equivalent There is no exact equivalent of the Choloretics

See Cholagogues and choloretics.

Cholagogues and choloretics One definition is that chloretics stimulate the secretion of bile by the liver cells and cholagogues stimulate the £low of bile from the gallbladder and bile ducts into the duodenum. However, most choloretic herbs also have a cholagogue action, and not all traditional texts distinguish between the two actions. Many texts refer to . the cholagogue action in the treatment of all disorders of the biliary system, such as cholecystitis, cholelithiasis, and cholangitis. Most herbs with choloretic and cholagogue action have a bitter taste, for example, Berberis, Chelone, Chelidonium, Chionanthus, Gentiana, Leptandra, and Taraxacum. However, some herbs that have these actions do not have the bitter taste, for example, Zingiber (see the chapter on this herb).

Chinese equivalent Herbs with choloretic and cholagogue action are mainly found in the drain Damp and clear Damp Heat categories. Circulatory stimulants These herbs stimulate the circulation and warm the body. They can increase the efficiency of heart function, coronary circulation, and peripheral circulation to treat circulatory disorders, including arthritis aggravated by cold, Raynaud's syndrome, and Buerger's disease. Examples are Angelica archangelica, Capsicum, Cinnamomum, Myrica, Sanguinaria, Thuja, Zanthoxylum, and Zingiber.

Chinese equivalent This category has no exact equivalent in Chinese medicine. The closest category is that of herbs that warm the Interior. However, most of the herbs in the warm the Interior category warm the Spleen and improve digestion, rather than stimulate the Heart and improve circulation (see the Acrid section in the Taste chapter). Counterirritants See also Rubefacients. These are herbs that are used to irritate the surface of the body or the mucus membrailes of the mouth ~r sinuses, thus initiating wound healing responses and increasing blood supply to the area. This irritant effect may clear st~gnation in the area, remove accumulated wastes and toxins, and assist

counterirritant action in Chinese herbal medicine, but compounds with this action are found in the category of substances for External application. Also, the techniques of cupping and gua sha are based on a sin1ilar p~inciple.

Vesicants These are a subdivision of the counterirritant category. They were employed in the past to produce blisters on the skin, which could then be pierced and drained, to release toxins from the area. An example is mustard oil, which can produce almost instantaneous blistering on the skin. A similar principle underlies the use of moxibustion to produce blisters or cupping over an acupuncture point that has been pierced for bleeding.

Caution Piercing of blisters has an obvious risk of infection, and the vesicant technique lies outside the scope of this book. Demulcents See also Emollients. These are herbs with a high mucopolysaccharide content that can have a soothing and protective effect on inflamed mucus membranes of the gastrointestinal system. This is termed the 'direct demulcent effect: They may also have this effect on inflamed mucus membranes distant from the gut, for example, in the respiratory and urinary systems, and this is termed the 'indirect' or 'reflex demulcent effect: Demulcents can therefore be used for conditions involving inflan1ffiation of mucosa such as gastritis, enteritis, colitis, dry cough, bronchitis, and cystitis. Examples are Althaea, Plantago, Polygonum, Ulmus, and Viola.

Chinese equivalent There is no exact equivalent of the demulcent action in Chinese medicine. Most herbs with this action can tonifyYm and Fluids and also clear Heat. Deobstruants This is an old term for herbs that can clear obstructions in the body. The concept of obstruction to movement, whether ofblo<;>d or of the products of digestion, is an old one in Western medical theory. For example, Culpeper recommended Rosmarinus for opening obstructions of the liver. He warned against using medicines that are too binding to the liver since these may result in liver obstruction and hinder the circulation of the blood.

Combining Western Herbs and Chinese Medicine

76

The deobstruant action overlaps with the alterative and circulatory stimulant actions in moving stagnation and clearing accumulations and blockages. Examples are Lobelia, Myrica, Phytolacca, Smilax, and Zanthoxylum.

Chinese equivalent The deobstruant action has a very broad definition and there is no exact equivalent of such a general action in Chinese medicine. However, the concept of moving Stagnation to clear accumulation and obstruction is fundamental to Chinese medicine, and more specific action categories that include a deobstruant effect include the groups of herbs that clear Wmd Heat, clear Wmd Cold, clear Wind Damp, regulate the Qi, and move the Blood. Depurants

See Alteratives.

Types ofdiaphoretics The table shows examples of different types of diaphoretics. • -

,_ :~~~s~e~nc~~~~?~~';~!' ic,,-:_~'c

~~

... ,Chinese action' ..

NEPETA antipyretic diaphoretic

clear Wind Heat, clear Interior Excess Heat

ZINGIBER (FRESH) circulatory stimulant diaphoretic

clear Wind Cold

ANGELICA ARC. antirheumatic diaphoretic

clear Wind Damp

ACHILLEA alterative diaphoretic

clear Exterior Wind, clear Retained Pathogen

SAMBUCUS anticatarrhal diaphoretic

clear Exterior Wind, clear Lung Phlegm

Chinese equivalent The diaphoretic herbs are mainly found in the Chinese categories of clear Wind Heat, clear Wind Cold, and clear Wind Damp. Diaphoretics and antipyretics The antipyretic action does not necessarily involve diaphoresis. It may result from other physiologiCal "inechiulisms. Conversely, the diaphoretic action does not necessarily reduce fever. Diuretics

Types of diuretics The table shows examples of different types of diuretics. Western action'

Chinese

action'

CONVALLARIA

Diaphoretics (sudorifics) These are herbs that can increase sweating. This can be used to regulate body temperature so that during fever, diaphoretic herbs may have an antipyretic effect. The diaphoretic action can also have an aIterativ~'effectsin~~l~creased~~eating ~ help to eliminate toxins from the body surface. The diaphoretic action and its related antipyretic and alterative effects can be used in the treatment of acute fever, recurring fever, rheumatism, or arthritis.

,!.

substance that can increase excretion of urine. However, in Western herbal tradition, the term 'diuretic' has been appliecf'-····· to any herb used for disorders of the urinary system, whether urination is increased or not. In this book, the term 'diuretic' is used in the limited sense, so that diuretics are herbs used to treat edema or reduced urination. Examples are Arctium, Juniperus, Parietaria, Petroselinum, Taraxacum, and Zea.

The limited definition of diuretic is that it is a

cardiac diuretic

no exact equivalent

JUNIPERUS antimicrobial diuretic

drain Damp, clear Damp Heat, clear Heat Toxins

ZEA demulcent diuretic

drain Damp, tonity Yin, clear Heat

TARAXACUM alterative diuretic

drain Damp, clear Damp Heat, clear Heat Toxins

Chinese equivalent Diuretic herbs are found especially in the Chinese category of herbs that drain Damp. Emetics These are herbs that can induce vomiting. Promotion of vomiting was one of the main therapeutic methods in both traditional Western and Chinese medicine. In Western herbal medicine, vomiting was seen as one of the ways to help the body to eliminate toxins. Examples of emetics are Cephaelis, Lobelia (at high doses), and Urginea. In the past, herbal practitioners had to deal with more severe acute illnesses than today. In addition, patients were often more robust in constitution and more willing and able to take strong treatment modalities such as vomiting and purging. Emesis is now rarely used in Western herbal therapy. Emmenagogues The old definition of an emmenagogue was that of a herb that can stimulate menstruation and, in the language of Culpeper, 'procure women's courses: A more recent definition of emmenagogue is that of a herb that can normalize menstruation by assisting the self-regulating capacity of the female reproductive system. This includes the normalization of the muscle tone and rhythms of contraction of the uterus. This book uses the term 'emmenagogue' in this latter sense. The following categories have been used to describe emmenagogues: • tonic emmenagogues • antispasmodic emmenagogues

Actions glossary • stimulant emmenagogues • normalizing emmenagogues

Tonic emmenagogues These can gradually strengthen the uterus and be used for conditions associated with uterine weakness, for example, amenorrhea or habitual miscarriage. Herbs with this effect often also have an astringent action so that they can be used for uterine prolapse. Examples are Chamaelirium, Mitchella, and Rubus. In terms of Chinese medicine, these herbs can be said to tonify the Qi and Blood of the Uterus and to have a firming and binding action upon it.

Antispasmodic emmenagogues These can be used to relieve uterine muscle spasms and the associated pain. Herbs with this effect can be used for dysmenorrhea, excessive uterine spasms in pregnancy, and postnatal pain. Herbs with nonspecific antispasmodic action, such as Piscidia and Valeriana, can be used for these disorders. However, Viburnum can be described as an antispasmodic emmenagogue since it has a specific action on the uterus. In terms of Chinese medicine, these herbs can be said to move the Qi and Blood of the Uterus and relieve pain.

Stimulant emmenagogues These can be used to initiate

77

The expectorant action can be said to include one or more of the following effects: • promotion of the coughing action • increase of the ciliary action • reduction of mucus viscosity Expectorant herbs may also have the additional effects of reducing excessive mucus secretion and relaxing bronchial spasms. However, these two effects have been given separate action categories in this book: the anticatarrhal and antispasmodic actions, respectively. Expectorants are used to reduce mucus obstruction of the bronchioles and treat acute or chronic bronchitis with influenza, pneumonia, or asthma.

Types of expectorants Some of the main types of expectorant are given below, together with examples.

CEPHAEUS, URGINEA stimUlating expectorant.

LOBELIA

uterine contractions to treat amenorrhea (for example, Mentha pulegium) or delayed labor (for example, Hydrastis). In terms of Chinese medicine, these herbs are mainly in the category of herbs that move the Blood.

PRIMULA, INULA, MARRUBIUM

Normalizing emmenagogues Some herbs can act as anti-

antipyretic expectorant

spasmodic emmenagogues or stimulant emmenagogues, depending on the initial state of the uterus. These herbs can be said to have a normalizing effect on the uterus. Examples are Leonurus and Lobelia (see the chapters on these herbs). This category is not specified in Chinese medicine.

expel Phlegm by inducing vomiting

normalizing expectorantt

antispasmodic expectorant

transform Phlegm, regulate Qi

transform Phlegm, regulate Qi

ASCLEPIAS transform Phlegm Heat

GRINDELIA, HYSSOPUS sedative expectorant

transform Phlegm, calm the Spirit

GLYCYRRHIZA, VIOLA demulcent expectorant

stoP. cough and moisten dryness

ANGELICA ARC., COMMIPHORA

Emollients See also Demulcents. Emollients have a soothing anti-inflanunatory effect at the surface of the body. Some emollients, such as Althaea and Symphytum, contain mucopolysaccharides, while other emollients, such as olive oil, linseed oil, and flaxseed oil, contain oils.

F-

I

Expectorants The simplest defmition is a substance that can promote the coughing up of phlegm. However, a fuller definition of the expectorant action can be given in terms of bronchial physiology. The walls of the bronchioles are lined with ciliated mucosecretory epithelia and are provided with smooth muscle tissue. The mucus can trap particles from the air, which are then transferred up the bronchioles to the throat by the beating of the cilia and are coughed up by the coordinated action of the smooth muscle layer. The bolus of mucus can then be coughed out or swallowed.

anticatarrhal expectorant

transform Phlegm, transform Damp

• Stimulating expectorants can have an emetic action in high doses.

t Normalizing expectorants can have a stimulant or antispasmodic effect. depending on the state of the patient.

Chinese equivalent These herbs belong to the category of transform Phlegm and stop cough. Febrifuges

See Antipyretics.

Galaetagogues These are herbs that have a tradition of use of increasing milk secretion. Examples are Foeniculum, Pimpinella, Verbena, and Vitex. Ga1actophygics Hemostatics

See Antigalactagogues.

See Astringents.

78

Combining Western Herbs and Chinese Medicine

Hepatics This term is often used in a general sense for herbs that can strengthen and regulate hepatobiliary function, and that can be used to treat disorders of either the liver or the gallbladder. Based on the Western understanding of the range of liver function, hepatics may be appropriate in the following situations: • to strengthen and regulate the immune system • to treat combined gastrointestinal and hepatobiliary disorders • to treat liver disease and its sequela • to treat the sequelae of stress on the liver from excess consumption of fatty foods, alcohol, or other drugs, or from prolonged medication • to treat exposure to toxins and pollutants • to assist the antitumor activity of the liver Examples are Artemisia absinthium, Berberis, Rosmarinus, and Taraxacum.

Chinese equivalent ·"·There is no exact Chinese equivalent of this action. Herbs that can strengthen and regulate hepatobiliary function can be said to have one or more of the following Chinese actions on the Liver and Gallbladder: • tonify Oi, Blood, Yang, or Y"m • move Stagnant Oior Blood • clear Heat, Cold, Damp, or Phlegm Hepatoprotectives This term has been adopted from modern research by some recent herbal texts. The hepatoprotective action can be seen as a specific aspect of the hepatic action, consisting of the capacity to protect the liver against damage by toxic chemicals and other potentially harmful factors. Examples are Juniperus, Myrica, Schisandra, and Zingiber.

Chinese equivalent There is no exact Chinese equivalent of this action. Herbs with the hepatoprotective effect can be found in various Chinese action categories, including clear Heat Toxins, move the Blood, warm the Interior, tonify Oi, and stabilize and bind. Hepatoprotective and antioxidant Hepatoprotective effects are sometimes based on antioxidant processes occurring in the liver, for example, Artemisia absinthium and Curcuma have been reported to have hepatoprotective effects by lowering lipid peroxidation. Hypnotics See also under Tranquilizers. These are substances that are used to promote sleep. IIYP,otensives .

See Antihypertensives.. .

Laxatives These are substances that promote 'or facilitate bowel movement, and are generally used to treat or prevent constipation. The group of substances that facilitate bowel

movements is sometimes divided into three grades, in order of increasing strength: -laxatives • purgatives • cathartics

Laxatives Sometimes called aperients, the laxatives have a relatively gentle action on the bowel and are used for mild constipation, especially weak patients. For example, Glycyrrhiza is a mild, demulcent, anti-inflammatory laxative, Plantago seeds can act as a bulk. laxative, and Berberis and Taraxacum are bitter hepatics that promote bowel movement by increasing bile flow.

m

Purgatives These herbs have a stronger action on the bowel. They generally stimulate bowel movement by stimulating the lining of the intestines and causing stimulation of the smooth muscle of the bowels. They may cause intestinal cramping unless combined with antispasmodics such as Foeniculum or Zingiber. One of the main groups of purga~ .. tives are the herbs that contain anthraquinones, for example, Aloe, Cassia (senna pods); Rhamnus purshiana (cascara bark), and Rheum. Cathartics Sometimes called drastic purgatives, or simply drastics, these herbs have a very strong effect on bowel movement, producing violent peristalsis, drastic diarrhea, maybe with incontinence, and often severe intestinal pain. Another name for cathartics was hydragogues, that is, substances producing a watery.~owel movement. Cathartics were used, both in the West and in China, to remove fluids from the body in cases of severe edema, and this use continues in Chinese medicine. Cathartics are now rarely used in Western herbal medicine because of their weakening effect on the patients. Narcotics

See Tranquilizers.

Nervines See also under Tranquilizers. These have also been called nerve tonics, nervine tonics, nervous trophorestoratives, and nervine trophorestoratives. Nervines are herbs that can tonify and stabilize the nervous and endocrine systems, thereby stabilizing and normalizing the mental-emotional balance. Nervines can therefore be ~ used for either lowness of mood or emotional disturbance, especially when these are associated with physical, mental, and emotional debility. Examples include Avena, Cimicifuga, Hypericum, and Salvia officinalis.

Chinese equivalent .. The nearest equivalent in Chinese medicine is the action category herbs that of nourish the Heart and calm the Spirit. These herbs tonify Heart Oi, Blood, or Y"m. However, some nervines may also tonify the Oi and Y"m of the Kidney and Liver.

Actions glossary Avena (oats endosperm) is an example of a sweet nervine that can be said to tonify the Qi and Till of the Heart and Kidney and also to tonify Spleen Qi. Hypericum and Schisandra are examples of sour, astringent nervines that can firm and stabilize the Qi of the Kidney and Heart. Nutritives See also Tonics. These are sweet tonics that provide nourishment to build body tissues, whether in the form of sugars and starches or minerals and vitamins. Examples include Althaea, Avena (endosperm), Serenoa, Trigonella, Ulmus, and Ziziphus (fruit). Oxytocics These are herbs that can stimulate uterine contractions to facilitate or induce labor, for example, Hydrastis. These herbs should obviously not be taken at earlier stages of pregnancy. Parasiticides See Antiparasitics. Partus praeparator This term is used by the BHP for herbs that can be used to facilitate childbirth and help prevent miscarriages. They can be used to strengthen and normalize the function of the reproductive system prior to conception and in some cases during pregnancy. Examples are Chamaelirium, Mitchella, and Rubus.

Chinese equivalent In Chinese medicine, these might most closely correspond to the action categories of herbs that firm and bind or stop bleeding.

I.".

Purgatives

See Laxatives.

Relaxants

See Antispasmodics.

Rubefacients See also Counterirritants. These are substances that, if applied topically, increase capillary circulation at the surface, producing redness (hyperemia). They are thought to draw blood from deeper areas, thus relieving congestion and inflammation. An exampIe is Capsicum. Sedatives

See Tranquilizers.

Sialogogues These are herbs that stimulate the flow of saliva. Herbs with very bitter constituents, such as Cinchona and Gentiana, often have this action. Spasmolytics See Antispasmodics. Stimulants Seealso Tonics. These are herbs that can rapidly increase one or more body functions. The effect may be short term, rather than cumulative, and in the case of some of the stronger stimulants, prolonged use may decrease, rather than increase, body function. ' ' , ' H , ' ,

79

The stimulant action can be included in suitable combination with other action categories in the treatment of exhaustion and depression. It can also be utilized in the treatment of atonic conditions of the gastrointestinal or reproductive systems, such as loss of appetite, atonic digestion, atonic constipation, or lack of sexual drive and interest. Stimulants may have their effect via the cardiovascular, central nervous, or endocrine systems. Some herbs, for example, Panax ginseng, may affect all three systems.

Strength of stimulant action Herbs can be roughly divided into three levels according to the strength of their stimulant action: • strong • medium • mild

Strong Caffeine-based herbs, such as Cola (kola nut) and Ilex (yerba mate), have been used in the past as antidepressants for short-term use. However, in my opinion, long-term use of such herbs should be avoided since it can lead to weakening and destabilizing of the patient's energy. Capsicum can act as a strong stimulant to the cardiovascular, digestive, and other systems, but it also has a tonic action so that it is suitable for long-term use. Medium Rosmarinus and Turnera can have stimulant action via their effects on the central nervous system. Rosmarinus may also have an additional stimulant effect via the cardiovascular system, and Turnera may also have an additional stimulant effect via the endocrine system. These herbs may be suitable for long-term use, providing their specific cautions for use are observed. Mild Lavandula, Salvia officinalis, and Thymus may have mild stimulant action on the central nervous system. However, the aromatic constituents of these herbs can also have a tranquilizing action. Whether these herbs, or their aromatic constituents, have a stimulant or a tranquilizing action may depend on the state of the patient (see the discussion on camphor in the section on Research in the Rosmarinus chapter). Stimulants and tonics The difference between a stimulant and a tonic can be merely a matter of time and dose. Some herbs have an initial stimulant effect, followed by, or grading into, a tonic effect. For example, Capsicum can have a rapid, strong stimulant effect followed by a niilder long-term tonic action. Some herbs have a tonic effect in smaller doses, and a stimulant effect in higher doses. For example, Panax ginseng can gradually increase energy over a period of time in smaller doses, whereas in larger doses it can have a rapid more

80

Combining Western Herbs and Chinese Medicine

strongly energizing effect, which in susceptible persons can destabilize the balance of both energy and emotions. Styptics These are herbs that can be applied topically to reduce bleeding at the surface of the body, for example, Calendula. See Diaphoretics.

Sudorifics

Thrombolytics See Antithrombotics. Tonics See also Adaptogens, Nutritives. and Stimulants. These can be defined as substances that can strengthen the body as a whole or one or more of its functions. Tonics are characterized by a gradual. cumulative strengthening of function.

tranquilizers can calm Heart Spirit Disturbance or Liver. Hyperactive Yang directly, rather than by nourishing the Qi, Blood. or Yin of the Heart or Liver.

Tranquilizers, sedatives, and hypnotics Tranquilizers These herbs can have a calming effect without necessarily dulling consciousness or inducing drowsiness and sleep. The term sedative is sometimes used synonymously with tranquilizer, but it is often used to refer to a substance that calms, but may have a dulling effect on consciousness. This distinction between tranquilizers and sedatives is blurred by the fact that some of the minor tranquilizers used in conventional medicine may dull the consciousness.

Types of tonics Some of the main types of tonics as well as Sedatives In this book, when the term tranquilizer is

examples are shown in the table.

GENTIANA digestive tonic

tonify Spleen Qi. tonify Qi and Blood

ROSMARINUS hepatic tonic

tonify and move Liver Qi, tonify and move Spleen Qi

CRATAEGUS cardiac tonic

tonify Heart Qi, move Heart Blood

AVENA nervine tonic

tonify Heart and Kidney Qi and Yin, tonify Spleen Qi

CHAMAELIRIUM uterine tonic

tonify Qi and Blood of the Uterus. firm Uterus Qi

Tranquilizers Also called anxiolytics, these are substances that can have a calming effect without necessarily inducing dullness, drowsiness, or sleep. Some texts in conventional medicine distinguish between the major tranquilizers, used to treat severe mental disorders, and the minor tranquilizers, used to treat anxiety and nervous tension. In this book, the term tranquilizer. as applied to herbs, refers to the minor tranquilizing action only. Herbs with the tranquilizing action can be used to treat anxiety. They can also be used to treat such problems as insomnia, palpitations, headaches, or muscle tension and pain when these are associated with nervous tension. Examples of herbs that can have it tranquilizing a~i6n are Anemone, Humulus, Lavandula, Mentha pulegiuin, Passiflora, .Piscidia. .'and Valeriana... :: "

"

'

,

;'-:'~

'~.

Chinese equivalent The nearest equivalent in Chinese medicine is the category of herbs that calm the Spirit. More specifically, the herbs listed in the previous paragraph as

referring to a herb, it indicates that it can calm with no, or minimal, dulling of consciousness. The. term sedative refers to a herb that calms but produces mild to moderate dulling of consciousness. The distinction may be a matter of dose. The stronger herbal calming agents may have a tranquilizing effect at lower doses and a sedative effect at higher doses, for example, Piscidia or Valeriana.

Hypnotics These herbs can be defined as substances that can promote drowsiness and sleep. In conventional medicine, hypnotics have been described as intermediate between sedatives and narcotics. The difference between the three groups may, in some cases, be only one of dose. For example, the barbiturates have been used at low doses as sedatives to relieve anxiety, at intermediate doses as hypnotics to promote sleep, and at higher doses as narcotics to produce unconsciousness or anesthesia.

Tranquilizers, nervines, and cardioregulators Tranquilizing herbs can be defined as those that calm without necessarily having a dulling effect on consciousness, and which can have a direct calmm'g effect on the nervous system, rather than an

indirect calming effect via tonification. Nervines and cardioregulators (see the definitions above) can have a calming effect, but this effect is indirect, via tonification of the nervous or cardiovascular systems, respectively.

Tranquilizers and antidepressants Some herbs have the capacity to normalize emotional balance, so that they can be used as either tranquilizers or antidepressants, depending on the patient's needs and on the herbs with which they are combined. Some herbs do this indirectly by strengthening and stabilizing the function of the nervous or cardiovascular systems. These herbs are the nervines (such as Avena) and

Actions glossary the cardioregulators (such as Crataegus), respectively. Other herbs can have a direct calming or stimulant antidepressant action on the central nervous system. For example, Rosmarinus and Turnera can have some calming action but are predominantly stimulants to treat depression. Lavandula can have some antidepressant action, but the herb is predominantly a calming herb to treat anxiety and insomnia. Trophorestoratives Uterine tonics

\'

See Nervines.

See Emmenagogues.

Vermifuges Vesicants

81 See Antihelmintics. See under Counterirritants.

Vulneraries These are herbs that can proinote healing of wounds. The vulnerary action may involve the capacity to promote the regeneration of cells and tissues, especially of connective tissue, cartilage, and bone. This vulnerary action may be combined with astringent, antihemorrhagic, antiinflammatory, and antimicrobial effects. Examples are Calendula, Commiphora, Hypericum, and Symphytum.

Principles of herb combination herb combination form the bridge between the diagnosis and the choice of herbs. The patient can be diagnosed in terms of syndromes, and herbs can be selected with actions to match these syndromes. This is the basic level of herb combination. At a more sophisticated level of herb combination, herbs can be chosen not only to match the syndromes of the patient but also to coordinate with each other, in terms of temperature, taste, and herb interactions, to form a balanced combination. The better the mutual balance of the herbs in a combination, the more readily the pathologies can be corrected with minimum disturbance to the body and with maximum enhancement of the natural ability of the body to heal itself. To create a balanced and effective herb combination, it is important to apply the following principles:

T

\:.i

• use herb pairs or trios as the basis for the combination

HE PRINCIPLES OF

• follow the cautions and contraindications for each herb

Primary and secondary syndromes Many patients have complex chronic conditions, and it may emerge from the diagnosis that the patient has up to 12 or even more different syndromes, in terms of Chinese medicine. This complexity can be confusing and the practitioner has to start somewhere. It is necessary to form a treatment plan and decide which syndromes are of relatively greater importance (primary syndromes) and which are of relatively lesser importance (secondary syndromes). The decision as to which syndromes are primary and which are secondary is made partly according to which disorders are most important to the patient, and partly according to medical principles, such as the optimum sequence for treating 'root' and 'branch' in the specific case.

• differentiate the patient's syndromes into those of primary and secondary importance • match herb actions to the patient's syndromes and ensure a balance between the different herbal actions in the combination

Example A patient's main complaint is cardiac weakness with exhaustion. This is associated with Heart Deficient Qi, in terms of Chinese medicine. In addition, the patient complains of chronic insomnia, but this is more recent and of lesser importance to the patient. The insomnia is associated with Heart Spirit Disturbance. In this simple example, the primary syndrome is Heart Deficient Qi, and the secondary syndrome is Heart Spirit Disturbance. ..

• match herb temperatures to the patient's syndromes and ensure a balance of temperature in the combination • match herb tastes to the patient's syndromes and ensure a balance of tastes in the combination • use the principles of herb interaction to create a balanced combination

~

83

84

. ~. \

Combining Western Herbs and Chinese Medicine

Actions The actions of a herb are the types of therapeutic effects it has on the body (see the Actions chapter). Actions sometimes relate to the treatment of a particular organ system or even a specific organ syndrome. For example, in terms of Chinese medicine, if the patient has exhaustion associated with Heart Deficient Qi, herbs can be selected with the action of tonifying Heart Qi. In Western herbal tradition, such herbs would be said to have a cardiotonic action.

to ensure that there is a maximum balance between the herbs included in the fmal combination. This is done to .. =: maximize the herb combination's effectiveness and minimize the herb combination's side effects. The provisional combination can be screened in terms of the following factors: -~

• temperature • taste • herb interactions • contraindications

Temperature

PRIMARY AND SECONDARY ACTIONS AND HERBS Having decided which syndromes are of primary importance and which are of secondary importance, the practitioner can then select herbs with the appropriate actions to correct these syndromes. The factors that determine which actions are of primary importance and which are of secondary importance in a specific situation is discussed in the section Working with actions in the Actions chapter. In the example above, the patient has Heart Qi Deficiency as the primary syndrome and Heart Spirit Disturbance as the secondary syndrome. Crataegus can be chosen as a primary herb for this patient, since it has the primary action of tonifying Heart Qi. Passiflora can be chosen as a secondary herb for this patient, since it has the primary action of calming Heart Spirit Disturbance. However, a herb may be considered primary in one situation and secondary in another. For instance, in contrast to the example above, a different patient has the main complaint of chronic insomnia, associated with Heart Spirit Disturbance. For this second patient, cardiac weakness and exhaustion, associated with Heart Deficient Qi, is of more recent origin and of lesser importance. In this situation, Passiflora can be used as a primary herb, since the action of calming Heart Spirit is of primary importance. Crataegus can be used as a secondary herb, since the action of tonifying Heart Qi is of secondary importance.

The concept of temperature is discussed in detail in the Temperature chapter. In practice, it is important to consider two main aspects of the temperature balance of a combination: • overall temperature • range of temperature

OVERALL TEMPERATURE The overall temperature of a herb combination is the result of the temperatures of all the herbs in the combination. It will primarily depend on the number andarnount of herbs in each temperature category. The overall temperature of a combination should be a reflection of the overall temperature of the patient's syndromes.

Example The patient has influenza with mild fever and sore throat, associated with Wind Heat and Heat Toxin. The overall temperature value of the patient's syndromes is warm. Therefore, a herb combination with an overall temperature value of cool is required. The combination Achillea: influenza + sore throat can be used. In this combination, the variable-temperature herbs, Achillea and Mentha, can both have a cooling effect in the context of the Wind Heat condition, especially when they are combined with the cooling herb Sambucus. , . ,"-'

A PROVISIONAL COMBINATION Once the practitioner has decided which syndromes are primary and which are secondary, and which actions are appropriate to correct them, a provisional list of herbs can be made on the basis of a selection of herbs according to -their actions. However, this is merely the preliminary stage of herb combination. .. -' - . Screening the provisional combination The provisional list of herbs can be subjected to a series of screens or fIlters

Herb Achillea Mentha pip. Sambucus

"'--~

.." ~-

--")<:"r~':..r·-11;;';.o··

...... ~

-- . Daily dose .. ·.Temperature/·,·..... Jaste+,·;~·t~·"' . '.- ...I,.I<,'i;;.i'; .. h:b- .. ~fj .....

6g 3g 3g

warm-cool warm-cool cool

~-,

acrid, bitter acrid, aromatic acrid, sl. bitter

RANGE OF TEMPERATURE Many combinations contain some herbs that are warming and some herbs that are cooling. There are two main reasons for this:

~.

Principles of Herb Combination • mixed patterns of Heat and Cold • moderation of extremes Mixed patterns of Heat and Cold The patient may have hot patterns in some organs and cold patterns in others.

l~

Example The patient has chronic irritability, depression, and sensations of heaviness and heat, which can be aggravated by fatty foods and alcohol. However, less frequently, the patient can have abdominal distension with sensations of cold, aggravated by the consumption of excessive amounts of raw or cold foods. The primary syndromes are Liver Stagnant Qi and Liver Damp Heat, but the patient also has the secondary syndrome of Spleen Deficient Qi with Cold. A herb combination is therefore required with a majority of cooling herbs to clear Liver Damp Heat, but also with one or more warming herbs to warm the Spleen. The combination Artemisia: food intolerances + heat sensations can be used. The majority of the herbs, Artemisia, Berberis, Taraxacum, and Hydrastis, combine to cool Liver Damp Heat, and the secondary herb'~, Zingiber and Mentha, can combine to warm the Spleen. -' ._',":' '.'__ ' ,.":_._~_ ...,,

Herb Artemisia Berberis Taraxacum Hydrastis Mentha pip. Zingiber Glycyrrhiza

Ratio

~ -.t,~ ...., ..,.-:~ "';:;-,;,',"" "~'~"'fr't}!W'("'~.t:!'!cf":-t:·-.-.'!:",,

.:Te~peratur~ :;;;)~~t~}£~~;.t.+,j~~J warm-cool cool cool-cold cool warm-cool hot neutral-cool

1 1 1 0.5 0.5 0.5 0.5

bitter, aromatic bitter bitter bitter aromatic, acrid acrid, aromatic sweet

Moderation of extremes In practice, combinations for patients with hot conditions are rarely composed of cold herbs only. Cold and cool herbs may be predominant in such a combination, but there are generally also warm or hot herbs in lesser number and amount to balance and moderate the effects of the cooling herbs on the body.

Example The patient has acute influenza with fever and cough associated with Wind Heat and Lung Heat, and the overall temperature of the syndrome is hot. The combination Asclepias: influenza + fever may be appropriate, in which the leading herb Asclepias is cold. However, the hot secondary herb fresh Zingiber is included to moderate the potentially depressing effect of cold Asclepias on the patient's metabolism. (See the Asclepias chapter for cautions on the use of this combination.)

Asclepias Achillea Lobelia Zingiber (fresh)

6g 6g 0.6g 3 slices

cold warmcool warmcool hot

'bitter acrid, bitter acrid . acrid, aromatic

85

Similarly, even if the patient's overall tempera~e classification is cold, combinations are rarely composed of hot herbs only. The concept of temperature is discussed in detail in the Temperature chapter.

Taste Temperature gives one approach to balancing a combination, and taste gives a different but complementary perspective. Once the provisional combination has been screened according to considerations of temperature, it can be screened according to taste. As with herb actions, the nature and relative importance of the patient's syndromes will decide which taste properties are of primar:y importance in a combination and which are of secondary importance.

Example The patient has recurring fever with postfebrile debility associated with both cardiac and digestive weakness. In Chinese herbal medicine terms, the patient has Retained Pathogen producing the recurring fever and also Deficient Qi of both the Heart and Spleen. Since the bitter taste can be associated with antipyretic, cardiotonic, and digestive tonic actions, it is likely to be the most important taste in a combination selected to treat this patient. However, to produce a balanced combination, the bitter taste would be generally combined with other taste properties to complement and moderate its effects. The combination Cinchona: recurring fever + cardiac weakness can be used for this patient. Herb

Ratio

Temperature.

Taste

Cinchona Achillea Echinacea Crataegus Pseudostellaria Glycyrrhiza Zingiber

1 1 1 1 1 0.5 0.5

cool warm-cool cool 51. warm neutral neutral-cool hot

bitter acrid, bitter acrid, bitter, 51. sweet sour, sweet sweet, 51. bitter sweet acrid, aromatic

BALANCING THE FIVE TASTES The combination Cinchona: recurring fever + cardiac weakness is a good example of the balancing of the five tastes and of the relationship between tastes and actions. In brief, the bitter, sweet, and acrid tastes can be regarded as primary. the bitter taste being the most important, and the ~our and aromatic tastes are of secondary importance. The contribution of each taste to the final balance of this combination is discussed here.

Bitter In ~ combination, the bitter taste property can be

Combining Western Herbs and Chinese Medicine

86

associated with three different actions, shown in the table with their associated temperatures and herbs: Action

Temperature

bitter cardiotonic

cool

Cinchona

bitter digestive tonic

neutral

Achillea, Cinchona

bitter antipyretic

cool

Achillea, Echinacea, Cinchona

Sweet In this combination, the sweet polysaccharides of Echinacea may be associated with the immunoregulatory action, or in Chinese herbal medicine terms, they can tonify the Defensive Qi. The sweet constituents of Crataegus, Glycyrrhiza, and Pseudostellaria may support both the cardiotonic and digestive tonic actions, or in Chinese herbal medicine terms, the three herbs tonify the Heart and Spleen Qi. Acrid If this combination is used during the acute febrile phase, the acrid property is of primary importance in clearing both Wind Heat and Retained Pathogen from the surface. This is associated with the diaphoretic and antimicrobial actions of Achillea, Echinacea, and Zingiber. However, during the remission phase, the diaphoretic aspect of the acrid property is of secondary importance. Sour The sour taste, contributed by Crataegus, is of secondary importance in this combination and is associated with a cardiotonic action, that is, with the tonification and stabilization of Heart Qi. Aromatic The aromatic property, contributed by Zingiber, is also of secondary importance and is associated with the carminative action, that is, with warming and moving the Qi of the Spleen, Stomach, and Intestines to assist in the digestion. Concepts of taste are discussed in detail in the Taste chapter, which contains the clinically useful table Balancing

the tastes.

Principles ofherb interaction Assessment in terms of the principles of herb interaction provides the third stage of screening. This is done to check the mutual balance of the herbs in the provisional combination. In this book, four main types of beneficial interactions between herbs are discussed: • complementarity • emphasis • extension • moderation

COMPLEMENTARITY One herb can be said to complement another when the two herbs have the same action, but operate via different mechanisms. There are two main types of complementarity: • two herbs can have the same action via very different routes • two herbs can have the same action by mechanisms that are slightly, but significantly, different Complementarity by very different mechanisms In this case, the herbs have similar end results but attain those results by completely different routes. They, thus, complement each other's effects.

Example Both Gentiana and blackstrap molasses can be used for debility with anemia. Both can be said to tonify the Qi and Blood, but they do this by very different mechanisms. Gentiana can act as a bitter tonic to stimulate the appetite, digestion, and absorption, thus tonifying the Spleen and indirectly tonifying Qi and Blood. Molasses can act "as a sweet tonic to supply nutrients such as sugars and minerals, and thus strengthens the Qi and Blood by a more direct route.

_"'i

~

~-:~

Complementarity via slightly different mechanisms The two herbs can have the same actions via similar chemical mechanisms, perhaps even involving constituents from the same chemical group. However, there may be small, but important, differences in the chemistry of their respective active constituents. These chemicals may be different enough to affect different receptor sites in the tissues. The two herbs may each do something that the other cannot, and thus, they have complementary effects.

Example Both Astragalus and Glycyrrhiza can have a sweet adaptogenic tonic action. This may be due to the presence of pentacyclic triterpenoid saponins. In Astragalus, the main saponins are the astragalosides, and in Glycyrrhiza, the main saponin is glycyrrhizin. Both astragalosides and glycyrrhizin may have an adaptogenic action. They have chemical similarities, but they are sufficiently different so that they may affect different receptor sites and thus achieve their adaptogenic effects by somewhat different pathways. EMPHASIS Most herbs can have a number of different actions. For a particuiar h~rb, which of these pot~~tial actions manifest or predominate in a particular situation depends in part on the other herbs with which it is combined. To emphasize a specific action of one herb, it can be combined with another --

Principles of Herb Combination herb for which that action is primary.

Examples For Angelica archangelica, the circulatory stimulant action is of secondary importance. However, this action can be emphasized by combining Angelica archangelica with Zanthoxylum, for which the circulatory stimulant action is of primary importance. Similarly, for Matricaria, the tranquilizing action is secondary. However, this action can be emphasized by combining Matricaria with Passiflora, for which this action is primary. EXTENSION Each herb has a limit to its range of actions. The addition of a second herb can extend the range of actions of the pair beyond the limitations of the first herb. In this book, the principle of extension refers to a pair of herbs with a common action to which one or both herbs contribute an additional action. :.-,':"'1

Example Achillea and Asclepias can both have an antipyretic action and are a specific pair for acute respiratory infections with fever. In addition to the common antipyretic action, Asclepias can extend the range of the pair beyond the limitations of Achillea by contributing the expectorant, bronchial antispasmodic, and tranquilizing actions. Conversely, Achillea can extend the range of the pair beyond the limitations of Asclepias by contributing the bitter digestive and general tonic actions. MODERATION One herb can be said to moderate another herb when it reduces the potential adverse effects of the other herb in the body. The potentially adverse effects of a particular herb may be associated with its temperature, taste, actions, or toxic effects. Temperature For example, taken long-term, the cooling anti-inflammatory herb Berberis may aggravate a condition of Spleen Deficiency with Cold. The hot herb Zingiber may be used to moderate this potentially adverse effect. Taste For example, taken long-term, the sweet tonic herb Lycium may aggravate a condition of Stagnation of Qi with Damp. The aromatic herb Citrus may be used to moderate this potentially adverse effect. The Balancing the tastes table in the Taste chapter gives many examples of using one taste to moderate another. Action For example, taken long-term, the sedative and analgesic herb Piscidia may aggravate a condition of Defi-

87

cient Heart and Kidney Qi, that is, it may depress the function of the cardiovascular and nervous systems. The cardiovascular and nervous stimulant herb Rosmarinus may be used to moderate this potentially adverse effect. The Balancing actions table in the Actions chapter gives many examples of using one action to moderate another. Toxicity Alterative herbs, such as Arctium and Taraxacum, taken in large doses, may result in the release of accumulated toxins into the system at a rate beyond the ability of the body to detoxify or excrete. This may trigger or aggravate inflammatory conditions. Demulcent anti-inflammatory herbs, such as Althaea, may help to relieve resulting inflammation, and hepatoprotective and detoxicant herbs, such as Glycyrrhiza and Zingiber. can moderate resulting toxic effects. NEGATIVE HERBAL INTERACTIONS In Western herbal tradition, less emphasis is placed on the mutual incompatibility and antagonism of herbs than in China. From the viewpoint of phytopharmacology, it is theoretically possible that there may be negative interactions between the constituents of one herb and another. However, when herbs are used in combination, balanced according to their temperature and taste, and in the therapeutic doses recommended in this book, negative interactions may be unlikely.

Herb pairs and trios as the basis for combinations Herb pairs, trios, or even foursomes, can often be used as a useful starting point in building a balanced combination. HERB PAIRS A herb pair. in this context, refers to two compatible herbs, frequently used together, which complement, emphasize, extend, or moderate each other's actions. The herb pair can be said to be a basic unit of herb combination, and each of the materia medica chapters in this book gives examples of useful pairings of the title herb. Pair Examples The following examples of herb pairs illustrate the principles of complementarity, emphasis, extension, and moderation:

• Echinacea + Baptisia Both herbs are general-purpose antimicrobials that complement each other by inhtbiting microbial growth via different chemical routes. Also, they extend each other's uses into different areas:

88

Combining Western Herbs and Chinese Medicine

.. :.-:'~

:-<;;.

Baptisia is specific for infections of the throat and lymph system, and Echinacea is specific for infections of the sinuses or bronchi.

• Myrica + Capsicum The primary actions of Myrica are anticatarrhal and astringent. Thecirculatory stimulant action is of secondary importance, but this <:lction can be emphasized by combining Myrica with Capsicum, for which the circulatory stimulant action is primary.

Herb Rheum Rhamnus Foeniculum Zingiber

....

Ratio

Temperature

Taste ...

1.5 1.5 0.5 0.5

cool-cold cool 51. warm hot

bitter, sour bitter aromatic, 51. acrid acrid. aromatic

-

-

• Rheum + Foeniculum Rheum is the primary herb in this pair and is used as a purgative to treat constipation. It is frequently paired with Foeniculum since the carminative action of the latter can moderate the tendency of Rheum to produce intestinal spasms when used in high doses.

ADVANCED HERB COMBINING In advanced herb combination, herb pairs, trios, or foursomes from a preexisting combination can be combined with others from another preexisting combination to form a new combination that is specific for the patient's needs. This is discussed in the next chapter Practical herb combination.

HERB TRIOS By adding a comp,atible single herb, a herb pair can be expanded to form a herb trio. Trio Examples The herb pair Crataegus + Convallaria, used to treat cardiac arrhythmia, can be expanded to the following trios:

• Crataegus + Convallaria + Cinchona This trio treats cardiac arrhythmia with digestive weakness.

• Crataegus + Convallaria + Sarothamnus This trio treats cardiac arrhythmia with cardiac edema.

• Crataegus + Convallaria + Leonurus This trio treats cardiac arrhythmia with anxiety. In each trio, all three herbs can treat cardiac weakness and arrhythmia, but the third herb gives a different additional emphasis to the combination.

Contraindications Screening in terms of temperature, taste, and actions is the first step in ensuring the safety of a herb combination. The final step in the screening process is to check for specific herb cautions and contraindications, especially in the context of the patient's specific syndromes and any conventional drugs that have been prescribed. This topic is also discussed in the chapters Practical herb combination and Safety in clini-

cal practice. Examples Three examples of herbs with contraindications in certain situations or above specific dose levels are:

• Cinchona

contraindicated for cinchonism or thrombocytopenia

• Glycyrrhiza

high doses are contraindicated for hypertension or hypokalemia contraindicated for intestinal obstruction or abdominal pain of unknown origin

• Rhamnus HERB FOURSOMES The addition of two compatible pairs can result in the formation of four herbs as a functional unit. Example Rheum + Rhamnus is a pair of primary purgative herbs for acute or chronic constipation, and Foeniculum + Zingiber is a pair of primary herbs for intestinal spasms and flatulence. .. " .. These four herbs' together make up the combination Rheum:,acu~~ ,ccmstipation.. In this combination, Rheum + Rhamnus is the primary pair to treat acute constipation. Foeniculum + Zingiber is the secondary pair since its dose is only one-third that of the primary pair. Its role is to moder-

i

ate the potential spasmodic action of Rheum and Rhamn~:.. ~~;~ on the intestines. . .

The cautions and contraindications on the use of the herbs that are included in the combinations in this book are given in: • the materia medica chapters for those herbs with a chapter of their own • the table in the Additional herbs chapter for those herbs that do not have a chapter of their own

It is the responsibility of the practitioner to to be aware of the cautions on the use of the individual herbs, comparing as many sources as possible, and referring to primary research data when this is available.

'I

Practical herb combination T

HERE ARE TWO

Using a preexisting combination

main approaches to practical herb com-

bination. Practitioners can select a preexisting combination, or they can create a new one. In either case, the same principles of herb choice apply that were discussed in the previous chapter. The herbs that are combined must match the syndromes of the patient and also interact with each

There are three main possibilities: • using a preexisting combination without alteration • modifying a preexisting combination

other to produce a balanced combination.

• combining elements of different preexisting combinations

Checklist USING A PREEXISTING COMBINATION Answering the questions in the following checklist can help the practitioner to ensure that the combination selected is

WITHOUT ALTERATION A preexisting combination can be used unaltered if it is a good match for the patient's syndromes. If the condition of the patient changes, the initial combination chosen may no

well balanced, effective, and safe.

1. Which disorders are primary and which are secondary?

longer be appropriate and must be stopped, modified, or replaced by a different combination.

2. Which herbal actions match the patient's syndromes?

Example The patient has a history of allergic asthma and is now in the acute phase. The patient has moderately severe wheezing and occasional coughing. The Lung pulse is wiry and the tongue is slightly purple. The diagnosis is Stagnant and Rebellious Lung Qi. The preexisting combination Lobelia: acute asthma (Lung Stagnant Qi) can be used to treat these syndromes and this patient's condition. .

3. What are the temperature requirements of the combination? 4. What is the optimum balance of taste properties? 5. Which herb interactions can be utilized? 6. Which herb pairs or trios can form a useful starting point? 7. Are there contraindications for this patient?

89

90

Combining Western Herbs and Chinese Medicine

;-Hert)7~~~~iid~tCff¥~~~~~;~J~T~~t~rfJ~~~'c~

. '.0:

Ephedra Lobelia Prunus Glycyrrhiza

1 1 1 1

warm warm-cool neutral neutral-cool

acrid, 51. bitter acrid bitter, aromatic sweet

Caution

Before using this combination, it is necessary to work through the questions in the checklist at the start of this chapter (see also the two examples in the section Creating a new combination). For this combination, it is especially important to read the practical notes in the Lobelia chapter, and the precautions and restrictions on the use of Ephedra in the Additional herbs chapter.

MODIFYING A PREEXISTING COMBINATION If a preexisting combination does not exactly match a situation, or if it ceases to do so, it can be suitably ~odified. Modification refers to relatively minor alterations to the constituent herbs and their doses, reflecting relatively small changes in the treatment aims of the combination. The modified combination thus retains its original core identity. If the alterations to the constituents and treatment aims become so radical that the combination loses its core identity, this is no longer regarded as a modification, but as a change to a different combination. A combination can be modified in four main ways: • addition of one or more herbs • removal of one or more herbs • replacement of one or more herbs • change of the dose of one or more herbs

Thymus Prunus Lobelia Glycyrrhiza

1 1 0.5-1 0.5-1

warm-cool neutral warm-cool neutral-cool

aromatic bitter, aromatic acrid sweet

Caution Before using this combination, it is necessary to work through the questions in the checklist at the start of this chapter (see also the two examples in the section Creating a new combination). For this combination, it is especially important to read the practical notes in the Lobelia chapter. Example 2: addition and dose change The patient has allergic asthma as the primary disorder, and allergic urticaria as a secondary disorder. The signs and symptoms are otherwise as for the previous patient with asthma. The diagnosis is Stagnant and Rebellious Lung Qi as the primary syndrome, with Exterior Wmd and Kidney Qi Deficiency, associated with the allergic urticaria, as the secondary syndromes. The following modification of Lobelia: acute asthma can be used:

Ephedra Lobelia Prunus Schisandra Arctium (seeds) Glycyrrhiza

1 1 1 0.5 0.5 0.5

warm warm-cool neutral warm cool neutral-cool

acrid, 51. bitter acrid bitter, aromatic sour acrid, 51. bitter sweet

• Ephedra, Lobelia, and Prunus remain in the combination with their dose unchanged since the primary problem is asthma, associated with Lung Stagnant and Rebellious Qi

The following two examples illustrate these four types of modification. Example 1: removal and replacement The patient does not have asthma but instead has a spasmodic, dry cough. The Lung pulse is wiry and the tongue is slightly purple. The diagnosis is that of Stagnant and Rebellious Lung Qi. The previous combination of Lobelia: acute asthma could be modified by removal of Ephedra, which is not necessary in this case since there is no asthma. This would leave the herbs Lobelia, Prunus, and Glycyrrhiza, which can be used together to treat spasmodic, dry cough. However, a stronger combination would be made by the replacement of Ephedra with Thymus, which is specific for spasmodic cough and combines well with each of the other three herbs. This new combination is described as Thymus: spasmodic cough (Lung Rebellious Qi) in the chapter on

Thymus.

• Schisandra and Arctium are added, in lesser amounts than the primary herbs, to treat the secondary condition of allergic urticaria (Arctium combines with Ephedra to clear External Wind)

• Schisandra

combines with Glycyrrhiza to strengthen the Kidney and Heart Qi, thereby reducing the potentially depleting effect of Ephedra and allowing for a reduced dose of Glycyrrhiza relative to the original combination.

Caution

Before using this combination, it is necessary to work through the questions in the checklist at the start of this chapter (see also the two examples in the section Creating a new combination). For this combination, it is especially important to read the practical notes in the Lobelia chapter, and the precautions and restrictions on the use of Ephedra in the Additional herbs chapter.

~

'\

/\-,.

Practical Herb Combination

91

COMBINING ELEMENTS OF DIFFERENT PREEXISTING COMBINATIONS A new combination can be made by using herbal units from two to three preexisting combinations. These herbal units can be single herbs, herb pairs, herb trios, or even larger groups of herbs. If appropriate, other herbs, which are not in the preexisting combinations can be included in the new combination.

1 1 1 1

0.5-1 0.5-1 0.5 5-10

warm warm-cool sl. warm cold warm neutral hot hot

aromatic, bitter, acrid aromatic, acrid aromatic, bitter, 51. acrid bitter sweet, aromatic, bitter sweet acrid, aromatic acrid

drops

Example The patient has recurring headaches, which can be triggered by any factor that aggravates either of her chronic conditions of anxiety and anemia. The headaches may occur with sensations of cold either at the body surface or within the body. The pulse is wiry, especially in the Liver position, and somewhat choppy and irregular. The tongue is pale and slightly thin. The diagnosis is as follows:

• Primary syndrome

Liver Hyperactive Yang

• Secondary syndromes

Liver Deficient Blood Heart Spirit Disturbance Exterior Cold Interior Cold

The patient requires a balanced herb combination that will address these syndromes and the patient's specific symptoms. Neither of the two preexisting combinationsLavandula: headache + anxiety and Salvia: headache + anemia -meets all the requirements of the patient.

Lavandula: headache + anxiety

Salvia: headache + anemia

Liver Hyperactive Yang + Heart Spirit Disturbance

Liver Hyperactive Yang + Liver Deficient Blood

Lavandula

1

Salvia off.

1

Salvia off.

1

Rosmarinus

Mentha pul.

1

Artemisia abs.

Anemone

1

Angelica sin.

Valeriana

1

Lycium (fruit)

Glycyrrhiza

0.5 0.5

Valeriana

1 1 0.5-1 0.5-1 0.5-1 0.5

Zingiber

Rosmarinus Salvia Lavandula Anemone Angelica sin. Lycium Zingiber Capsicum

Zingiber

The Lavandula combination treats the anxiety but not the anemia, and the Salvia combination treats the anemia, but may not be sufficient to tre~t the anxiety. The new combination below incorporates elements from both preexisting combinations.

As shown in the table below, the new combination contains herbs that treat all the syndromes and symptoms of the patient. It contains Anemone and Lavandula to treat anxiety associated with Heart Spirit Disturb.ance, taken from the preexisting Lavandula combination. It also contains the sweet tonics Lycium and Angelica and the aromatic bitters Rosmarinus and Salvia, taken from the preexisting Salvia combination. Both these pairs can treat anemia associated with Liver Deficient Blood. In addition, the new combination contains Capsicum, which was not present in either of the preexisting combinations' to treat Interior Cold, and to assist Zingiber in clearing Exterior Cold. Herbs "",:" ,'," " Hyperactive Liver Yang

headache (non-specific)

Lavandula, Rosmarinus, Salvia, (Anemone)

Heart Spirit Disturbance

anxiety

Anemone, Lavandula, (Salvia)

Liver Deficient Blood

anemia

Lycium, Angelica sin., Rosmarinus, Salvia

Exterior Cold

sensations of cold at surface

Interior Cold

sensations of internal cold

_ Zingiber

Capsicum

Caution Before using this combination, it is necessary to work through the questions in the checklist at the start of this chapter (see also the two examples in the next section: Creating a new combination). Note for beginners Creating a new combination by combining elements of different preexisting combinations is an advanced technique. If the technique is used by those who are inexperienced in herbal medicine, it can easily result in an assortment of ill-matched fragments rather than in a carefullypalanced and harmonious combination. . Beginners are recommended first to become thoroughly familiar with the properties of the individual herbs and with the principles of herb combination. They can then develop

--- \

.. :::?,"!

Combining Western Herbs and Chinese Medicine

92

their skills by using preexisting combinations, with simple modifications where appropriate, and by learning to create simple new combinations from first prinCiples.

Creating a new combination

• tonify Heart Yin and clear Deficiency Heat herbs with this action, such as Salvia officinalis, Salvia miltiorrhiza, and Ophiopogon, are required to treat the primary syndromes of Heart Deficient Ym and Heart Deficiency -Heat associated with hot flashes, insomnia, and night sweats

• calm Heart Spirit herbs with this action, such as When creating a new combination to match the specific syndromes of the patient, it is necessary to work through the sequence of questions in the checklist at the start of this chapter. This is illustrated by the following two examples, the first with no mistakes and the latter with mistakes. AN EXAMPLE WITH NO MISTAKES In this first example, for simplicity, no mistakes are made in the herb selection. The second example is more complex since it gives examples of mistakes that can be made at each stage of the herb selection process. Signs and symptoms The patient is a woman whose main complaints are exhaustion, which is sometimes accompanied by arrhythmia when the exhaustion is severe, and menopausal hot flashes. She also has insomnia. and night sweats, but these are of lesser importance. Although she has hot flashes, at other times she can feel slightly cold. Her pulse is slightly rapid and slightly irregular, thin, and forceless. Her Heart pulse especially is lacking in force. Her tongue is slightly red and thin, but it also has tooth marks, especially at the tip. Primary and secondary syndromes A simplified diagnosis for this patient is that she has three primary syndromes: Heart Deficient Qi, Heart Deficiency Ym, and Heart Deficiency Heat. The Heart Deficient Qi manifests in exhaustion from cardiac weakness with occasional arrhythmia. The Heart Deficiency Heat is associated with Heart Deficient Ym and manifests in menopausal hot flashes. In addition to these three primary syndromes, and resulting from them, she has the secondary syndrome Heart Spirit Disturbance, manifesting in insomnia. In addition to these three primary syndromes, and resulting from them, she has the secondary syndrome of Heart Spirit Disturbance, manifesting in insomnia. Actions

Herbs with the following actions are required:

• tonify and stabilize Heart Qi ·'~herbs with this aCti<:)ll,' such as Crataegus and Leonurus, are required to treat the primary syndrome of Heart Deficient Qi associated with cardiac weakness, exhaustion, and arrhythmia

Anemone, are required to treat the secondary syndrome of Heart Spirit Disturbance associated with insomnia There is considerable overlap between these actions and herbs. For example, Anemone can both calm Heart Spirit and clear Heat, and Leonurus can both tonify Heart Qi and calm Heart Spirit. Provisional combination These six herbs can be listed as a provisional combination, which can now be evaluated in terms of their temperature, taste, herb interactions, and herb pairs.

Crataegus Leonurus Salvia off. Salvia mil. Anemone Ophiopogon

1 1 1 1 1 1

51. warm neutral warm-cool cool cold cool

sour, sweet sour, 51. bitter aromatic, acrid bitter bitter sweet, 51. bitter

Temperature During hot flashes, the temperature of the patient's syndromes can be classified as warm-hot, but at other times it can be classified as neutral-cool. The sensations of heat are associated with Heart Deficient Yin and Heart Deficiency Heat. The occasional slight sensations of cold, and the phenomenon of fluctuating temperature, can be associated with Heart Deficient Qi. The combination therefore requires not only cool or cold herbs to clear the Heat, but it also requires neutral herbs and variable-temperature herbs to help stabilize the temperature fluctuations. Of the herbs listed in table above, Anemone is cold, Ophiopogon and Salvia miltiorrhiza are cool, Crataegus and Leonurus are neutral or close to it, and Salvia officinalis can have warm-cool temperature effects depending on the situation. These herbs, in combination, can thus have a balanced and appropriate temperature effect for this patient. Tastes This combination illustrates a balance between the five taste properties, the primary tastes being sweet, sour, and bitter, and the secondary tastes being aromatic and acrid.

• sweet

sweet constituents of Crataegus may assist tonification of Heart Qi, and sweet constituents of Ophiopogon may assist tonification of Heart Yin

Practical Herb Combination • sour

sour constituents of Crataegus and Leonurus may help to firm and stabilize Heart Qi

• bitter

bitter constituents of Anemone, Ophiopogon, and Salvia miltiorrhiza may help to clear Heart Heat and to calm Heart Spirit

• aromatic aromatic constituents of Salvia officinalis may help to calm Heart Spirit to treat insomnia

• acrid

in the specific case of Salvia officinalis, acrid constituents may regulate the surface of the body and help to normalize body temperature

Herb interactions and herb pairs The provisional combination illustrates the use of the principles of herb interaction, that is, complementarity, emphasis, extension, and moderation. It also illustrates the use of various useful herb pairs, four of which are briefly considered here.

Crataegus + Leonurus I

•

These two herbs complement each other in tonifying and firming Heart Qi. They also extend each other's cardiotonic action into different areas: Crataegus is specific for arrhythmia with exhaustion, and Leonurus is specific for palpitation with nervous tension.

Salvia officinalis + Anemone Both of these herbs can help to clear Heart Deficiency Heat in the treatment of menopausal hot flashes. The tranquilizing action of Salvia is secondary, but it can be emphasized by Anemone, for which this action is primary. The potentially warming and moving aromatic constituents of Salvia can help to moderate the tendency of Anemone to have cooling and sedative effects on metabolism.

Salvia officinalis + Ophiopogon These two herbs complement each other in tonifying Heart rm and clearing Heart Deficiency Heat in the treatment of excessive sweating, for example, during menopause. Ophiopogon can extend this effect by tonifying the Fluids, to reduce the effects of dehydration, and Salvia can extend it by helping to tonify Blood, to nourish the Spirit and thus treat the insomnia.

Salvia officinalis and Salvia miltiorrhiza These two herbs complement each other in clearing Heart DeficiencY Heat tq treat menopausal hot flashes and insomnia. S. officinalis extends this effect by its surfaceactive effect of regulating sweating.

T

Contraindications This is a carefully balanced combination in terms of the actions, temperatures, tastes, and inter-

93

actions of the herbs. Potential adverse effects of moist sweet Ophiopogon and cold sedative Anemone are unlikely to manifest themselves because of the moderating effects exerted by the other herbs in the combination. However, the trio, Leonurus, Salvia officinalis, and Salvia miltiorrhiza, are inadvisable if there is excessive menstrual bleeding or if there is a likelihood of conception. Also, this is a theoretical example, and for a real patient, practitioners are advised to read carefully the cautions for all the herbs in any combination to be used. Conclusion The provisional combination has stood up to screening in terms of temperature, taste, interactions, and contraindications, and is ready for use.

AN EXAMPLE WITH

MISTAKES

This example assumes that the practitioner makes essentially the correct diagnosis but makes .errors of emphasis in deciding which syndromes are of primary importance and which are of secondary importance. This results in the incorrect choice of herbs. Signs and symptoms The patient complains of exhaustion, some sensations of cold in the extremities, lethargy, a sensation of heaviness in the limbs, and a tendency to weight gain. His pulse is empty, especially at the Spleen position, and slightly empty at the Kidney position. The pulse does not have the hard and sharp feel of the wiry quality, but feels instead congested and sluggish. It is also somewhat slippery and slightly slow. The tongue is slightly pale, with tooth marks, and a moist white coat. Primary and secondary syndromes decides that:

The practitioner

• the primary syndromes are Spleen Deficient Qi, Spleen Deficient Yang, and Kidney Deficient Yang • the secondary syndrome is Spleen not transforming Fluids

Mistakes Spleen Deficient Qi is in fact primary. However, the other primary syndromes are Spleen Stagnant Qi and Spleen Damp. In this case, Spleen Deficient Yang and Kidney Deficient Yang are not primary syndromes, but rather, they are secondary syndromes. For this patient, the slightly slow pulse, the moist white tongue coat, the weight gain, and the cool extremities are not primarily signs of Deficient Yang. Rather, they are primarily due to Spleen Qi Stagnation and obstruction of the channels by Damp.

Note: The practitioner's error of emphasis may seem obvious. However, when seeing a patient for the first time, there

94

Combining Western Herbs and Chinese Medicine

is often such a wealth of diagnostic data that it is hard to perceive any clear patterns. It can be hard for the practitioner to know where to begin, and it can be especially difficult to decide which syndromes are primary and which are secondary. Actions The practitioner chooses three herbs with the action of tonifying Spleen and Kidney Yang and three herbs with the action of tonifying Spleen and Kidney Qi, resulting in the Provisional combination shown below.

Mistakes There is an unnecessarily large number of Yang tonics, Kidney tonics, and sweet nutrient tonics for the Spleen. These mistakes are discussed in more detail below. There are not enough moving and drying herbs with anticatarrhal, carminative, and circulatory stimulant action. Provisional combination

Panax ginseng (red) Cinnamomum bark Turnera Serenoa Glycyrrhiza Ziziphus

1.5 1.5 1.5 1 1 1

warm hot warm neutral neutral-cool neutral

sweet, sl. bitter acrid, sweet. aromatic bitter, aromatic, acrid sweet, sl. sour sweet sweet

Temperature The practitioner diagnoses the overall temperature of the patient as cool-cold, and chooses a herb combination that is warm-hot in its overall temperature. The warming herbs in the provisional combination are specifically aimed at tonifying the Yang of the Kidney and Spleen.

Mistakes

The coolness of the extremities in this case is primarily due to Spleen Qi Stagnation and obstruction of the channels by Damp, and not due to Yang Deficiency and Cold. It is more accurate to say that the overall temperature of the patient is slightly cool so that the herb combination's overall temperature should be only slightly warm. Also, if warming herbs are used in the combination, they should be: • aimed at moving the Qi and clearing Damp obstruction, rather than warming the Kidney • balanced with cool herbs to maintain the overall temperature at only slightly warm Tastes There is a large number of sweet nutrient tonics in the provisional combination. This is slightly offset by Cinnamomum and Turnera, which have acrid and aromatic properties. " '.

\-.1.

Mistakes As a result of the initial error of emphasis in differential diagnosis, the practitioner makes two important mistakes in the choice of taste properties.

... _~-~~=".

1. Stagnation and Damp obstruction are primary syn- .. '::: dromes. The first mistake is therefore the choice of too many sweet tonics, which may increase the Stagnation and Damp. aggravating the exhaustion. lethargy, and weight gain. The acrid and aromatic properties of Cinnamomum and Turnera are not 'enough to moderate this effect of the sweet tonics since these herbs do not primarily move Qi and clear Damp obstruction. There should be fewer sweet and moistening herbs. such as Serenoa. Glycyrrhiza. and Ziziphus, and more aromatic and drying herbs. such as Angelica archangelica and Juniperus, in order to assist the Spleen in transforming Fluids (see the Preferred combination below).

2. The second error provides an excellent example of the importance of choosing the correct aspect of a particular taste property (see the Acrid section in the Taste chapter for a more complete discussion of this point). The practitioner chooses herbs with the warming and stimulating aspects of the acrid property. In this situation, warming and stimulating acrid herbs such as red ginseng. Cinnamomum bark, and Turnera. can create Interior Heat that can combine with Stagnation and Damp to produce Damp Heat syndromes, resulting in symptoms such as irritability, eczema, cystitis, prostatitis, or other inflam, matory disorders. This patient requires herbs that have the moving, dispersing. penetrating. and drying aspects of the acrid property, such as A. archangelica, Phytolacca, and Zanthoxylum (see Preferred combination below). Herb interactions The practitioner is focusing on complementarity rather than moderation, and this is a mistake. In this situation. these two principles of herb interaction are of equal importance. It is important to have moving and drying herbs that complement each other's effect, but it is of equal importance to use cooling herbs to moderate warming herbs as well as moving herbs to moderate sweet tonic herbs. (Complementarity and moderation are principles of herb interaction that are described in the chapter Principles

ofherb combination). Pairs and trios The provisional combination contains such excellent pairs as Panax + Cinnamomum, Turnera + Serenoa. and Glycyrrhiza + Ziziphus (see the Cinnamomum, Glycyrrhiza. and Turnera chapters). It also contains two important trios:

• Panax + Cinnamomum + Turnera warming stimulants to tonify Yang

• Serenoa + Glycyrrhiza + Ziziphus moistening, sweet tonics to tonify Qi

Practical Herb Combination

95

Mistakes

The provisional combination in itself In the case of a patient

moving Stagnation, and clearing Damp. This illustrates an important principle.

for whom the practitioner's diagnosis were correct, the provisional combination would still be too extreme for a first prescription. It contains three warming stimillants and three moistening sweet tonics, which is too many for a first prescription. It would be safer if the combination had the following balance:

Unfortunately, these pairs and trios are inappropriate in this situation since they focus on tonifying Yang and Qi, rather than tonifying the Spleen to transform Damp,

Before using a trio ofherbs, each of which has the same action, it is essential to ensure that the diagnosis is correct.

If the wrong action has been selected, the use of a trio will multiply that mistake three-fold. Contraindications In addition to the use of moist sweet _ tonics in a situation of Stagnation and Damp, there is the specific caution on the use of Panax: ginseng for patients with Qi Stagnation or constraint. Panax: ginseng, and especially red ginseng, may aggravate conditions of Qi constraint and produce unpleasant sensations of heat and obstruction in the chest (see the Additional herbs chapter). This may be aggravated by the use of the trio of herbs Panax:, Cinnamomum, and Turnera, which stimulate and warm, rather than disperse Stagnatio~. Summary of the mistakes Two questions are raised by the

• 2 warming stimulants to tonify Spleen and Kidney Yang, such as Panax: ginseng and Turnera • 2 moistening sweet tonics to tonify Spleen Qi, such as Glycyrrhiza and Serenoa • 1-2 herbs to move Spleen Qi and transform Damp, such as Citrus and Juniperus Even if these last two herbs were in lesser amounts than the first four, they help to prevent the tendency of the sweet tonics to aggravate patterns of Stagnation and Damp. It should be emphasized that the provisional combination is not incorrect in itself. However, it is more appropriate for a later prescription when the practitioner has noted the reactions of the patient to previous prescriptions, and is more certain of the diagnosis. Preferred combination The following combination fits the correct diagnosis and satisfies screening according to temperature, taste, herb interactions, and contraindications.

discussion above: i~

_

• what would be the overall effect of the mistakes made in herb selection for this patient? • would the provisional combination be appropriate for a different patient, for whom the practitioner's diagnosis is correct?

}:;t'_

Overall effect of the mistakes The essential diagnostic error is that Deficient Yang of Spleen and Kidney are not primary syndromes in this case. The key primary syndromes are Spleen Stagnant Qi and Spleen Damp. This diagnostic error results in the incorrect choice of herbs with the following effects on this patient:

• an excess ofwarming and sweet stimulant herbs increases Stagnant Qi, Damp, and Heat, resulting in inflammatory disorders, such as eczema or cystitis, or emotional disorders, such as irritability or depression with sensation of disturbance and constraint in the chest

• an excess ofmoistening and sweet tonic herbs '¥i {

I

T

increases Damp and associated Stagnation, resulting in aggravation of the original symptoms of exhaustion, lethargy, and weight gain; in addition, there may be obstruction of sinuses or bronchi by excessive production of mucus

Herb

Ratio Temperature Taste

Astragalus Zanthoxylum (bark) Angelica arc. Juniperus

1.5 1 1 1

51. warm

Phytolacca Arctium (root)

1 1

cool cool

hot warm 51. warm

sweet acrid, aromatic, bitter bitter, acrid, aromatic aromatic, 51. acrid, 51. sour acrid 51. acrid, 51. bitter

Actions The moistening sweet tonics in the previous combination-Serenoa, Glycyrrhiza, and Ziziphus-have been replaced with the more drying sweet Spleen tonic Astragalus. The metabolic stimulant Yang tonics-red ginseng, Cinnamomum bark, and Turnera-have been replaced by the anticatarrhal circulatory stimulant Zanthoxylum and by Angelica archangelica and Juniperus, which have anticatarrhal, diuretic, and carminative actions. Juniperus also has the secondary action of tonifying the Kidney. In this combination, Phytolacca and Arctium assist Zanthoxylum, Angelica, and Juniperus to clear obstruction of the channels by Damp and Phlegm.

Temperature The overall temperature of the preferred combination is slightly warm. Hot Zanthoxylum and warm Angelica are balanced by cool Arctium and cool Phytolacca.

96

Combining Western Herbs and Chinese Medicine

...-'~i&\

This matches the slightly cool overall temperature of the patient. Also. the warming herbs in the preferred combination are aimed at moving Stagnation and clearing Damp obstruction. rather than at tonifying Kidney Yang. which might aggravate the patient's condition.

Pairs and trios In the case of the preferred combination•. _-',,~~~ " the pairs and trios are appropriate to the patient's condition. -~ .:~;,.._~ ;- .. '=,' For example, Zanthoxylum. Angelica, and Juniperus, are a .. trio of herbs that can tonify Spleen Qi. stimulate the Spleen to transform Damp. move Spleen Qi Stagnation. and clear·.'·•. ~ ~

Tastes The taste balance of the preferred combination differs from the provisional combination in the following ways:

obstruction from Stagnation and Damp in the channels. ..'7...,,,,.; Zanthoxylum and Angelica are a pair of herbs that can be . 1:'; used for poor peripheral circulation associated with lethargy. sensations of heaviness in the limbs. weight gain. and patterns of Damp.

• herbs with the moistening sweet property-Serenoa. Glycyrrhiza. and Ziziphus-are removed from the combination • herbs with the aromatic property of stimulating the Spleen to transform Damp-Zanthoxylum, Angelica, and Juniperus-are added • herbs with the warming. stimulant. Kidney Yang tonic aspect of the acrid property-Cinnamomum. Panax, and Turnera-are removed from the combination • herbs with the dispersing, penetrating, Damp-clearing aspect of the acrid property-Zanthoxylum, Angelica. Juniperus. Phytolacca. and Arctium-are added Herb interactions The preferred combination has a better balance between complementarity and moderation. Cool Phytolacca and Arctium moderate the warming effects of Zanthoxylum and Angelica. The aromatic herbs. Zanthoxylum, Angelica. and Juniperus. moderate the sweet tonic Astragalus.

:"~

Contraindications Since the patient is a male. the caution :-~ on the use of Juniperus during pregnancy does not apply. However. some texts recommend caution on the use of Juniperus in patients with renal inflammation (see the chapter on Juniperus). If the Preferred combination were taken long-term. the .~" .::-~-*'} patient should be monitored for increasing signs of dryness• . y..:;~ _.-.. .. since Angelica archangelica and Juniperus together can have a drying effect. It is theoretically possible that their prolonged use might result in signs such as dryness and soreness of nose and throat, even in a patient with an initially Damp pattern. If this were a real patient. the cautions on each of the herbs in the preferred combination would have to be checked in detail (see materia medica chapters). Otherwise, the preferred combination is correct and ready to use. '--:-;";':~:

~ '

Dose T

with the topics of dose, dose form, and administration. These terms are defined as follows:

HIS CHAPTER DEALS

• dose the quantity of herb prescribed within a particular time period, for example, the daily dose refers to the quantity of herb given in 24 hours, which may be divided into several individual doses

cate two opposite approaches to dosing. The reductionist approach derives from the mechanistic and reductionist philosophy that underlies modern conventional medicine. The holistic approach, on the other hand, derives from the vitalistic and holistic philosophy that is the basis of traditional medicine in both China and the West. Focus of controversy The difference in the two approaches lies mainly in their response to the natural variability and the chemical complexity of plant material.

• dose form

the form in which the herb material is prepared and dispensed to the patient, whether as an infusion, decoction, tincture, powder, or other form

Variability of plant material There may be considerable variation in the type and quantity of active constituents between different samples of the same herb. This can be due to both genetic and environmental variation. This can mean that the therapeutic effect of a specific dose of the herb can be variable, even on the same patient, because the dose may

• administration the method in which the preparation is used, whether orally, by injection, by topical application, by steam inhalation, or by another method Further definitions are given in the Glossary.

contain variable quantities of the key active constituents.

Dose controversies

Phytochemical complexity It is not common for a herb to

The main emphasis of this chapter is on the practical

have a single pharmacologically active constituent. It is more

aspects of dose and dispensing. However, dose is one of the most controversial topics in herbal medicine, and two dose

usual for a herb to have a number of different active constituents that contribute to its therapeutic effects.

controversies are briefly discussed below:

Reductionist approach Adherents of this approach see both the natural variability and the chemical complexity of plant material as a disadvantage. Their response is to try to . isolate a single active constituent to be used as a criterion of standardization (see the Safety chapter). Different batches of herb material can then be assayed to determine if the marker active constituent is within accepted levels. If only standardized material is used, then it is possible to be more precise

• reductionist approach versus holistic approach • controversy of the minimum dose

REDUCTIONIST APPROACH VERSUS HOLISTIC APPROACH I have used the terms 'reductionist' and 'holistic' to indi-

97

98

Combining Western Herbs and Chinese Medicine

about the actual quantity of the selected active component in a dose of herbal medicine. More precise limitations on dose range can then be set, and the effect on the patient is more predictable. Holistic approach In this approach, the variability of plant material is not seen as a disadvantage, but as a fundamental manifestation of the life force. Adherents of this approach accept the variability of plant material, in both quantity and type of active constituents, and see natural genetic variability as an important resource. They tend to adopt a more flexible approach to dose in response to variability both in the plant material and in the human response to phytotherapy. In the holistic approach, the fact that a single herb may have several different active constituents is not seen as a disaJvantage but as a benefit. Adherents of this approach believe that the different active constituents may support and moderate each ot4er's actions to produce a safer, more balanced, and, in some cases, more powerful overall effect than that of a single isolated chemical.

Flexible dosing The reductionist approach emphasizes accurate measurement of dose, precise limitations on dose range, and standardization of plant material. The holistic approach is not so much concerned with these criteria of accuracy. The response of this approach to the natural variability and the chemical complexity of plant material is the flexible adjustment of dose according to result. This was true of some of the very experienced practitioners of the past, especially those who were less academic and more 'hands-on.' For example, as Crellin and Philpott pointed out, precise measurement of herbal material was not a Icature in the practice of the Appalachian herbalist, the late Tommie Bass. He adjusted dosage according to the degree of rdief of the patient's symptoms. l

.-:-_ -t.---~

CONTROVERSY OF THE MINIMUM DOSE The minimum therapeutic dose is the minimum amount of a herb that is likely to produce a therapeutic effect in the majority of patients, in the opinion of a particular authority.. A dose that is too small to have a therapeutic effect is termed a subtherapeutic dose.

In modern Western herbal medicine, there are two main philosophies regarding the size of the minimum therapeutic herb dose. These may be termed the 'higher dose approach' and the 'lower dose approach: This topic has recently been reviewed by Mills and Bone in Principles and Practice of

Phytotherapy: Modern Herbal Medicine. 2 The higher dose approach The majority of herbal texts support the higher dose approach. They generally recommend, for the average nontoxic herb, doses of 0.5-4 grams of the dried herb, three times per day, or doses of at least 1-4 ml of 1:5 tincture of the herb, three times per day. The table below shows support for the higher dose approach from: • representatives of the Eclectic movement, such as Felter and Lloyd3 and Ellingwood4 • modern representatives of the Physiomedical movement, such as ChristopherS • European pharmacopoeias and expert committee texts 7 such as the BHp6 and the Commission E monographs • Chinese herbal medicine texts, such as Bensley and Gamble8 What is evident from the table is a surprising uniformity of dose, considering that the texts listed represent different times, different traditions, and different cultures. In addition, there is support for the higher dose approach from pharmacological and clinical research. 2 HIGHER DOSE APPROACH TEXTS

Combined approach Both the flexible and the precise approaches make valuable contributions that can be incorporated into a combined approach. This approach accepts the concept of vital energy, the importance of natural variability, and the chemical complexity of plant material. In addition, the combined approach accepts the need for safety in the use of herbal medicine and welcomes the adoption of correct standardization and quality control of herb material (sec the Safety chapter). However, the combined approach looks forward to the not-so-distant future when it maybe possible to standardize a herb not just in terms of a single active chemical, but in terms of each of its main active constituents. This would combine the advantages of both standardizing herbs and of using the full spectrum of active ingredients.

Daily doset American Felter and Lloyd Ellingwood Christopher

Bass 1 Tierra 9

British Grieve10

BHP SHC 11 German Weiss 12 Commission E Wichtl 13

0.65-2 g* 0.65-2 g* 2-3 g (infusion) 10 g (decoction) 4-6 g 1-5g

0.65-3.5

g*

* *

6-9 g 30 g

12-18 g 3-15 g

*

1-4 g 1-4 g

3-12 g 3-12 g

2-6 g (infusion) 0.66-3.3 g

6-18 g 2-10g

1-5g

3-15 g

_,.. i ~-I

,

--'."~ z:~,

Dose .-.-

.-~:,::,7:::'

Text

._

.7

:!h!'··

_

Individual :doset::=;~;:

. -, ' " (3

Chinese medicine Bensky and Gamble

t

.'<_·. • ~_.;:.:·::_::":.:':~··:'

:.~. _:_::::.:~::;,

per clay):,

1-3.3g

.. '';'".''''

',;:~:

__.;".:;~...... ;~..

~~~~-.+'~=-~ '-=~

Dailydose't::~

3-10 g

Unless specifically stated, the dose figures: • may refer to the use of the herb as powder (to be taken in water), infusion, or decoction; it is not always clear from the text which dose form is intended • refer to the use of dried herbs in all cases except Bass, who sometimes used dried and sometimes fresh herbs • given in grams have been converted in some cases from other measurements; for example, the figures for Felter and Lloyd, Ellingwood, and Grieve have been converted from grains and drachms to grams (see the Weights and measures section)

*It is not clear from the text whether the dose referred to is a daily dose or an individual dose (to be taken a number of times per day).

Lower dose approach This approach uses doses of one or a few drops of tinctUres of 1:5 strength or less. This contrasts with the higher dose approach which generally uses doses in excess of 1-4 mlof 1:5 tincture, three times per day.2.6,1l The lower dose approach may have originated in Europe as a side branch of homeopathy and in America as a side branch of the Eclectic movement. The lower dose approach has two main variants: using lower concentration tinctures or using concentrated tinctures.

Lower concentration tinctures In Europe, some homeopaths use drop doses of herbal mother tinctures. 2 In America, the Eclectic doctor John Scudder originated a branch of Eclectic tradition using drop doses of tinctures from the fresh plant, which he called 'specific medicines: 14• 1s Concentrated tinctures The Eclectic pharmacist Uri Lloyd believed that both drop doses and Scudder's tinctures were inadequate. 4 He developed a series of very concentrated fluid preparations which he also called 'specific medicines' or 'specifics.' However, these were quite different from the specific medicines of Scudder, and it was claimed that Lloyd's preparations were up to eight times more potent than ordinary 1:5 tinctures. 14

(-

I I

When Lloyd's specifics were used, as they occasionally were, in single drop doses, this would fall within the range of the lower dose approach. However, the upper end of Lloyd's dose range exceeds the upper limits of the higher dose approach. The doses for specifics given by Ellingwood4 o~ by Felte'r and lloyd) are generally between 1-60 drops three times per day. Thisis' a"maximum of 180 drops per day, which is approximately 9 ml. If Lloyd's specifics were really 8 times stronger than ordinary 1:5 tincture, this would be the equivalent of 72 ml of 1:5 tincture per day.

99 Author's position For the average nontoxic herbs, I generally use individual doses of 0.5-5 g dried herb three times per day or individual doses of 0.5-5 ml of 1:5 tincture three times per day. These dose figures apply to a herb when it is used by itself; they do not apply when a herb is used in a combination with others. It is important to distinguish between these two situations, which are discussed in the subsection Dose for infusions of more than one herb in the section on Dose form below.

DOSE AND COMMON SENSE Different people have different dose requirements, and for a particular patient, dose requirements may vary with time and circumstances. Some commonsense guidelines for dose are given below: • use the least dose required to get the desired therapeutic effect • in chronic cases, start at the minimum therapeutic dose for 1 to 3 days so that the patient's body can become accustomed to the herbs, and then raise the dose to halfway between the minimum and maximum therapeutic dose levels • use the herbs for the minimum time before reducing the dose (this time may be 3 days for an acute situation or 2 to 4 weeks for a chronic situation); if this reduction still produces the same therapeutic effect, keep this reduced dose • increase the dose if the symptoms return (alternatively, modify the herb content of the combination or change to a completely different combinati~n) • vary the dose to meet the changing requirements of the patient

Factors affecting dose Each of the following factors can affect a herb's dose: • philosophy of dose size • specific herb • quality of a sample • dose form • number of herbs in the combination • type and stage of illness • age of the patient • tolerance of the patient to herbs in general • tolerance of the patient to a specific herb • t a s t e ' '.

100

Combining Western Herbs and Chinese Medicine ,;;!,:-r.-

PHILOSOPHY OF DOSE SIZE The effect of the philosophical approach on the dose has already been discussed in the section on Dose controversies.

This book adopts the combined approach with respect to the precise versus flexible controversy, and follows the higher dose approach with respect to the controversy of minimum dose.

dried herb of 2:1.5) Practitioners should be aware that aro- ..~?'; matic oils may vary greatly in strength and that the use of -.-:C •. :.~._ aromatic oils is outside the scope of this book.

--

_.~

fresh herb dried herb 1:5 tincture Lavender oil

2-4 g 1-2 g 2-4 ml 0.06-0.2 ml

SPECIFIC HERB Herbs can be roughly divided into three groups according to dose (data is from the BHP for the dose of dried herbs): Group

. . Exa·mple·>;:<.. :~; •.. ..... ;,..-..

Dose

. .• . - .. 'i·-~

~ ~

.;.;.".~

average dose herbs

about 1-4 g, three times per day

Calendula

higher dose herbs

about 4-10 g, three times per day

Taraxacum leaf

lower dose herbs

about 0.1-1 g, three times per day

Convallaria

The majority of herbs fall into the average dose range. Some herbs in the lower dose range have local regulations governing their maximum dose. For example, Convallaria is on Schedule Part III of the Supply of Herbal Remedies Order 1977 of the UK, with maximum dose limitations of 0.15 g, three times per day.

QUALITY OF A SAMPLE The quality of a particular sample of herb material can affect the dose. If a sample of dried herb is old or of poor quality, it will generally require an increase in dose to counter this. If the sample is of especially good quality, it may require a decrease in dose. For example, I normally use about 0.6 g of dried Lobelia as a daily dose. However, I once got a batch of excellent quality Lobelia that was stronger than the previous sample. I therefore reduced the daily dose of the new material to 0.45 g since this had the same effect as 0.6 g of the previous material.

NUMBER OF HERBS IN THE COMBINATION The dose of a particular herb can depend on the number of other herbs with which it is combined. Generally, the dose of a herb prescribed by itself is higher than when it is prescribed with other herbs as part of a combination. This is discussed later in this chapter in the following subsections:

• Dose in the section on Infusions and decoctions • Problems with 1:5 multiherb tinctures in the section on Tinctures and liquid extracts TYPE AND STAGE OF ILLNESS The daily dose and the frequency of dosing of a herb may depend on whether the illness is acute, subacute, or chronic. For example, Christopher recommended Mentha piperita infusion for acute influenza with fever. Initially, the patient would be given 1 teacup (very roughly 150 ml) of hot infusion every 30-45 minutes until there was free perspiration, and then 2 tablespoons (roughly 15 ml) every 1-2 hours thereafter.

AGE OF THE PATIENT For the purposes of dose size, patients can be divided into different groups according to age. The proportion of the dose size for the different age groups relative to the standard adult dose is shown in the table, with figures for individual doses of 1:5 tinctures of average nontoxic herbs. These figures can be compared with those .in the table of Proportionate doses at different ages on page 2154 of Felter and Lloyd. 3

DOSE FORM The dose form can greatly affect the dose required. As discussed below, each different dose...form h~ itsa~v:antages and disadvantages. For example,dosesfordiff'erent preparations of Lavandula are shown in the. table. (Th~ 'fi~es for all . . .. , ' but the fresh herb are from the BHP. The. ~esh herl> figures are calculated according to Christopher's ratio of fresh to ,"

",'

TOLERANCE OF THE PATIENT TO HERBS IN GENERAL Human variability Some patients require higher levels of herbs in order to have a therapeutic effect, while other people require lower amounts. This is why there is a therapeutic dose range.

-'

Dose

Age

-" __~ "

101

,~__ p.roportiori',~f__ Jndlyigual dqsi.~Qf~~,lndiyiclua~" ~~~~;6f"'" -:: , "-adult dose

infants 6-12 months infants 1-2 years children 2-5 children 6-10 teens 11-18 adults elderly

0.01-0.1 0.02-0.2 0.2-0.5 0.5-0.75 0.75-1 1 0.5-0.75

0-0

1 :5 tincture'ii'i'ml-: -1:5 tincture fri::aropsF 0.05-0.5 ml O.l-lml 1-2.5 ml 2.5-3.75 ml 3.75-5 ml 5ml 2.5-3.75 ml

1-10 drops 2-20 drops 20-50 drops 50-75 drops 75-100 drops 100 drops 50-75 drops

experienced to some degree by a substantial proportion of the patients. In contrast, idiosyncratic reactions can be defined as unusual, rare, and unexpected reactions.

Side effects Within the recommended therapeutic dose range, the majority of the herbs listed in the BHP do not have *Assumes 20 drops per ml (see the Weights and measures section below). side effects. However, there is an appreciable number of herbs that can have moderate side effects at the top of their However, the human reaction range seems to be wider dose range, and a few herbs that can have more severe side than the recommended dose range for many herbs. For effects if used at the upper end of their dose range with example, the BHC sets 3-5 ml of 1:5 tincture as the dose patients for whom they are not suited. range for an individual dose of Valeriana. In my experience, Side effects can mostly be avoided if practitioners obsome people react to as little as 0.5 ml, whilst others require serve the herb cautions and contraindications. If a patient as much as 10 ml for a therapeutic effect. It seems that they has a pattern for which there is a caution for a specific herb, have a natural tolerarice to herbs in general or to one or it may still be possible to use it at lower doses. However, if more herbs in particular. the patient has a pattern for which the herb is contraindicated, it may not be possible to use it at all. Caution Although, in my experience, those people that require such large doses do not usually experience side effects, Moderation Even if a herb has side effects in some cases all precautions must be taken, and such high doses should be when used by itself, it may be possible to use it either at full used only for the minimum time. or reduced dose when it is combined with another herb that Patients with lowered tolerance of medication A patient with weak general health or weakness and hypersensitivity of the gastrointestinal or hepatobiliary system may have difficulty with foods, herbs, and allopathic medications. If herbal medicine is appropriate in a specific situation of this kind, a reduced dose is necessary.

General and digestive weakness In the case of general debility or gastrointestinal hypersensitivity, it may be initially advisable to use a dose 0.25-0.5 that of the usual one for the patient's age range. If there are no problems at this dose, then, if appropriate, the dose can be raised after about a week.

modera~es its potentially adverse effects.

For example, a patient has headaches and exhaustion. Piscidia at a dose of 1ml of 1:5 tincture, three times per day, removes the headache but aggravates the exhaustion due to its sedative action. However, when this dose of Piscidia is taken with 1 ml of 1:5 tincture of Rosmarinus, the headache is removed without aggravation of the exhaustion. This is because the stimulant action of Rosmarinus moderates the sedative action of Piscidia.

Caution The technique of moderation should be used with circumspection and not be taken as a license to ignore cautions and contraindications.

Liver disorders If the patient has a severe liver disease or is currently taking potentially hepatotoxic conventional medication, it is advisable that the initial dose be very small if herbal medicine is appropriate. For example, if the usual dose of a herb is 5 ml of 1:5 tincture three times per day, the starting dose could be 0.5 ml once per day. This could gradually be increased if there are no side effects. Regular liver function testing may be advisable in such cases (see the Safety chapter).

TOLERANCE OF THE PATIENT TO A SPECIFIC HERB Some herbs have potential side effects, especially at the upper end of their therapeutic dose range, which can be

Partial replacement Another method of reducing side effects is that of partial substitution. The herb with side effects is reduced in dose and the same dose of another herb with a similar action is added. For example, a patient has exhaustion with digestive weakness and sensations of cold. Cinnamomum bark at a dose of 2 ml of 1:5 tincture, three times per day, improve.s the symptoms, but has the side effect of a flushed face and uncomfortable sensations of heat. However, when the dose of Cinnamomum bark is reduced to 1 ml and 1 ml of 1:5 tincture of dried Zingiber is added, the symptoms improve and there are no side effects. This is because ZingIber has digestive and circulatory stimulant action, as does Cinnamomum bark, but Zingiber has a more diffusive effect on the

.-

. Combining Western Herbs and Chinese Medicine

102

. ~)~1 - .. _____

-

1

-~=

-

-

circulation, so that it does not have the side effects of Cinnamomum. Idiosyncratic reactions People can have idiosyncratic reactions, allergic or otherwise, to just about anything, including such staples as milk, bread, carrots, and apples. I once had a patient who was made more excited by Scutellaria, and another patient who became more nauseous by the use of Mentha piperita. If there is an idiosyncratic reaction to a particular herb, or even to an entire herb family, such as the Asteraceae, lowering the dose may not be enough in some cases. However, it is usually possible to substitute another herb to which the patient does not have an idiosyncratic reaction. TASTE ',"

A few patients have a,n aversion to strong-tasting herbs, especially those that ar~,b#ter,~our,or acrid. This is especially the case for decoctiorirand to a lesser extent for infusions and tinctures. This can meanthatthed~se of strong-tasting herbs has to be reduced for these patients. In some cases, the patients will take the herbs if they are in smaller, more frequent doses, or if the taste is masked by taking the herbs with milk, fruit juice, honey, or licorice, or mixed with food. However, some practitioners are concerned that masking of a particular taste in the mouth may reduce the effect of the associated taste property. For example, if a bitter herb is used to stimulate the secretion of digestive enzymes, coating the tongue with a layer of milk or honey may impair the function of the bitter taste receptors. Many of the herbal combinations that I dispense are carefully balanced according to taste properties to produce specific effects. When this is the case, I ask that the patient not use masking substances to ensure that these do not interfere with the desired taste effects.

• infusions and decoctions • tinctures and fluid extracts

.~

-

...

_. --'<~~l -::.u.,.

• powders • pills, capsules, and concentrates There are various other oral dose forms, such as fresh juices, stabilized juices, and essential oils, but these are outside the scope of this book.

Infusions and decoctions Infusions are teas made by pouring boiling water on fresh or dried herbs and allowing then to steep without simmering or boiling. Decoctions are teas that are made by simmering or boiling herbs in water, and they are usually made from dried herbs. SUITABILITY OF INFUSIONS AND DECOCTIONS Infusions These may be suitable for lighter, softer plant material, such as leaves and flowers, from which the active principles are more easily extracted than from the denser, harder bark and roots.

Volatile constituents Infusions are especially suitable when the main active principles are volatile and would be lost by simmering or boiling. Plants with important volatile ingredients are particularly found in the diaphoretic, circulatory stimulant, carminative, and tranquilizing action categories. Decoctions These are especially suitable for plant parts such as roots, stems, and the denser leaves and fruit that require more powerful extraction than is possible with infusions,

----!"""':

Decoction/infusion Some herbs that have volatile oils as the

Dose form This book is primarily concerned with dose forms that are administered orally. The preparation and administration of topical forms such as liniments, ointments, and poultices is not discussed. The use of nonoral internal forms such as boluses and, douches i~ only briefly discussed (under the heading Combining oraJ and otherforms ofadministration at the end of the Clinical'efamples,5ection below). For information. onthe,p~o~uction,;an,d.rii~inistrationof nonoral fonus, please/'refer to::'oth~i~1texis;such"" as' those by . Christophe~ and Tierra.9 .. :." ',. .' Oral dose forms are discu~s~d b~low in the following four sections: ' ,.:.~.'

main active ingredients should not be simmered with the decoction but should be added to the decoction after the heating is stopped and the decoction is allowed to steep for a suitable time. This technique is termed decoction/infusion. PREPARATION METH0D Some practitioners prefer using glass, enamel, ceramic, or earthenware vessels for the preparation of infusions and especially of decoctions. Other practitioners use stainless steel, but avoid iron, copper, and especially aluminum. This may be more due to concern over toxicity from high levels of these minerals l6 than concern over possible reduction of the activity of the herb's active constituents by the mineral.

' :;Jt.

Dose Infusions

Steeping The vessel should have a well-fitting lid, whether it is a teapot, a pan, or a wide-necked vacuum flask. The vessel is warmed with a little boiling water, which is then discarded. The herbs are put in the vessel, and boiling water, which has just been brought to a rolling boil, is then poured on the herbs. The lid is placed on the vessel, and the herbs are steeped.

Straining and pressing After steeping, the liquid is strained and the herbs can be pressed firmly to release any further liquid, which is also strained off. The herbs can then be discarded and the liquid drunk as required. Decoctions

There are many variations of the decoction

method.

Soaking Generally, the herbs to be decocted are soaked for at least 30 minutes in ~e water in which they are to be boiled. I prefer to soak them overnight.

Simmering After soaking, the water containing the herbs is

t.....'.

quickly brought to a boil, and the heat reduced to simmer the decoction for the required time. The pan lid can be kept on if it is desired to minimize the loss of volatile components, or it can be left off if it is desired to reduce the volume of the liquid.

Straining and pressing

L-

After simmering, the liquid is strained, and as with infusions, the herbs can be pressed firmly to release any further liquid, which is also strained off. The herbs can then be discarded, and the liquid drunk as required.

PREPARATION TIME The quantity of some of the active constituents extracted and the types of constituents extracted - the extraction profile - will depend on the length of time of steeping or simmering. Infusions Herbs are generally steeped for 5-20 minutes in an infusion.

Extraction prOfile Some aromatic herbs may only need 5-7 minutes to extract' the volatile oils on which their activity primarily depends. Longer infusion may change the chemical prome of the extraction as increasing amounts o~ the volatile' oils are lost to the air; as a result, the infusion becomes less aromatic'aridmore bitter. For example, if Mentha pulegium is steeped for more than 7 minutes, the tranquilizing action of this herb may be reduced since it primarily depends on its volatile constituents.

103 Other herbs may need a longer steeping time of up to 20 minutes to extract some of their nonvolatile active ingredients. In the case of a multiaction herb, such as Achillea, the length of steeping time depends on which action is required. If the bitter tonic action of Achillea is needed, it should be steeped for 20 minutes, to increase the extraction of nonvolatile bitter constituents. Decoctions The simmering time can vary between 5 minutes and 1 hour.

German practice The monographs in Herbal Drugs and Phytopharmaceuticals 13 indicate that some German practitioners prefer infusions to decoctions. In the few cases in which they use decoctions, for example, for hard materials, such as Gentiana root or Ratanhia root, they use short decoction times of 5-15 minutes.

John Christopher The German approach contrasts with that of Christopher, who recommended decoction times of 15-60 minutes. He used longer decoction times for harder plant material in order to extract the active components more thoroughly. He also used longer decoction times when he wished to reduce the volwne of liquid for convenience of administration.

Chinese practice Chinese tradition also uses longer decoction times-about 30 mmutes for the first simmering and 20 minutes for the second.

Extraction profile This may change with decoction time: The extraction of some chemicals may be maximal with shorter simmering times while others will be maximal with longer simmering times. Some chemicals may be progressively driven off, for example, the aromatic oils, or increasingly changed and inactivated by heating, for example, the anthraquinones. Texts on Chinese medicine may reco~­ mend that Rheum should not be cooked for longer than 10 minutes. This may be because the laxative anthraquinones are increasingly denatured by heat, leaving an increasing quantity of astringent tannins to dominate the extraction profile. Herbs decocted last In Chinese tradition, herbs with aromatic constituents are often added to the decoction about 5 minutes before the end of the simmer~g process to reduce the loss of volatile oils. This 5-minute decoction technique for aromatic herbs can be used for Western herb combinations and is especially suitable for moderately aromatic herbs, such as Achillea or Zingiber, since their full,spectrum of active ingredients may not be released by infusion. However, herbs such as Mentha pulegium or M. piperita. which have a greater proportion of volatile active constitu-

"' 1 1 wate/~::'-j~ .~ . .. _.. ,

----

~

104

Combining Western Herbs and Chinese Medicine

ents, are best added after the heat has been turned off and the decoction is allowed to steep. This combination of the decoction and infusion techniques minimizes volatile oil loss.

REHEATING Infusions For herbs that do not depend so much on volatile components, such as Taraxacum leaf, the daily amount can be prepared at one time. The infusion can be reheated, if required, for subsequent individual doses. This can be done on low heat, so that the liquid does not simmer or boil, in a pan with a well-fitting lid. For herbs with volatile components, such as Mentha pulegium, it is better to avoid reheating in order to minimize the loss of volatile oils. For optimum effect, each individual dose of such an infusion should be freshly prepared, but for convenience, sufficient infusion for one day can be made at one time and kept warm',~ a vacuum flask. Decoctions If enough decoction for one day is prepared, it can be kept warm in a vacuum flask. However, if two days supply is made up, and especially if the weather is hot, it is preferable to refrigerate the liquid and to reheat the doses as required. I reheat decoctions on the cooker, rather than use a microwave, but this is a matter of preference. Some decoctions used in acute conditions, such as Asclepias: acute respiratory disorders + fever, can be so effective that only 1-3 doses may be required. It may therefore be wasteful to make up more than a I-day supply.

.c .•

Stronger infusions 1 oz of dried herb per pint of represents the daily dose for a single herb (representing

-,~~!! -, about three individual doses). This is approximately 30 g ""~ ,.,~",,:W.

of herb in 500 ml of water. This means that the infusion,':~ ~repared according to the second system is about five-::-:-:o~a.~ tlffies stronger than the first. ... --.::::!!""

Author's position I generally use 1 heaped teaspoon per cup of water for an individual dose, which is approximately 3 g of herb in 150 ml of water. If there are three individual doses, then the daily dose represents about 9 g of herb. However, acute situations may require 5-10 cups per day, which represents 15-30 g of herb per day.

Dose for infusions

Dose for infusions of a single herb There are two main approaches to the strength of an infusion: • 1 teaspoon of dried herbs per cup of water l3 • 1 oz of dried herbs per pint of water6

Some texts suggest using the first system for weaker infusions and the second system for stronger infusions. 17 Whether a weaker or a stronger infusion is required depends on the herb and on the situation. ,.:.,:' .~ : -:. '

Weaker infusions' .I,level teaspoon of dried herb per cup of water represents'an 'individual dose for a single herb. This is approximately 2 g of herb in 150 ml of water. If there are three individual doses, the daily dose represents about 6 g of herb.

.~

.~~

Measurement equivalents There can be considerable confusion over the different systems of weights and measures. The table below summarizes some common measurement equivalents, based on the assumption that an individual dose of one heaped teaspoon of dried herb weighs 3 g.This topic is discussed in detail in the Weights and measures section

;"~

-~~-

..,.~

-'-';

....':.j.; .:

.~

-.~;-.~--~

later in this chapter.

?~~~mN!~~~~iXi~~~i:~~1¥[~~S:'ic;:~~~!~~:~~~l~' Measurement' ,,:~~of a single herb ,T.' :' Dally dose of .co~:,::. system"'; ;:';/"">(3doses'perday)'" a single herb"I} teaspoons and cups

1 heaped tsp herb per cup water

3 heaped tsp herb per 3 cups water

grams and milliliters

3 g herb per 150 ml water

9 g herb per 450 ml water

ounces and pints

0.1 oz herb per 5 fl. oz water

0.3 oz herb per pint water

DOSE The philosophy of dose has been discussed above, and this book generally follows the higher dose approach.

j

Dose for infusions of more than one herb Infusions are generally made from one, two, three. or at the most four herbs, since infusions are generally used for relatively simple acute or chronic situations. When a herb is used as a single herb, its dose is generally larger than when it is used in combination with other herbs. This is because. in a combination, its actions are assisted by the actions of the other herbs. For example, when I use Achillea as a single herb in an infusion, I use an individual dose of about 3 g. When using Achillea in combination with other herbs. I use less; thus, an individual dose of the combination Achillea: influenza + sore throat contains 2 g of Achillea. in addition to 1 g of Mentha and 1 g of Sambucus. Dose. for decoctions , The two main approaches to the. ...... strength of a decoction are the same as those for an infusion: "

• 1 teaspoon of dried herbs per cup of water 6 • 1 oz of dried herbs per pint of water

l3

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'_~f

-~"

.-

=

Dose However, the difference is not as extreme as it might at first appear. The 1 oz ofherbs per pint ofwater does not necessarily represent a daily dose. Rather, it may represent the amount of herbs to be taken during 2-3 days. For some of his decoctions, Christopher recommended a dose of 3 tablespoons per day, not 3 cups per day. Also, the figure of 1 oz (approximately 30 g) often refers not to a single herb but to the combined weight of all the herbs in the decoction. Most of my decoctions contain 4-8 herbs. The individual dose of each average dose herb in a combination is about one teaspoon (approximately 2 g). At three individual doses per day the daily dose of each herb is 6 g. If there are 5 herbs in the decoction, each at 6 g per day, then the total quantity of herbs in a daily dose is 30 g.

Note:

Christopher recommended 1.5 pints of water for a decoction, as opposed to his recommendation of 1 pint for an infusion. This was to allow for loss due to evaporation of 0.5 pints since he generally simmered or boiled decoctions for 20-60 minutes.

Average, higher, and lower dose herbs Herbs differ in their strength, so that their doses may be very different. Whilst the daily dose of an average dose herb is about 9 g of dried material, the daily dose of the higher dose herb Taraxacum leaf is 12-30 g, and the maximum daily dose of the lower dose herb Convallaria is 0.45 g.

ADVANTAGES OF INFUSIONS AND DECOCTIONS Cheapness and accessibility Throughout history, infusions or decoctions of fresh or dried herbs have made herbal medicine available to ordinary people who could not afford the expensive herbal preparations provided for the rich. This also applies today when there is a danger in some Western countries that therapeutic doses of herbal preparations, for example, tinctures, are priced beyond the reach of a large proportion of the population. Not only are dried herbs generally the cheapest form of herbal medicine, but those with access to the countryside can gather fresh herbs, and those with a garden, a city plot. or even a window box, can grow them.

: .... -

Link to the natural world Some modern sedentary societies are becoming increasingly out of touch with the world of nature. The use of dried and especially fresh herbs is an excellent way to begin to reconnect with the energy of the natural world that can be such an imp~rtant part of the process of healing. To walk in the woods and fields. to get to know the plants, and to gather them and to use them can bring a sense of peace and fulfillment that is not normally found in a bottle of pills or tincture.

105 Therapeutic value of water Infusions and decoctions are the dispensing forms that combine the therapeutic effects of herbs with the therapeutic effects of water. Water in itself can be cleansing and healing to the system, and the combined cleansing effect of herbs and water can be utilized in the treatment of conditions involving accumulation of toxins and waste materials in the body. Infusions or decoctions are therefore especially appropriate for diaphoretic, diuretic, laxative, and alterative herb combinations. Extraction profile Infusions and decoctions are appropriate to extract active constituents that are water soluble, for example, tannins and polysaccharides. They are therefore appropriate to use for astringent herbs containing tannin, such as Potentilla, for herbs containing demulcent mucopolysaccharides, such as Althaea, and for herbs containing nutritive polysaccharides, such as Chondrus. Whilst decoctions are inappropriate for herbs in which the key acti,ve constituents are aromatic oils, infusions can be an excellent medium for these herbs since the heat of infusions releases some of the aromatic oils from the plant material, allowing these aromatic compounds to be both ingested and inhaled. For example, the wonderful smell of Mentha pulegium infusion can be relaxing even without drinking the tea. Such infusions effectively combine herbal medicine and aromatherapy. Treatment of patterns of Cold The warmth of a hot infusion or decoction can be an important element in the treatment of Cold Deficient or Stagnant conditions of the Spleen, Lungs, or Heart. The warmth of the water combines with the warmth of the carminatives, diaphoretics, or circulatory, stimulants respectively, to treat these patterns. The warmth can have a diffusive, relaxing, and comforting effect on the mind and body. Treatment of patterns of Dryness Infusions or decoctions of herbs containing demulcent mucopolysaccharides, such as Althaea and Viola, are an excellent way to combine the moistening and rehydrating effects of water with the soothing, demulcent. anti-inflammatoryaction of mucopolysaccharides. These can be used to treat patterns of Deficient Ym and Dryness, whether of the respiratory, digestive, or urinary systems.

DISADVANTAGES OF INFUSIONS AND DECOCTIONS Taste If the herbs are unpleasant in taste, some patients may prefer a different dispensing form since there is a relatively large volume of liquid to ingest with infusions or

Combining Western Herbs and Chinese Medicine

106

decoctions (see the subsection on Taste in the section on Factors affecting dose above). However, many patients become accustomed to the bitter taste of decoctions and have good compliance. Convenience Infusions, and especially decoctions, a~e a relatively inconvenient form. If the patients are exhausted, lazy. impatient, or forgetful, or if they have an extremely busy life, they may prefer a more convenient form such as tinctures or capsules. However, the discipline and the routine of making and taking decoctions can be an important first step in learning to care for self and in stabilizing a chaotic lifestyle. Extraction profile Water is a poor solvent for some types of constituents, such as resins. Herbs that have a high proportion of resinous constituents, such as Commiphora or Grindelia, are generally extracted with 90% alcohol.

Infusions These are especially unsuitable for compounds with low solubility in water since the plant material only has a short exposure to water and there is no simmering.

Decoctions To maximize extraction of constituents with low water solubility, the plant material can be presoaked for at least 30 minutes in cold water, and preferably overnight. The mix is then simmered for at least 30 minutes to maximize extraction. and in some cases. can be simmered for an hour or more. Preservation Dried herbs lose their quality more quickly than some other dose forms. tinctures for example, and are also more susceptible to fungal and insect invasion. Dried herbs should be discarded if they do not have their characteristic smell and taste, or if they are looking 'old and graY:

Tinctures and llquid extracts I have experimented with various strengths of tinctures and with various types of liquid extracts, but the bulk of my own experience has been with 1:5 tinctures. Therefore, the different types of tinctures and extracts are briefly compared below, but the emphasis of this book is on 1:5 tinctures. COMPARISON OF TINCTURES AND EXTRACTS Three groups of preparations are compared below: • 1:5 tinctures • 1:2 liquid extracts • 1:1 liquid extracts

1:5 Tmctures Tinctures are made by the process known as '-:-= maceration, that is, by soaking the herb material in a mixture _ ' of water and another solvent, usually ethyl alcohol (ethanol), but sometimes vinegar or glycerol. The term 'tincture' in this book refers to water/ethanol tinctures unless otherwise stated. Tinctures can be of various strengths, ranging from 1:10 to 1:3.The ratio refers to the quantity of herb to the quantity of solvent. Therefore the higher the second figure of the ratio. the weaker the tincture. For example. 5 ml of a 1:5 tincture was made with 1 g of dried herb. whilst 5 ml of a 1:10 tincture was made with 0.5 g of dried herb. Tinctures weaker than 1:5, for example, 1:10 tinctures, can be inconvenient since the patient has to take a greater volume of ethanol tincture. Theoretically, 1:4 and 1:3 tinctures would be more convenient to use than 1:5 since the patient could take a lesser volume of ethanol tincture, providing that these higher concentration tinctures genuinely extracted proportionally more active constituents than a 1:5

_'1 ~'_'

i

--"'

-1

'P' 'l

tincture. 1:2 liquid extracts Preparations that are more concentrated than 1:3, that is, 1:2 and 1:1, are called liquid extracts (fluid extracts). Whilst tinctures are usually made by so~g (maceration), extracts are made by percolation. 1:2 extracts are the highest concentration that can be prepared by cold percolation without using concentration by heat or by vacuum. 2 Theoretically. 1:2 extracts should be 2.5 times stronger than 1:5 tinctures, but I have not yet seen independent research data that demonstrates that 1:2 extracts genuinely contain 2.5 times as much of a range of different active

-..

f"

ingredients than 1:5 tinctures. 1:1 liquid extracts These were traditionally made by the process of reserved percolation. but are now usually made by reconstituting soft or powdered concentrates. In either case, procedures involving vacuum or heat are involved. Equivalents Theoretically, a 1:1 extract should contain five times the quantity of active ingredients than a 1:5 tincture. However. research has shown that the heating and vacuum techniques involved in making 1:1 extracts can cause the loss of active constituents. IS For example, vacuum concentration of Matricaria extract caused the loss of up to half of the aromatic oil content. 19 For herbs with active constituents that may be lost in heating or vacuum procedures, such as aromatic oils or phenols, 1:2 extracts, or'even 1:5 tinctures. may be equal to or even preferable to 1:1 extracts. I do not use 1:1 liquid extracts for aromatic herbs such as __ Lavender, Rosmarinus, Salvia, or Thymus. I have smelled

Dose and tasted various 1:1 extracts, and I have yet to find one that smells and tastes of the full range of aromatic constituents as strongly as a good quality 1:5 tincture. In myopinion, if I cannot smell and taste the characteristic aromatic constituents with which I am familiar, either they are not there or they are denatured.

107 from the catalogue of East West Herbs,23 except that of Panax, which is from their data on the bottle label. Since ethanol can act as a preservative, the usual minimum strength of ethanol is 25%. Below this percentage. there may be microbial growth.

OTHER SOLVENTS ETHANOL AS A SOLVENT Wine has been used since antiquity, both as a medicine and

Two of the main alternative solvents to ethanol are glycerol and vinegar.

as a solvent.

Glycerol

Western tradition In the twelfth century. Hildegard von Bingen20 used cooking in wine as one of her main methods of preparing herbal medicines and recommended wine by itself as a warming tonic for a variety of disorders. Chinese tradition Wine itself is regarded as tonifying. with the ability to move Stagnant Qi and Blood. Tinctures (jiii.) were made by soaking herbs in wine. and to this day. tonic wines are popular in Chinese culture. as they were in the West in my grandmother's generation. In America, in the past, herbal medicines were sometimes made with moonshine whisky as the solvent. I Percentage of ethanol The water and ethanol mixture can extract a wide range of chemicals, but what constitutes the optimum percentage of ethanol is a matter of dispute.19.21.22 The optimum percentage of ethanol varies depending on the type of active constituent. Some manufacturers use 25% ethanol for the majority of their tinctures. This strength may be optimal to extract water-soluble constituents, such as mucopolysaccharides, tannins, and some of the glycosides. For example••the bark of Viburnum prunifolium contains viburnin, a bitter glycoside. According to one research report, an extract of Viburnum bark using 30% ethanol was reported to be five times more spasmolytic than an extract using 60% ethanol.:!:! % ethanol

Active constituents

25%

mucopolysaccharides tannins glycosides

Althaea Quercus Viburnum pru.

45%

aromatic oils alkaloids

Rosmarinus Cinchona

60%

alkaloids steroidal saponins

Lobelia Panax gin.

90%

resins'

Commiphora

1-

Other glycosides, aromatic oils, alkaloids, and many saponins may be more efficiently extracted at higher percentages, between 45-60%. Resins are. usually extracted with 90% ethanol. The ethanol percentages in the table above are

This compound has the following advantages:

• it is a better solvent than ethanol for water-soluble chemicals, such as mucopolysaccharides • it can be used by those who prefer not to take ethanol in any form • it is sweeter in taste than ethanol and therefore more palatable to some • it may be milder and more soothing to the digestive system than ethanol However, glycerol has the following disadvantages: • it is not as effective a preservative as ethanol • it is not as effective a solvent for many active constituents as ethanol • it may be less warming and moving than ethanol, and more likely to aggravate Damp conditions because of . its sweeter property and heavier nature Vmegar Like wine. vinegar has been used for centuries both as a medicine in itself and as a medium for herbal preparations. Hildegard von Bingen recommended a small amount of vinegar to cleanse the body and help digestion. and she used vinegar as an extracting medium in a variety of her herbal preparations. Apple cider vinegar is often preferred in modern vinegar extracts. Vinegar is especially used for extracting alkaloids, for example, the alkaloids of Lobelia and Sanguinaria. However, vinegar is not as effective a solvent as ethanol for other active constituents.

DOSE OF 1:5 TINCTURES OF A SINGLE HERB This depends on which of the following three dose groups the herb belongs to (data is from the BHP):

average

about 1-4 ml, three times per day

Agrimonia

higher

about 5-15 mi. three times per day

Agropyron

lower

about 0.5-1 ml, three times per day

Convallaria

108 . .

Combining Western Herbs and Chinese Medicine

PROBLEMS WITH 1:5

WHAT IS THE MINIMUM DOSE?

MULTIHERB TINCTURES

BHP minimum dose The basic premise from which this problem arises is that of the BHP minimum dose. However, it may be that the BHP figures were referring to single herb. prescriptions, rather than multiherb combinations. In a combination, lesser amounts of a particular herb can be used since its actions are supported by the actions of the other herbs. The example of Achillea is given in the subsection Dose for infusions ofmore than one herb above.

The individual dose of 1:5 tincture recommended by the BHP for the average nontoxic herb is 1-4 mI. Many practitioners use an average of 5 mI of 1:5 tincture as the standard individual dose of a herb combination. This means that if five herbs are combined, there is 1 mI of each herb in a 5-mI individual dose of the combination. Each herb is ,then at the lower end of the range recommended by the BHP as an individual dose. If there are more than five herbs in the combination, then there is less than 1 mI of each herb in a 5-mI individual dose of the combination. Each individual herb is then below the minimum BHP dose and may have no therapeutic effect. Lower dose herbs This problem does not apply to the use of 1:5 tinctures of lower dose herbs, since the minimum individual dose of theSe herbs is about 0.3-0.5 mI. Even if there were 10 such herbs in a combination, resulting in 0.5 mI as the quantity of each herb in an individual dose of the combination, this would still be at or above the minimum individual dose for each herb. Higher dose herbs However, the problem is acute for the higher dose herbs, since the individual dose of just one of these herbs can be greater than the figure of 5 mI for an individual dose of a combination. For example, the individual dose of 1:5 tincture for Agropyron is 5-15 mI. Such herbs might therefore be better taken as decoctions or infusions. Otherwise, if 5 such herbs were together in a combination, each with an individual dose of 5-15 ml, the individual dose of the total combination would be 25-75 ml of tincture. If the solvent for the 1:5 tincture were 45% ethanol, 75 ml of the tincture, three times per day, would be ~quivalent to more than one bottle of wine. Average dose herbs Mills and Bone are concerned that, when using 1:5 tinctures for multiherb combinations, the quantities of the individual herbs may be below therapeutic leve1. 2 If the individual dose of the total combination were kept at 5 ml, then it is only possible to have between 1-5 herbs in a combination, if BHP minimum doses for average dose herbs are to be observed. Mills and Bone recommend 1:2 liquid extracts to overcome this problem. The only way·to increase the number of herbs in a combination, when using 1:5 tincture, is to raise the individual dose of the herb combination above 5 mL However, above the dose of 10.ml of tincture, three times per day, the quantity of alcohol the patient would have to consume would be very high, especially if the percentage of alcohol in the tincture is greater than 25%.

Mills and Bone minimum dose These authors are at the high end of the higher dose approach discussed earlier in this chapter, and many practitioners would not agree with their high figures for minimum dose. For 1:5 tinctures, they tend to recommend higher doses than the BHP. For example, the BHP gives 0.5-1 ml as the individual dose of 1:5 tincture of Harpagophytum, whereas Mills and Bone give it as 5-10 ml. In the case of Harpagophytum, they base this higher dose on data from clinical trials (see the Harpagophytum chapter). However, such clinical data on minimum dose is not available for the majority of herbs. Need for further research More systematic research on the minimum and maximum doses for commonly used herbs is essential for the development of herbal medicine. In addition, a range of independent studies on the comparative extraction profIles of 1:1 and 1:2 liquid extracts, and 1:5 tinctures is important to determine the comparative efficiency of extraction for these methods with respect to different types of active constituents.

FLEXIBLE PRESCRIBING One solution to the problem of using 1:5 tincture for multiherb combinations is that of flexible prescribing. My standard individual dose for a total herb combination using 1:5 tinctures is 5 ml. The average number of herbs in my combinations is about six. which gives about 0.83 ml as the individual dose for each herb in the combination. However, various methods can be used to increase this dose when required. For example: • increase the individual dose of the combination from 5 ml (l teaspoon) to 7.5 ml (1.5 teaspoons). which raises the quantity of each herb in an individual dose of the combination from about 0.83 ml to 1.25 ml • increase the ratio of a particular herb in the combination from equal ratio with the other herbs to double, which raises the quantity of that herb in a individual dose of the combination from 0.83 ml to 1.66 ml*

-. ..

Dose • increase both the combination dose to 7.5 ml and the proportion of a particular herb to double, which raises the quantity of that herb in a individual dose of the combination to 2.5 ml • prescribe a particular herb separately from the combination, so that individual doses of up to 7.5 ml of that herb can be given, if appropriate (as with Valeriana in the Clinical examples section below)

'-"

-

*This means that the dose each of the other herbs is now less than 0.83 ml, unless two of the other herbs are only present in 0.5 ratio. In the example below, Astragalus is used at double ratio, whilst Glycyrrhiza and Zingiber are used at half ratio.

Astragalus Echinacea Achillea Cinchona Glycyrrhiza Zingiber

....,....,,-

~-

2 '1 1 1

0.5 0.5

ADVANTAGES OF TINCTURES AND LIQUID EXTRACTS Convenience Tinctures and fluid extracts can be very convenient. There is no preparation for the patient, they can easily be carried with the patient wherever they go, and, because of the relatively small volumes required, compared to infusions and decoctions, they can be easy to use for children and infants. Taste Because of the lesser volume, unpleasant tasting herbs can more easily be taken in tincture form than as decoctions. Preservation Providing they are kept in brown glass bottles out of direct sunlight in a cool place, tinctures in 25% ethanol or higher will usually keep for years. Dried herbs are more likely to lose their effectiveness in a shorter time or become invaded by fungi or insects. Extraction profile Tinctures or liquid extracts with 4560% ethanol are suitable for extracting chemicals, such as aromatic oils, alkaloids, and saponins, and tinctures of 90% ethanol are effective for extracting resins and oleoresins. Treatment of Cold. Damp. Deficiency; and Stagnation In itself, ethanol can be said to be warming, drying, tonifying, and moving. In terms of Chinese medicine, it can therefore be a favorable medium for treating Cold, Damp, Deficient, or Stagnant patterns. This does not mean that ethanol tinctures

109 are inappropriate for the treatment of patterns of Heat, Dryness, or Excess since suitable cool moist herbs can override the nature of the ethanol, especially if the tincture is taken with plenty of water.

DISADVANTAGES OF TINCTURES AND LIQUID EXTRACTS Ethanol Some patients prefer not to take ethanol, whether for religious reasons, because they had an alcohol addiction, or because they do not like the taste of ethanol. They may fmd glycerol extracts acceptable, but these are not suitable for herbs containing resins or aromatic oils. At least some of the ethanol can be evaporated from a tincture by putting an individual dose of the tincture in a cup and then fllling about three-quarters of the cup with boiling water. This method is not so suitable for herbs containing volatile oils, since these will tend to evaporate with the ethanol. Very few children have taste problems with the small amounts of alcohol present in children's doses of 1:5 tincture, providing the tinctures are taken in the appropriate dose for their age, diluted with water, and mixed with fruit juice, milk, or food. Extraction profile Tinctures are not as effective as decoctions in extracting water-soluble chemicals, such as tannins and mucopolysaccharides. Diaphoretic treatments Hot infusions or decoctions are best for diaphoresis, for example, to treat acute influenza and fever. Tinctures are not as effective even if they are taken with large amounts of hot water. ' Alterative treatments Since ethanol is inherently warming and drying, tinctures are not as appropriate for alterative treatments, although they can be used. For these treatments, infusions or decoctions are best since the water and herbs combine in their cleansing effects.

Powders The term 'powders' in this context refers to powdered dried herbs rather than to powdered concentrated extracts.

ADVANTAGES OF POWDERS Flexibility Powders, like infusions, decoctions, tinctures, and liquid extracts, have the advantage of flexibility. Powders of individual herbs can be mixed to make tailor-made combinations for individual patients. This is not generally done

110

Combining Western Herbs and Chinese Medicine

with pills and capsules since the practitioner would have to make up separate batches of pills or capsules for each patient

Pills, capsules, and concentrates

visit.

PILLS AND CAPSULES

Convenience Powders and tinctures are convenient in that the patient only has to mix them in water. The amount and temperature of the water depends on the patient's condition.

Pills and capsules are convenient and do not have problems with taste. However, they have the huge disadvantage of being fixed in composition, so that they cannot be matched to the specific needs of an individual patient. This means that they cannot replace the more flexible dose forms, such as infusions, decoctions, and tinctures. It is theoretically possible to mix powders to make capsules that are specific for the needs of a patient at a particular time. However, it is so time-consuming as to be impractical. There are certain combinations that are so well balanced that they can be used as a useful preliminary or as an adjunct to more specific herbal treatment. A good example is Christopher's lower bowel tonic (now called Dr. Christopher's ......,.""" Fen-L-Bee), which is available in capsules. However, even this excellent formula is not appropriate for everyone and may need modification or to be replaced with more individually tailored combinations.

For example, if it is necessary to produce diaphoresis, the powder can be taken with a greater amount of hot water. If a sedative effect is required, the powder can be taken with a lesser amount of cold water. Slow release Powders can have the advantage of slow release of active constituents, which can be advantageous for the treatment of colon problems since constituents, such as tannins, are still being released when the powder reaches the colon. Extraction profile A possible advantage of powders is that all the constituents reach the digestive system, rather than only those that are soluble in water or alcohol. In contrast, decoctions, for example, are poor at extracting resins. Therefore, a lesser amount of resins will reach the digestive system if herbs are taken in the form of decoctions, than if herbs are taken in the form of powder. However, it is not

known how efficiently the digestive system extracts the various types of active constituents from the powder that reaches the gut.

DISADVANTAGES OF POWDERS Digestive disorders

In terms of Chinese medicine, many

patients have Deficient Spleen patterns. In my opinion, powders, pills, and capsules may be difficult for them to digest and absorb, particularly if they are already taking medication or nutritional supplements in this form, since this will place an additional load on the weak Spleen. Infusions, decoctions, and tinctures extract the active ingredients, which then enter the body in solution. With powders, the body has to do the extraction, and if the Spleen is weak, this process may be inefficient and may put further stress on the weak Spleen. Powders can be taken with warm water, but unless they actually dissolve, the problem remains. Aromatic constituents Powders may not be the best form in which to take herbs with aromatic constituents. Such herbsare better taken as infu.sions, when the oils are released by the heat of the infusion, or as ethanol tinctures, which are the most efficient common means of extracting volatile constituents and making them available to the body.

CONCENTRATES The use of concentrates has already been briefly mentioned under the heading of 1:1 liquid extracts. Whether the concentrates are given as liquids or in solid form, their disadvantage is that active constituents may be lost or denatured during the heating or vacuum processes. Concentrates may therefore be especially unsuitable for herbs containing volatile or heat-labile active constituents. If the concentrates are made into tablets, there is further chance of denaturing of active constituents during the stages of this process. In addition, the number of additives and adulterants are likely to increase.

Advantages and disadvantages ofthe different dose forms The advantages and disadvantages of the different dose forms that are discussed in the text above, are summarized _ in the following table:

Infusions and decocllons • cheapness and accessibility

taste

• link to the natural.world.

lack of convenience

• therapeutic value of water

unsuitable for water-insoluble constituents, such as resins

• infusions suitable for . volatile constituents '

preservation

Dose

111 For example, all of the following items can be said to have a dried herb equivalent of 1 g:

• decoctions suitable for water-soluble constituents, such as polysaccharides and tannins

• 1 ml of 1:1 liquid extract • 2 ml of 1:2 liquid extract • 5 ml of 1:5 tincture • 10 ml of 1:10 tincture

• treatment of patterns of Cold • treatment of patterns of Dryness • diaphoretic treatments • alterative treatments Tinctures and liquid extracts

l~

__

• convenience

unsuitable for patients who h~ problems with alcohol

• taste

less suitable for water-soluble ccr.s:itue~ts, such as polysaccharides and tannins

• preservation

less suitable for diaphoretic treatments

• suitable for ethanol-soluble constituents, such as essential oils, alkaloids, resins, and saponins

less suitable for alterative treatments

• treatment of patterns of Cold and Damp, Deficiency, and Stagnation

limitations on the number of herbs in a combination

• convenience

unsuitable for patients with digestive disorders

• slow release of active constituents

less suitable for volatile cor.stituents

Pills and capsules lack of flexibility: it is not possible to match them to the specific needs of the individual patent

• slow release of active constituents

WEIGHT OF ACTIVE CONSTITUENTS PER UNIT OF PRODUCT

Powders

• convenience

However. the phrase dried herb equivalent can be misleading. The four items above are equivalent in that they all derive from 1 g of dried herb starting material. However, they are not necessarily equivalent in terms of the amounts and relative proportions of the active constituents that they contain. This is due to the fact that extraction efficiency for the different types of active constituents is not equal between the different extraction methods and the different ratio strengths, as reported by research studies.18.19.21.22

digestive disorders; less suitable for volatile ccr,stituents

Equivalence of dose

A more informative method of comparing the different dose forms would be to state the amount (in milligrams) of each of the main active constituents contained in one gram or one milliliter of the dose form. This kind of data is rarely available at present, but may become increasingly available in the future, since it is a useful way to compare the different dose forms. However, this approach is not without difficulties, as described below.

Extraction before or after ingestion Dose forms can be divided into two groups according to when the active constituents are extracted from the raw plant material: • extraction occurs before the dose form is taken into the body • extraction occurs after the dose form is taken into the body

Extraction before ingestion In dose forms such as infusions, In the absence of research data, it is difficult to compare doses between the different dose forms. Three alternative approaches to this comparison are: • dried herb equivalent • weight of active constituents per unit of product • therapeutic efficiency

DRIED HERB EQUIVALENT Mills and Bone have suggested the use of the concept of

1 i

dried herb equivalent in order to make dose comparisons. The dried herb equivalent derives from the product ratio, which expresses the weight of original dried herb material to the weight or volume of finished product.

decoctions, tinctures, fluid extracts, and solid concentrates, the active constituents are mainly extracted from the raw plant material before ingestion. The extract is swallowed and the residue of the original solid raw material is discarded. It is possible to compare these dose forms by assaying the weights of active constituents per unit of extracted product.

Extraction after ingestion In dose forms such as cut fresh herbs, powdered dried herbs taken in water, or powdered dried herbs taken in capsules, the extraction process takes place in the digestive system, after the raw herb material has been ingested. It is not possible to compare these dose forms, either with each other or with dose forms where· extraction takes place prior to ingestion, since there is no standardized method for assaying extraction efficiency after ingestion.

.•

-:;;;;,;;-

112

Combining Western Herbs and Chinese Medicine

Multiple active constituents A few herbs may have one main active constituent, such as capsaicin in the case of Capsicum. However, most herbs have multiple active constituents, and the effectiveness of the herb may depends on the balance between a number of different active constituents which may complement and moderate each other's effects. If the relative levels of the different main active constituents extracted vary between the different dose forms, the therapeutic effectiveness of these dose forms may also vary. Inactivated constituents If a particular extraction process makes a constituent less absorbable or pharmacologically less active, it is not possible to get accurate data on the weight of active constituents that are actually available per unit of product. THERAPEUTIC EFFICIENCY Compari~on in terms of the weight of active constituents per unit of product can be useful for dose forms in which the active constituents are mainly extracted from the plant material before ingestion. However, perhaps the only way in which it is possible to compare these dose forms with dose forms in which the active constituents are mainly extracted from the plant material after ingestion, is in terms of therapeutic efficiency, that is, in terms of reduction of specific signs and symptoms.

It would be useful in the future for research studies to compare the relative therapeutic efficiency of the different types of dose forms to determine which are most suitable for different types of patients and different disorders.

Timing of the dose STANDARD PROCEDURE For chronic conditions, I usually advise patients to take their herbs as a daily routine, usually three times per day, and preferably at set times. For optimum absorption, this can be on a more-or-Iess empty stomach, 1 hour before meals or between meals. For acute conditions, herbs may need to be taken much more frequently, and at any time. BITTERS AS APERITIFS ••<.

.L·.

If bitter herbs, or herbs which are both bitter and aromatic, are taken with the specific intention of enhancing appetite and increasing the efficiency of digestion and absorp-

------

,

tion, they may best be taken 15-30 minutes before the meal. .. _ _. ~ This is the principle of aperitifs, which are notgenercill -::~ gulped down in one swallow, but are sipped slowly and ""..,... pleasantly before the meal to prepare the mind and body for''''':' .• digestion. _:...~ Bitter prescriptions used in this way should als9 be;I.~ sipped slowly, and it is up to the ingenuity of the practitioner ---.:.~ to combine the bitter and aromatic tastes to make these prescriptions more palatable and therefore more likely to be sipped slowly by the patient. For example, Gentiana can be combined with Rosmarinus, Citrus, and a little Zingiber to make for a more palatable prescription.

y..

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....

-;

HERBS TAKEN AFTER MEALS

If the patient fmds that herbs in general or some herbs in particular, such as Capsicum, tend to produce gastric discomfort if taken on an empty stomach, then they can be __ taken after meals. The gastric irritant effect of such herbs can ,_, also be reduced by combining them with sweet demulcent herbs, such as Althaea and Glycyrrhiza. TIMES FOR STIMULANT AND CALMING HERBS The best time for herbs with both tonic and stimulant action is in the morning and early afternoon. Stimulant herbs, such as Rosmarinus and Panax ginseng, may aggravate insomnia if taken after about 5 PM. Herbs with potentially sedative action, such as Valeriana or Piscidia, may be best taken in the afternoon or evening since they may aggravate drowsiness and lethargy if taken in the morning. Many patients suffer from depression in addition to anxietyand insomnia. I commonly give such patients two bottles of tincture: the 'morning' bottle of an antidepressant combination and the 'afternoon' bottle of a calming combination. The tonic and stimulant combination can be taken before breakfast, before lunch, and again, if required before 5 PM. The calming combination can be taken before bed and again in the night on waking if required.

Duration ofthe prescription The length of time for which a particular herb or herb combination is prescribed depends partly on whether the patient's condition is acute or chronic. Generally, acute conditions require short-term treatment and chronic conditions require long-term treatment. The duration of a'prescription for a chronic condition also depends on the rate of improvement of the patient.

;-;-.::i.-

::¥ '.~

Dose SHORT-TERM PRESCRIPTIONS These are appropriate for acute conditions. They are also appropriate for herbs with constituents that have potentially cumulative side effects. the risk of which is therefore increased by long-term use. For example. there is the possibility that long-term use of herbs with high tannin content. such as Potentilla. may cause constipation or reduce the absorptive efficiency of the intestines. These problems are less likely with short-term use. For example. if Potentilla is included in a combination for a patient with acute diarrhea. once the diarrhea is substantially reduced. Potentilla can be replaced in the combination by a milder astringent with a lower tannin content. such as Alchemilla or Capsella.

LONG-TERM PRESCRIPTIONS WITH BREAKS The use of breaks in pre.scriptions for long-ter:m use maybe advantageous in situati~ns where there is either declining therapeutic effect or the risk of cumulative side effects. Declining therapeutic effect During long-term treatment, the reaction of the patient's body to the herbs may sometimes decrease and the clinical effectiveness of the herbs may decline. Regular breaks in treatment can help to reduce this phenomenon of declining effectiveness. For example. the patient can take the herbs for 2-4 weeks and then come off the herbs for 1 week before starting them again. An example of this is the use of Valeriana as a single herb for patients with insomnia. If the effectiveness of Valeriana declines, there can be a I-week break in taking this herb. If the effectiveness of Valeriana does not decline. this may be unnecessary. This technique is not appropriate for herbs•.such as Vitex. which may need to be taken for a number of months continuously to establish their effect. Cumulative side effects If the patient takes a specific herb or herb combination for long periods without a break there may be an increased possibility of cumulative side effects. For example, if Piscidia is taken long-term for chronic pain. there is the possibility that it may depress metabolism in an exhausted patient. Regular breaks in treatment can help to reduce the chance of cumulative negative effects.

113 between Valeriana and Humulus than to use either herb continuously. Valeriana can be used until its effect begins to decline, then Humulus can be used until it starts to be less effective. then Valeriana can be used again, or there can be a break in the use of herbs.

Clinical examples This section gives some examples of selecting suitable dosage and dose forms to meet the needs of different clinical situations.

TINCTURE OF A SINGLE HERB Many modern patients have complex combinations of syndromes. When treating such patients. many herbalists do not use single herbs, but use several herbs in combination that are carefully balanced to address these multifactorial situations. However, there are circumstances in which a single herb is appropriate. for example. when a herb is specifically appropriate for a particular disorder or when it has to be taken at a specific time. Vitex agnus-castus exemplifies both of these situations. Vitex is often given as a single herb for menstrual or menopausal problems to correct hormonal imbalance. It is usually given in the morning as one dose of about 2.5 rnl of 1:5 tincture. The single herb prescription ofVitex may be the only herbal treatment necessary. unless other herbs are required to treat specific syndromes or symptoms. Example A patient h~s menopausal problems with severe anxiety, night sweats. and insomnia. She can be prescribed Vitex as a single herb. at 2.5 ml of 1:5 tincture every morning. to regulate hormonal imbalances. In Chinese terms, Vitex can be said to regulate the Qi of the Liver, Kidney. and Uterus. In addition to the Vitex as a single herb. the patient can take 5 rnl of 1:5 tincture of the combination Salvia: menopausal hot flashes,· three times per day. This combination is specific to treat the anxiety, night sweats. and insomnia by clearing Heart Heat and tonifying Heart Deficient yoill.

HERBS GIVEN SEPARATELY TO LONG-TERM USE WITH ALTERNATIONS

ENABLE VARIABLE DOSE

If there is declining therapeutic effect during long-term prescription. one technique is to use breaks in treatment, but another way of dealing with this is to alternate between two herbs with similar effect. For example. for patients with chronic insomnia, it may be more effective to alternate

It is sometimes convenient to supply certain herbs as separate single tinctures so that their dose can be varied according to the patient's need without affecting the dose of the main herb combination. Capsicum and Valeriana are given as examples.

114

Combining Western H~Tbs and Chinese Medicine

Capsicum When prescribing Capsicum in tincture form, I usually give it as a single tincture, separate from the main tincture combination, and advise the patient to take between 5-20 drops of the 1:5 Capsicum tincture, with each individual dose of the main medicine. This enables the patient to vary the amount of Capsicum to find their own individual tolerance level of this herb, which may vary from time to time, even for the same patient If the Capsicum were included in the main combination and the patient found the level of Capsicum too high to tolerate, then a whole bottle of medicine would be wasted.

tincture is 1 drop, the second dose is 2 drops, the third is. 4. drops, the fourth is 8 drops, the fifth is 16 drops, and so on. In other words, the dose is doubled each time, until the required dose level is reached for the age of the child (see subsection on Age ofthe patient in the section Factors affect-ing the dose above). This enables the child to become accustomed to the taste

Example A patient has arthritis with poor peripheral cir-

Taste Starting with 1 drop is a great way of avoiding problems with taste, but if these persist, even though the tincture is mixed with a little water, milk, or fruit juice, a half ratio of Glycyrrhiza or Foeniculum can be added to the combination. Alternatively, the drops of tincture can be mixed with a

culation and sensations of cold in the body and limbs. The patient can be prescribed 5 ml of 1:5 tincture of the combination Zanthoxylum: arthritis + cold extremities, three times per day. Capsicum tincture can be given in a separate bottle so that the requisite number of drops of Capsicum can be added to each dose of the main medicine. Valeriana I sometimes give Valeriana as a single tincture, separate from the main tincture combination. I advise the patient to take between 0.25-1 teaspoon (about 1.25-5 ml) of the 1:5 Valeriana tincture, with each individual dose of the main medicine. This enables the patient to vary the amount of Valeriana taken according to the level of stress they are experiencing in their lives at a particular time. If the stress levels are higher, they can increase the dose of the Valeriana, and if the stress levels are lower, they can reduce the level of Valeriana or stop taking Valeriana altogether at that time. In this way, they can vary Valeriana without necessarily having to vary the dose of the main combination, as they would have to do ifValeriana were included with the other herbs.

Example A patient has premenstrual nervous tension, irregular menstruation, dysmenorrhea, and anxiety. She can be prescribed 5 ml of 1:5 tincture of the combination Leonurus: menstrual disorders + anxiety, three times per day. In addition, she can take 1.25-5 ml of 1:5 Valeriana tincture, with each individual dose of the main medicine and vary the amount of Valeriana depending on the severity of her anxiety.

PRESCRIBING FOR CHILDREN When treating babies and children, I generally use the dose form of 1:5 ethanol tinctures. Providing the following system is adopted, there is rarely a problem with this form. Start with 1 drop··' When prescnbing for babies or children up to about 10-years old, I advise parents to usethe following system. Each individual dose of the tincture is mixed with a little water, milk, or fruit juice. The first dose of the

of the herbs gradually, and this approach is successful in the great majority of cases. If the baby or young child is given the full dose for its age from the beginning, it may decide it does not like the taste, and then resist each further dose.

little honey. Example A teething baby is fretful and hot with disturbed sleep. The parents are advised to use a 1:5 tincture of Matricaria and Passiflora, in equal proportion, three times per day-midday, afternoon, and when the baby wakes teething in the night. The dose is started at one drop, in the usual way, and increased to a maximum of 10 drops for an individual dose. After 4 days there is a definite improvement, but this does not improve further by the end of 10 days, and the baby is still fretful at night with disturbed sleep. Rather than increase the dose of this combination above the level of 10 drops per individual dose, an equal proportion of Anemone is added to the combination, to treat the pattern of Heart Heat underlying the nocturnal restlessness. The initial individual dose is 5 drops, increasing to 10 drops after two days. There is further improvement in sleep, with decrease in heat and restlessness. After 2 weeks on the combination with Anemone, the baby is put back on the first combination, which proves adequate at 10 drops per individual dose.

VARIATION OF DOSE WITH TIME A good example of changing dose with time is the use of Christopher's lower bowel tonic for patients with chronic constipation and habitual overuse of laxatives. This combination is usually given in capsule form, as described for the combination Rheum: chronic constipation.

Initial dose An initial individual dose can be two '00' capsules, taken with a glass of organic apple juice, three times per day. Should the stool become too loose, the individual dose can be reduced to one '00' capsule, three times per day.

-

;:?---'

Dose However, the dose may often need to be increased up to as much as five capsules three times per day, in order to get normally soft, well-formed bowel movements. Long-term dose The dose should not be reduced too much or too soon. For example, if an individual dose of three capsules was needed to normalize defecation, this dose can be maintained for about 2 weeks, unless the stools become too loose. The individual dose can then be reduced to two capsules, and this long-term dose can be maintained for about 2-3 months, unless the stool becomes too loose, to cleanse the body and to rebalance bowel function after years of constipation and laxative abuse. To taper off the bowel tonic, the dose can gradually be reduced to one capsule three times per day, down to one capsule per day, and then none. Dietary improvements can accompany the process.

115 patient is advised to take the third dose for the second day and then stop taking the herbs. Herb Asclepias Echinacea Achillea Prunus Glycyrrhiza Lobelia Zingiber (fresh)

- Daily dose 6g 6g 4g 4g 3g 0.6 g* 3 slices

Temperature

Taste

cold cool warm-cool neutral neutral-cool warm-cool hot

bitter acrid, bitter acrid, bitter bitter, aromatic sweet acrid acrid, aromatic

*The UK daily maximum dose for dried Lobelia is 0.6 g; see the Dose section in the Lobelia chapter. This is a good example of a combination for an acute condition that is taken for a maximum of 3 days. If the acute condition does not clear by this time, the combination is not appropriate, and the diagnosis needs to be reassessed and a different combination given.

TRANSITIONS BETWEEN ACUTE, SUBACUTE, AND CHRONIC CONDITIONS For patients with fluctuation between acute, subacute, and chronic phases of illness, dose and dose form often need to be adjusted depending on the illness phase. Example: influenza and bronchitis A patient has a history' of recurring acute influenza and bronchitis, and chronic cough and tiredness. The dosage and dose form can be varied according to the phase of the illness, as follows:

• acute phase • subacute phase • chronic phase

"""--

decoction/infusion tincture/infusion tincture

Note: The combinations given below for the subacute and chronic phases only appear in this section and do not appear in the materia medica chapters of this book. .

Acute phase: decoction/infusion

In the acute phase, the patient has fever and severe painful coughing with yellow or green phlegm, which antibiotics do little to improve. The combination Asclepias: acute respiratory disorders + fever can be given during the acute phase, in the form of a decoction/infusion as described in the Asclepias chapter. Briefly, the Achillea is packed separately from the other herbs. The technique of decoction/infusion is as follows: One daily dose of all the herbs except Achillea is gently simmer~d for 20 minutes in about 500 ml of water. The heat is turned off and the Achillea added to the decoction and allowed to infuse for 10 minutes. The patient is advised to take an individual dose of about 150 ml of the hot decoction/infusion three times per day. Since the acute condition clears after a day and a half, the

Subacute phase: tincture/infusion After 2 days on the acute combination, most of the Lung Phlegm Heat and W md Heat are cleared, and the acute symptoms are gone. The patient has the subacute symptoms of occasional feverishness, persistent cough with white or slightly yellow phlegm, and irritability, associated with Retained Pathogen, Lung Phlegm, and some Liver Heat. The following 1:5 tincture can be given during the subacute phase, mixed with Achillea infusion. Herb ""'''''''"'''''''Ratio .... Temperature,., Taste . . ·.·';"b';,~""·,· ..··-· Berberis Echinacea Phytolacca Glechoma Prunus Glycyrrhiza Lobelia

1 1 1 1

0.5 0.5 0.5

cool cool cool neutral neutral neutral-cool warm-cool

bitter acrid. bitter, 51. sweet acrid sour, bitter bitter, aromatic sweet acrid

During the subacute phase, the patient takes 5 rnl of the combination, three times per day. Each dose is taken in a cup of hot Achillea infusion. This is made by pouring about 150 ml of boiling water on about 3 g of Achillea herb in a cup, and allowing it to steep for about 10 minutes. The hot Achillea infusion helps to clear Retained Pathogen from the body and to carry th~ other herbs more quickly than if the tincture were taken in cold water. Berberis and Echinacea also help to clear Retained Pathogen, and Berberis clears Liver Heat. Phytolacca and Glechoma clear Lung Phlegm, and Prunus, Glycyrrhiza, and Lobelia treat the cough.

Chronic phase: tincture After 2 weeks on the subacute prescription, the patient has no feverishness, but now is in the

116

Combining Western Herbs and Chinese Medicine

chronic phase, with weak cough and exhaustion, associated with Lung Phlegm and Lung Deficient Qi. The following 1:5 tincture is given for this chronic condition, at the dose of 5 ml in a glass of water, three times per day.

Thuja Angelica arc. Marrubium Hydrastis Panax qui. Ophiopogon Zingiber (dried)

1 1 1 1 1 1 0.5

wann~ool

wann neutral cool neutral cool hot

acrid, aromatic, bitter bitter, acrid, aromatic bitter bitter sweet, 51. bitter sweet, 51. bitter acrid. aromatic

Arctostaphylos Althaea Hydrastis Vinca Mitchella Rumex Zingiber (dried)

cool cool cool neutral neutral cool hot

bitter, sour sweet, 51. bitter bitter sour sl. sour bitter acrid, aromatic

the bolus. It is a modification of Christopher's vaginal bolus formula.

Thuja, Angelica, Marrubium, and Hydrastis, assisted by

--

Arctostaphylos

Zingiber, combine to tonify Lung Qi and help the Lung to

Althaea

disperse Lung Phlegm. Panax quinquefoilum and Ophiopo-

Hydrastis

gon tonify Lung Qi and rm. After taking this prescription

Mitchella

for 1 month, the patient's cough and exhaustion are considerably improved.

Rumex

COMBINING ORAL AND OTHER FORMS OF ADMINISTRATION Herb combinations taken orally can be used at the same time as the following forms:

• topical applications such as liniments, ointments, and

Stellaria

Ratio

Temperature

Taste

1.5 1.5 1 1 1 1

cool

bitter, sour

cool

sweet, 51. bitter

cool

bitter

neutral cool

51. sour 51. bitter

cool

bitter

A suitable amount of the combination of finely powdered dried herbs is mixed with cocoa butter to form vaginal boluses (see Christopher,s p. 478, for instructions on making boluses). A bolus is inserted in the vagina at bedtime and left overnight, held in place with a sanitary napkin. In the morning, the herb powder from the melted bolus can be flushed out of the vagina with a douche of Berberis decoction at body temperature.

Douche A decoction of Berberis is made by simmering 2

poultices

• preparations for orifices such as drops for the nose, eyes or ears; or suppositories, boluses or douches for the anus or vagina Detailed discussion of these applications is outside the scope of this book, and the reader is recommended to read Christopher's text. A

teaspoons (about 6 g) of Berberis powder in 1 pint (about 500 ml) of water for about 15 minutes. The liquid is filtered, for example, through coffee filter paper, to remove all particles of powder, and allowed to cool. This can be used as a vaginal douche as required.

Duration of treatment

A week is the minimum for this combination of tincture, bolus, and douche. The patient can then have 2 days without any herbs, before repeating the treatment for another week. This whole cycle of 7 days on, 2 days off can be repeated for 2 months or more as required.

woman has recurring cystitis, vaginitis with leukorrhea, and anogenital herpes, associated with Damp Heat in Liver-Gallbladder, Liver channel, and Bladder. She is prescribed a com-

Weights and measures

bination of forms fOf this condition: oral tincture, vaginal bolus, and vaginal douche: ..

Tincture She is prescribed the combination Arctostaphylos: vaginitis as 5 ml of 1:5 tincture in a glass of water, three times per day.

~1!'"

Bolus The following herb combination is used to prepare

Herb

Example: Combining tinctures, boluses, and douches

1.5 1.5 1 1 1 1 1

Different systems of weights and measures are described and compared below. Some potential points of confusion are clarified, for example, " • the differences between US customary units and apothecary units of weight

Dose

117 tern of apothecary units. This was a system of weights used in a pharmacy, in which an ounce equaled 480 grains, and a pound equaled 12 ounces,3 as opposed to the US customary system, in which an ounce equals 437.5 'grains and a pound equals 16 ounces. In the US customary system, 1 dram =1.77 grams, but in the apothecary system 1 dram" = 3.89 grams. In the US customary system, 1 ounce = 28.3 grams, but in the apothecary system, 1 ounce = 31.1 grams. 25

• the differences between US customary units and Imperial (British) units of capacity • variations in household units of capacity, such as cups, teaspoons, and drops The definitions and figures used below derive mainly from The Concise Oxford Dictionari~ and from Websters II

New College Dictionary.25 UNITS OF WEIGHT

"The word dram can also be written drachm or drach-

mao

Metric units

Chinese units and metric conversions Originally, one Wing was equal to 31.25 g, but from 1979, a simplified system has been used: 8

1 milligram (mg) = 1000 micrograms (!Jog) 1 gram (g) = 1000 mg 1 kilogram (kg) = 1000 g

.:.j

Units ofconcentration These are usually expressed as mglkg or glkg, but there are two other systems: • that expressed as percent (%) • that expressed as parts per million (ppm), that is, parts per 106

1 If (10 Mol 1 fen (10 If)

0.03 g (30 mg)

1 qian (10 fen)

3g

1 liang (10 qianl 1 jin (16 liang)

30 g

0.3 g (300 mg)

For example, since 1 kg = 1,000,000 mg, then

..

1--;<;

;

10 mg,tkg 100 mg,tkg 19,tkg

%

ppm

0.001% 0.01% 0.1%

10 ppm 100 ppm 1000 ppm

UNITS OF CAPACITY Metric units

US customary units

1 deciliter (dl) = 100 milliliters (ml) 1 liter (1) = 1000 milliliters

1 dram (dr) = 27.34 grains (gr) 1 ounce (oz) = 16 dr 1 pound (1b) = 160z Metric and US/Imperial conversions For the following measurements US and Imperial units are equivalent. _. !-:~"----...... _--. ~ ;

~.:...:--.-~--:-~"1

.

-

64.8 mg

1 dram

1.77g

1 ounce

28.3 g

(1 oz is often rounded off to 30 gl

1 pound

454 g

(lib is often rounded off to 500 g)

.--:".---

Metric weight and volume conversions. Assuming that the liquid is water, one milliliter weighs one gram and one liter weighs one kilogram. US customary units

,"

Metric"· - ._- -- ..

1 grain

480g

._---_.

~--

_._.-._-"---_._-

~-.;.--_.-

-.

1 fluid dram (fl. dr) = 1 fluid o~ce (fl.oz) = 1 pint (p) = 1 quart (qu) = 1 gallon (gal) =

60 minims 8 fl. dr 16 fl. oz 2 pints = 32 fl. oz 4 quarts = 128 fl.oz

.:..;--;-.~

Imperial units The Imperial units· of capacity follow the same hierarchy as the US capacity units above. However: 1 milligram

0.015 gr

1 gram

0.564 dr (15 gr)

1 gram

0.0350z

1 kilogram

2.21b

Apothecary weights

Some older books may use the sys-

• there are 20 fluid ounces in an Imperial pint, as opposed to 16 fluid ounces to a US pint • US units of capacity for pint, quart and gallon are smaller than their Imperial equivalents, but the US units of capacity for fluid ounce, fluid dram, and minim

Combining Western Herbs and Chinese Medicine

118

are bigger than their Imperial equivalents, as shown in the metriclUS/lmperial conversion table below Christopher Weiss Wichtl

MetriclUS/lmperial capacity units conversions CONVERSION TO METRIC

from US 1 minim 1 fluid dram 1 fluid ounce 1 pint 1 quart 1 gallon

0.0616 ml 3.7 ml 29.57 ml 473 ml 946 ml 3.781

0.059 ml 3.55ml 28.41ml 568ml 1.1361 4.5461

oz

5 (-8) fl. oz

Spoons The usual US convention is that one teaspoon is 5 m!' so that there are three 5-ml calibrated teaspoons to one 15-ml calibrated tablespoon. However, definitions vary, and uncalibrated teaspoons found in kitchens vary in size. For example, according to Christopher,

There are standard US units and equivalents, and when a calibrated domestic measuring tool is used, there will be approximate uniformity. However, when an uncalibrated. domestic utensil, such as a cup is used, there can be considerable variation, as discussed below.

1 teaspoon = about 4 ml 2 teaspoons = 1 dessertspoon of about 8 ml 4 teaspoons = 1 tablespoon of about 16 ml Cups) spoons, and equivalents As stated above, the 'cup' measure used in this book is 150 ml (5 fl. oz), as opposed to the US cup unit of240 ml (8 fl. oz).

Cups A 'cup' measurement from a calibrated US domestic measuring utensil is dermed as 8 fl. oz (about 240 ml), but uncalibrated domestic cups used by patients to drink their herb infusions and decoctions may vary in volume. Also, the volume will depend on how full the cup is filled. For example, an uncalibrated teacup filled to the brim may be only about 7 fl. oz or less, (about 200 ml) and filled to about 1'4 full may be about 5 fl.oz (about 150 ml). A coffee mug is about 8 fl. oz (about 240 ml) filled to the brim and filled to about %full is about 6 fl. oz (about 180 ml).

Drops This is also a rather variable measurement. According to the Shorter Oxford Dictionary, a drop is defined either as the smallest quantity ofliquid that falls in a spherical form or, with respect to dispensing, the smallest separable quantity of liquid. This dictionary also defines a minim as one-sixtieth part of a fluid dram-about one drop. Drops and minims Some authors, for example, Christopher, equate one drop with one minim. However, as Felter and Lloyd state, a drop is not necessarily equal to one

Different herbal authorities give different values for a cup, for example:

Cups _--

5 fl.

• 150 ml (5 fl. oz) is the estimate used in this book for a 'cup' measure

HOUSEHOLD UNITS OF CAPACITY

Spoons

6 fl. oz

For the purpose of dispensing herbal infusions or decoctions, I think that a % full teacup is probably a realistic estimate of what the average patient uses for an individual dose of infusion or decoction. Therefore,

-from Imperial

• 1 fluid oz is often rounded off to 30 ml • 1 pint is often rounded off to 500 ml

US

180 ml 150 ml 150 (-250) ml

_,~-o'_ -Auid ounces:, ,; : Pints

Milliliters (ml)

ml rounded off -

1/2 teaspoon

2.5ml

1 teaspoon

5ml

1 tablespoon

15ml

2 tablespoons

1 fl.

- ------------- - - - - - - - - - - -

oz

------------

30 ml

2 fl.

oz

59.14 ml

60ml

4 fl.

oz

118.3 ml

120 ml

177.4 ml

180 ml

6 fl. oz 1 cup

29.57 ml -

-Sfl.oz

- - - - _..

-_

....

_-_...

_-~-----,._._----~---'-._._-------------_

0.5 pint

236.6 ml

240 ml 500 ml

2 cups

16 fl. OZ

1 pint

473ml

4 cups

32 fl. OZ

2 pints (1 quart)

946ml

. 1 liter

..

__._----.

i-.-

Dose minim. A drop may be more or less than one minim, depending on the nature of the fluid and of the container from which it is dropped. Drops and teaspoons Both Christopher and Tierra state that there are 60 drops per teaspoon. However, Christopher's teaspoon is about 4-5 mI, whilst Tierra's teaspoon is 5 ml. I found that the droppers from both the 2-oz glass bottles and the 4-oz plastic bottles that I use in my clinic give about 100 drops to 5 ml. The figures in the table are approximations, and proportions of a teaspoon have only been entered down to one-quarter since further fractions are unlikely to have any meaningful accuracy. Drops

ml

5 ml teaspoon

100 drops 75 drops 50 drops 25 drops 20 drops 10 drops 5 drops 2 drops 1 drop

5ml 3.75 ml 2.5ml 1.25 ml 1ml 0.5ml 0.25ml 0.1ml 0.05ml

1

Gentiana root Humulus strobules Lavandula flowers Mentha pip. folium Matricaria flowers Pimpinella seeds Trigonella seeds Valeriana root

3.5 g 0.4 g 0.8 0.6 g 1g 3.5 g 4.5 g 2.5 g

Range Average

0.4-4.5 g

2g

The average weight of herb in a level5-rnl spoon, for the herbs shown in the table, is 2 g. Very approximately, the average weight of herb in a heaped 5-ml teaspoon is 3 g. This means that a level 15-ml tablespoon will contain about 6 g of the average herb, and a heaped tablespoon will contain about 9 g. However, as seen from the table, there is a considerable range in the density of the herb material. A level table.spoon of Humulus strobules weighs 1.2 g and a level tablespoon of Trigonella seeds weighs 135 g. Also, what constitutes a 'heaped' spoon is variable, depending on how high it is heaped. It can vary from about one and a half to two times the capacity of a level spoon.

0.75(%) 0.5 (Y2) 0.25(%)

Handfuls In earlier times, herbs were sometimes measured by handfuls. I Again. a handful will depend on whether

These figures can be a useful guide in prescribing for children. However, I always give a range of dose from which parents, working from the low end, can find the number of drops that has optimum therapeutic effect for their child.

US HOUSEHOLD

119

just the palm or the whole hand is covered, the size of the hand, and on how high it is heaped. Very approximately, I find a handful, a heaped 'palmful: to be about double a level tablespoon. that is about 12 g.

UNITS OF WEIGHT

Spoons used as a measure of weight

References

Some herbal texts use

the teaspoon as an approximate measure of weight. There is considerable variation in the size of teaspoons found in the home, which are often less than 5 rnl. Even if a level 5-rnl

1. Crellin JK. Philpott J. A Reference Guide to Medicinal Plants. Duke University Press, Durham, North Carolina (1990)

2. Mills S, Bone K. Principles and Practice of Phytotherapy: Modem

spoon is used, the weight of a level teaspoon of herb will

Herbal Medicine. Churchill Livingstone, Edinburgh, United Kingdom

depend on the density of the herb, and in some cases on how

(2000)

finely it is powdered. In a dispensary, in many cases, some of the herbs used are roughly cut, some are finely cut, and some are finely powdered. The figures in the table below come from the Wichtl text, which usually gives the weight of one level 5-ml teaspoon of the herb in the Making the Tea section of the monograph for each herb.

3. Felter HW, Lloyd ju. King's American Dispensatory, vols. 1 and 2, 18th edn. (1898). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1983) 4. Ellingwood . F. American Materia Medica, Therapeutics and Pharmacognosy, 11th edn. (1919). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1994)

5. Christopher (1976)

JR.

School of Natural Healing. BiWorld, Provo, Utah

6. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983)

Achillea herb Althaea root Angelica arc. root Artemisia wI. herb

1.5g 3g 1.5g 1.2g

7. Blumenthal M (ed). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council, Austin, Texas (1998) 8. Bensky D, Gamble A. Chinese Herbal Medicine Materia Medica. Eastland Press, Seattle, Washington (1986)

120

Combining Western Herbs and Chinese Medicine

9. Tierra M. Planetary Herbology. Lotus Press, Twin Lakes, WISCOnsin (1988)

17. Mabey R (ed). The Complete New Herbal. Elm Tree Books. Londol1':::~ United Kingdom (1988)

10. Grieve M. A Modern Herbal. vols. 1 and 2. Dover Publications. New York. New York (1971)

18. Van Es MJ. Some Applications of the Spray-dryer in Gallenical Pharmacy. Ph.D. thesis. Utrecht Universiry. Netherlands (1953)

11. Bradley PR (ed). British Herbal Compendium, vol. 1. British Herbal Medicine Association. Bournemouth. United Kingdom (1992)

19. Munzel K, Huber K. Pharmaceutica Acta Helvetica 36:194-204 (1961)' -

12. Weiss RF. Herbal Medicine, English edn. Beaconsfield Publishers. Beaconsfield. United Kingdom (1988) 13. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn. Medpharm. Stuttgart. Germany (1994). from 2nd German edn. Wicht! M (ed) (1989) 14. Felter HW. The Eclectic Materia Medica, Pharmacology, and Therapeutics. 18th edn. (1922). Reprinted by Eclectic Medical Publications. Sandy. Oregon (1994)

20. Von Bingen H. Hildegard von Bingen's Physica. Healing Arts, Rochester, Vermont (1998) 21. Meier B. Planta Medica 57(suppl. 2):A26 (1991) 22. Balansard G. Chausse D. Boukef K et al. Plantes Medicinales et Phytotherapie 17(3):123-132 (1983) 23. East West Herbs. Price List and Catalogue. East West Herbs. Kingham, United Kingdom (1993)

15. Scudder JM. Specific Medication and Specific Medicines. Scudder Bros Co, Cincinnati, Ohio (1913)

24. Sykes JB (ed). The Concise Oxford Dictionary of Current English. 6th edn. Oxford Universiry Press, Oxford. United Kingdom (1976)

16. IGrschmann G. Nutrition Almanac. 4th edn. McGraw Hill, New York, New York (1996)

25. Webster's II New College Dictionary. Houghton Mifflin. Boston, MA (1995)

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Safety are essential to the practice of herbal medicine. However, safety considerations need not stifle the scope of clinical practice; rather, they can be used to enhance the effectiveness of herbal treatments whilst reducing the risk to the patient. Safety is discussed in this book in three chapters: ONSIDERATIONS OF SAFETY

C

tain and extend the availability of beneficial herbs to the public. THREE OPINIONS There are three main opinions regarding ~e safety and availability of herbal products.

• Safety • Safety and the organ systems • Safety in clinical practice Safety This chapter reviews the debate on the safety and availability of herbs, discusses measures to improve the safety of herbal medicine, and investigates reports of adverse herb reactions. Safety and the organ systems This chapter discusses herbal contraindications and adverse reactions in each of the main organ systems-in terms of both Western and Chinese medicine.

• herbs are safe • herbs may be unsafe • maximize both herb safety and availability Herbs are safe Many herbal practitioners and many members of the general public are of the opinion that herbs are safe. Therefore, they believe that their availability should not be restricted, at least when they are supplied by practitioners specifically qualified in herbal medicine. Holders of this opinion believe that exaggeration of the risks of herbal medicines may result in legislation that increasingly restricts the availability of beneficial herbs to the public.

Safety in clinical practice This chapter presents a checklist of eleven measures for the practitioner to use in the clinic to improve the safety of ~erbal practice. Each measure is discussed with examples.

Herbs may be unsafe The opposing opinion, held by many members of the medical profession, is that herbs are not safe or may later prove to be unsafe. This group also generally believes that herbs have little or no therapeutic benefit. Therefore, if there is any doubt about the safety of a herb, its availability should be restricted.

Safety and availability

Maximize both safety and availability The first two opinIt is the premise of this book that every effort should be

ions represent the opposite extremes, neither of which can be definitively proved by data. There is a third opinion, held

made to improve the safety of herbal medicine and to main-

121

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Combining Western Herbs and Chinese Medicine

by a growing number of practitioners and scientists according to which it is possible to maximize both the safety and availability of herbal products. They believe that it is possible to increase the safety of both herbal products and herbal practice. This will reduce the frequency of adverse reactions and thereby reduce the risk of restrictive legislation. They are also working to increase the quantity and quality of data on the positive effects of herbs and make this data available to legislators. Increasing the knowledge of the benefits of herbs will also reduce the risk of restrictive legislation.

may genuinely reflect the relative safety of herbal therap~ ...__ adverse reaction reporting has not been satisfactory in the past, and measures are being taken to remedy this • adverse reaction data can be very valuable. but each case needs to be evaluated carefully to determine if it is the herb or another factor that caused the adverse reaction • poor quality control in the manufacture of herb products may have been a major factor contributing to adverse herb reactions, but since quality control is being steadily improved, there may be a reduction in adverse reactions and an increase in herb safety

TOPICS OF DEBATE IMPORTANCE OF MULTIPLE Four of the main topics that feature in the debate on the safety and availability of herbs are: • risk of adverse herb reactions • importance of multiple active constituents • qualityofherball'ractitioners • risk:benefit ratio

These four topics are discussed below in terms of each of the three main opinions listed above. RISK OF ADVERSE HERB REACTIONS Herbs are safe • herbs have been used worldwide by millions of people for centuries, and there are surprisingly few reports of adverse reactions • very few plants currently used as herbs have been reported by research to have serious adverse reactions in humans when they are used within their recommended therapeutic dose ranges Herbs are unsafe • adverse reactions may not have been satisfactorily reported in the past • no satisfactory format for reporting adverse reactions from the use of herbs has yet been established • there have been a number of reports in the medical literature suggesting adverse reactions from herb use • there is particular concern over damage done by the long-term use of herbs, which may initially show no adverse r~ac~ons but maylead to cumulative, perhaps irrevers.i?l~~~~age . . Maximizing safety and availability • whilst the relatively few reports of adverse herb reactions

ACTIVE CONSTITUENTS Herbs are safe • herbs have far fewer adverse reactions than allopathic medicines because herbs tend to have multiple active constituents that can buffer and moderate each other's effects Herbs are unsafe • because herbs can contain so many potentially active constituents, it is possible that one or more of these constituents may have potentially harmful effects • there can be considerable variability in the quantity of key active constituents from batch to batch of herbal material, so that the effect on the patient of a standard amount of the herb is less predictable Maximizing safety and availability • the argument that herbs contain many active constituents and that one or more of these may have potentially harmful effects can also be applied to foods, but unless a herbal constituent is proved to be harmful-at therapeutic doses ofthe herb-it is no more logical to limit the availability of the herb than to limit the availability of a foodstuff • standardization of herbal material can reduce batch-tobatch variability and increase safety, but this should be done using multiple markers-perhaps one marker from each of the herb's main active constituent groups

QUALITY OF HERBAL PRACTITIONERS Herbs are safe • herbs are safe, when prescribed by a qualified herbal practitioner since they can be matched to the specific individual needs of the patient

Safety Herbs are unsafe • there is no recognized minimum level of training, and prescription of herbal products by inadequately trained individuals may result in adverse reactions Maximizing safety and availability • improvements in the minimum level of training of herbal therapists will decrease adverse reactions and reassure legislators • if the practitioner is well-trained and so has detailed knowledge of the potential side effects of a herb for a particular patient. it may be possible to gain the benefits of the herb whilst minimizing potential side effects

RISK:BENEFIT RATIO Herbs are safe • in some cases, herbs can be just as effective as conventional drugs or even more effective • herbs have fewer adverse reactions than conventional drugs because herbs can strengthen the self-regulatory capacity of the body, whilst drugs tend to suppress specific symptoms and, in doing so, may suppress and disturb the natural metabolism Herbs are unsafe • herbal remedies do not have any real benefit

• if there is any doubt as to the safety of a herb or even one of its constituents, even if the doubt comes from theoretical considerations rather than adverse clinical reports, the use of that herb should be restricted Maximizing safety and availability • research data is accumulating demonstrating the benefits of individual herbs, and in most cases, the data emphasizes their safety when they are used within their therapeutic dose ranges i\

• for most herbs, the available evidence suggests that the benefits outweigh the risks, and this evidence can be presented by the herbal profession to the regulatory

123

benefit assessment to herbal products that they do to pharmaceuticals. They believe that in the case of herbal products• regulators tend to exaggerate the risks and ignore the benefits of herbal medicines.\ This topic is further discussed in the next section In perspective and in the section Improving interpretation ofadverse reaction data later in this chapter.

In perspective Many practitioners and many members of the public believe in the right to choose herbal therapy. They regard herbal knowledge as a treasure house of over 2000 years of medical experience. They believe that in a society increasingly alienated from the natural world, herbal therapy provides them with an important link to living things and to the earth. They find it ironic and unacceptable that a therapy, which they 'consider to be much safer than conventional medication and more supportive to the body, should be restricted due to exaggeration of its risks and ignorance of its benefits. Whilst the bulk of this chapter deals with the investigation of adverse reactions to herbal products, it is useful to put this discussion of the risks of herb use in the context of the dangers from other substances ingested in modern life. Herb products can be compared on the one hand with food and drink, and on the other with conventional medications.

HERBS) FOOD) AND DRINK The adverse effects of excessive consumption of coffee, tea, salt, and sugar are well known2 and are greater than those of the majority of herbal medicinal products. What is less well known is that many common vegetables also contain potentially toxic constituents. For example:3 • beans can contain toxic lectins • cabbages contain glucosilinates that can convert to toxic nitriles • potatoes can contain poisonous alkaloids when the tubers turn green

authorities Regulating authorities assess conventional medicines according to risk:benefit ratio and allow a certain statistical level of adverse drug reactions, providing that the benefit seems to outweigh the risk. However, many herbal practitioners believe that regulatory bodies do not always apply the same standards of risk:

However, these vegetables are generally regarded as safe, even when they are consumed in large quantities. Although they may contain chemicals that are potentially toxic in themselves, these chemicals are not normally present at levels that present a risk to the public. The same principle can be applied to herbs (see the discussion in the section Improving

interpretation ofadverse reaction data).

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Combining Western Herbs and Chinese Medicine

HERBS AND CONVENTIONAL MEDICATIONS Side effects from conventional medications are far more common and can frequently be more severe than those from herb products, as illustrated by the comparisons below between a herb and a comparable conventional medication: • digoxin and Crataegus • diazepam and Valeriana

DIGOXIN AND CRATAEGUS Both the cardiac glycoside drug digoxin and the herb Crataegus can be used to increase the force of the myocardial contraction and reduce arrhythmias. Their risks and benefits can be compared as follows: Digoxin The data given below on the negative effects of digoxin is from Martindale. 2

Side effects Digoxin commonly produces side effects because there is only a narrow margin between the therapeutic and toxic doses. These may include headache, facial pain, fatigue, weakness, dizziness, and mental confusion. Toxic doses may produce cardiac arrhythmias and may result in heart failure.

Drug interactions Digoxin can interact with many other types of drugs, including alpha blockers, antiarrhythmics, antibacterials, antiepileptics, antifungals, antimalarials, antineoplastics, immunosupressants, benzodiazepines, calciumchannel blockers, diuretics, nonsteroidal anti-inflammatories, and sympathomimetics. Some of these interactions can have serious consequences.

Fatalities In massive overdose, digoxin can result in progressive hyperkalemia, which can be fatal. Crataegus This herb is an excellent example of a herb that does not have side effects because it has a homeostatic or normalizing effect on the body. It can therefore be used to treat both hyper- and hypoactive states of the cardiovascular system (see the Crataegus chapter).

Comparison studies When compared with a digoxin preparation, Crataegus was reported to increase erythrocyte flow rate and decrease leukocyte endothelial adhesion in the vascular network of the rat. 4 In a study on isolated guinea pig hearts, digoxin was reported to shorten the effective refractory period, whilst Crataegus lengthened it. 5 Thus Crataegus has less risk of causing arrhythmias than digoxin and may even have ~tiarrhythmic action. Side effects ..No significant side effects have been reported. Drug interactions No adverse herb-drug interactions have

been reported for this herb. In fact, Crataegus has been reported to reinforce the beneficial effect of cardiac glycosides in increasing the force of heart contraction without increasing glycoside toxicity.6

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Fatalities No overdose effects have been reported. DIAZEPAM AND VALERIANA Both the benzodiazepine drug diazepam and the herb Valeriana can be used to treat anxiety and insomnia. Their risks and benefits can be compared as follows: Diazepam The data given below on the negative effects of ....... diazepam is from Martindale.!

Side effects The most common side effects of diazepam are

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sedation, drowsiness and ataxia. Side effects can also include depression, confusion, amnesia, slurred speech, headache, vertigo, visual disturbances, tremor, gastrointestinal disturbances, and urinary system disorders. Respiratory depression and hypotension occasionally occur with high dosage, and some patients experience a paradoxital excitation that may include such symptoms as aggression and disinhibition.

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Dependence and withdrawal Physical dependence may develop, with severe and distressing withdrawal symptoms, which may include dizziness, tinnitus, headache, hypertension, irritability, insomnia, anxiety, palpitations, tachycardia, vomiting, and abdominal cramps.

Drug interactions Enhanced sedation or respiratory and cardiovascular depression may occur if diazepam is given with other CNS-depressant drugs.

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Fatalities During the years 1980-1989,891 fatal poisonings in Britain were attributed to overdosing with benzodiazepines used alone. Valeriana

Comparison studies In a double-blind study with 100 patients suffering from moderate anxiety, a preparation of-Valeriana combined with Hypericum was shown to be more effective than diazepam and to have fewer side effects. 7

Side effects

The side effects of therapeutic doses of Valeriana are occasional and mild, Valeriana has no general contraindications, and there are no reports of adverse reactions either during pregnancy and lactation (see the Valeriana chapter). One study compared Valeriana with flunitrazepam, a_ benzodiazepine with similar general properties to diazepam. s The authors reported that the flunitrazepam group showed impairment of perlormance on the morning follow-

Safety ing medication, whilst the valerian group reported only a very slight impairment of vigilance.

Drug interactions There are no clinical reports of herb-

125

and saponins, chromatographic analysis of both types of compounds is required for identification and standardization.9

drug interactions with Valeriana, although it would be prudent not to combine high doses of Valeriana with alcohol or sedatives prior to operating machinery (see the Valeriana chapter).

The use of multiple markers For herbs with multiple active constituents, the use of multiple markers would give a more complete and accurate assessment of herb effectiveness and herb safety. As an initial step, it might be possible to select

Dependence and withdrawal I have not seen reports of

three to four main active constituents. or to select one constituent from each main chemical type present, for example, one flavonoid, one saponin, and one volatile oil.

dependency or withdrawal symptoms with Valeriana.

Fatalities

I have not seen reports of fatalities with Vale-

riana.

Definition of standardization The term standardization, as

Necessary improvelnents Improvements in five key areas would go a long way to reduce doubts about herb safety: • improvements in quality control for the manufacture of herb products • restriction of certain herbs to qualified practitioners only • improvements in the level of training of herbal practitioners • improvements in recording of adverse reactions • improvements in interpretation of adverse reactions

QUALITY OF HERB PRODUCTS This topic is discussed in two parts: Standardization and

used above, is taken to indicate the assaying of different batches of herb material to determine if the marker active constituents are within acceptable levels. It may also include the use of standardized preparation and extraction procedures in the manufacture of a herbal product. In this context. it does not mean the addition of a previously isolated chemical to the herb material to produce an artificial standard level of that compound, for example, the addition of caffeine to products made from Cola species. This is not standardization, but adulteration. Other quality issues Some of the adverse reactions occurring with the use of herbal products may be due to poor quality control in their production. Standardization has already been discussed. This section is concerned with: • general manufacturing standards • misidentification and substitution • contamination and adulteration

Other quality issues. l.~ __

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Standardization The concern is that even if the herb material is correctly identified, down to the species, or if necessary, the subspecies, there may be an unacceptable degree of variability in the quantity of active constituents from one batch of the herb to another. To minimize this, one or more active constituents are selected as markers, and the quantity of these markers in a batch of herbs is assessed. for example. by chromatography, to determine if the quantity is within the acceptable minimum-maximum range of standardization.

Disadvantages of a single marker

The pharmacological activity of a herb may depend not on a single constituent, but on a complex of mutually re~ating chemicals. If only one active constituent is used as a marker for purposes of standardization. this may not give an accurate picture of the overall effectiveness of the herb. For example, Wagner et al. point out that since the therapeutic effect of Astragalus species (huang qi) may be due to a synergism of flavonoids

General manufacturing standards if herbal products are manufactured according to the full code of pharmaceutical GMP (Good Manufacturing Practice). this gives a baseline of quality control; it is a legal requirement in some countries.

Misidentification and substitution Misidentification can occur when laypersons gather herbs without adequate knowledge of plant identification. An example of incorrect identification resulting in adverse effects is given in the section

Examples ofadverse reports. Misidentification is less common in the manufacture of herb products, but substitution has been an accepted part of herbal supply in both China and the West. It is now less acceptable since some substitutes have been identified as higher risk herbs. For example. in the past. Teucrium species were commonly used as substitutes for Scutellaria. 1o This is no longer acceptable since Teucrium chamaedrys has been reported to have a hepatotoxic effect. ll

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Combining Western Herbs and Chinese Medicine

Contamination and adulteration To maximize safety, it is necessary to include testing for the following: • microbial contamination • contamination with heavy metals • contamination with unacceptable levels of pesticide and herbicide residues • contamination of a nontoxic herb with a toxic herb during harvesting • adulteration with conventional drugs To maintain quality control, these tests need to be performed on a regular basis. The future As standards of manufacture of herbal products continue to improve, problems of misidentification, substitution, contamination, and adulteration are likely to decline. Increased herbal safety and less adverse reaction reports should help to decrease the demand for restrictions on the availability of herbs.

QUALITY OF PRACTITIONERS

If the supply of certain herbs is to be restricted to practi- - '" tioners only, this raises the question of the quality of practitioner training in herbal medicine. In some Western countries, it may be that a large number of practitioners prescribing ----".0-' herbal treatment do not have a level of training that is sufficient either to diagnose or to prescribe effectively and safely. Necessary measures As long as a significant part of the herbs supplied to the public comes from individuals with inadequate diagnostic and herbal training, government regulators are more likely to restrict the use of herbs. If phytotherapy is to survive as a profession, it is essential that certain measures be taken.

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Minimum training and external examination Rather analogous to the development of acupuncture in the United States, one possibility is to set a minimum level of training for courses on Wes.tern herbal medicine and to have an external national or state examination.

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RESTRICTION OF CERTAIN HERBS TO QUALIFIED PRACTITIONERS ONLY OTC sales It is likely that the majority of Western herbs supplied to the public in the West are at present bought overthe-counter (OTC), that is, from retail stores or by mail order. The vast majority of OTC sales are without a prior full diagnosis by a practitioner qualified in herbal medicine.

Membership and registration Those who pass the examination are then eligible for membership in a professional phytotherapy organization with a code of ethics 'and a consumer complaints procedure. They may then also be eligible for licensing and registration on a state or national basis, having satisfied these authorities as to the adequacy of other aspects - <:;7' of their training, such as, for example, a basic minimum of training in Western medicine. ;;" ..

When aTe sales are inappropriate For those herbs without side effects when taken within the therapeutic dose range, aTC sales may be appropriate. However, in my opinion, aTC sales are inappropriate for those herbs that can have potentially severe side effects for some persons, just above or even within the therapeutic dose range.

Accreditation for schools An external accreditation and inspection procedure for schools of herbal medicine could be installed to ensure quality of both theoretical and clinical training.

Supply by practitioners only Some countries, for example, the United Kingdom, have a list of restricted herbs that may not be supplied on demand by retail outlets but may be supplied to patients by a practitioner, subsequent to a professional consultation. (see the Regulation of herb use section below). There are maximum dose restrictions on these herbs.

In the past, the reporting procedures for adverse herb reactions have been unsatisfactory. In some countries, gov- ernment regulators may have tended to feel that the herbal profession has no concept of evaluation of safety, does not care about safety, or is too disorganized to act effectively. This has increased the possibility of restrictive legislation.

Reducing risk of restrictive legislation In my opinion, herbs such as Cinchona, Convallaria, Ephedra, and Gelsemium, are not suitable for aTC sales. If such herbs were restricted to qualified practitioner use only, as they are in the United Kingdom, there would be l~ss adverse reactions and less likelihood of a total restriction on the availability of these very useful herbs to the public.

Progress made Escap (the European Scientific Coopera- _ tive on Phytotherapy) has been involved in the improvement of adverse reaction reporting in Europe. This project brings together scientists, herbalists, and manufacturers from the_ European countries. ESCOP has a web site for online reporting of adverse reactions:

REPORTING OF ADVERSE REACTIONS

www.escop.com/phytonethtm

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Safety In Britain, the National Institute of Medical Herbalists (NIMH) issues adverse reaction report forms to its members, which include the vital questions 'Was the patient rechallenged?' and 'Did the reaction recur?' The NIMH web site is currently: www.nimh.org.uk/

Future needs Individual practitioners can contribute to the survival of herbal medicine by sending adverse herb reaction and herb-drug interaction data to the collecting bodies in their particular country. The accumulation and promulgation of data on adverse reactions is essential to a practitioner's understanding of herbs, to the fair regulation of herb products, and most of all to the safety of the public. However, it is also essential that the reporting of an adverse reaction is objective and accurate, and clearly determines that the adverse reaction was brought on by the herbs and not by another factor. This is discussed in the next section.

Improving interpretation of adverse reaction data This subject is discussed under four main headings: • increasing objectivity • excluding factors other than the herb itself • investigating reactions apparently due to the herb itself • distinguishing between actual clinical adverse reactions and the theoretical possibility of adverse reactions

INCREASING OBJECTIVITY The media of both complementary and conventional medicine may sometimes be less than objective in the reporting of adverse reactions. There may be a natural inclination among some herbal practitioners to play down adverse reaction data, and there may be a tendency in some medical journals to play it up. There has been some less than rigorous reporting in medical journals, in which herbal remedies were implicated in adverse reactions without sufficient evidence. 3• 12

Any report of adverse reactions requires thorough investigation before public pronouncement is made or restriction on availability is imposed. Objectivity can be increased by applying the following basic principles of scientific investigation to an adverse reaction publication:

127 • full citation of all relevant primary sources • thorough assessment of reports • caution in extrapolation from a single report • caution in generalizing from one species to a genus • careful exclusion of the effects of factors other than the one under study (see the next section) Full citation of all relevant primary sources If any statement is to be made in a book or journal about the toxicity or adverse reactions of a herb, it is essential to cite full references to the primary sources. This has not always been done in the past.

German Commission E Monographs This text, published in English translation in 199813 did not 'include any references to the literature used by the Commission in assessing the safety of the herbs discussed. EXAMPLE 1: The monograph on Echinacea angustifolia stated that this herb is not to be used internally in systemic diseases such as multiple sclerosis, AIDS, HIV infection, and other autoimmune diseases. According to Mills and Bone, there are no clinical studies that document adverse effects resulting from the use of Echinacea in any of these conditions. 3

The monograph on Smilax states that taking preparations of this herb leads to gastric irritation and temporary kidney impairment. The editors of the English translation of the Commission E monographs pointed out that they could find nothing in the scientific literature that substantiated this assertion. 13 EXAMPLE 2:

Examples such as these led one author to question whether some of the statements on herb safety made by the Commission were actually based on clinical research or on theoretical speculation. In his opinion, the failure to cite primary sources makes the Commission E monographs unsuitable as a basis for regulation ofherb availability.14 Thorough assessment of reports No public pronouncement on herbal safety should be made on the basis of an uninvestigated anecdotal report of a clinical incident. Any report of adverse reactions to a herb requires rigorous investigation of methodology, record keeping, data, conclusions made, and experimental design and statistical interpretation of data, where appropriate. Caution in extrapolation from a single report A basic principle of scientific research is never to accept fully the data and conclusions of a single investigation. It is preferable to weigh a single report against research by other investigators before coming to a provisional conclusion, and it is wise

128

Combining Western Herbs and Chinese Medicine

always to be prepared to change this conclusion in the light of new data. Caution in generalizing from one species to a genus Because one species in a genus is reported to have adverse reactions, it does not mean that other species in the genus will also have that effect. For example, there has been a report of hepatotoxicity in rats for Teucrium chamaedrys,1I but another Teucrium species was shown to have hepatoprotective effect in mice. IS Different species in a genus may have different profiles of active constituents and thus have different pharmacological effects. If one species has been reported to have adverse effects, it may be necessary to investigate other species in the genus, but each species must be assessed separately.

Adverse drug-drug interactions An adverse reaction may be . __ due to a negative interaction between a herb and a drug that the patient is taking concurrently. However, when investigating this possibility, it is important to consider the possibility of an adverse drug-drug interaction between two of or more of the conventional medications that the patient is taking.

INVESTIGATING REACTIONS APPARENTLY DUE TO THE HERB ITSELF After the exclusion of other factors, the following key question can help to determine whether the reaction is due to the herb product itself:

Do the symptoms decline when the patient stops taking the product and increase when the patient is 'rechallenged: that is, when administration ofthe product is resumed?

EXCLUDING FACTORS OTHER THAN THE HERB ITSELF One of the most fundamental principles of scientific investigation is the exclusion of the effects of factors other than the one under study. Before it is possible to say that a herb product can cause adverse reactions, it is necessary to exclude the following alternative possible causes of the reaction. These may include: • adverse reactions from conventional medicines or change in type or dose of conventional medicines • changes in intake of drugs, such as coffee, alcohol, tobacco, cocaine, or other 'recreational' drugs • changes in nutritional pattern, fasts, mega-doses of nutritional supplements, or excessive amounts of'junk' food • changes in life situation, such as change of partner, promotion, demotion, or bereavement, with accompanying shocks, grief, or changes in level of stress Only the first of these alternative causes is discussed below. Reaction due to conventional drugs It is essential in the reporting of adverse reactions to make careful note of the conventional drugs that the patient was taking at the time of the reaCtion:" . It is espeCially important to record recent changes in the type or dose of conventional medications. For example, an increase 'in ,the dose of the antidepressant drug venlafaxine hydrochloride may be accompanied by nausea, headache, insomnia, somnolence, anxiety, vomiting, hypertension, and skin rashes. 2

Caution Suitable precautions should be taken if the patient is rechallenged, and rechallenge may not be appropriate if the symptoms are severe. See the Monitoring section in the chapter on Safety in clinical practice. Is the reaction due to the herb product or to the herb itself? After a rechallenge, it may appear that the herb product is responsible for the adverse reaction. However, it may be that the reaction is due to the product rather than to the herb itself. The product may contain misidentified or substituted herb material, or it may suffer from contamination or adulteration. If the factors of misidentification, substitution, contamination, or adulteration of the product can be excluded, it may appear that the adverse reaction is due to the herb itself. It is then important to determine: • whether the herb was taken within the recommended therapeutic dose range or whether it was taken in overdose • whether the herb was taken in one of the recommended dose forms of phytotherapy, such as dried powder, infusion, decoction, tincture, or fluid extract, or whether it was taken as an essential oil or with added concentrated isolated active constituents (see the next section) • whether the herb was taken by the recommended administration methods of phytotherapy, such as orally or topically, or whether it was taken by inappropriate forms, such as injection If the herb was taken in inappropriate dose, dose form, or administration method, then the adverse reaction may not be relevant to situations in which the herb is used in an appropriate manner.

•.•. J

Safety DISTINGUISHING BETWEEN CLINICAL AND THEORETICAL ADVERSE REACTIONS It is sometimes not clear in the literature as to whether the author is referring to an adverse reaction to a herb that has actually occurred in the clinic or to the theoretical possibility of an adverse reaction. It is most important to distinguish between the two. Theoretical possibility of an adverse reaction The possession of an active constituent that in some cases may confer toxicity does not mean that a herb possessing this constituent will necessarily produce adverse reactions. Toxicological experiments may not give data that is fully relevant to humans using the herb itself when the herb is administered orally within the therapeutic dose range. This is because these experiments often: • use cell cultures or animals rather than humans • use isolated constituents rather than the herb itself • use doses far in excess of the human therapeutic dose range • use substances administered by injection rather than oral administration This topic is further discussed in individual materia medica chapters, such as those on Artemisia, Berberis, Cinchona, Lobelia, and Salvia. It is also discussed in the section

Herb-drug interactions below.

Examples of adverse reports The examples of adverse reports discussed below are used to illustrate the principles of interpretation of adverse reaction data. These reports are divided into two groups: • adverse reactions which appear to have been due to causes other than the herb itself, such as incorrect identification, adulteration, and overdose • adverse reactions which appear to have been due to the

129

prepared from what his parents thought was Tussilago farfara (coltsfoot). However, it was found that the parents had erroneously gathered Adenostyles alliariae, a plant that contains much more hepatotoxic pyrrolizidine alkaloids than Tussilago. 16 Although the boy recovered completely after 2 months, this example illustrates both the importance of correct plant identification for the patient, and the importance of verifying plant identity in adverse reaction reports. Substitution and adulteration Between 1990 and 1992, over 30 patients in Belgium developed renal failure after taking a slimming preparation which was supposed to contain Stephania tetranda (him fang ji), but in fact contained Aristolochia fangchi (guang fang ji). The renal failure may in part have been due to the potentially toxic constituent aristolochic acid present in the Aristolochia (see the discussion in Adverse reactions from the herb itselfbelow). However, on investigation it was found that the slimming preparation contained not just Aristolochia, but also conventional synthetic drugs. It was suggested that the tragedy was due to a herb-drug interaction. 17 Dose in excess of the recommended maximum Glycyrrhiza is a safe herb at the recommended daily dose for the dried herb of 3-12 g per day,lOand providing that the cautions on its use are observed (see the Glycyrrhiza chapter}. An adverse reaction to Glycyrrhiza was reported for an II-year-old boy with hypoparathyroidism and Addison's disease who developed pseudohyperaldosteronism from an excessive daily intake of 300-400 g of Glycyrrhiza. After complete withdrawal of Glycyrrhiza, all symptoms of hypermineralocorticoidism diminished and growth velocity increased. 18 This is an example of a herb that is safe within the therapeutic dose range, but not when it is taken in massive overdose. Use of concentrated forms There have been reports of adverse effects from the use of the alkaloids quinine and quinidine as isolated chemicals.2 Although the herb Cinchona contains these alkaloids, I have not seen reports of adverse reactions to the use of Cinchona as a dried herb or tincture when it is used within its recommended therapeutic dose range. The. possible reasons for lack of adverse reactions to Cinchona are discussed in the chapter on this herb.

herb itself

Note Some herbs appear in both groups.

ADVERSE REACTIONS FROM THE HERB ITSELF

ADVERSE REACTIONS FROM CAUSES OTHER THAN THE" HERB ITSELF Misidentification An IS-month-old boy developed venoocclusive liver disease after long-term consumption of a tea "

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Aristolochia fangchi This herb, guang fang jI, has been associated with cases of renal failure in Belgium between 1990 and 1992, as noted above under the heading of Sub-

stitution and adulteration.

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Combining Western Herbs and Chinese Medicine

Studies ofmedical records A recent Belgian statistical analysis of medical records between 1990 and 1992 reported that the results confrrmed that regular ingestion of Aristolochia species extracts wascausally involved in the onset of chronic interstitial nephropathy leading to end-stage renal disease. 19 However, an epidemiological study in France found a large difference between France and Belgium in the frequency of cases of nephropathy that could be associated with the intake of Aristolochia fangchi. This was despite the fact that similar preparations prescribed at the same doses were widely used in France as well as Belgium. The authors suggested that the difference in the frequency of adverse effects between the two countries might be due to an unrecognized factor that promotes the toxicity of aristolochic acid (see below) and is peculiar to the Belgian prescriptions. 20

Pharmacological studies A study on rats reported that daily, subcutaneous injections of aristolochic acid (AA) could induce chroriiC interstitial renal fibrosis. A daily dose of 10 mg/kg of AA induced interstitial fibrosis. However, it should be pointed out that this is equivalent to 600 mg of AA for a 60 kg human?l Another study reported that high doses of orally administered decoction ofAristolochia manshuriensis could induce renal failure in rats. 22

Summary The number and severity of the cases in Belgium justify the restriction of the supply of herbs with an appreciable content of AA, pending thorough investigation. However, whilst Aristolochia fangchi may have been a contributing factor in the Belgian tragedy, it has been suggested that another factor or factors potentiated the adverse effect of the AA. t7.20 It would also be valuable to determine if AA has adverse effects when it is administered orally at levels equivalent to

those in therapeutic doses of Aristolochia fangchi or an equivalent herb. The pharmacological studies noted above used amounts of AA or Aristolochia herb in excess of therapeutic levels. Teucrium chamaedrys This herb, known as germander, has been associated with liver disease in several studies. 23.24. 2S.26 In some cases, the patients recovered after discontinuing the herb preparation, and in four cases, rechallenge resulted in recurrence of liver injury or hepatitis. 23 • 24 Hepatotoxicity of Teucrium chamaedrys was demonstrated in isolated rat hepatocytes and may be due to furanoditerpenoids. II However, it was reported that a different species of Teucrium, T. stocksianum, cm have hepatoprotective effect. Pretreatment with an ethanolic extract of this herb significantly ameliorated paracetamol-induced liver damage in mice. ls

-_.:~.::.-

As discussed above, Teucrium illustrates the principle of the danger of generalizing from one species in a genus to another since they may have different spectra of active constituents. However, if one species has adverse effects linked to a specific toxic constituent and that constituent is found in another species of the same genus at similar or higher levels, this could be grounds for a temporary ban on the second species, pending full investigation. Symphytum This herb, comfrey, was one of the most widely used and respected herbs for both internal use, such as inflammation and ulceration of the stomach and intestines, and external use, such as wound healing. In recent years, the supply of Symphytum in some countries has been restricted due to the presence of toxic pyrrolizidine alkaloids (PAs). These chemicals, subsequent to their breakdown in the body to toxic pyrroles, have been associated with liver damage resulting in hepatic venoocclusive disease (VOD).

Cases with adverse reactions A review published in 1996 reported that, worldwide, there had only been four cases 27 reported of PA poisoning involving Symphytum species. These are briefly reviewed since they illustrate the difficulty of separating the herb itself from other possible causative

\i;•..•

factors when studying adverse reactions. CASE 1: This case was an example of dose in excess of the recommended maximum, which was given by the BHP as 6-12 g per day. This case was of a 47-year-old woman who drank up to 10 cups of Symphytum tea per day in addition to 'taking comfrey pills by the handful, which continued for more than a year: 28 CASE 2: This case was that of a 49-year-old woman who developed ascites subsequent to taking comfrey-pepsin tablets. 29.3o However, it is not clear to what degree the ascites was due to the Symphytum since she was also taking Mu-16 tea, which also contained PAS. 27 CASE 3:

A 14-year-old boy suffering from Crohn's dis31

ease developed VOD, which was ascribed to Symphytum. However, he was also taking prednisolone. Some drugs affect the levels of cytochrome P-450 enzyme and thus increase the levels of toxic pyrrole in the liver. 27 If this were so for prednisolone, then this case would be an example of an adverse herb-drug interaction, rather than a simple adverse herb reaction. CASE 4: The death of a young man from liver failure was ascribed to Symphytum,32 but this man was predominantly vegetarian and ate in binges of, for example, grapes or cashews lasting for days. It has been suggested that protein malnutrition may have increased his susceptibility to very 27 small amounts ofPAs.

Safety Minimizing PA content Some Syrnphytum species contain less toxic PAs than others, for example, S. officinale has lower levels of toxic PAs than S. x uplandicum, and the PA levels of S. tuberosum are lower still. Also, leaf samples have much less PAs than roots, and in addition, the use of extracts of Symphytum rather than powder greatly decreases the PA concentration. It has therefore been suggested that, if extracts of the leaves of the Symphytum species with lower PA content are used, the PA levels would be so low as to make liver damage unlikely, even with long-term use. It has also been suggested that low PA varieties of S. officinale could be developed and then propagated vegetatively by root division. 27

Risk.·benefit ratio

Considering that millions of people

worldwide have been taking Symphytum, four adverse reaction reports might be dismissed as idiosyncratic reactions. However, the concern of legislators is that PA damage to the hepatoeytes may occur without signs or symptoms until serious liver damage has occurred. Symphytum is an excellent example of different interpretations of the risk:benefit ratio of a therapeutic substance. The conventional drug acetaminophen in high doses can cause similar damage to the hepatoeytes as the toxic PAs, but the legislators are obviously of the opinion that the risk of adverse reactions is outweighed by the advantages of the drug. Herbal practitioners, on the other hand, think that the great benefits of Symphytum outweigh its very rare adverse effects, but the legislators are unaware of these benefits and therefore take only the risk factor into account in assessing the risk:benefit ratio. Herbal practitioners believe that Syrnphytum is especially appropriate in cases in which the conventional drug involves a much higher risk of adverse effects than does this herb. For example, in the treatment of arthritis in the elderly, Symphytum has less risk of adverse effects than conventional nonsteroidal anti-inflammatory drugs, which can result in

131

FDA restriction. There was already concern over the widespread inappropriate use of this herb for weight loss and as a stimulant 'recreational drug' ('herbal ecstasy'). 34 As with the case of Symphytum, the case of Ephedra illustrates several important principles. This is a potent herb with a number of potential side effects (see notes on this herb in the Additional herbs chapter). The following is therefore important: • the practitioner should be thoroughly familiar with the cautions and contraindications for the use of Ephedra • the practitioner should perform a full differential diagnosis to determine whether the patient has any syndromes for which Ephedra is either contraindicated or indicated but with special caution or at a lower dose • the practitioner should be thoroughly familiar with the therapeutic dose range of Ephedra • the practitioner should be thoroughly familiar with the herbs that can be combined with Ephedra to moderate its potential side effects In my opinion, Ephedra is a most useful herb that should remain available to qualified health practitioners and that should not be restricted to a maximum dose level at which it no longer has therapeutic effects. However, for the safety of the public and to restrain inappropriate use of this herb, it is my opinion that its supply should be restricted to qualified health practitioners, as it is in the UK under Schedule Part III of the Supply of Herbal Remedies Order 1977. If the use of this and similar herbs is not restricted to practitioners, it is likely that legislators will either ban its supply or restrict its maximum dose to a subtherapeutic level.

Herb-drug interactions

and Western herbal medicine. In my opinion, it is one of the best herbs for asthma and can also be effective for allergic rhinitis and allergic skin conditions.

One substance can be said to interact with another if it modifies the absorption, availability, metabolism, or excretion of the other substance; thus increasing or decreasing its concentration at its final reactive site. For example, one substance might modify the reaction mechanism of another by stereochemical modification of its receptor site.

In America, the FDA restricted the sale of products of Ephedra sineca (rna huang) following a case of acute hepati-

TYPES OF INTERACTION

death due to severe gastric bleeding. 2' Ephedra sineca

This is an important herb in both Chinese

tis allegedly due to the use of Ephedra. Some have suggested that Ephedra was unlikely to be the cause of the hepatitis in this case since Ephedra is not generally associated with hepatotoxicity; rather, the possibility of adulteration of the product should have been considered. 33 However, the case of hepatitis may have been only the precipitating factor in the

Interactions can be divided into four main types:

• positive:

- one substance increases the beneficial effects of another - one substance decreases the side effects of another

;;;

132

Combining Western Herbs and Chinese Medicine

• negative:

- one substance decreases the beneficial effects of another - one substance increases the side effects of another

POSITIVE INTERACTIONS Herb-herb interactions The art of herbal medicine is to combine herbs so that they increase each other's beneficial effects and decrease each other's side effects, where these exist. The theory and practice of utilizing herb-herb interactions is discussed in the chapters Principles ofherb combination and Practical herb combination. Herb-drug interactions Herbs can be said to have a positive interaction with a drug when they either: • increase the beneficial effect of the drug • reduce its side effects

Increase beneficial effects There is little information at present available on this important topic. In the future, herbs may be more widely used to increase the beneficial effects of conventional drugs, as suggested by the following research studies. CIMICIFUGA. This herb has been reported to enhance the antiproliferative effect of tamoxifen on human breast cancer cells.35 CRATAEGUS This herb has been reported to reinforce the beneficial effect of cardiac glycosides of increasing the force of heart contraction without increasing the side effects of the glycosides.6

Decrease side effects

It is already common practice in phy-

totherapy to prescribe herbs to counter the side effects of conventional medication, as shown by the following examples: REDUCTION OF INFLAMMATION Anti-inflammatory herbs, such as Althaea, Filipendula, and Glycyrrhiza can be given to reduce gastric inflammation and ulceration caused by some conventional nonsteroidal anti-inflammatory drugs. REDUCTION OF NAUSEA AND VOMITING Antiemetic herbs, such as Ballota, Mentha piperita, and Zingiber, can be given to reduce the nausea and vomiting caused by some chemotherapy medications for cancer.

NEGATIVE HERB-DRUG INTERACTIONS Please see the previous sections in this chapter:

• Necessary improvements: Reporting adverse reactions

• Improving interpretation ofadverse reaction data For each of the herbs with its own materia medica chapter in this book, available information on interactions is given in the Toxicology and Cautions sections. Distinguishing clinical adverse reactions from theoretical possibilities There is a paucity of information available on the important topic of negative herb-drug interactions, and relatively few herb-drug interactions have actually been demonstrated in the clinic. Many herb-drug interactions discussed in the literature are merely concerned about the theoretical possibility of an adverse reaction and have not been clinically demonstrated. For example, Mills and Bone presented a table of possible herb-drug interactions, but emphasized that the great majority

ofthe interactions listed in the table were only theoretical. 3 These theoretical concerns are usually raised because a herb contains constituents that may have adverse interactions with conventional drugs when they are taken as isolated

chemicals. Applicability of studies on isolated chemicals Interaction data from studies on isolated active constituents can be valuable as a guide to possible herb-drug interactions to be watched for and avoided. However, the occurrence of negative interactions using isolated constituents does not necessarily mean that these interactions will ever occur when the

herb itselfis used within the therapeutic dose range. Buffering systems in the plant When the herb itself is taken. an individual constituent may be part of a complex of buffering and moderating chemicals that may reduce the tendency of that constituent to cause side effects or herb-drug interactions. If the constituent is administered as the isolated chemical. without this buffering system, adverse reactions are more likely.

Generic interactions may not apply to herbs Sometimes statements of possible negative interactions are given in terms of generic action categories of conventional drugs. For example, it is often stated that vasoconstrictors and vasodilators may interact with antihypertensives. However, herbs with these generic action categories often have a different and more complex mechanism than their conventional equivalents. Their effect is often milder and tends to be selfbalancing. For example, Crataegus can act as a vasodilator, but it tends to h~ve a normalizing effect on the cardiovascular system and on blood pressure, depending on the initial state of the patient (see the Crataegus chapter). It is therefore less likely than a conventional vasodilator to have adverse effects by potentiating an antihypertensive drug.

."",

Safety EXAMPLES OF REPORTS OF NEGATIVE HERB-DRUG INTERACTIONS Angelica sinensis There has been one report of the potentiation of warfarin, but see the Cardiovascular system section in the next chapter. Capsicum A rat study reported that orally administered doses of Capsicum annuum extract of 100 or 300 mg/kg per day for 4 weeks reduced salicylate bioavailability after oral administration of aspirin. 36 However, this is equivalent to 6-18 g of Capsicum extract for a 60 kg human, in contrast to the daily dose of 90-360 mg per day of dried Capsicum recommended by the BHP.

'.~-

Cinchona One or both of the Cinchona constituents quinine or quinidine may have adverse interactions with other antiarrhythmics (especially cardioactive glycosides), ~-blockers, antihistamines, anticoagulants, and drugs to treat ulcers (see the Cinchona chapter). I have not seen research evidence that these drug interactions occur when using therapeutic doses of Cinchona bark. However, it is prudent to use caution. Also, in my opinion, the supply of Cinchona should be limited to health practitioners, as it is in the UK. Convallaria There is evidence that cardiac glycosides may have adverse interactions with a number of other drugs, including ACE (acetylcholinesterase) inhibitors, antiarrhythmic agents, anthranoid laxatives, antiepileptics, antifungals, antimalarials, calcium channel blockers, diuretics, muscle rela.xants, and nonsteroidal anti-inflammatories. 2 Convallaria contains cardioactive glycosides, but 1 have not found any adverse drug interaction data for Convallaria as a herb when it is used within its therapeutic dose. In fact, one study on the treatment of the aging heart reported a positive interaction. The authors reported an increased tolerance of digitalis glycosides through combined treatment with Convallaria glycosides. 37 However, it is prudent to use caution. In the UK, the supply of Convallaria is limited to health practitioners (see the chapter on this herb). Glycyrrhiza The following herb-drug interaction data has been reported for Glycyrrhiza.

Prednisolone It has been reported that Glycyrrhiza can increase plasma levels of prednisolone by inhibiting the metabolism of this drug by the enzyme 11 ~-hydroxysteroid dehydrogenase.38.39.40 Glycyrrhiza may thus potentiate the negative effects of prednisolone, such as hypokalemia, edema, and hypertension. However, Glycyrrhiza has also been reported to potentiate the positive effects of corticosteroids

133

and to reduce some of their adverse effects (see the Glycyrrhiza chapter). Cases of hypokalemia hav~ been reported in patients taking Glycyrrhiza preparations while taking thiazide diuretics. In two of these cases, the patient was taking overdose levels of Glycyrrhiza: In one case, the patient was taking 200 g of licorice per day,4\ and in the other report, the patient was taking 3 liters of licorice tea per day.42 It would be prudent to use caution in prescribing Glycyrrhiza whilst patients are taking prednisolone or thiazide diuretics (see the Glycyrrhiza chapter).

Thiazide diuretics

Hypericum There have been reports of herb-drug interactions involving Hypericum perforatum. It has ~een suggested that Hypericum may influence cytochrome P-450 (CYP) enzymes, especially CYP3A4, thus affecting the metabolism of certain drugs. This subject has recently been reviewed. 43 However, the authors of the review point out that the evidence of CYP induction or inhibition by Hypericum is conflicting. For example, it has been reported that the naphthodianthrone constituents of Hypericum, hypericin and pseudohypericin, may induce CYP3A4. However, another Hypericum constituent, the flavonoid quercetin, has been reported to inhibit CYP3A4. The authors of the review suggest that the synergistic effect of the combined constituents in the whole plant extract may have a balancing effect on CYP enzymes. The review assessed evidence for reported interaction of Hypericum with the following conventional drugs: • HIV protease inhibitors • HIV non-nucleoside reverse transcriptase inhibitors • warfarin • cyclosporin • oral contraceptives • anticonvulsants • digoxin • theophylline" • selective serotonin re-uptake inhibitors • triptans • benzodiazepines The review gave a useful checklist for practitioners, including screening and monitoring procedures, and cautions and contraindications for Hypericum when the patient is concurrently taking conventional drugs. Panax ginseng The following herb-drug interaction data has been reported for P. ginseng.

Digoxin One review mentioned that ginseng can interact with digoxin."'" However, the only research report that 1 have

134

Combining Western Herbs and Chinese iVIedicine

seen was a study in which 45 patients with class IV cardiac function were divided into three groups: digoxin. ginseng. and digoxin + ginseng. The greatest improvement was seen in the third group. and the authors concluded that ginseng and digoxin had a synergy for the treatment of congestive heart failure. and that ginseng was an effective and safe adjuvant. 45

Phenelzine One review listed an interaction between Panax and phenelzine.4-I However. my search of the Internet PubMed website did not find any research studies that demonstrated this interaction. Warfarin One report claimed that there is an interaction. and another report stated that there is not (see the Cardiovascular system section in the next chapter). Potentilla This herb contains tannins. It has been reported that tannins can reduce the absorption of thiamine and iron (see the Toxicology section in the chapter on Potentilla). but I have not seen any reports of adverse herb-drug interactions for Potentilla. However, it would be prudent to use caution in prescribing Potentilla. or other herbs with a high tannin content. for patients who are deficient in iron or thiamine. or who have reduced intestinal absorptive function. . Rheum According to the ESCOP monograph on Rheum. long-term laxative abuse can result in hypokalemia. which may potentiate the action of cardiac glycosides (see the Rheum chapter). However, I have not seen evidence that Rheum can cause hypokalemia or that it has negative herbdrug interactions when it is used within its therapeutic dose range. Salvia miltiorrhiza There are reports that this herb can potentiate the anticoagulant effects of warfarin (see the Cardiovascular system section in the next chapter). Sarothamnus This herb contains the amine tyramine. Concurrent ingestion of tyramine and MAO inhibitors can result in hypertension. I have not seen research evidence that Sarothamnus preparations can have adverse interactions with MAO inhibitors or indeed with any other drug. However. it would be prudent to exercise caution with concomitant administration of Sarothamnus and MAO inhibitors. Zingiber There has been concern that Zingiber may aggravate bleeding problems in humans (see the Zingiber chapter). However. according to one recent review of the literature. there is no evidence that Zingiber has an interaction with warfarin. 46 According to a recent rat study. Zingiber had no effect on warfarin-induced changes on blood coagulation. and the authors concluded that Zingiber is pharmacologically safe in this respect. 47

Regulation ofherb use In the last 50 years there has been increasing concern over the safety of herbal medicine. This has led to an increase in legislation regulating or restricting the supply of . herbs to the public. This in turn caused concern amongst those of the public that use herbal remedies and amongst herbal practitioners because they fear that the availability of herbs will become increasingly limited. Regulatory authorities decide whether to restrict the availability of a herb product largely on the basis of their perceptions of its risk:benefit ratio. Many herbalists believe that past restrictions have often been made on the basis of distorted perceptions of this ratio. They believe that regulatory authorities tend to exaggerate the risks and ignore the benefits.

THE NEED FOR COOPERATION Both the herbal profession and government regulators are working for the benefit and safety of the public. Each have specific responsibilities in what can be a cooperative effort. Responsibility of the herbal profession As discussed earlier in this chapter. it is the responsibility of herb product manufacturers and of herbal practitioners to make the nec- _. essary safety improvements in order to reduce the risk of adverse reactions. It is also their responsibility to make available to the regulatory authorities increased numbers of reputable research studies that demonstrate the benefits of individual herbs used. Responsibility of the regulatory authorities As discussed earlier in this chapter, it is the responsibility of the regulating agencies to make the necessary improvements in their interpretation of adverse reaction data. It is also their responsibility to study the available data on herb benefits more thoroughly and with a more open mind than they have done in the past. They can then make more objective assessments of risk:benefit ratios. If they are not seen by the public as acting ._ fairly in considering these ratios, the public may lose trust in the regulating bodies.

NATIONAL REGULATORY STATUS This section deals with existing regulations governing the availability ofherbs at a natlon311evel in Australia, the United Kingdom. and the United States.

Regulations governing the availability of a specific herb -

Safety may change at any time, and it is the responsibility of the individual practitioner to be aware of the regulations in their particular country.

complex and confusing. Five main groups of regulations are summarized below:

Australia Herbal medicines are governed by federal law (Therapeutic Goods Act and Regulations) and State and Territories legislation (Standard for the Uniform Scheduling of Drugs and Poisons). Part 4 of Schedule 4 of the Therapeutic Goods Act and Regulations lists herbs that are considered relatively more toxic. These herbs are not restricted to practitioners only, but they can only be included in OTC sales after prior evaluation and approval by the Complementary Medicines Evaluation Committee; this may be refused on grounds of safety.

• Dietary Supplements Health and Education Act 1994 (DSHEA)

Herbs in this book The only herbs included in combinations in this book that are listed in Part 4 of Schedule 4 are Phytolacca decandra and Mentha pulegium.

Information The relevant website is: http://www.health.gov.au/tga/

United Kingdom Herbal medicines are governed by the Medicines Act of 1968 and subsequent supplementary legislation to this act, such as:

• Substances that are generally recognized as safe (GRAS)

• Dietary Supplements Associated with Illness and Injuries (by the FDA) • Current Import Alerts (FDA) • Prohibited Substances (FDA)

GRAS Until 1994, the Food and Drug Administration (FDA) regulated dietary supplements (including herb materials) as foods. The term GRAS was used by the FDA to refer to foods generally recognized as safe fOf human consumption. However, GRAS status is linked to intended use. For example, rosemary is on the FDA list Spices and other natural seasonings and flavorings. This means that the FDA confers GRAS status on rosemary when it is used as a spice, but does not necessarily confer GRAS status if it is usedfor another purpose, such as a herbal medicine. Therefore, herbs are not described in terms of GRAS status in this book since their intended use is clearly therapeutic.

• The Medicines (General Sale List) No. 2129

DSHEA By the Dietary Supplements Health and Educa-

• The Medicines (Supply of Herbal Remedies) Order 1977 No. 2130

tion Act of 1994, separate provisions were made for the supply of dietary supplements. However, there is a distinction made between dietary supplements and drugs, which are regulated by the FDA. A dietary supplement cannot be claimed to 'diagnose, treat, cure, or prevent any disease.' Such a claim would be illegal under FDA regulations. There is no list of substances recognized as dietary supplements under the 1994 Act. Therefore, this book cannot describe herbs as 'listed as a recognized DSHEA dietary supplement?

General Sale List Herbs on this list are those available for general sale.

Supply of Herbal Remedies Schedule Part III of the'Medicines (Supply of Herbal Remedies) Order 1977 governs the supply by the herbal practitioner of herbal remedies to patients subsequent to a consultation, as defined in the schedule. Herbs in schedule Part III have maximum dose restrictions when supplied by a herbal practitioner and are not available for OTC sale. L--

135

Dietary Supplements Associated with Illness and Injuries This FDA list includes: • Ephedra species

mahuang

• Larrea tridentata

chaparral

• Lobelia inflata

lobelia

• Magnolia species

magnolia

• Pausinystalia yohimbe

yohimbe

• Salix species

willow bark

Information The New Herbal Practitioner (volume 4, num- , ber 3 of April 1978) contains the article Herbal Practitioner's Guide to the Medicines Act 1968 by Fletcher Hyde.48

• Species uncertain

'jin bu huan' *

• Stephania species

stephania

• Symphytum species

comfrey

United States In the United States, the regulations governing the supply of substances used in herbal therapy are both

• Teucrium species

germander

Herbs in this book The herbs included in combinations in this book that are listed in Schedule Part III are Chelidonium, Cinchona, Convallaria, Ephedra, and Lobelia. Cinchona, Convallaria, and Lobelia have their own materia medica chapters, and Chelidonium and Ephedra are discussed in the Additional herbs chapter.

*tones unknown

Combining Western Herbs and Chinese Medicine

136

Except in the case of Symphytum, which the FDA has advised manufacturers to remove from the market, this list does not represent an official FDA fmding that these substances are unsafe or that they are restricted in use by the FDA. The presence of a substance on this list indicates that the FDA has concerns about its safety and that a firm markets the substance at its own risk.

10. British Herbal Pharmacopoeia. British Herbal Medicine Association._._=-~ West Yorks, United Kingdom (1983) : : :..;.;;;; "-....

11. Lekehal M. Pessayre D. Lereau JM. et al. Hepatology 24(1):212-218

~.

-......

(1996) ._- .~;... c.'

12. De Smet PAGM.Ned T Geneeskd 138:2516-2517 (1994)

13~ Blumenthal M (ed)~ The Complete German Commission E '.~.7'".~: :__~\ Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council. Austin, Texas (1998)

Current Import Alerts (FDA) The herbal materials on the

14. Treasure J. Eur J HerbMed 5(1):38-43 (2000)

current FDA Import Alert list (which means that these substances may be 'detained') are:

15. Rasheed RA. Ali BH, Bashir AK. General Pharmacol 26(2):297-301 (1995) 16. Sperl W, Stuppner H, Gassner 1, et al. Eur J Pediatrics 154(2):112-116

• plantain because of contamination with Digitalis • any herbal material containing aristolochic acid

Prohibited Substances (FDA)

The following herbal materi-

als are on the current FDA list Substances prohibited from use in food: calamus (Acorus calamus), coumarin (in tonka beans), safrole (in sassafras). SummaryPractitioneis' of herbal therapy in the United States should avoid the use of herbs on the FDA 'Prohibited substances' or 'Import alert' lists. The FDA has advised manufacturers to remove Symphytum species from the market. It is advisable to use caution when prescribing herbs that are on the FDA list of Dietary Supplements Associated with Illness and Injuries, and practitioners are advised to read the information given by the FDA on these herbs: However, since the FDA does not give references to research reports to substantiate its warnings, practitioners may wish to investigate the research evidence themselves.

Information The FDA website is:

(1995) 17. Violon c.J Pharmaceutique Belge 52(1):7-27 (1997) 18. Doeker BM,Andler W. Horm Res 52(5):253-255 (1999) 19. Martinez MC, Nortier J, Vereerstraeten P, Vanherweghem

JL. Nephrol

Dial Transplant 17(3):408-412 (2002) 20. Stengel B. Jones E. Nephrologie 19(1):15-20 (1998) 21. Debelle FD. Nortier]I., De Prez EG. et al. J Am Soc Nephrol13(2):4~1: .......~~ 436 (2002) .. :...:..;;-~.. 22. Qiu Q, Liu ZH. Chen HP, et al. Acta Pharmacol Sin 21(12):1129-1135 (2000) 23. Pauwels A, Thierman-Duffaud D, Azanowsky JM. et al. Gastroenterol Clin Bioi 16(1):92-95 (1992) 24. Larrey D. Vial T, Pauwels A et al. Ann Intern Med 117(2):129-132 (1992) 25. Mostefa-Kara N, PauwelsA. Pines E,et al. Lancet 340(8820):674 (1992) 26. Loeper J, Descatoire V, Letteron p. et al. Gastroenterology 106(2):464472 (1994) 27. DenhamA.Eur J Herb Med 2(3):27-38 (1996) 28. Bach N. Thung SN.Schaffner EAm J Med 87(1):97-99 (1989) 29. Ridker PM. Ohkuma S. McDermott WV, et al. Gastroenterol 88(4):1050-1054 (1985)

http://www.fda.gov/

30. Huxtable RJ. Luthy J. Zweifel U. New England J Med 315(17):1095 (1986)

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31. Weston CFM et al. BMJ 295:183 (1987) 32. Yeong ML. Swinburn B. Kennedy M, et al. J Gastroenterol Hepatol 5(2):211-214 (1990)

1. Tierra M. Eur J Herb Med 3(1):3 (1997)

33. Nadir A. Agrawal S. King PD, et al. Am J Gastroenterol 91(7):1436-

2. Reynolds EFJ (ed). Martindale: The Extra Pharmacopoeia, 31st edn. Royal Pharmaceutical Society. London, United Kingdom (1996)

34. Bruneton J. Pharmacognosy: Phytochemistry Medicinal Plants. 2nd

3. Mills S. Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone. Edinburgh. United Kingdom (2000) 4. Ernst F-D. Reuther G. Walper A. Munch Med Wochenschr 136(Suppl 1):S57-S59 (1994) 5. Joseph G.Zhao Y.Klaus W.Arzneim Fersch 45(12):1261-1265 (1995) 6. Trunzler G. Schuler E. Arzneim Forsch 17:198-202 (1962) 7. Panijel M. Therapiewoche 35(41):4659-4668 (1985) 8. Gerhard U. Linnenbrink N, Georghiadou C, et al. Schweiz Rundsch Med Prax 85( 15):473-481 (1996) 9. Wagner H, Bauer R. Xiao Pei-gen. et al. Chinese Drug Monographs and Analysis: Radix Astragali (Huang Qi) vol. 1(8). Verlag fur Ganzheitliche Medizin. Klitzting, Germany (1997)

1438 (1996) edn. Lavoisier. Paris, France (1999) 35. Bodinet C, Freudenstein J. Breast Cancer Res Treat 76(1): 1-10 (2002) 36. Cruz L. Castaneda-Hernandez G. Navarrete A. Can J Physiol Pharmacol77(6):441-446 (1999) 37. Meixner HK. Dobler S. ZAllgemeinmed 51(10):501-512 (1975) 38. Chen MF, Shimada F, Kato H. et al. Endocrinol Jpn 37(3):331-341 (1990) 39. Chen MF, Shimada F. Kato H. et al. Endocrinol Jpn 38(2):167-174 (1991)

., ...:......,:.

40. Homma M, Oka K. N"titsuma T, et al. J Pharm PharmacoI46(4):305309 (1994) 41. Folkerson 1, Knudsen NA, Teglbjaerg PS. Ugeskr Laeger 158(51):74207421 (1996)

Safety 42. Brouwers AI, van der Keulen 747 (2001)

J. Ned Tijdschr Geneeskd 145(15):744-

137 15(6):325-327 (1995) 46. Vaes LP,Chyka PA.Ann Pharmacother 34(12):1478-1482 (2000)

43. Broughton A, Denham A. Eur I Herb Med 5(2):19-26 (2000)

47. Weider MS,Sigwart K. J EthnopharmacoI73(3):513-520 (2000)

44. Bonie! T, Dannon P. Harefuah.140(8):780-783,805 (2001)

48. Hyde F. Herbal Practitioner's Guide to the Medicines Act 1968 New Herbal Practitioner 4(3) (1978)

45. Ding DZ, Shen TK, Cui yz. Zhongguo Zhong Xi Yi lie He Za Zhi

-_.:"';§

-",....-~

.~~.,

-:-~-+~-,

"'::-=~

:

-

Safety and the organ systems contains examples of adverse herb reactions that have actually occurred, and that illustrate the problems in interpreting adverse reaction data. This chapter gives examples of adverse herb reactions for each of the main organ systems. It includes both reports of adverse herb reactions that have actually occurred, and theoretical concerns over potential adverse herb reactions, although these may never have been reported clinically for

BALANCING TEMPERATURE, TASTE,

the specific herb. This chapter brings together information on actual or potential adverse herb reactions from two main sources:

SCREENING BY CHINESE ORGAN

T

HE PREVIOUS CHAPTER

AND ACTIONS Balancing herb combinations to maximize safety and using moderating herbs to minimize side effects is discussed in the following chapters: Temperature, Taste, Actions, and

Practical herb combination.

SYNDROMES Both the patient's disorders and the potential side effects of herbs can be classified in terms of the Chinese organ syndromes. Then, if the patient has a specific syndrome, for

• modern research: reports from both clinical and pharmacological studies

• Chinese herbal medicine: traditional cautions and

example, Heart Spirit Disturbance, herbs that may aggravate this syndrome can be avoided or used with caution.

contraindications

The advantage of the Chinese paradigm is that each organ syndrome can encompass not only physical, but also emotional and mental manifestations. For example, the syn-

Chinese contribution to herb safety

drome of Heart Spirit Disturbance can include physical heart arrhythmias, emotional overexcitement, and poor mental concentration.

Chinese medicine has made great contributions to the

Herbs that may increase Heart Spirit Disturbance, for example, Ephedra or Panax ginseng, may aggravate one or more of these potential physical, emotional, or mental manifestations. Knowledge of a herb's potential side effects in

safe use of herbs especially in two areas: • minimizing adverse reactions by carefully balancing temperature, taste, and actions

terms of Chinese medicine can thus form an additional screening process to ensure herbal safety.

• minimizing adverse reactions related to specific Chinese · organ syndromes

139

140

Combining Western Herbs and Chinese Medicine

CHINESE SYNDROME SUMMARY TABLE The following table gives examples of herbs that may aggravate or induce the Chinese organ syndromes listed. These herbs should therefore be avoided or used with caution when the patient has a tendency to the syndrome listed.

Respiratory system WESTERN DATA 1have not seen reports of negative effects of herbs on the respiratory system when the herbs are used within the therapeutic dose range as orally administered infusions, decoctions, or tinctures.

• Lung Lung Deficient Qi

Ephedra

CHINESE MEDICINE

Lung Phlegm and Damp

Glycyrrhiza Lycium Ophiopogon Ziziphus

The main cautions and contraindications come under the syndromes of:

Lung Dryness

Angelica arc.

• Spleen/Stomach Deficient Spleen with loose stools

Rheum Taraxacum

Deficient Spleen + Cold

Baptisia Hydrastis Pulsatilla chinensis Sanguisorba

Deficient Spleen + Damp

Avena Glycyrrhiza Lycium Ophiopogon Pseudostellaria Ziziphus

Stomach Rebellious Qi

Lobelia

Stomach Heat

capsicum Cinnamomum

• Liver/Gallbladder Liver Hyperactive Yang

Liver Deficient Qi + Liver Stagnant Qi

Astragalus Cimicifuga Ephedra Panax gin. Rumex Taraxacum Arctium

• Heart Heart Heat

Cinnamomum Panax gin.

Heart Spirit Disturbance

Ephedra Panax ginseng Rosmarinus

Heart Stagnant Qi

• Lung Deficient Qi • Lung Phlegm • Lung Dryness Lung Deficient Qi Herbs that strongly disperse Lung Qi, such as Eph~dra, are to be avoided or used with caution for patients with Lung Deficient Qi and Deficient Defensive Qi. This is especially so if there is profuse sweating or if the herbs are used in high doses or for long periods of time. This is because such herbs may dissipate and further weaken the Qi. Lung Phlegm Although not specifically contraindicated in some Chinese medicine texts, 1 generally avoid the use of moist, sweet tonics, such as Ophiopogon and Ziziphus, for patterns of Lung Phlegm involving accumulation of Damp and Phlegm linked to Spleen Stagnation. The use of such herbs may increase the amount of mucus secreted by the mucus membranes and hinder the dispersing function of the Lung. Lung Dryness Angelica dahurica (bai zhl) is contraindicated in Chinese medicine for cases with Yin Deficiency because it is very drying. In cases of Lung Deficient Yin with Lung Dryness, I use caution when using the warming, drying anticatarrhal herbs such as Angelica archangelica. Too much of such herbs can result in dryness and soreness of the respiratory mucous membranes.

Gastrointestinal system

Panax gin.

• Kidney Deficient Kidney Yin + Heat

Cinnamomum Ephedra Panax gin. SChisandra

Deficient Kidney Yang

Ephedra Piscidia

Negative gastrointestinal reactions are perhaps the most -common side effects for herbal products taken orally. They may include indigestion, burning sensation in the epigastrium, nausea or even vomiting, abdominal distension and pain, and diarrhea or constipation. The majority of these negative reactions can be avoided by the following measures:

Safety and the organ systems • using caution with herbs that can disturb the digestive system, such as circulatory stimulants and laxatives • using moderating herbs to minimize potentially negative effects of the primary herbs • using caution with patients with weak or sensitive digestive systems • starting with the minimum dose of the herbs and slowly increasing the dose

WESTERN DATA Tannin-containing herbs It has been reported that preparations of isolated tannins may inhibit digestive enzymes, reduce the absorption of iron and thiamine, produce gastrointestinal irritation, and cause constipation. However, other studies have reported that tannins have antiulcer action (see the Potentilla chapter). It is advisable to avoid the prolonged use of high doses of herbs with a high tannin content, especially in patients with a tendency toward digestive weakness, gastrointestinal irritability, or constipation. Bitter digestive tonics Some texts contraindicate the bitter digestive tonic herbs Gentiana and Centaurium for peptic ulcer and hyperacidity. However, there is evidence that in some circumstances, these herbs can reduce, rather than increase, gastric ulceration (see the Gentiana chapter). If gastric ulceration is associated with gastric hypersecretion, it may be advisable to use strongly bitter herbs with caution. Use of emetics and cathartics

Past use In the past, emesis and catharsis were popular therapeutic methods, and certain herbs were prized for their powerful emetic or cathartic action. Nowadays, the techniques of emesis and catharsis are rarely used in the West. It is interesting that what was seen by one generation as valued therapeutic effects should be seen by the next generation as adverse reactions.

Potential emetic effects Some expectorant herbs in current use, for example, Lobelia and Sanguinaria, may have an emetic effect at high doses. It is therefore advisable to start at the lower end of the standard dose range for the desired expectorant action. This will reduce the likelihood of nausea in sensitive patiel1ts~ Potential cathartic effects The cautions and contraindications to be used with purgative herbs are described in the chapter on Rheum.

141

CHINESE MEDICINE The main cautions and contraindications come under the syndromes of: • Deficient Spleen with Cold • Deficient Spleen with Damp and Stagnation • Stomach and Intestines Heat In addition, herbs with potential purgative effects, such as Rheum, should be used with caution for patients with Deficient Spleen Qi with a tendeqcy to loose stools. Herbs with potential emetic effects at high doses, such as Lobelia, should be used with caution for patients with Stomach Rebellious Qi and a tendency to nausea. Deficient Spleen with Cold Herbs that are cold or even cool should be used with caution in cases of Deficiency and Cold in the Spleen, Stomach, and Intestines. In some cases, this may be related to their strong antimicrobial action, which has the negative effect of destroying beneficial gut bacteria. This may be the case for Pulsatilla chinensis (bai tou weng) and Baptisia. In other cases, it may be due to the downward-draining (laxative) action of the herb, for example, in the case of Taraxacum mongolicum (pu gong ying) and T. officinale. Deficient Spleen with Damp and Stagnation Herbs with the sweet taste property, especially those with a known moistening effect, should be used with caution if the patient has a Deficient Spleen with a tendency to Stagnation and Damp. High doses of these herbs may aggravate these syndromes and their accompanying symptoms. For example, Ophiopogon and Ziziphus may aggravate signs like lethargy, obesity, and chronic nasopharyngeal catarrh. Stomach Heat Herbs that are hot or even warm in temperature should be used with caution in patients who have Heat in the Stomach or Intestines. Generally, herbs, such as Capsicum or even Zingiber and Cinnamomum, should be avoided or should be used with caution if there are such symptoms as burning sensations and pain in the epigastrium, or the patient has a history of diarrhea with burning sensation on defecation (see the chapters on these herbs).

Hepatobiliary system WESTERN DATA: HEPATOTOXICITY One of the greatest areas of concern in the discussion of herbal safety is that of hepatotoxicity, especially if the toxicity is asymptomatic until the point when the liver damage is serious and irreversible.

.."" 142

Combining Western Herbs and Chinese Medicine

Herbs in general There has been concern that herbs in general are a likely cause of hepatotoxicity. This subject has been reviewed by McLeod et al.,1 who published a preliminary report of a clinical trial to determine if the use of herb products could contribute to hepatotoxicity. Statistical analysis was performed on the results ofliver tests on 81 patients takiDg herbal medicine. The conclusion was that the use of herbal medicine in the clinic is unlikely to cause significant and consistent elevation of serum enzymes or to cause hepatotoxicity. Chinese herbs for skin disorders There have been reports of hepatotoxicity following herbal treatment for skin disorders with Chinese herb combinations.!.J·4 In three cases, after discontinuing the herbs, liver function returned to normal. 2•4 Due to the variation in the herb content of the formulas, no one herb could be implicated, the reactions were not apparently dose-related, and it was suggested that the reactions were idiosYncrati~? ' Tannin-containing herbs There have been reports of acute hepatotoxicity associated with the past use of barium enemas containing tannic acid as a result of the absorption of large amounts of tannic acid directly into the bloodstream from the colon. These adverse effects occurred using tannic acid as an isolated chemical, and it has been stated that such effects are highly unlikely when using tannin-containing herbs. s It is prudent to avoid the long-term use of herbs with a high tannin content. However, in perspective, it should be noted that the daily intake of tea in countries such as Britain results in a far higher tannin intake than any recommended dose of tannin-containing herb (see the Potentilla chapter). Herbs containing pyrrolizidine alkaloids Potential hepatotoxicity associated with plants containing toxic pyrroIizidine alkaloids has been recently reviewed,1.6.7 and the specific case of Symphytum is discussed in the section Examples of adverse reports in the previous chapter. Teucriurn chamaedrys The potential hepatotoxicity of this lerb is discussed in the section Examples of adverse reports n the previous chapter. arrea tridentata. There have been reports of hepatotoxicy associated with tbe;irigestion' ~f Larrea tridentata (chapTal). The American Herbal Products Association reviewed lur of these·cases.. ni~y proposed that the report~d toxicity as due to idiosyncratic reactions in persons with preexist19 liver conditions. 7 In perspective, it has been noted that ver 200 tons of Larrea were consumed over 20 years in the SA,s yet only a few cases of liver damage were reported.1

There have been more recent reports associating the use" of 1. tridentata with hepatotoxicity, usually characterized by cholestatic hepatitis. 9.10 However, a retrospective clinical study published in 2001 did not report signs of liver damage from the use of Larrea and proposed that relatively small intakes of Larrea tincture are safe when it is prescribed by a trained botanical practitioner. ll The authors recommended that Larrea should be used with caution in patients with a history of liver disease.

1_"

In perspective As pointed out in three reviews, 1.6.7 the reports of hepatotoxicity associated with herbs, such as Larrea and Syrnphyturn, are very rare considering the enormous amounts of these herbs that have been consumed in the past. However, all three reviews recommend caution in the use of the herbs. As noted by Denham,6 many conventional medications can have hepatotoxic effects at high doses but remain on the market. The topic of perceived risk:benefit ratio is discussed in the previous chapter in the section Examples of adverse reports under Symphytum.

~~,

,

Practitioner precautions Safety considerations for the use of herbs for patients with impaired liver function is discussed in the next chapter, Safety in clinical practice.

CHINESE MEDICINE The main cautions and contraindications corne under the syndromes of: • Liver Hyperactive Yang • Liver Deficient Qi with Liver Stagnant Qi Liver Hyperactive Yang This pattern may have various manifestations, including high blood pressure, dizziness, headache, irritability, impatience, and mental restlessness. Any herb, for example, Ephedra or Panax ginseng, that can aggravate Liver Hyperactive Yang may aggravate one or all of the symptoms, and should be avoided or used with caution if the patient tends to experience these symptoms. I also recommend caution when using Astragalus or Cimicifuga species in the case of patients with Liver Hyperactive Yang since these herbs can have the action of raising the Qi (see the Cimicifuga chapter). Liver Deficient Qi with Liver Stagnant Qi I have not seen examples of herbs that are contraindicated for this combination of syndiomes in texts on Chinese medicine. However, in my opinion, there are two main situations in which herbs should be used with caution when the patient has the syndromes of Liver Deficient Qi and Liver Stagnant Qi. Firstly, if there is a history of poor liver function, there

.

'~

~"

-

--Safety and the organ systems may be reduced tolerance to herbal medicine. Whilst herbs may slowly improve liver function, it is wise to initially use low, or even very low, doses of herbs. Secondly, if alterative herbs, such as Taraxacum and Rumex, are used in high doses, toxins may be released from the tissues at a greater rate than can be metabolized and detoxified by the weakened liver. This may result in negative reactions such as the aggravation of inflammatory conditions. The use of herbs in these situations is discussed in the next chapter, Safety in clinical practice.

Cardiovascular system WESTERN DATA It may be necessary to use certain herbs with caution in

the case of patients taking anticoagulant medication Or patients with hypertension or cardiac arrhythmias.

143

Hypertension Of the herbs discussed in this book, there have been suggestions that the following may aggravate or induce hypertension: Ephedra, Glycyrrhiza, Hydrastis, Panax ginseng, and Sarothamnus.

Ephedra A review of 140 adverse effect reports for Ephedra showed that hypertension was the single most frequent adverse effect.16 This herb is generally to be avoided in cases of hypertension (see the Additional herbs chapter).

Glycyrrhiza Research reports indicate that high doses of Glycyrrhiza may result in hypertension (see the Glycyrrhiza chapter). This herb is therefore contraindicated in high doses for moderate hypertension and even in low doses for patients with severe hypertension.

Hydrastis The BHp 17 recommended avoiding the use of this herb in hypertension, but there does not appear to be any research evidence to support this suggestion (see the Berberis and Hydrastis chapter).

Panax ginseng Higher doses of this herb have been reportAnticoagulant effects Of the herbs discussed in this book, there have been suggestions that the following herbs may potentiate the anticoagulant effect of warfarin: Angelica sinensis, Panax ginseng, Salvia miltiorrhiza, and Zingiber.

ed to cause hypertension. IS This is especially the case at excessive doses, when taken over long periods, and in susceptible persons (see the Additional herbs chapter).

Angelica sinensis I have seen only one research report that

cation for this herb, 17.I~ut I have not seen any research data to substantiate this claim (see the Sarothamnus chapter).

indicated that this herb may potentiate the anticoagulant action of warfarin. 12 In this study, rabbits received 4 glkg of orally administered A. sinensis extract per day. This is equivalent to 240 g per day for a 60 kg human and is far in excess of the therapeutic dose. L:.•.

Panax ginseng A recent review of the literature 13 mentioned one case report associating ginseng use with decreased warfarin anticoagulation effect. However, an in vivo rat study reported that there was no significant impact of ginseng on the pharmacokinetics or pharmacodynamics of 14 warfarin when they were concomitantly administered.

Salvia miltiorrhiza Reports of possible interaction between this herb and the anticoagulant drug warfarin were reviewed by Chan in 2001. 15 It was concluded that this herb can enhance the anticoagulant effect of warfarin and should be avoided by patients who are taking this drug.

Zingiber As discussed in the Zingiber chapter, this herb may have different effects on platelet aggregation, depending on the situation. According to one review, Zingiber has not been reported to result in 'bleeding problems in humans. However, the authors· recommend that daily doses of this herb exceeding 4 g should be used with caution for patients with increased risk of hemorrhage or who are taking bloodthinning drugs, such as aspirin or warfarin. 5

Sarothamnus Hypertension has been listed as a contraindi-

Cardiac arrhythmia

Cinchona, Convallaria, and Sarothamnus There have been theoretical concerns that these herbs, which can be used to treat cardiac arrhythmia, may, in certain circumstances, aggravate this disorder. Isolated constituents from these herbs, such as quinine from Cinchona or sparteine from Sarothamnus, may aggravate cardiac arrhythmias or have the potential for adverse . herb-drug interactions. However, these adverse effects were observed when the isolated constituents were administered at levels greatly in excess of those found in therapeutic doses of the herb (see the Cinchona and Sarothamnus chapters). I have not seen any research reports of adverse effects when these herbs are administered orally as infusion, decoction, or tincture within the therapeutic dose range. Nor have I seen reports of herb-drug interactions for these herbs resulting in cardiac arrhythmias (see the materia medica chapters of these herbs). However, in my. opinion, these herbs should be used with caution, and it might be advisable to restrict their supply to health practitioners specifically trained in herbal medicine.

Ephedra This herb has been associated with adverse effects, including palpitations and tachycardia,16 and is generally to

Combining Western Herbs and Chinese Medicine

144

be avoided in cases of hypertension (see the Additional herbs

Aristolochia

chapter).

NEPHROTOXICITY The potential nephrotoxicity of Aristolochia is discussed in the section Examples ofadverse reports

CHINESE MEDICINE

in the previous chapter.

Chinese contraindications for cardiovascular disorders mainly relate to cardiac arrhythmia and hypertension when these disorders are associated with Heart Spirit Disturbance and Liver Hyperactive Yang. Therefore, herbs, for example, Ephedra and Panax ginseng. that may aggravate or induce these syndromes should generally be avoided. In high doses and in susceptible persons, Glycyrrhiza may cause hypertension. In Chinese medicine, Glycyrrhiza is contraindicated in cases of Excessive Damp, and since Damp is one possible cause of hypertension, this might explain the hypertensive effect of this herb. However, it is also possible that Glycyrrhiza may aggravate hypertension by overstimulating Kidney Qi.

Urinary system

CARCINOMA A recent review of the literature reported evidence that aristolochic acid (AA) can have carcinogenic effects in both animals and humans. The authors recomH mended a ban on botanicals containing AA. However, it would be valuable to determine whether AA has carcinogenic effects at dose levels equivalent to those in AAcontaining herbs, such as Aristolochia.

CHINESE MEDICINE I have not seen specific cautions and contraindications for Kidney-Bladder patterns involving urinary disorders in texts on Chinese medicine. However, I would not generally use herbs that warm the Interior and tonify Kidney Yang in cases of urinary disorders for patients with patterns of Excess Heat, Deficiency Heat, or Damp Heat. Such herbs include Cinnamomum bark and Panax ginseng.

WESTERN DATA Individual herbs

Reproductive system

Juniperus There has been one report suggesting that Juniperus berries may cause renal irritation,20 but this has not yet been clearly demonstrated by research. It has been suggested that misidentification21 or contamination22 may have been responsible for some of the earlier adverse reaction reports for this herb. However, it might be prudent to avoid Juniperus tinctures or aqueous extracts until further data is available (see the Juniperus chapter).

Petroselinum The Commission E monograph on parsley herb and root contraindicated this herb for inflammatory kidney conditions, but no references were given to support this claim. It may have been based on theoretical speculation regarding the presence of the potentially toxic constituent apiol in the essential oil fraction of this herb. This concern needs to be put in perspective since parsley is a commonly used culinary herb. The lowest fatal daily dose of apiol has been reported as 0.77 g per day. taken for 14 days.23 Since parsley leaf essential oil contains about 20% of apiol,21 the equivalent dose of essential oil would be approximately 3.85 g per day. Assuming that the dried herb contains about 1% of the essential oil. the equivalent dos~ of dried herb would be approximately 385 g.This assumes th~t efficiency of extraction of apiol fr~m the'herb by the body is 100%. However, the dose of dried Petroselinum root recommended by the BHP was only 6-12 g per day.

WESTERN DATA: GENERAL There is a paucity of research data on this topic. Many of the recommendations, cautions. and contraindications given in the literature on the use of herbs for reproductive disorders, or during pregnancy and lactation, appear to be based on theoretical considerations, rather than evidence from research. The main areas of concern are that: • specific herbs given during menstruation may aggravate blood loss • specific herbs given to regulate menstruation may occasionally disturb the endocrine balance • specific herbs given during pregnancy may cause miscarriage or fetal abnormalities • specific herbs given during lactation may cause infantile illness • specific herbs may aggravate or induce carcinoma of the breasts or of the female reproductive system The topic of carcinoma is dealt with separately in the section Western data: carcinoma below.

~.

Safety and the organ systems Blood loss during menstruation The concern that specific herbs may aggravate blood loss during menstruation is not as strong in traditional Western phytotherapy as in Chinese phytotherapy. Therefore, this topic is discussed under the heading Chinese medicine below. Disturbance of the endocrine balance There has been one report that Vitex agnus-castus may have contributed to the disturbance of reproductive hormone balance in a woman undergoing unstimulated in vitro fertilization treatment. 25 However, the results of two uncontrolled clinical trials indicated that Vitex is beneficial in the treatment of female infertility.26.27 According to Mills and Bone, Vitex may aggravate pure spasmodic dysmenorrhea when this is not associated with PMS, possibly via the effect of this herb on progesterone levels. However, they note that Vitex is usually beneficial for spasmodic dysmenorrhea associated with PMS and for congestive dysmenorrhea. Pregnancy: general The following commonsense guidelines for practitioners can be followed during pregnancy: • prescription of herbal medicine during pregnancy is inadvisable unless the practitioner is specifically trained in phytotherapy and has had at least two years pf subsequent clinical experience • herbal medicine is best avoided during pregnancy unless it is to treat an acute condition or a disorder of pregnancy itself; herbal treatment of chronic disorders can be postponed until after the delivery • it is prudent to use the minimum dose necessary to obtain therapeutic effect and to observe the cautions and contraindications for individual herbs, especially those with specific restrictions on use during pregnancy What little data there is on the potential adverse effects of herbs during pregnancy mainly relates to the risk of miscarriage. There is very little information on fetal toxicity or fetal developmental abnormalities caused by the use of herbs.

145

Herb

Pregnancy

Breastfeedlng ..-, ........ .:-: .....:';~ ~ _... ~~~ ...'H-"-""'~ .. _-,.

Angelica archangelica

'.·'r,

:"';":~~

·;-,.... :.,;,~--tr

T

Artemisia absinthium

~~ernlsia·abrotan~.~.'~':'.' Asclepias

Capsicum ...

".~'--:.'"

',

.

Caulophyllum Chamaelirium

.~im5!!~~~,-_c;~, ,'.

,,','

Cinchona

Commiphora 'ccirivallaria

~:""~.·4~~.......,.-,," ';.~... ;{.:~,-!.W'..Aa; ..':"":<... _,:•...•• _

T #,."-.,,,,"",""K.'; .

Hydrastis JUniperus .~:~ i;"'_' , " 3'1-," -.• ~..:;.- .. ~,,'

,': .•

.

>.,.' .:~-;.., "-':_;"i".-" , ~

Leonurus species

Mentha pulegium

T

-Petroselln~ni-~:"~"~~··

T

Phytolacca

Potentilla T-

Rosmarinus

RUta' Salvia species

T

~J~~':':2::~">c,,._~!.",~ ..,,-_~_2_~~~~~~ Tanacetum

Pregnancy: herb list The herbs marked with a "f" in the table are those mentioned in this book that have had cautions or contraindications listed for their use during pregnancy in one or more journals or texts (including this book).

In perspective

For the majority of the herbs listed in the table, their proposed cautions or contraindications are un-

substantiated by research.

~Thuj3-'::.:>~i;:-~:~'.;;·":~;:;-:·- • .... _:_lo-~ ..

'.'

_~.'~~._;~'.':".'

Vitex

Zingiber

T Herbs marked with this symbol are contraindicated in pregnancy and/or lactation, or have cautions on their use during these times.

Combining Western Herbs and Chinese Medicine

146

Juniperus A research study using an ethanolic extract of the berries reported abortifacient activity in rats.

28

Zingiber The Commission E monograph on this herb stated that Zingiber should not be used for morning sickness. However, the editor of the English translation of the Commission E monographs pointed out that a review of the research literature could not justify this caution. In fact, research data indicates. that Zingiber may be of value in reducing vomiting during pregnancy (see Zingiber chapter).

Herbs to prevent miscarriage Some of the herbs in the table, such as Chamaelirium and Lobelia, have a tradition of use during pregnancy to strengthen the uterus or to prevent miscarriage.~9 They are only included in the table since, in my opinion, any herb with a regulatory effect on uterine contractions should be used with caution during pregnancy and should only be prescribed by experienced and qualified practitioners of phytotherapy.

Importance of the dose Some of these herbs in the table may be appropriate for use in pregnancy, providing their specific dose recommendations are followed. For example, it may be prudent to avoid high doses of Glycyrrhiza during pregnancy, especially if there is a history of high blood pressure, but according to Mills and Bone, doses of up to 3 g per day are likely to be safe.

Importance of syndrome Some of these herbs may be appropriate for use in pregnancy, providing that their use is avoided for patients who have specific syndromes that may be aggravated by the particular herb. For example, I have not seen any adverse reports on the use of Capsicum in pregnancy. It may be appropriate to use this herb in pregnancy except for patients with syndromes of Interior Heat. Lactation There is very little research data on the effect of herbs on the infant, when these are taken through the mother's milk. The herbs marked with a T in the table above are contraindicated or to be used with caution during lactation because of theoretical concern over the possibility of active constituents passing into the breast milk. For example, the ESCOP monograph on Rheum did not recommend the use of this herb during lactation. However, two studies have reported that the active constituent rhein does not have a laxative effect on infants when taken by nursing mothers. 30• 31 It was found that the amount of rhein transmitted to the infant was 0.3% of the rhein intake of the mother, which the authors pointed out is far below the oral rhein dose necessary for inducing a laxative effect. 3l

ing types of herbs should be used with caution during menstruation:

_cooling herbs especially for patients with Cold in the Uterus

_ downward-draining herbs especially for patients with Deficient Qi and Yang

_herbs that move the Blood especially for patients with heavy menstrual flow However, if the menstrual flow is absent or less than normal, it may be appropriate to use herbs that move Stagnant Blood in the Uterus throughout the whole cycle, including menstruation itself, until the flow is at a satisfactory level for the patient. The Chinese concept of moving Stagnant Blood in the Uterus has some degree of overlap with the Western herbal concept of stimulant emmenagogue, which refers to herbs with the potential of stimulating uterine contractions. In my opinion, herbs of this type are generally best avoided during menstruation itself if the flow is heavy, and should be used with caution if the flow is normal. Herbs of this type listed in the table above include: - Artemisia absinthium - Artemisia abrotanum - Caulophyllum - Cimicifuga - Commiphora - Hydrastis - Juniperus - Lobelia - Mentha pulegium - Petroselinum - Ruta -Salvia - Sarothamnus - Thuja

Pregnancy According to Chinese medicine, some herbs that invigorate the Blood and clear Blood Stagnation are contraindicated or to be used with caution during pregnan- _ cy, for example: - Commiphora (mb yao) - Curcuma longa tuber (yiI jin) - Leonurus heterophyllus (yl mil ci'iO)

WESTERN DATA: CARCINOMA CHINESE MEDICINE Menstruation

According to Chinese medicine, the follow-

Concern about the possibility that herbs may aggravate or induce carcinoma is largely of recent origin, and was not a-

Safety and the organ systems major consideration of traditional Western or Chinese medicine. This section therefore concentrates on evidence from recent pharmacological and clinical research. Inhibition or stimulation of cancer cells? below, there is evidence that:

As discussed

• some herbs may inhibit breast or uterine carcinoma • some herbs may aggravate or promote the growth of breast or uterine carcinoma • some herbs may either inhibit or promote carcinoma, depending on the methodology of the experiment, including the type ofliving material used, and the dose of the herb material For some herbs, there is evidence that some constituents may inhibit and other constituents may promote carcinoma. Relevance of research studies Promotion of carcinoma in cell cultures or animal studies using overdose levels of isolated constituents does not necessarily mean that infusions, decoctions, and tinctures of the dried herb are carcinogenic when used in the therapeutic dose range. Angelica sinensis One mouse study reported that a polysaccharide from A. sinensis had strong antitumor activity.32 A study using an in vitro culture system reported antiestrogenic activity for A. sinensis. B A third study reported that A. sinensis significantly stimulated the growth of MCF-7 cells, a human breast cancer cell line. This stimulation was independent of estrogenic activity.34 Cimicifuga racemosa Isolated fukinolic acid (2-E-caffeoylfukiic acid) was reported to have estrogenic activity as shown by increased proliferation of an estrogen dependent MCF-7 cell system. 3; However, a more recent study using the MCF-7 cell system reported that an isopropanol extract of Cimicifuga significantly inhibited estrogen-induced proliferation of MCF-7 cells. In addition, the proliferationinhibiting effect of tamoxifen was enhanced by the Cimicifuga extract. According to the authors, the data suggested a nonestrogenic or estrogen-antagonistic effect on human breast cancer cells. 36 An in vivo mouse study reported that a Cimicifuga extract does not stimulate breast cancer cells that are estrogenreceptor positive. The authors concluded that Cimicifuga might be a safe remedy for the treatment of menopausal symptoms in women with a history of breast cancer in which hormone-replacement therapy is contraindicated. 37 (See also the discussion in the Cimicifuga chapter). Glycyrrhiza An in vivo animal study reported that the isolated Glycyrrhiza constituents glabrene and isoliquiritigenin

147

both had a biphasic effect on the growth of breast tumor cells. Both showed an estrogen receptor-dependent growthpromoting effect at lower concentrations (l On~l-l O!lM), and an estrogen receptor-independent antiproliferative effect at higher concentrations (> 15f.l.M).38 However, a study using MCF-7 human breast cancer cells reported that Glycyrrhiza did not significantly stimulate the growth of these cells. 34 Also, a study on estradiolinduced carcinogenesis in mice suggested that Glycyrrhiza may be a promising preventative agent for endometrial cancers (see the Glycyrrhiza chapter). Panax ginseng One study reported that P. ginseng significantly stimulated the growth of MCF-7 human breast cancer cells. This stimulation was independent of estrogenic activity.34 However, an earlier study using MCF-7 cells reported that ginsenoside Rh2 significantly inhibited the cell growth in a concentration-dependent manner. 39 Also, an animal study reported that P. ginseng preparations inhibited the growth of both mammary and uterine tumors. 40 Panax quinquefolium A series of in vitro stL>
Nervous system and behavior WESTERN DATA The main concerns are with stimulant herbs that overexcite the nervous system or sedative herbs that depress its function. Stimulant herbs Herbs of this type, such as Cola, !lex, Ephedra, and Panax ginseng, may overexcite the nervous system when taken in excessive doses. They may even have adverse effects when taken within the therapeutic dose range in susceptible persons. They have the potential to aggravate or induce mental, emotional, and physical restlessness, inability to concentrate, insomnia, palpitations, fearfulness, anxiety, panic attacks, irritability, aggressive behavior, emotionallability, and manic episodes (see the section on Stimulants in the Actions glossary).

148

Combining Western Herbs and Chinese Medicine

It is therefore essential that these herbs are only prescribed when appropriate. Chinese differential diagnosis can act as an important screening process to identify patients with syndromes for which these herbs are inappropriate (see Chinese medicine below).

Valeriana nor Piscidia should be used prior to driving or operating machinery if the patient has also taken alcohol or sedative drugs.

Sedative herbs There has been concern .that herbs with sedative action can depress the nervous system and induce or aggravate drowsiness, inattention, lack of coordination, or depression. The tranquilizing herbs mentioned in this book that generally have the strongest calming action are Anemone, Humulus, Piscidia, and Valeriana. In higher doses, these may have a mild to moderate sedative effect.

In terms of Chinese medicine, adverse herb effects on the nervous system and behavior can include the following:

Anemone I have not seen reports of negative herb reactions for therapeutic doses of preparations of dried Anemone. This includes the ability to drive and use machines (see the Anemone chapter).

• warming herbs may aggravate patterns of emotional disturbance associated with Heat

Humulus . . ~c~~rdin.g.~~.~_e.ESCOP monograph on Humulus (Lupuli flos), there are no special warnings or precautions required for the use of therapeutic doses of infusions or tinctures of this herb. No toxic effects have been reported, and there is no effect on the ability to drive or use machines. 44 Piscidia No adverse effects have been reported when this herb is used within the therapeutic dose range, but, in my opinion, it is possible that Piscidia may produce sensations of mental dullness in high doses. Ecclectic texts reported adverse reactions to overdose (see the Piscidia chapter). Valeriana There have been reports of somnolence the morning after taking Valeriana root preparations. 4s • 46 However, a more recent, controlled study concluded that the residual sedative effects (hangover) observed in some earlier studies cannot be confirmed for Valeriana at the recommended doses. 47 This study reported a very slight impairment ofvigilance 1-2 hours after administration ofValeriana. There have been no reports of adverse interactions between Valeriana and conventional drugs or alcohol. However, there has been one report of reversible negative reactions to an overdose of Valeriana (see the Valeriana chapter). Summary There have not been any reports of adverse reactions or adverse herb-drug reactions with Anemone, Humulus, Piscidia, or Valeriana when these herbs are taken at therapeutic dose levels. However, it is prudent to start administration of these herbs at the lower end of the therapeutic dose range. With respect to driving or operating machinery, it may be inadvisable to take Valeriana immediately before these .. activities, depending on the dose and the strength of the patient's reaction to this herb. In my opinion, neither

CHINESE MEDICINE

• stimulants may increase disturbed upward movement of energy • stimulants may aggravate symptoms of Qi constraint in the chest

• prolonged use of stimulants may exhaust Kidney Qi • prolonged use of sedatives may damage Kidney and Heart Yang • inappropriate use of moistening sweet tonics may aggravate depression associated with Damp and Phlegm Disturbance of upward movement As discussed above, stimulant herbs, such as Ephedra and PanaX ginseng, may aggravate or induce mental and emotional disturbance associated with Heart Spirit Disturbance or Liver Hyperactive Yang. Aggravation of Qi constraint In my experience, the use of Panax: ginseng in some patients with preexisting constraint of Qi in the chest may result in unpleasant sensations of obstruction in the chest with emotional distress. This is especially likely if the constraint is associated with Heart Stagnant Qi. Panax: tends to increase the upward movement of Qi. When this reaches the constrained Qi in the chest, it does not clear the Stagnation. Rather, it may aggravate the sensation of obstruction and pressure, and create a disturbance of movement within the Qi of the chest. Aggravation of Heat syndromes Inappropriate use of warming Kidney Yang tonics, such as Cinnamomum bark, may aggravate syndromes of Heat associated with '1m Deficiency of the Kidney and Heart, and increase symptoms of restlessness, insomnia, and emotional disturbance. Exhaustion of Kidney Qi Prolonged use of stimulant herbs, such as Cola, Ephedra, and Ilex, may eventually deplete the Kidney Qi, resulting in exhaustion and depression. In the case of exhaustion of Kidney Qi and Yang, there may be depression with apathy and sensations of cold; in the case of exhaustion of Kidney Qi and Yin, there may be depression with restless anxiety and sensations of heat.

Safety and the organ systems Aggravation of Kidney and Heart Yang Deficiency Inappropriate use of cooling herbs that calm Heart Spirit Disturbance and Liver Hyperactive Yang may aggravate depression associated with Yang Deficiency of the Kidney and Heart. This inappropriate use may occur when the pattern of Kidney Deficient Yang is masked by a simultaneous pattern of Deficient Kidney Yin or by a severe acute painful condition. For example, if the cold herb Piscidia is given for acute trigeminal neuralgia, it is important to check the pulse and tongue and patient history to determine if there is an underlying Kidney Deficient Yang pattern. If so, it may be necessary to moderate the potentially depressing effect of Piscidia on metabolism and emotions by adding Capsicum or Rosmarinus to the combination. Aggravation of Damp and Phlegm Excessive or inappropriate use of moistening sweet tonics, such as Glycyrrhiza, Lycium, or Ziziphus, may aggravate lethargy and depression. This is especially likely in patients with a tendency to Spleen Qi Stagnation and accumulation of Damp and Phlegm.

149

18. Siegel RK. JAMA 241(15):1614-1615 (1979) 19. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn. Medpharm, Stuttgart. Germany (1994). from 2n d German edn. Wichtl M (ed) (1989) 20. Czygan F-C. Z Phytotherapie 8:10 (l987) 21. Tisserand R. Balacs T. Essential Oil Safety A Guide for Health Care Professionals. Churchill Livingstone. Edinburgh. United Kingdom (1995) 22. European Scientific Cooperative on Phytotherapy: Monographs on the Medicinal Uses of Plant Drugs (monograph on Juniperus fructus). European Scientific Cooperative on Phytotherapy. Exeter. United Kingdom (1997) 23. Lowenstein L. Ballew DH. Canadian MedAssoc J 78:195-198 (1958) 24. Arlt VM. Stiborova M. Schmeiser HH. Mutagenesis 17(4}:265-277 (2002) 25. Cahill DJ, Fox R. Wardle PG et al. Hum Reprod 9(8):1469-10170 (1994) . 26. Propping D. Katzorke T. Z Allge Med 63(31):932-933 (1987) 27. Propping D, Katzorke T. Belkien 1. Therapiewoche 38(41}:2992-3001 (1988) 28. Agrawal OP et al. Planta Medica 39:98-101 (1980) 29. Christopher JR. School of Natural Healing. BiWorid. Provo. Utah (1976) 30. Faber P. Strenge-Hesse A. Pharmacology 36(Suppll):212-220 (1988)

References

31. Faber P. Strenge-Hesse A. Geburtshilfe Frauenheilkd 49(11} :958-962 (1989)

1. McLeod D. Bone K. Morgan M. European J Herbal Med 2(3}:39-50 (1996) 2. Graham-Brown R. Lancet 340:673 (1992)

33. Rosenberg Z. Rosenberg RS. Jenkins DJ et al. Clin Chim Acta 312(l2}:213-219 (200l)

3. Penharic L, Shaw D. Leon C et al. Veterinary and Human Toxicology 37(6):562-566 (1995)

34. Amato P. Christophe S. Mellon PL. Menopause 9(2}: 145-150 (2002)

4. Kane JA. Kane SP. Jain S. Gut 36(1}:146-147 (1995)

35. Kruse SO. Lohning A. Pauli GF et aI. Planta Med 65(8}:763-764 (1999)

5. Mills S. Bone K. Principles and Practice of Phytotherapy: Modern

36. Bodinet C. Freudenstein J. Breast Cancer Res Treat 76(1):1-10 (2002)

Herbal Medicine. Churchill Livingstone. Edinburgh. United Kingdom (2000) 6. Denham A. European J of Herbal Med2(3):27-38 (1996) 7. McGuffin M, Hobbs C. Upton R et al. American Herbal Products l.,

32. Choy YM. Leung KJ."I. Cho CS et al. Am J Chin Med 22(2):137-145 (1994)

Association's Botanical Safety Handbook. CRC Press. Boca Raton. Florida (199i)

37. Freudenstein J. Dasenbrock C, Nisslein T. Cancer Res 62(12}:34483452 (2002) 38. Tamir S, Eizenberg M. Somjen D et al. J Steroid Biochem Mol Bioi 78(3}:291-298 (200l) 39. Oh M.Choi YH.ChoiS et aI. Int J OncoI14(5):869-875 (1999)

J Korean Med

8. Blumenthal M. HerbalGram 28:38 (1993)

40. Bespalov VG. Alexandrov VA. Limarenko AY et al. Suppl:S42-53 (2001)

16

9. Batchelor ....'B. Heathcote J. Wanless IR. Am J GastroenteroI90(5):831833 (1995)

41. Duda RB. Taback B, Kessel B et al. Ann Surg Oncol 3(6):515-520 (1996)

10. Sheikh NM, Philen RM. Love LA. Arch Intern Med 157(8):913-919 (1997)

42. Duda RB. Zhong Y. Navas Vet aL J Surg Oncol72(4):230-239 (1999)

11. Heron S, Yarnell E. J Altern Complement Med 7(2):175-185 (2001)

43. Duda RB. Kang SS. Archer SY et al. (2001)

12. Lo AC. Chan K. Yeung JH. Woo KS. Eur J Drug Metab Pharmacokinet 20(l}:55-60 (1995)

44. European Scientific Cooperative on Phytotherapy: Monographs on the

13. Vaes LP,Chyka PA.Ann Pharmacother 34(12):1478-1482 (2000) 14. Zhu M, Chan KW. Ng LS et al. (1999)

J Pharm

Pharmacol 51(2):175-180

J Korean Med

16Suppl:S54-60

Medicinal Uses of Plant Drugs (monograph on Lupuli flos). European Scientific Cooperative on Phytotherapy. Exeter. United Kingdom (l997)

15. Chan TY.Ann Pharmacother 35(4}:501-504 (2001)

45. Leathwood PD. Chauffard F. Heck E et al. Pharmacol Biochem Behav 17:65-71 (l982)

16. Haller CA, Benowitz NL.N Eng! JMed343(25):1833-1838 (2000)

46. Leathwood PD, Chauffard F. Planta Med 51:144-148 (1985)

17. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983)

47. Gerhard U, Linnenbrink N. Georghiadou C et al. Schweiz Rundsch Med Prax85(15}:473-481 (19%)

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Safety in clinical practice is easier for the practitioner to distinguish between adverse drug reactions. drug-drug interactions, adverse herb reactions, and adverse herb-drug interactions.

the following checklist to minimize adverse reactions stemming from the use of herbs:

RACTITIONERS CAN USE

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Correct differential diagnosis

3. .decide iffurtherili~9J.is.~,~gtH!~~~i¥?\l1;;~~>J 4. decide if herbal tr~tm~t is app~pnate·c::ii!ii2,~;

Errors in diagnosis are likely to result in an incorrect choice of herbs. with possible aggravation of preexisting conditions or the production of new ones. Errors in diagnosis include errors ofemphasis in deciding which of the patient's syndromes are of primary and which are of secondary importance. as discussed in the Practical herb combination chapter.

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If the patient has symptoms that may represent a potentially serious condition and the patient has not yet been seen by a conventional medical specialist. this should be done

Full medical history

before commencing herbal treatment.

During the first patient visit. it is important to take a full medical history. including details of all prescribed and selfprescribed conventional medicines. herbs. and food supplements. At the start of each subsequent patient visit. the practitioner should determine if there have been any changes in the substances taken by the patient, including changes in dose. If this is done, should there be any negative reactions. it

Situations in which herbal treatment is inappropriate There may be laws in a particular country or state that restrict herbal treatment of certain conditions, at least by practitioners who are not medical doctors. However,. on 1.", -

151

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Combining Western Herbs and Chinese Medicine

152

therapeutic as opposed to legal grounds, whilst specific disorders may be contraindicated for individual herbs, it is not easy to list disorders that are contraindicated for herbs in

general. The decision whether or not to use herbs is generally decided on a case-by-case basis by the individual practitioner, often depending on the level of their training and eXperience.

This topic is discussed in the chapter Practical herb combination. The Taste and Actions chapters contain tables showinghow potential side effects may be avoided by the use of moderating herbs.

.Cautions and contraindications for 'specific herbs and specific pa~ients

EXAMPLES Pregnancy Some practitioners avoid the use of herbs in general during pregnancy. Other practitioners use herbs during this time to treat disorders of pregnancy, but avoid or minimize the use of herbs for conditions that are not pregnancy-related. These practitioners use appropriate precautions and avoid herbs for which pregnancy is a specific contraindication (see the discussion and table in the Safety and the organ systems chapter). Liver damage Similarly, some practitioners avoid the use of herbs for weak patients who have liver damage. However, other practitioners consider that certain types of herbs, such as the hepatoprotectives, can be specifically helpful in assisting in the improvement of liver function for some patients of this type. This is discussed in the Prevention of adverse reactions section below. Patients on multiple medication A patient who is exhausted and depressed from prolonged or severe illness and already has to take many conventional medications may not have the energy or interest to take further medications of any kind. In such cases, it is often preferable to wait until there is a reduction in the number of drugs before prescribing herbal medicine. Patients undergoing changes in medication If the patient is on multiple medication and is in the proc.ess of changing drug doses, or changing from one group of conventional drugs to another, it is prudent to let some time elapse before commencing herbal therapy. This gives time for the following effects to resolve themselves: • adverse reactions to the change in drug dose • withdrawal effects from the first group of drugs • initial adverse reactions to the second group of drugs

Once the herb combination has been screened in terms of actions, temperature, and taste, the next step in the screening process is to determine whether any of the herbs in the provisional combination have cautions or contraindications, especially in the context of the patient's specific syndromes.

CAUTIONS AND CONTRAINDICATIONS DATA In this book, data on cautions, contraindications, and herb-drug interactions is given for each herb in the materia medica chapters. There is additional information in the Safety and the Safety and the organ systems chapters on herbs that have cautions or contraindications: • during pregnancy and lactation • for specific Chinese syndromes • due to the possibility of adverse herb-drug interactions

Informed patient choice If the practitioner is considering using a herb that may have side effects for a specific patient, the patient should be clearly informed of the benefitrisk ratio so that they can make an informed choice. The patient also should be informed of the nature of any potential side effects so that they can report them to the practitioner as soon as possible, should they occur. The patient can be asked to reduce the dose or to stop taking the herbs if side effects are experienced, as appropriate (see Side effects acceptable to the patient in the section Management of adverse reactions below).

Balancing herb combinations

Prevention ofadverse reactions

To ensure that a herb combination is effective and safe, it should be properly balanced in terms of: herbal actions, temperature, taste, and the principles of herb interaction.

The possibility of adverse reactions can be minimized by ensuring that the following factors are appropriate to the specific needs of the patient

Safety in Clinical Practice • dose level • dose form • timing of the dose • duration of the prescription • breaks in the treatment • alternation between prescriptions • use of moderating herbs

153

the herb for a short-term only. If long-term treatment is necessary, then the possibility of cumulative side effects can be reduced by either: • having regular breaks in the herb treatment • alternating between two herbs with a similar effect

BREAKS IN THE TREATMENT' -DOSE LEVEL As discussed in the Dose chapter, the following com- monsense guidelines can be followed: • use the least dose required to get the desired therapeutic effect • in chronic cases, start at the minimum therapeutic dose and then raise the dose as appropriate • use the herbs for the minimum time at the standard dose before reducing the dose, if appropriate • increase the dose only if the symptoms return • vary the dose to meet the changing requirements of the patient Data on the dose range of individual herbs is given in the materia medica chapters.

-DOSE FORM The dose form used should be appropriate to the partic~ ular patient. For example, tinctures are unsuitable for an alcoholic patient, and powders may be unsuitable for a patient with weak digestion. Infusions or decoctions would _be the preferred forms for such patients (see the table in the section Advantages and disadvantages of the different dose forms in the Dose chapter).

TIMING OF THE DOSE Appropriate timing of the dose can reduce the possibili:y -of negative reactions. For example, if the patient takes a tonic prescription containing Rosmarinus and Turnera just before ~. bed, they may experience restlessness. and insomnia. If the patient takes the combination earlier in the day and never 'ater than 5 PM, it is possible to get the full beneficial effect _ Nithout the negative reaction (see the section Timing of the dose in the Dose chapter). ~DURATION OF THE PRESCRIPTION

The length of time for which a particular herb or herb :ombination is prescribed can be varied to minimize side ~ effects, as discussed in the Dose chapter. Even when a herb 'las potential side effects, these can often be avoided by using

When a herb or herb combination is taken long-term, it may be possible to minimize potential side effects by having regular breaks in the treatment. This is discussed in the section Duration ofthe prescription in the Dose chapter. .

ALTERNATION BETWEEN PRESCRIPTIONS Another method of minimizing potential side effects during long-term treatment is to alternate between herbs or herb combinations. This is discussed in the section Duration ofthe prescription in the Dose chapter.

USE OF MODERATING HERBS Moderating herbs can be included in a combination to minimize potential ~ide effects by balancing the temperature, tastes, and actions of the other herbs in the combination. The Taste and Actions chapters contain tables for balancing tastes and actions, respectively, by using moderating herbs. A specific example of the use of moderating herbs is given under the heading Use of additional herbs to treat side effects in the section Management ofadverse reactions below.

EXAMPLE OF PREVENTIVE MEASURES: PATIENTS WITH LIVER DISORDERS Herbs should be either be avoided or used with especial caution for patients with preexisting liver damage or liver carcinoma, or who are currently taking potentially hepatotoxic conventional medication. If the type or dose of the hepatotoxic drugs is in the process of being changed, herbal therapy is contraindicated until the drug regime is stabilized. Liver tests An initial liver function test may be advisable as a baseline before commencing herbal therapy. Further liver tests can then be used to monitor positive or negative changes due to the herbs or due to herb-drug interactions. The herbal practitioner may wish to work in close association with the patient's general medical practitioner or medical specialist. Dose level If the liver function is impaired, it is advisable for the initial dose of herbal medicine to be very small. For

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example, instead of the standard dose of 5 ml of 1:5 tincture three times per day, the starting dose could be 0.5 ml once per day, which can gradually be increased if there are no side effects. Dose form Especially if the hepatic weakness is associated with past alcohol abuse, it may be better to prescribe herbs as aqueous infusions or decoctions, rather than as alcoholbased tinctures or liquid extracts. Restricted use of alterative herbs The use of standard doses of alterative herbs is contraindicated in cases of severe liver damage. Alterative herbs may release toxins from the tissues into the bloodstream, which may put a strain on the detoxification capacity of a weak or damaged liver. However, it may be possible to use very low doses of alterative herbs providing special procedures are taken. The first step is to strengthen the liver by the use of small quantities of:

• bitter tonics with hepatoprotective effects, but no alterative action, such as Artemisia species, Gentiana, and Rosmarinus

• sour/astringent hepatoprotective herbs, such as Schisandra

• sweet tonics with hepatoprotective and detoxicant effects, such as Glycyrrhiza

• acrid herbs with hepatoprotective and detoxicant effects, such as Zingiber Once the use of such herbs has begun to improve liver function, it may be appropriate to add very small amounts of alteratives to the combination.

Monitoring Monitoring can be done by the practitioner, by the patient, and by conventional medical testing.

PATIENT The patient can be asked to keep a record of the following: • any suspected side effects or adverse herb-drug interactions, noting such details as the severity and the time and date the symptoms occurred • any changes to prescribed or self-prescribed conventional medication, herbs, or food supplements • any changes in the level oflife stresses that may have been responsible for the symptoms Rechallenge If it is appropriate and if the patient agrees, the herbs can be taken again, at a lower dose and/or in a different form if preferred, to determine if the symptoms recur. The patient should be asked to keep in contact with the practitioner during this process and to stop the herbs immediately if the adverse effect recurs. A rechallenge may not be appropriate for herbs with potentially severe adverse effects even if the dose is greatly reduced. .

CONVENTIONAL MEDICAL TESTS There are certain circumstances in which laboratory tests can give useful information to the herbal practitioner on changes in specific parameters. The example of liver function testing is mentioned above in the section on

Prevention ofadverse reactions. Varying treatment strategy according to test results Herbal therapy is increasingly being used as an adjunct to the treatment of carcinoma and to moderate the adverse effects of chemotherapy. Some antineoplastic agents cause bone marrow depression with reduction in the numbers of various types of white blood cells. It is useful to the herbal practitioner to see regular blood cell data printouts in order to decide on the appropriate herbal prescription. For example, if the white blood cell count has markedly fallen, it may be more appropriate, in terms of Chinese medicine, to tonify the Blood and to tonify Defensive Qi, rather than to clear Damp Heat and Retained Pathogen.

PRACTITIONER The practitioner should check for signs and symptoms of any potential side effects that are to be expected with the specific herbs and the specific patient. Monitoring is essential for herbs with the possibility of severe adverse reactions. Three of the herbs that have their own materia medica chapter in this book. Cinchona. Convallaria. and Lobelia. are on Schedule Part III of the United Kingdom (see the section Regulation ofherb use in the Safety chapter). For these herbs, special details of screening and monitoring are given (see the chapters on these herbs).

Management ofadverse reactions EXCLUSION OF OTHER POSSIBILITIES It is necessary to. distinguish between symptoms arising from adverse herb reactions to correct treatment and symptoms due to the following alternative possibilities: "

• inco':;'ect diagnosis:

see the section An example with mistakes in the Practical herb combination chapter

l

Safety in Clinical Practice • herb-drug interaction:

see the section on this topic in the Safety chapter

• healing crisis:

see Healing crises in the Appendix

SIDE EFFECTS ACCEPTABLE TO THE PATIENT

155

• reduce the dose • change the dose form • change the of timing of the dose • replace one or more herbs in the combination • partially replace one or more herbs in the combination • use additional herbs to treat the side effects • use breaks in treatment • alternate between prescriptions

The practitioner and patient may decide to continue with the herb if the patient is obtaining benefits that out-

Reduce the dose

weigh the side effects but only:

sure that can be taken to reduce side effects is to reduce the dose of the prescription. The optimum situation is that the reduction of dose removes the side effects without decreasing the beneficial effects of the herbs. However, reduction of dose may reduce the beneficial effects as well as the negative effects. Nevertheless, it may be possible to find a reduced dose at which the levels of both the beneficial and negative effects are acceptable to the patient. The topic of adjusting dose levels to meet the changing needs of the patient is discussed in detail in the Dose chapter in the sections Factors affecting dose and Clinical examples.

if the side effects are mild to moderate. For example, in the short-term treatment of acute bronchitis with a herb combination including Lobelia, some patients may experience mild nausea. This is a common side effect of Lobelia, especially for patients who easily experience nausea. This is acceptable to most patients if the bronchitis is greatly improved. Caution If a herb has side effects, the decision whether or not to continue treatment depends on the type of negative reaction. For example, the commonest side effect of Lobelia is nausea, and, more rarely, vomiting. Providing that this herb is not used for very weak or pregnant patients, these effects are not, in themselves, life threatening. In contrast, in the case of Cinchona, a theoretically possible side effect is cardiac arrhythmia. If this were to occur, even if it were only of mild to moderate severity, the herb should be discontinued immediately since it is theoretically possible for arrhythmia to progress to a life-threatening cardiac condition. However, it should be noted that there have been no reports of adverse reactions to Cinchona when taken within the therapeutic dose range (see the Cinchona chapter).

SIDE EFFECTS UNACCEPTABLE

Reduce the dose of the prescription The most obvious mea-

Reduce the amounts ofindividual herbs in the prescription One possibility is to reduce the dose of the entire combination. Another possibility is to reduce the amount of the individual herb or herbs in the combination that are likely to be producing the side effects. For example, if the combination Lobelia: acute asthma is used, a few patients may experience restlessness or insomnia from the Ephedra. Reducing the dose of the entire combination may result in a large decrease in the beneficial effects of the combination. Herb

Ratio

Temperature

Taste

Ephedra Lobelia Prunu5 Glycyrrhiza

1 1 1 1

warm warm-cool neutral neutral·cool

acrid, 51. bitter acrid bitter, aromatic sweet

TO THE PATIENT

The first step is to stop the herbs. The side effects may then decline and disappear. If they do not and they are severe, the practitioner should proceed as described in the section below on Treatment of severe

adverse reactions. If the side effects are not severe and if the patient is bene- . fiting from the specific.herb combination, the patient may wish to try the combination again, providing that measures are taken by the practitioner to reduce the side effects. These measures may include the following:

An alternative is to keep the dose of the entire combination at the previous level but to reduce the ratio of Ephedra in the combination to 0.75 or 0.5. This may maintain the benefits whilst decreasing the side effects to an acceptable level. If reduction of the ratio of Ephedra results in a decrease of the side effects but also markedly decreases the benefits, the technique of partial replacement may be preferable to simply reducing the amount of the individual herb (see below).

Change the dose form

reactions.

See the section Prevention ofadverse

Combining Western Herbs and Chinese Medicine

156

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Change the timing of the dose See the section Prevention ofadverse reactions. Replace one or more herbs in the combination If the side effects are likely to be due to an individual herb or herbs in the combination, these can be replaced by other herbs. The latter should have similar actions and indications as the herbs they are replacing, but not their specific side effects. For example, the patient has asthma associated with profuse bronchial phlegm, rather than allergic asthma without profuse phlegm. In this case, if the patient is known to experience side effects with Ephedra, a combination based on Lobelia: acute asthma can be used, in which Ephedra is replaced by Euphorbia hirta.

Euphorbia Lobelia Prunus Glycyrrhiza

1 1 1 1

cool war~ol

neutral neutral-cool

bitter, acrid acrid bitter, aromatic sweet

Partially replace one or more herbs If the patient has allergic asthma without profuse phlegm, replacement of Ephedra with Euphorbia may result in an unacceptable decrease in beneficial effects. If this is the case, then partial replacement of Ephedra may be preferable to total replacement. A modification of Lobelia: acute asthma can be used in which the ratio of Ephedra is reduced to 0.5 and Ephedra is partially replaced with Euphorbia hirta at a ratio of 0.5. \ ~ ..,"

Herb

Ratio'

Temperature

Taste

Ephedra Euphorbia Lobelia Prunus Glycyrrhiza

0.5 0.5

warm cool warm-cool neutral neutral-cool

acrid, sl. bitter bitter, acrid acrid bitter, aromatic sweet

1 1 1

Another example of partial replacement is given in the section on Tolerance of the patient for a specific herb in the Dose chapter. Use additional herbs to treat the side effects The use of moderating herbs to prevent side effects is discussed in the chapters on Temperature, Taste, and Actions. The following example illustrates the use of moderating herbs to treat side effects.

Example A patient has allerii~ asthma, and the conibina~ tion Lobelia: acute asthma is effective at removing asthiriatic symptoms. However, in this patient, Ephedra incre~s the patient's preexisting symptoms of anxiety (Heart Spirit

Disturbance) and exhaustion (Kidney and Heart Qi Defi-=__ ~: ;, ciency). The patient is pleased by the improvement and . wishes to continue with the combination if it can be modified so that the side effects are removed or reduced to an acceptable level. Schisandra is added to the combination, at a ratio of 0.5, to tonify and firm Kidney and Heart Qi and thus reduce both exhaustion and anxiety. Anemone is also added, at a ratio of 0.5, to reduce anxiety by calming Kidney fear and Heart Spirit Disturbance.

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Taste

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1 1 1 1

warm warm-cool neutral neutral-cool warm cold

acrid, sl. bitter acrid bitter, aromatic sweet sour bitter

0.5 0.5

The patient may then experience the full benefits of the original combination without its side effects. If the side effects are reduced but not sufficiently, then the ratios of Anemone and Schisandra may be increased from 0.5 to 0.75 or even to 1. Use breaks in treatment See Duration of the prescription in the Dose chapter. Alternate between prescriptions scription in the Dose chapter.

See Duration of the pre-

TREATMENT OF SEVERE ADVERSE REACTIONS The procedures for treatment of severe adverse herb reactions, whether due to therapeutic levels of dose or to overdose, can be summarized as follows:

• stop the herbs • get emergency conventional medical treatment Stop the herbs Prior to commencing the herbal treatment, it is prudent to advise the patients to stop taking the herbs immediately if there is any severe adverse reaction, whether it is obviously due to the herbs or not. They should also stop herbal treatment immediately even if the adverse reactions occur only , in mild form if there is'the possibility that they might progress to a seriouscondition (see the discussion on Cinchona in Side effects acceptable to the patient above).

In case of emergency The treatment of severe and lifethreatening situations is usually outside the scope of the gen-

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Safety in Clinical Practice eral herbal practitioner, and requires immediate notification and intervention of emergency medical facilities.

REPORTING OF ADVERSE REACTIONS

157

It is ideal ifboth the patient and practitioner keep a record of the details of any suspected adverse reactions or herbdrug interactions. This is discussed in the Necessary improvements section in the Safety chapter.

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Using the materia medica in the study of herbal therapy, and the most important one, is learning to make a clear differentiation between the uses of the different herbs. This requires a very thorough understanding of the properties, actions, and uses of each herb. Without a detailed knowledge of the differences between herbs, especially those with similar uses, the choice of herbs for a combination will be imprecise or even incorrect, and clinical effectiveness will be reduced.

T

HE HARDEST PART

Main herbs In this materia medica, each chapter, except the last, is devoted to a single herb and is organized into sections as shown below in Chapter organization. Each section is designed to present the herb from a different perspective. This is done to bring out the essence of what makes the herb unique and to show the different facets of its nature and its

Two ways to use the materia medica The materia medica can be used in two main ways: • for an in-depth study on a particular herb • as a reference text for finding specific information IN DEPTH STUDY Readers may wish to obtain a thorough understanding of a particular herb. They may wish to read the whole chapter, follow up concepts and data by reading primary sources, check the tastes of tinctures and decoctions of the herb, and tryout combinations that include this herb in their clinical practice.

As A REFERENCE TEXT

Additional herbs

Readers may wish to use the materia medica as a reference to get information on specific topics. For example, for a particular herb, they may wish to find information on its Chinese properties, traditional Western uses, or biochemical constituents.

Herbs that do not have individual chapters, but are included in one or more of the combinations in this book, are briefly descnbed in the last chapter of the materia medica, entitled Additional herbs.

Caution If practitioners are going to use a herb in their clinical practice, they are advised to familiarize themselves, in detail, with the sections on Toxicology, Dose, and Cautions in the chapter on that herb.

range of use.

161

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Combining Western Herbs and Chinese Medicine

Actions as coordinating theme . In each main chapter of the materia medica, the herb actions are used as a coordinating theme to link data from Western herbal tradition, Chinese medicine, and biochemistry. • in the What is special section, the Western actions and uses of the herb are discussed in terms of its Chinese actions

Research Constituents Pharmacological and clinical research Research verification of traditional actions Toxicology Dose Cautions Regulatory status ~

• in the Traditional sources section, there is a bulleted list of the traditional Western actions, and each action is then discussed in detail • this can be compared with the bulleted list and discussion in the Pharmacological and clinical research section to see how far the traditional actions have been supported by modem research

Traditional sources Properties Organs Actions Comparison ofWestern and Chinese use (when appropriate) References

..

.

~~~

.;~~._ . ••

Chapter section,outline Each Materia medica chapter is organized in sections as follows: Introduction Names Use in the West Use in China What is special about the herb Properties and meridians Key to understanding the herb Chinese actions Western actions Western uses . Direction of energy Typical case example Limitations ofthe herb Temperature Taste Actions Herb pairs (including that herb) Caution Pairs Combinations Caution Individual combinations Comparison of combinations Other combinations (including that herb)

.i;...

Chapter section commentary INTRODUCTION In this book, herbs are referred to by their botanical name. Alternative names are given in the chapter introduction, together with the plant family and plant part used. For the Mandarin name, the phrase 'not used' indicates that the species used in the West is not in common use in China, and is not included in the Chinese Herbal Medicine Dictionary (Zhong yao da ci dian) from Jiangsu New Medicine Institute, published by Science and Technology Press, Shanghai, China (1975). Chinese characters are generally only given: • for herbs with their own individual chapter in the materia medica, and not for herbs in the Additional . herbs chapter • for Western species if the herb has an entry in the

Chinese Herbal Medicine Dictionary • for Chinese species if they are in the same genus as a species used in the West and have comparable use This nomenclature information is followed by a general introduction to the history of use of the herb in the West and, if applicable, in China.

WHAT IS SPECIAL ABOUT THE HERB Properties and organs (meridians entered) are listed, and the key to understanding the herb is given briefly in italics to

',;

Using the Materia Medica pinpoint what makes this lerb special and different from other herbs. Actions and uses The main Chinese actions for the herb are listed and the Western uses are then described in terms of

the numbered Chinese actions. Direction of energy Where this is appropriate, the effect of the herb on the direction of energy movement in the body is described. Typical case example The signs and symptoms of a hypothetical patient are described, a diagnosis is given, and the reasons for choosing the herb are listed.

LIMITATIONS Defining the limitations of a herb can give a clearer understanding of what it can and cannot do. The limitations to the range of temperature effects, taste properties, and actions are discussed, and for some of the herbs, examples are given of situations in which other herbs would be preferable.

HERB PAIRS For a particular herb, suitable combination with another herb can extend its range of use beyond its limitations or moderate its potential side effects. Clinically effective examples are given. The herb pair can be seen as the basic unit of herb combination. This section lays the foundation for the discussion of combinations that follows.

COMBINATIONS Over 150 herb combinations are discussed in the materia medica chapters. Most of these derive from my own experience - see Evidencefor statements made under Sources in the Front matter of this book. Individual combinations In most cases, six combinations are discussed to illustrate the use of the herb. Each of these combinations is described in a table and text.

Table In the combination table, the complete range of temperature and taste values is given for each herb. However, not all may be applicable to the specific situation described. For a particular herb, which temperature and taste values manifest in a particular situation depends on the individual needs of the patient and on the properties of the other herbs with which it is combined. If the combination is to be prepared from dried herbs, the dose in grams is given for each herb. If the combination

163

is to be taken in the form of a tincture or fluid extract, then the ratio of each herb in the combination is given, since tinctures can be of different strengths, 1:1, 1:2, 1:3, and so on (see the Dose chapter). If Capsicum is given as a tincture, the amount is listed in drops to be added to the main combination. This is based on the assumption that Capsicum is given in a separate bottle from the bottle of the main combination tincture.

Text The combination is then discussed with respect to its Chinese syndromes and Western uses and, if it is appropriate, with practical details of its administration and precautions. Comparison of the combinations The comparison of the combinations is arranged in pairs, each with two tables and accompanying text. This is done simply because it is easier on the eye and mind to compare two items at a time, rather than to be confronted with one complex table of six combinations. The comparisons may be both within and between the pairs. Other combinations This section lists examples of other combinations that include the herb. It is not always a complete list since in the case of a herb such as Zingiber, a complete list would include over 80 combinations.

RESEARCH Constituents The major chemical groups of pharmacologically active constituents are listed and then discussed. Pharmacological and clinical research Research studies are organized by the herb's action (effect). Data from this section can then be compared with the Traditional sources section later in the chapter.

Caution As discussed in the Safety chapter, some in vitro, in vivo. and even clinical studies may have limited applicability to humans taking therapeutic doses of the whole herb. This is especially true of studies using isolated constituents rather than the whole herb, and of studies using administration by injection rather than by an oral route. Wherever possible, the reader is advised to refer to the primary sources cited in the References section. Research verification of traditional actions The traditional actions that have been supported by research are listed, as are additional effects demonstrated by research studies. Toxicology Data on toxicology is given for the herb where it is available. A distinction is made between effects reported for the whole herb as opposed to its essential oil or isolated constituents.

--,;:;...

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Combining Western Herbs and Chinese Medicine

It is most important to keep a sense of perspective in this section. For example, I have often converted figures given in mg/kg from animal studies to mg for a 60-kg human. In many cases, it is then obvious that toxic effects only arise at dose levels far higher than the recommended herbal therapeutic dose (see Interpretation ofresearch data).

Caution The regulatory status of herbs is constantly changing, and it is the responsibility of the practitioner in a particular country or state to be familiar with their local regulations.

DOSE

A range of opinions on the properties, associated organs. and range of actions is presented from traditional Western texts, especially from Germany. Britain. and the USA. The Chinese Herbal Medicine Dictionary (see Books chapter) has been used as the main source for information on traditional Chinese material. The properties. associated organs. and actions are discussed. Information on the actions from traditional sources can be compared with research data in the Research section. When the herb is used in both the West and China. the two traditions of use are compared. This may be for the same species or for different species of the same genus.

The dose for the dried herb and tincture, and the initial dose and duration of administration are given. The figures for dose are usually cited from the BHP or BHC. If I use doses differing from these, then my doses are cited also. Please read the chapter on Dose for a detailed discussion of this topic.

CAUTIONS Where applicable, data is given on Western and Chinese contraindications, cautions on use during pregnancy and lactation, side effects, overdose, and herb-drug interactions. In a few cases, especially when the herb is on Schedule Part III of the Supply of Herbal Remedies Order 1977 of the UK, details on screening, treatment precautions, and monitoring are given. Please read the chapter on Safety for a discussion of this topic.

REGULATORY STATUS Australia It is stated whether the herb is included in Part 4 Schedule 4 of the Therapeutic Goods Act Regulations (meaning, there are restrictions on its use). United Kingdom It is stated whether the herb is on the General Sale List (meaning, it is generally available) or on Schedule Part III of the Supply of Herbal Remedies Order 1977 of the UK (meaning. there are restrictions on its use). United States It is stated whether the herb was listed, at the time of writing. by the FDA as a prohibited substance. as subject to an import alert. or as a substance with a warning on its use. Please read the section on Regulatory status in the chapter on Safety for a discussion of this topic.

TRADITIONAL SOURCES

REFERENCES The references given in this book can be divided into two types: journals and basic reference texts. Journals References to journals are usually specific to one chapter. To save space, the references to journals are given without the names of the articles. Where references to a journal are incomplete. because they were taken from another text that did not cite their full details. the reference the citing text is given. Basic reference texts A. number of basic reference texts are quoted in most of the ~ateria medica chapters in this book. Such basic texts are given a superscript reference number only on their first mention.

Abbreviations Some of these basic texts are given abbreviations. such as 'BHP' for the British Herbal Pharmacopoeia . Others are given brief designations such as 'Grieve' for A Modern Herbal by M. Grieve. The reader is referred to the explanation of reference notations given in Sources in the front matter of this book.

Achillea Botanical name Achillea millefolium L. Family Asteraceae (Compositae) Pharmaceutical name Millefolii herba cum flore Part dried aerial parts with flowers English yarrow German Schafgarbe French millefeuille Mandarin yang sill cao (5f f :¥-) aerial parts ofA. millefolium L.

• diaphoretic and antipyretic for the common cold, influenza, and fever

• anticatarrhal for sinusitis or sinus congestion with headache

• bitter digestive tonic and cholagogue for loss of appetite and biliary disorders

• gastrointestinal anti-inflammatory and antispasmodic for indigestion, epigastric distension, flatulence, and intestinal colic • antihypertensive for hypertension and sequelae of CVA • diuretic and urinary antiseptic for urinary retention or cystitis • emmenagogue for amenorrhea or menstrual irregularities • astringent and antihemorrhagic for urinary incontinence, diarrhea, menorrhagia, or leukorrhea • vulnerary and topical anti-inflammatory for slow-healing wounds and skin inflammations

Achillea is a fascinating herb. Study of Achillea can show how the use of a herb in the Roman armies of the emperor Nero has been continued down a line of tradition to the present day; how differences in the use of a herb can be linked to chemical differences relating to variation in chromosome number; and how Native American use can be related both to traditional Chinese medicine and to modern biochemistry. Use in the West Yarrow has been used in Europe since at least the time of Dioscorides.\ As a doctor with the Roman army, he used it for healing wounds, an important use for soldiers, hence the old name wound wort. He wrote 'pound the leaves and put them on a fresh wound to close and heal it, to clear heat and inflammation from the wound, and to congeal the blood: Dioscorides also used Achillea for dysentery, which until relatively recently, whether associated with cholera or other causes, killed as many soldiers as did steel and lead. Yarrow now has one of the widest ranges of applications of any herb used in the West. It is used for disorders of the respiratory, digestive, hepatobiliary, cardiovascular, urinary, and reproductive systems. For example, it can be used as a:

Yarrow is one of my favorite herbs. On mountain walks, I have found that chewing the freshly gathered leaves can reduce the dizziness of altitude sickness, allay the weakness of sunstroke and the effects of dehydration, and give increased endurance. The fresh leaves also seem to clear the mind and help concentration. Use in China According to Perry,! the uses of A. millefolium seem to have originated in European folk medicine, with subsequent transfer to the East. The nature of the entry for yang sill cao in the Chinese Herbal Medicine Dictionary' also gives this impression. It did not list the meridians entered, but it gave much information on chemical constituents and pharmacology.

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Combining Western Herbs and Chinese Medicine

166 Species and subspecies

CHINESE ACTIONS

Nomenclature The name Achillea millefolium has been applied to a complex of barely distinguishable species or subspecies, which have evolved by polyPloidy (changes in chromosome number). This has resulted in some confusion in nomenclature. 4 Unless otherwise stated, the name Achillea is used in this chapter to means A. millefoliu~, without differentiation between the different subspecies (see discussion at the start of the section on Research).

In terms of Chinese medicine, Achillea, as used in the West, can be said to have three main actions:

Chromosome number and chemical differences What is interesting to the herbal practitioner is that differences in chromosome number between the A. millefolium subspecies are often accompanied by important chemical differences,s which, in their turn, may lead to differences in temperature, actions, and uses. This is discussed in this chapter: • in the Limitations section under Circulatory stimulant • in the Research section under Constituents • in the Traditional sources section under Temperature

What is special about Achillea

I. clear Exterior Wind II. tonify Deficiency III. clear Heart Phlegm

WESTERN ACTIONS Achillea can be said to have three main action groups, which are listed below and related to their corresponding Chinese action:

• diaphoretic • tonic • antihypertensive

clear Exterior Wind tonify Deficiency clear Heart Phlegm

The individual actions included in each of the three main Western action groups are shown in the table below, and the leading action in each group has been italicized: Chinese actions '.- .-. I. clear Exterior Wind

diaphoretic antipyretic anticatarrhal alterative

II. tonify Deficiency

The key to understanding Achillea is that it is a variabletemperature herb with a very wide range of potential actions and uses. This is associated with its unusually wide range of active constituents, including essential oils, sesquiterpene lactones, flavonoids, alkaloids, polyacetylenes, sterols, phenolic acids, coumarins, and tannins.

tonic bitter digestive tonic astringent tonic emmenagogue

III. clear Heart Phlegm

antihypertensive antilipidemic antithrombotic circulatory stimulant

VARIABLE TEMPERATURE

ACTION GROUPS

Achillea can be said to have a range of potential temperature effects from cool to warm. Whether Achillea acts as cool, neutral, or warm in temperature can depend on the situation:

Achillea is a good example of an herb with multiple actions in which the actions may work together in groups. _ Three Western action groups are discussed below.

In terms of Chinese medicine, Achillea millefolium, as used in the West, can be said to be a warm-cool, acrid, and bitter herb that has its main effects on Lung, Spleen, Heart, and Uterus.

• cool • neutral • warm

diaphoretic and antipyretic for influenza or fever to clear Wind Heat bitter digestive tonic for atonic digestion to tonify Spleen Qi diaphoretic and anticatarrhal for influenza with sinus- headache .. and chills to clear Wind Cold Damp

The temperature effect manifested can also .depend on the herbs with which Achillea is combined.

Diaphoretic Whilst the diaphoretic action of Achillea may be primary, it is usually modified by one or n:ore of the other actions of this herb, so tha: the actions work together as a group. The diaphoretic action may be modified by one or more of the following actions: • antipyretic • anticatarrhal • alterative • circulatory stimulant • bitter digestive tonic

Achillea Examples of action pairs are given below. but in practice, three or more actions may be in simultaneous operation. In each example, the Chinese actions are linked to the corresponding Western actions.

Diaphoretic + antipyretic For example, Achillea can be used for influenza with fever. The diaphoretic action, increased sweating. can help to clear \V"md Heat from the Exterior. The antipyretic action can help to clear Wind Heat from the Exterior and Excess Heat or Deficiency Heat from the Interior. Diaphoretic + anticatarrhal For example, Achillea can be used for influenza with sinus congestion. The diaphoretic action can help to clear Wind Cold from the Exterior and the anticatarrhal action can help to clear Phlegm from the head and reduce sinus congestion and associated sinus headache. Diaphoretic + alterative For example, Achillea can be used to treat recurring fever. The diaphoretic action can help to clear Wind from the Exterior, to treat the acute phase, and the alterative action can help to clear Retained Pathogen from the body surface, thus helping to prevent recurrence of the condition. Diaphoretic + circulatory stimulant For example. Achillea can be used to treat influenza with poor circulation at the body surface. The diaphoretic action of Achillea to clear Wind Cold from the Exterior may be assisted by its capacity to dilate the peripheral arteries and increase blood flow to the surface. In Chinese terms, this can be described as moving Qi and Blood in the surface channels and vessels. Diaphoretic + bitter digestive tonic For example, Achillea can be used to treat influenza with debility associated with digestive weakness. In this situation. Wind invasion may be facilitated by Deficiency of Defensive Qi. By acting as a bitter digestive tonic, Achillea may help to tonify Spleen Qi and also Defensive Qi, thus reducing Wind invasion. This can complement the diaphoretic action of clearing Exterior Wind. Tonic Achillea can be said to have four aspects to its tonic action, which are shown below with their Chinese equiva-

167

Digestive and general tonic The bitter digestive tonic action of Achillea, which increases the efficiency of digestion and assimilation, may indirectly result in general tonic action. In Chinese medicine terms. tonifying the Spleen can lead to an increase in Qi and Blood. Immune system tonic The general tonic action of Achillea. which strengthens Qi and Blood, can combine with its diaphoretic and circulatory stimulant actions at the surface of the body to strengthen the circulation of Defensive Qi. This reduces Wind invasion, leading to a reduction in the number of recurring respiratory infections. Convalescent tonic The tonic, alterative, and antipyretic actions of Achillea can combine to treat recurring subacute fever or chronic feverishness and speed postfebrile recovery. Achillea can help to tonify Yin and clear Deficiency Heat associated with Deficient Yin. It can also help to clear Retained Pathogen, thus normalizing the circulation of Defensive Qi and assisting recovery. Antihypertensive The following actions of Achillea may combine to normalize the function of the circulatory system and contribute to an overall antihypertensive effect: • circulatory stimulant • anticatarrhal and antilipidemic • antithrombotic

Circulatory stimulant Achillea has a tradition of use to dilate the peripheral arteries. increase the flow of blood to the surface, 'equalize the circulation; and thus help to lower blood pressure. Anticatarrhal and antilipidemic These actions can combine to reduce excessive lipid levels in the blood and to reduce deposition of fatty material on the walls of the arteries. Reduction of atherosclerosis may assist treatment of hypertension. In terms of Chinese medicine, the anticatarrhal and antilipidernic actions can result in a reduction of Phlegm in the body and in the vessels. This can assist in the reduction of Heart Phlegm and improve circulation of Heart Blood.

lents:

-,-

Antithrombotic Formation of atheroma may limit blood circulation and predispose to thrombosis. Achillea may help to reduce thrombosis by reducing excessive blood lipids, and may help to treat associated hypertension.

I. bitter digestive tonic

tonifies Spleen Deficient Qi

II. general tonic

tonifies Qi and Blood

III. immune system tonic

tonifies Defensive Qi

WESTERN USES

IV. convalescent tonic and

tonifies Yin clears Deficiency Heat clears Retained Pathogen

The Western uses of Achillea relate to its three main Chinese action groups:

antipyretic

168

Combining Western Herbs and Chinese Medicine .- ---.": -

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Chinese actions ·~-'c-:=:::':::-Westemuses --:-:-.: '~--.~:-::-:::::, ···c.;- 7 I. clears Exterior Wind

colds, influenza, acute fever, recurring fever, low-grade fever, rhinitis, sinusitis, sinus headache, bronchitis

II. tonifies Deficiency

exhaustion, anemia, poor appetite, postfebrile debility, debility with night sweats, chronic fatigue sync drome, atonic amenorrhea, loose stools, atonic menorrhagia

III. clears Heart Phlegm

poor peripheral circulation, hypertension with atherosclerosis, sequelae of eVA

Other uses Achillea can have the following secondary actions and uses: • antispasmodic for abdominal distension, intestinal colic, and flatulence .• anti-inflammatory for gastroenteritis • cholagogue for hiliary disorders • diuretic and urinary anti-inflammatory for inflammation and catarrh of the urinary tract • emmenagogue for amenorrhea or irregular menstruation • astringent and antihemorrhagic for excessive sweating, diarrhea, menorrhagia, or leukorrhea • vulnerary and topical for slow-healing wounds, skin inflammations, nosebleeds, varicose veins, hemorrhoids

DIRECTION OF ENERGY When taken as copious hot infusions, Achillea is an excellent example of a surface-active herb with an outward, diffusive, opening effect. However, when taken cold, other effects may become dominant, such as the tonic or diuretic actions, and the outward movement is reduced.

TYPICAL CASE EXAMPLE Signs and symptoms The patient has debility, poor appetite, poor peripheral circulation, frequent colds and influenza, which usually occur with sinus congestion and sinus headache. She also has recurring subacute febrile episodes and some night sweats, especially when she is particularly tired. She also tends to have amenorrhea.

and accumulation of Phlegm, with some Stagnation of Qi -:c.:. _"~-: ~_ and Blood. A mix of Deficiency, Stagnation, and Phlegm -'~~ Damp in the Uterus may be contributing to the amenorrhea.~:-' Choice of Achillea This herb can clear Exterior Wind to treat the influenza, clear Phlegm to treat the sinusitis, clear Retained Pathogen to treat the recurring febrile episodes, tonify Spleen Qi to treat poor appetite and debility, tonify Defensive Qi to reduce the incidence of Wind invasion, and move Qi and Blood to treat the poor peripheral circulation.

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Limitations ofAchillea TEMPERATURE Although Achillea can be used for high fever, it is not a cold herb in the sense that it depresses the metabolism of the body. Therefore, its range has been classified in this !?ook as warm-cool, rather than warm-cold. Also, it can be termed warm in the sense that it can help to clear Wind Cold from the surface, but it is not an herb that can rapidly increase body temperature, such as Capsicum or Zingiber.

TASTE The predominant taste properties of Achillea are acrid and bitter. This distinguishes Achillea from Berberis, for example, which is simply bitter, or from Rosmarinus, which is bitter, acrid, and aromatic. Acrid taste property Achillea is an acrid herb to clear Pathogens from the Exterior, rather than an acrid herb to warm the Interior. Bitter taste property Like Gentiana or Centaurium, Achillea can act as a bitter digestive tonic. However, it is not as effective a bitter anti-inflammatory for the digestive and hepatobiliary systems as Berberis or Hydrastis.

ACTIONS

The pulse is empty, especially at the superficial depth, and is also slippery and slightly wiry. The tongue is flabby, pale, and slightly purple, with a greasy white coat.

Diaphoretic Achillea is an excellent diaphoretic with a very wide range of complementary actions. However, for maximum diaphoretic effect, it should be taken as a hot infusion and combined with warmer diaphoretics, such as Zingiber.

Diagnosis There is Deficient Qi, especiallyDeficient Defensive Qi, which allows for frequent Wind invasions. There is some Retained Pathogen, a slight amount of Deficient Yin,

Antipyretic Achillea cools the body by diaphoresis and by increasing peripheral circulation, rather than by sedation of metabolism. It is especially useful for fever accompanied by

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Achillea Deficiency and Stagnation. For acute severe fever with Excess, a colder more sedative herb, such as Asclepias, may be preferred. Anticatarrhal Achillea is specific for oversecretion of mucus by the membranes of the upper respiratory system as seen in acute or subacute cold or influenza. I do not consider Achillea as effective an anticatarrhal for the gastrointestinal, hepatobiliary, or urogenital systems as is Hydrastis. Alterative The main alterative action of this herb is characteristically linked to its diaphoretic, and anticatarrhal actions. It is not an alterative in the sense that it is a strong cleanser of liver or kidneys, like Tara..xacum.

,-""

Digestive tonic The bitter digestive tonic action of Achillea can be used to treat debility during convalescence, recurring febrile episodes with debility, and anorexia occurring with amenorrhea. However, Gentiana or Artemisia may be more effective for digestive and hepatobiliary weakness. Circulatory stimulant The term circulatory stimulant is an approximation.in the case of Achillea. This herb is not a hot acrid herb to warm the Interior like Capsicum or Zingiber. The effect of Achillea on peripheral circulation may be due to the combination of its diaphoretic, mild circulatory stimulant, antihypertensive, and alterative actions.

Camphor and chromosome number The strength of the warming circulatory stimulant action of Achillea may depend partly on the camphor content, and this may vary with the chromosome number of the subspecies. The hexaploid subspecies of Achillea can contain 0.2-1% essential oil, of which camphor can be 18%, whereas the tetraploid subspecies do not contain appreciable amounts of camphor.6 One of the reasons that Rosmarinus is a stronger warming circulatory stimulant than Achillea may be that Rosmarinus contains more camphor than Achillea: Rosmarinus has 1-2.5% essential oil, of which 15-25% can be camphor.7 Astringent and hemostatic Achillea has mild astringent properties anq has been used as a vulnerary for bleeding wounds, fistulas, ulcers, diarrhea, leukorrhea, menorrhagia, melena, and epistlUis. I do not consider Achillea as effective as Quercus or Potentilla, or even Geranium or Capsella, and I would use it as a secondary astringent or hemostatic. Emmenagogue I consider this to be a secondary action of Achillea. Artemisia abrotanum would be more effective both as a bitter tonic and as an emmenagogue for amenorrhea with anorexia and exhaustion.

169

Antihypertensive Achillea has not been reported to produce significant rapid reductions in blood pressure. Rather, it can be used long-term to assist gradual reduction of hypertension, especially when this is associated v:rith atherosclerosis and thrombosis.

Achillea paired with other herbs Discussion of the limitations of each of the main actions of Achillea can be useful to clarify just what this herb can and cannot do. However, suitable combination with other herbs can extend the range of use of Achillea beyond its limitations as a single herb. The basic unit of herb combination is the herb pair. Twelve pairings of Achillea with other herbs are briefly explained below. CAUTION

Before using any of the herb pairs below, it is important to be familiar with the cautions listed for each herb in the pair. Achillea + Eupatorium perfoliatum

Influenza + myalgia Warm Eupatorium emphasizes the warming diaphoretic action of Achillea to dear Wmd Cold. Eupatorium is specific for influenza with a deep aching sensation. Achillea + Salvia officinalis

Influenza + headache Achillea can treat headache via its diaphoretic and anticatarrhal actions. Salvia is specific for headache and for muscle ache at the surface of the body associated with a combination of Exterior Wmd and nervous tension. Achillea + Angelica archangelica

Influenza + sinus congestion Warm, dry Angelica emphasizes the anticatarrhal diaphoretic action of Achillea to clear Wind Cold and Phlegm Damp from the head and sinuses.

Caution This pair is potentially drying and should be used with caution for patients with a tendency to dryness of the sinuses. Achillea + Mentha piperita

Influenza + sore throat Cool Mentha emphasizes the potential action of Achillea to clear Wind Heat and contributes its own specific antiinflammatory effect on the throat. Therefore, this pair can be used to treat influenza with laryngitis.

Combining Western Herbs and Chinese Medicine

170 Achillea + Asclepias

Influenza +fever Cold Asclepias emphasizes the antipyretic action of Achillea and contributes expectorant, antispasmodic, and sedative actions. Therefore, this pair can treat acute pleurisy or bronchitis. Achillea + Echinacea

Recurring influenza Echinacea emphasizes the anticatarrhal, alterative, and diaphoretic actions of Achillea to clear Retained Heat and treat recurring respiratory infections. Also, both herbs can act as tonics to speed recovery after a fever or infection.

phasizing the bitter digestive tonic action of Achillea. Artemisia can also strengthen the emmenagogue action of Achillea so that the pair can be used to treat amenorrhea with anemia. Achillea + Capsella

Menorrhagia + debility Capsella emphasizes the astringent and hemostatic -";'\ actions of Achillea to reduce diarrhea or abnormal uterine bleeding. Achillea can help to treat debility by acting as a bitter digestive tonic.

Achillea combinations

Achillea + Pseudostellaria

Debility + low-grade febrile episodes Moist, sweet Pseudostellaria complements the bitter . digestive tonic action of Achillea and moderates its slightly drying effect. Therefore, this pair can be used for postfebrile recovery. Achillea + Marrubium

Six Achillea combinations are discussed below:

1. influenza + sore throat

Wind Heat

2. influenza + sinusitis

Wind Cold Damp

3. recurring fever + exhaustion

Retained Pathogen + liver Deficient Qi

4. recurring fever + respiratory infection

Retained Pathogen + Deficient Defensive Qi

5. amenorrhea + exhaustion

Deficient Blood and Qi --

6. atherosclerosis + hypertension + cold extremities

Heart Phlegm Cold + Heart Stagnant Qi

Debility + digestive weakness Bitter Marrubium emphasizes the bitter digestive tonic action of Achillea and directs Achillea to the Lungs where the expectorant action of Marrubium adds to the anticatarrhal diaphoretic action of Achillea. This pair can be used for digestive and general weakness with bronchial phlegm. Achillea + Zanthoxylum

Debility + poor circulation Warm Zanthoxylum emphasizes the anticatarrhal, circulatory tonic, diaphoretic, and antirheumatic actions of Achillea. As a result, this pair can treat weak patients with rheumatism or arthritis and poor peripheral circulation. Achillea + Crataegus

CAUTION

Before using any of the combinations below, it is importanr •., to be familiar with the cautions listed for each herb in the combination. 1. Influenza + sore throat

Wind Heat

Hypertension Herb

Crataegus can be said to direct Achillea to the heart and circulatory system, and emphasizes its antiatheromatic, antithrombotic, and antihypertensive actions. This pair can be used to treat cardiac weakness and exhaustion, poor circulation, labile blood pressure, hypertension, and the sequelae of CVA. A~ea + Artemisia spp~

Amenorrhea + debility The Artemisia species, especially A. absinthium, are aromatic bitter herbs that can indirectly tonify Blood by em-

Achillea Mentha pip. Sambucus

Daily dose

Temperature

Taste

6g 3g 3g

warm-cool warm-cool cool

acrid, bitter acrid, aromatic acrid. sl. bitter

GENERAL This is one of the best-known infusions for acute cold: or influenza associated with Wind Heat, and has been rec:: ommended by Grieve,S Christopher,9 and the BHP.IO Christ opher used either Sambucus nigra or S. canadensis. In tht context of a Wind Heat condition, the overall temperature is-

---

Achillea cool. For cold conditions, Zingiber can be added. This is an acrid combination to clear Exterior Wind with secondary bitter and aromatic properties to normalize digestion. USE

• acute cold or influenza • acute influenza with sore throat • influenza with acute rhinitis PRACTICAL NOTES

The amount of herbs given in the table is enough to make about 3 cups of infusion (see the chapter on Dose). The herbs are steeped in boiling water for about 10-15 minutes, then strained and drunk warm. The hot infusion is given in large amounts, for example, 0.5-1 cup, every 0.5-2 hours, until the patient is perspiring freely. The patient should be well wrapped in warm clothes and in bed. If more than 3 cups of this tea are required in a single day-and this is quite common-more infusion can be made. This combination should break the cold or influenza within 1-2 days. If it does not, then a different combination or treatment is required. This combination is for short-term use only, during the acute phase.

Caution. Patients should be warned that, once they are perspiring freely, they should keep warm and avoid exposure to cold and wind, or the condition may be worsened.

171 • acute bronchitis with sinusitis

PRACTICAL NOTES

The amount of herbs given in the table is enough to make about 3 cups of infusion (see the chapter on Dose). The herbs are steeped in boiling water for about 10-15 minutes, then strained and drunk warm. The hot infusion is given in large amounts, for example, 0.5-1 cup may be given every 0.5-2 hours until the patient is perspiring freely and there is relief of sinus congestion and headache. The patient should be well wrapped in warm clothes and in bed. If more than 3 cups of this tea are required on the fIrst day, more infusion can be made. Once the symptoms improve, ha~f a cup can be taken three times per day for up to 3 days. After 3 days, it may be appropriate to change to a less diaphoretic combination.

Caution Patients should be warned that, once they are perspiring freely, they should keep warm and avoid exposure to cold and wind, or the condition may be worsened. 3. Recurring fever + exhaustion

Retained Pathogen + Liver Deficient Qi Herb Achillea Artemisia abs. Gentiana

2. Influenza + sinusitis

Berberis

Wind Cold Damp

Pseudostellaria Glycyrrhiza Zingiber

Herb Achillea Angelica arc. Sambucus Euphrasia Zingiber

Daily dose

Temperature

Taste

3g 3g 3g 3g 3 slices

warm-cool warm cool neutral-cool hot

acrid, bitter bitter, acrid, aromatic acrid, 51. bitter acrid, sour, bitter acrid, aromatic

GENERAL This combination can be used as a strong infusion for Wind Cold invasion with Phlegm Damp. It is a warm combination that can be used for Wind Cold patterns. For Wind Heat patterns, Angelica and Zingiber can be removed and Echinacea added. This is a combination that is acrid both in the sense of clearing Exterior Wind and in the sense of warming the Interior. USE

• acute influenza with sinus congestion and headache

Ratio

Temperature

1 1 1 1 1 0.5 0.5

warm-cool

acrid, bitter

warm-cool

bitter, aromatic

neutral-cool

bitter

cool

bitter

neutral

sweet, 51. bitter

Taste

neutral-cool

sweet

hot

acrid, aromatic

GENERAL This combination is for Retained Pathogen associated with Liver DefIcient Qi. The combination treats recurring fever with exhaustion associated with weakness of liver function and the inability of the liver to complete detoxification. The overall temperature of the combination is neutral to treat warm, neutral, cool, or mixed conditions. The acrid property assists clearance of Retained Pathogen at the surface, the bitter property assists strengthening of the Liver to assist in the detoxification, and the sweet property has a tonic function. USE

• recurring febrile episodes with exhaustion following a disease such as malaria, drug abuse, or prolonged multimedication

.. ,ojj -~-\

",;,;;,.

Combining Western Herbs and Chinese Medicine

172

F• • exhaustion with recurring infections as in some patterns of chronic fatigue syndrome • exhaustion with gastrointestinal and hepatobiliary weakness after a fever

• recurring low-grade fever and respiratory infections

,~.~~~-::-=--J

• postfebrile exhaustion

4. Recurring fever + respiratory infection

Retained Pathogen + Deficient Defensive Qi

l:'~rpJ.~;i~:g~i1~~~ii~~i~Jt~EL;I~,~~e~~~~

0.5 0.5 0.5

'"

.'::"';j;-

This combination can be taken as 2.5-5 ml of 1:5 tincture in quarter of a cup of warm water, three times per day. It can be taken for 1-2 months, with appropriate breaks and modifications during the subacute or remission phase. During the acute phase, Pseudostellaria can temporarily be omitted from the combination.

1 1 1 1

~

with exhaustion as seen in some patterns of chronic -... wc,fatigue syndrome, fibromyalgia, or H I V _ : ~ ~

PRACTICAL NOTES

Achillea Echinacea Thymus Pseudostellaria Panax qui. Glycyrrhiza Zingiber

,>:::

."-~

warm-cool cool warm-eool neutral neutral neutral-eool hot

acrid, bitter acrid, bitter, sl. sweet aromatic sweet, sl. bitter sweet, sl. bitter sweet acrid. aromatic

PRACTICAL NOTES

This combination can be taken as 5 ml of 1:5 tincture in quarter of a cup of warm water, three times per day. It can be taken for 1-2 months, with appropriate breaks and modifications during the subacute or remission phase. During the acute phase, Glycyrrhiza can be omitted from the combination and the proportion of Pseudostellaria reduced to 0.5. Alternatively, a combination for Wind invasion, such as a modification of Achillea: influenza + sore throat, may be more appropriate, depending on the diagnosis.

"" ~"

...

-.

-"'~'-­

5. Amenorrhea + exhaustion

Deficient Blood and Qi

.-_.,-~.

~.;"'"

'$

GENERAL

This combination is for patterns with a mixture of the following syndromes: • Retained Pathogen • Deficient Defensive Qi • Deficient Lung Qi • Deficient Kidney Qi • Deficient Fluids This is a more or less neutral-temperature combination. whi~h can be used for neutral-warm conditions. The acrid constituents help to clear Retained Pathogen from the surface, the sweet constituents tonify Defensive Qi, Lung, and Kidney, and the bitter constituents help to strengthen digestion. This combination is especially useful for postfebrile exhaustion or the remission phase of recurring fever when these conditions are associated with Deficient Qi and Fluids. For recurring respiratory infections turning into lingering bronchitis, Thymus: recurring respiratory infection would be a more appropriate combination. For postfebrile exhaustion with digestive weakness, Cinchona: digestive weakness + postfebrile exhaustion would be more suitable. USE

During the subacute or remission phase for:

GENERAL

This combination is·for Deficient Spleen, Deficient Qi and Blood, and Deficient and Stagnant Qi and Blood of the Uterus, with some Disturbance of Spirit. It is a neutral combination, which can be used for warm, neutral, or cool conditions. It is a bitter and aromatic combination in which the bitter taste is associated with tonification of the digestive and circulatory systems, and the aromatic property contributes to the moving and relaxing effects. USE -'

• amenorrhea with anorexia. atonic digestion, and anemia • amenorrhea with debility and nervous tension PRACTICAL NOTES

Although his combination can be taken as an infusion, it is most conveniently taken as 5 rnl of 1:5 tincture in quarter of a cup of warm water, three times per day. The combination can be used. with appropriate breaks and modifications, _, for up to 2 months.

Achillea 6. Atherosclerosis + hypertension + cold extremities

Heart Phlegm Cold + Heart Stagnant Qi Herb"

. "'~:Ratio".Temperature . Taste-

Achillea Crataegus Salvia mil. Angelica sin. Zanthoxylum (bark) Commiphora Zingiber Capsicum

1 1 1 1 1

warm-cool sl. warm cool warm

1

warm

acrid. bitter sour. sweet bitter sweet. aromatic, bitter acrid, aromatic, bitter

hot

0.5 5-20 drops

acrid, bitter acrid. aromatic

hot hot

acrid

GENERAL

This combination is for Heart Stagnant Qi and Blood with Phlegm and Cold obstructing the channels and vessels of the Heart and body. It is a hot combination for cold or cool conditions. The acrid and aromatic properties are important to warm and move Qi and Blood and to clear Cold and Phlegm from the channels; they are assisted by individual constituents in Commiphora, Crataegus, and Salvia.

173

1. This infusion is an excellent general diaphoretic, antipyretic, and anticatarrhal combination. Achillea is the primary herb and the strongest diaphoretic and antipyretic of the three. Sambucus emphasizes the anticatarrhal action of Achillea and directs its action toward the sinuses. Mentha has an anti-inflammatory action on the throat and a carminative action on the digestive system. Also, both Achillea and Mentha can assist the liver function in order to speed recovery.

2. Combination No.2 differs from combination No.1 by being specifically directed to the sinuses and head. Also, the previous combination is especially for Wind Heat, whilst the warming and drying herbs Angelica and Zingiber make this combination more for sinusitis with Wind Cold, Damp. and Phlegm. Achillea, Euphrasia, and Sambucus also help to clear Phlegm from the head and sinuses. 3. Recurring fever +. exhaustion

4. Recurring fever + respiratory infection

Retained Pathogen + Liver Deficient Qi

Retained Pathogen + Deficient Defensive Qi

'Heib':~' ·~·;~/";:5~~ti6>·

USE

• tendency to atherosclerosis with hypertension • chest pain from heart disease with cold extremities PRACTICAL NOTES

This combination can be taken as 2.5-5 ml of 1:5 tincture in quarter of a cup of warm water, three times per day. The Capsicum is given in a separate bottle so that the requisite number of drops of Capsicum can be added to each dose of the main medicine. It can be taken, with appropriate breaks and modifications, for 1-2 months, providing the patient is monitored for aJ:.ly adverse reactions to Capsicum and for any adverse increase in symptoms of heat.

COMPARISON OF THE SIX ACHILLEA COMBINATIONS 1. Influenza + sore throat

2. Influenza + sinusitis

Wind Heat

Wind Cold Damp

Achillea

6g

Achillea

Mentha pip.

3g

Angelica arc.

Sambucus

3g

Sambucus Euphrasia

3g 3g 3g 3g

Zingiber

3 slices

Gentiana Berberis Pseudostellaria

1 1 1 1 1

Glycyrrhiza Zingiber

0.5 0.5

Achillea Artemisia abs.

Herb Achillea Echinacea Thymus Pseudostellaria Panax qui. Glycyrrhiza Zingiber

1 1 1 1

0.5 0.5 0.5

3. Artemisia. Gentiana, and Berberis, assisted and mod-

erated by Zingiber and Glycyrrhiza, can tonify and move Liver Qi, clear accumulation of Liver Heat and Liver Damp Heat, and help to clear Heat Toxins and Retained Pathogen from the body. Achillea and Zingiber can help to clear Retained Pathogen from the body surface, and, with Pseudostellaria and Glycyrrhiza, can help to strengthen the energy of the body and thus of the body surface. 4. Combination No.3 focuses on clearing Retained Pathogen by strengthening the Liver, whilst combination No.4 focuses primarily on tonifying Deficiency of the Lung and Kidney. Achillea, Echinacea, Thymus, and Zingiber are included to clear Retained Pathogen from the surface, to clear Lung Phlegm and to tonify the Lung. The sweet herbs Pseudostellaria, Panax, and Glycyrrhiza, as a group, can tonify both Lung and Kidney Qi. Strengthening the Lung and Kidney can help to clear Pathogens from the surface and the Lung, thus, assisting in the recovery and reducing the incidence of both febrile episodes and infections.

Combining Western Herbs and Chinese Medicine

174 5. Amenorrhea + exhaustion

6. Atherosclerosis + hypertension + cold extremities

Deficient Blood and Qi

Heart Phlegm Cold + Heart Stagnant Qi

Herb

Achillea Artemisia abs. Ruta Leonurus Angelica sin. Gentiana Zingiber

Ratio 1 1 1 1 1 1 1

-

;Herb

Ratio

Achillea Crataegus Salvia mil. Angelica sin. Zanthoxylum (bark) Commiphora Zingiber Capsicum

1 1 1 1 1 1 0.5 5-20 drops

...

,.~

5. Artemisia, Ruta, and Leonurus are the primary herbs in combination No.5, which makes this combination specific for amenorrhea with _exhaustion and nervous tension. Artemisia and Gentiana provide the main bitter tonic action, helping to treat anemia, supported by Achillea, which also has a secondary emmenagogue effect. The sweet, bitter, and aromatic constituents of Angelica sinensis may combine to strengthen the blood. Zingiber warms and moves Qi and Blood in the Uterus and directs other herbs to this system. 6. This combination lacks the emmenogogues Artemisia, Ruta, and Leonurus, present in combination No.5. Instead it contains Salvia and Crataegus, which combine with Achillea to reduce formation of atheroma, the fatty degeneration of the inner coat of arteries, thus reducing cerebrovascular or cardiovascular incidents. Commiphora, Zanthoxylum, Zingiber, and Capsicum together can reduce the incidence of Phlegm obstruction of the channels and warm and move the Blood to improve peripheral circulation. Achillea, Crataegus, and Capsicum can combine to reduce hypertension. OTHER ACHILLEA COMBINATIONS

• Asclepias: acute respiratory disorders + fever • Asclepias: influenza + fever • Capsella: menorrhagia + anemia • Crataegus: atherosderosis + hypertension • Hamamelis: varicose veins • Salvia: excessive sweating + exhaustion • Salvia: headache + myalgia

Research In taxonomy, the phrase sensu lato (s.1.) can mean interpretation of a species in the broad sense. The phrase sensu stricto (s.s.) can mean interpretation of a species in the narrow sense. 1I

";':;'"k-'-

...

~

'-=-~.-=..--

The name Achillea L. s.1. refers to A. millefolium in the."C:.::: ._~, broad sense, without differentiation between the subspecies. The name A. millefolium L. s.s. refers to A. millefolium L. ssp. millefoliurn, which is the most widespread subspecies. Research reported under the name 'A. millefolium' may refer to A. millefolium s.s. or it may refer to any number of other Achillea species which have been more recently and narrowly defined. 4 CONSTITUENTS The following constituents have been reported: • essential oil • sesquiterpene lactones • flavonoids • alkaloids • tannins • other Essential oil Achillea can contain 0.2-1 % essential oil, which may contain 0-50% chamazulene. 12 The percentage of chamazulene and the general composition of the essential oil fraction vary greatly with the chromosome number of the plant material.

Hexaploid plants The most common subspecies of Achillea is A. millefolium L. ssp. millefolium, which is hexaploid and has no chamazulene. 13 The main components of the essential oil of hexaploid plants are oxygenated monoterpenes, especially linalool (26%) and camphor (18%), with some ~ borneol and 1,8-cineole.5

Tetraploid plants The main components of the essential oil _ of tetraploid plants are generally sesquiterpenes, mainly chamazulene (about 25%) and ~-caryophyllene (11-22%).5 Tetraploids may also contain monoterpenoids such as ~- _ pinene (23%) and a-pinene (5%).14 Usually, only tetraploid plants contain chamazulene. 15 Sesquiterpene lactones The guaianolide sesquiterpene achillicin (8-acetoxyartabsin)is considered to be the main prochamazulene. 16 Matricin is sometimes cited in the literature, but has not been found. 17 Flavonoids A. millifolium may contain apigenin and luteolin and their glucosides.' 8 A. pannonica has been reported ~ to contain rutin and glucosides of apigenin, luteolin, and acacetin. 19 Alkaloids Achillea can contain a range of alkaloids and other bases, mainly achilleine (betonicine or L-4-hydroxystachydrine) as well as stachydrine, betaine, and choline. 20 Tannins

Achillea can contain 3-4% tannins. 21

"'" -Achillea Other Achillea also contains polyacetylenes, triterpenes, sterols (including f)-sitosterol), coumarins. and phenolic acids (including salicylic and caffeic acids).21 Wichtl also listed the cyanogenic glycoside prunasin.

175

Antihypertensive and antilipidemic

A recent doubleblind

placebo-controlled clinical trial using tincture of A. wilhelmsii C. Koch demonstrated antihypertensive and antilipidemic effects. 15-20 drops twice daily of placebo or A. wilhelmsii tincture were given to the patients for over 6 months. Within this time, there was a significant decrease in triglycerides, total cholesterol, and LDL cholesterol, and an

PHARMACOLOGICAL AND CLINICAL RESEARCH

increase in HDL cholesterol. A significant decrease was

The following effects have been reported:

observed in diastolic and systolic blood pressure. 3l

• antibacterial and antifungal • anti-inflammatory • antispasmodic • antihypertensive and antilipidemic

hypertension, including cerebral and coronary thromboses, but I have not yet seen research support for antithrombotic

• choloretic • astringent and hemostatic

folium may help to clear blood clots and also help to reduce

• antitumor • antispermatogenic

The BHp32 listed Achillea for thrombotic conditions with

activity. Mabey3 suggested that the flavonoids in A. milleblood pressure by dilating the peripheral arteries, that the alkaloid fraction may also lower blood pressure, and that the I

Antibacterial and antifungal Extracts of A. millefolium have demonstrated antimicrobial activity against a range of bacteria. Z2 Essential oil from A. fragrantissima was found to have inhibitory effect on various bacteria and Candida albicans. 23 Linalool, found at up to 26% of the essential oil fraction in hexaploids. which are the most common subspecies of A. millefolium. has been shown to inhibit 17 types of bacteria and 10 fungi. 24 Extract of A. atrata subsp. multifida was shown to inhibit Candida albicans and Bacillus subtHis in vitro. Some flavones isolated from this plant were shown to inhibit C. albicans, whilst other flavones inhibited B. subtilis as well. 25 Anti-inflammatory Chamazulenes and prochamazulenes have demonstrated anti-inflammatory activity.26 Sesquiterpene lactones from A. setacea, rupicolin B and 1l,13-dehydrodeacetylmatricarin, have shown anti-inflammatory activity.27 According to Wichtl,I7 the a-methylene-y-lactone group is essential for the anti-inflammatory activity of the sesquiterpene lactones. Topical administration of a preparation of A. millifolium has demonstrated anti-inflammatory activity in rodents, attributed to a protein-carbohydrate complex. 26 A study using rats demonstrated anti-inflammatory activity of an A. santolina ethanol extract. 28 In a study using mice, it was found that the chloroform extract ofA. ageratum, and also of its components stigmasterol and ~-sitosterol, had topical anti-inflammatory effect, more in the acute than in the chronic phase.29 Antispasmodic Antispasmodic action may be due to flavonoids,4 including apigenin.26 Cirsili~l, a flavone isolated from A. fragrantissima, can have a concentration-dependent relaxing effect on isolated rat ileum. 30

cyanogenic glycoside may slow the heart beat via the vagus nerve. Choloretic

The BHC stated that the bitter properties are

due to the sesquiterpene lactones and the alkaloids. Choloretic activity has been demonstrated in animal experirnents. 34 Astringent and hemostatic The alkaloid achilleine has a hemostatic action. 4 The 3-4% tannins may also contribute to the astringent and hemostatic action (see discussion on tannins in the chapter on Potentilla). Antitumor

Three new sesquiterpenoids from A. millefoli-

urn, achimillic acids A, Band C. showed antitumor effect in mice. 3; Antispermatogenic

Extracts of A. millefolium showed antispermatogenic effect in mice. 36

RESEARCH VERIFICATION OF TRADITIONAL ACTIONS The following traditional actions have been supported by research: bitter digestive tonic (choloretic effects), antihypertensive, and antihemorrhagic. Additional effects demonstrated by research The following additional effects have been reported as discussed above: antibacterial. antifungal, anti-inflammatory, antilipidemic, antispasmodic, antitumor, and antispermatogenic effects.

TOXICOLOGY >.

This is a generally safe herb. A rare instance of yarrow allergic contact dermatitis has been reported, which is thought to be due to the guaianolide peroxide. a-peroxy-achifolide. 37

._------176

Combining Western Herbs and Chinese Medicine

Tisserand and Balacs38 suggested caution in the oral uSe of the essential oil of the camphor chemotype of Achillea. However, since the essential oil constitutes only 0.2-1 % of the dried herb, the camphor content may be unlikely to cause adverse effects in the infusion or tincture.

Goods Act Regulations of Australia. Achillea is not currently--:#.~ listed by the FDA (USA) as a prohibited substance, as subject~...,.._ to an import alert, or as a substance with a warning on its.;::... use.

Traditional sources

Dose Temperature

Tincture Both the BHP and the BHC recommended 2-4 ml of 1:5 tincture, three times per day.

Variations of opinIon The Chinese Herbal Medicine Dictionary classified Achillea millefolium as cold, but this

Can start at the standard dose.

Duration Generally suitable for long-term use, but large quantities of strong Achillea infusion are generally for acute conditions andJor short-term use only.

Cautions These cautions apply to the infusion and the tincture. The use of the oil is outside the scope of this book. Western contraindications The BHC mentioned a rare hypersensitivity to Achillea or to other members of the Compositae. Wichtl described this allergy as itching, inflammation, and formation of vesicles on the skin, in which case the intake of Achillea should be stopped. I have not yet seen this reaction. Chinese contraindications No contraindications were given in the Chinese Herbal Medicine Dictionary. Although I have not seen this reported elsewhere, I have found that strong infusions of Achi)lea can have a drying effect in a few people in some situations, for example, in individuals with sinusitis ac~ompanied by Lung D"eficient Y'm with Dryness. Pregnancy and lactation Side effects Overdose

No adverse reports.

Not reported. No adverse reports.

Interactions

No adverse reports.

herb does not seem to have had a strong tradition of use in Chinese medicine. In Germany, Hildegard von Bingen39 in the 12th century listed Achillea as slightly hot and dry. Tabernaemontanus listed it as drying and astringent and described it as having a temperate warmth with a cooling effect. 40 In England, Gerard41 classified Achillea as'meanely cold: Culpeper42 classified it as cold in the first degree and also considered it to be drying and binding. The variable temperature of Achillea Tabernaemontanus may have been the first to notice the variable temperature of Achillea when he described it as having a temperate warmth with a cooling effect. In this book, Achillea is classified as warm-cool, because, in my experience, it can be used for influenza and acute sinus conditions associated with either

Wind Heat or Wind Cold. Temperature and the needs of the body Whether Achillea has a cooling, neutral, or even warming temperature effect may depend on the needs of the body. If there is a hot condition, this may evoke a cooling effect; if there is a neutral condition, neither a cooling nor warming effect may be evoked; whilst if there is a cool condition, this may evoke a warming effect. According to Dr. Cole of Seattle,43 when there is raised temperature, Achillea has a diaphoretic effect, but when there is no abnormal temperature, it has only a diuretic action. Achillea can have cooling antipyretic and antiinflammatory actions, but according to Mills, +I it does not have this cooling effect in nonfebrile states and may even help to increase the body temperature if it is low.

Regulatory status

Temperature and biochemistry These different potential effects may be linked to different constituents. For example,

Please read the Regulatory status section in the chapter on Safety. .

the chamazulenes and prochamazulenes may be involved in a cooling effect and camphor may be involved in either cooling or warming effects, depending on the situation.

Achillea (yarrow) is on the UK General Sale List, and it is not included in Part 4 of Schedule 4 of the Therapeutic

~+:

PROPERTIES

Dried herb Both the BHP and the BHC recommended 2-4 g of dried herb, three times per day.

Initial dose

...

Temperature and chromosome number The differences of

.....,.

Achillea opinion on the temperature of Achillea may also be linked to the differences in chemical composition of the different subspecies. For example, in hexaploids, potentially warming camphor can be 18% of the essential oil fraction, and cooling sesquiterpenes are found in relatively lesser amounts. Tetraploids have higher levels of sesquiterpenes and camphor is not listed as a main ingredient.3 Therefore, if hexaploid material were used, the physician might conclude that Achillea was slightly warming, whilst if they had used tetraploid material, they might conclude it was slightly cooling.

177

Spleen

dyspepsia loss of appetite bitter tonic bitter aromatic for loss of appetite

Christopher SHC Weiss 46 Wichtl

Heart

thrombotic conditions with hypertension hypertension

SHP SHC

There is no information given in the Chinese Herbal Medical Dictionary for the meridians entered by A. millefolium (yang shi cao).

Taste

Taste in the mouth Yarrow is described in Wichtl as some-

I

~....

-

what bitter and faintly aromatic. I find fresh yarrow to be strongly bitter, definitely acrid, and somewhat aromatic. I find that the intensity of the taste of yarrow is greater in plants from warm climates or alpine meadows with sunny exposure, and less in plants grown in places with little sun and heat, such as Seattle, USA. The acrid taste may be due to the essential oils, and according to the BHC, the bitter taste is due to the sesquiterpene lactones and the alkaloids. The Chinese Herbal Medicine Dictionary classified Achillea millefolium as bitter and acrid in taste property, but that listing may be based on Western use, rather than Chinese tradition.

Taste properties Achillea millefolium, as used in the West, can be classified as acrid in the sense of clearing Exterior Wind from the surface of the body. Tabernaemontanus said that it was the bitter taste that gives yarrow a temperate warmth with a cooling effect. This is a fascinating statement because it implies the multiple functions of the bitter taste property. The pharmacology section of the A. millefolium entry in the Chinese Herbal Medicine Dictionary stated that the bitter taste of this herb can tonify the stomach. This statement may be following Western concepts of the physiological effect of the bitter taste.

ORGANS In terms of Chinese medicine, Achillea, as used in the West, can be associated mainly with disorders of the followingorgans:

Lung

colds hemoptysis respiratory catarrh colds and fever

Fox KlOSS

45

Christopher SHp32

ACTIONS Evidence from traditional sources for the following actions of Achillea is discussed below: • diaphoretic and antipyretic • anticatarrhal • alterative • bitter digestive tonic • circulatory stimulant • antihypertensive and antithrombotic • astringent and antihemorrhagic • emmenagogue • diuretic • antidiabetic Diaphoretic and antipyretic Hildegard von Bingen recommended Achillea for fever, and Tabernaemontanus gave a combination of yarrow and sage for malaria. The Eclectic doctor William Fox, writing in 1878, listed Achillea as a diaphoretic and said that there is not a single herb that has done so much good. He said th~t for a cold, take a strong tea of yarrow and have a hot brick wrapped up in a vinegar cloth applied to the feet, to produce sweat and to remove the cold.47 In 1898, Felter and Lloyd48 mentione.d that the isolated component achilleine, from Achillea, had been used in Southern Europe as a substitute for quinine in the treatment of intermittent fever. Ellingwood listed Achillea for fever, and both Kloss and Christopher recommended Achillea for colds, influenza, fever, and eruptive diseases, such as measles, chicken pox, and smallpox. The BHP listed Achillea as a diaphoretic and antipyretic for fever and the common cold. Anticatarrhal Ellingwood recommended Achillea for oversecretion by the mucous membranes due to atony or inflammation. Felter and Lloyd listed Achillea for leukorrhea with profuse discharge due to atonic or inflamed vaginal mucous membranes, and both Kloss and Christopher listed it for mucous discharges from the bladder. Christopher rec-

178

Combining Western Herbs and Chinese Medicine

ommended Achillea for influenza, respiratory catarrh, and congestive headache. I have found that a hot infusion of Achillea can relieve influenza with sinus congestion and sinus headache, associated with the pattern of Wind Cold Damp invasion.

ascribe this action to Achillea based on a combination of the anticatarrhal, antihypertensive, and antithrombotic actions, which were listed above, and an antilipidemic effect, which 3l has been reported by recent research.

Alterative Both Kloss and Christopher listed Achillea as an alterative herb, and according to Christopher. it can purify the blood of waste material. Both Weiss and Wichtllisted Achillea as a bitter herb that can stimulate secretion of bile, and Christopher stated that it can regulate liver function. However, its most powerful alterative action may be through the skin rather than the liver. Ellingwood stated that, in intermittent or bilious fever, Achillea can cause profuse sweating, which can discolor the bedclothes. Christopher also emphasized the use of copious hot infusions of Achillea to discharge impurities through the skin. I use it for conditions of recurring low-grade fever or for skin disorders or rheumatism when these disorders are associated with retention of toxins at the surface of the body, in the skin, muscles, or joints.

Wounds and ulcers Dioscorides prescribed pounded yarrow to put on a fresh wound to clear it from heat and in.fJ.ammation and to congeal the blood. Lonicerussl gave Achillea wine for both internal and external wounds and injuries. Hildegard von Bingen recommended Achillea for clearing putrid matter from ulcers and wounds, and Culpeper listed Achillea for inflamed wounds, moist ulcers, leukorrhea, and gonorrhea. It seems that the drying astringent, antihemorrhagic, and vulnerary actions of Achillea are assisted in this by its anti-inflammatory, antimicrobial, and

Bitter digestive tonic Tabernaemontanus prescribed a decoction of yarrow in wine for lack of appetite. He recommended that the patient drink a mug of the warm decoction every morning on an empty stomach. Lyle49 described Achillea as a tonic for the appetite, digestive organs, and the general system. He recommended it in cold infusions as a tonic in convalescence from fever, from nervous prostration, and in phthisis (pulmonary tuberculosis) and night sweats. Felter and Lloyd recommended Achillea for gastric and intestinal atony and for flatulence and spasms. Wichtllisted it as a bitter aromatic for loss of appetite and to stimulate the secretion of bile. He also listed it for gastrointestinal inflammation, diarrhea, flatulence, and colic. The German Commission E monograph listed Achillea for loss of appetite. 50 Circulatory stimulant Lyle stated that Achillea in hot infusions can arouse capillary circulation, and Christopher stated that it can equalize the circulation. Mills noted that this herb can be used as a diffusive vasostimulant, and, according to Mabey, Achillea encourages blood flow to the skin, dilating the peripheral arteries and helping to lower blood pressure. Antihypertensive and antithrombotic The BHP gave the specific indications for Achillea as thrombotic conditions with hypertension, whether the thromboses are cerebral or coronary in origin. Mabey listed Achillea for hypertension and for blood clots. and Mills noted its use for lowering moderately high blood pressure. The antiatheromatic action of Achillea is not mentioned in the traditional texts. However, it seems reasonable to

Astringent and antihemorrhagic

alterative actions. Diarrhea and dysentery Dioscorides recommended yarrow decoction for dysentery. Tabernaemontanus gave a combination of yarrow and plantain as an enema for dysentery and listed yarrow powder in red wine for cramps due to dysen-

tery or diarrhea. Culpeper also recommended this herb for bloody dysentery, menorrhagia, and urinary incontinence. However, Felter and Lloyd stated that it can be used for various types of hemorrhage when the bleeding is small in amount. They listed Achillea for hemorrhoids with bloody or mucoid discharges. Kloss recommended it for diarrhea and dysentery and especially for diarrhea in infants. Hemoptysis Tabernaemontanus prescribed yarrow with tormentil (that is, Potentilla erecta) for hemoptysis associat-

ed with pulmonary tuberculosis. Emmenagogue Menorrhagia and leukorrhea Dioscorides said that yarrow . can be made into a suppository with wool and put in the vagina to reduce excessive menstrual flow. Tabernaemontanus recommended yarrow decoction in wine for heavy menstrual flow and prescribed suppositories made from fresh yarrow

for leukorrhea. Culpeper listed Achillea as drying and binding and recommended it for menorrhagia and leukorrhea. Ellingwood listed Achillea for leukorrhea with profuse discharge from enfeebled mucus membranes. Amenorrhea and infertility Felter and Lloyd listed Achillea for atonic amenorrhea. Christopher, BHP, and Mabey all listed Achillea for amenorrhea. In my opinion, this herb can be included in prescriptions for amenorrhea or infertility when there is Deficient Qi and Blood, and a possibility of obstruction of the channels of the Uterus by Phlegm.

Achillea Diuretic Whether Achillea acts as a urinary astringent or as a diuretic may depend on the needs of the patient.

Achillea to reduce urination Culpeper listed this herb for urinary incontinence, and Christopher recommended it for enureSIS,

Achillea to increase urination Tabernaemontanus listed fresh yarrow juice and wine vinegar for urinary retention. Elingwood listed it for deficient renal action, Bright's disease, and edema, and Felter and Lloyd listed it for stranguary and urinary suppression. The BHP listed Achillea as a diuretic and urinary antiseptic. The tannins may be involved in the urinary astringent action, and the essential oils may be involved in the diuretic action. The asparagin listed by Mills as a possible diuretic component of Achillea is not mentioned by the BHC or by Wichtl as a component.

Hematuria Tabernaemontanus listed various Achillea combinations for blood in the urine. Urinary stones Tabernaemontanus also prescribed various Achillea combinations for difficult urination with gravel or stones in the urinary tract. Antidiabetic In an ethrlobotanical survey in Israel, A. fragrantissima was found to be used for treatment of diabetes. 52

COMPARISON OF WESTERN AND CHINESE USE OF ACHILLEA A. millefolium is a major herb in the Western tradition, but a minor one in Chinese medicine. The two traditions are compared under the following headings: • diaphoretic and antipyretic • anticatarrhal and alterative • general tonic and bitter digestive tonic • circulatory stimulant and antihypertensive • astringent and antihemorrhagic • emmenagogue Diaphoretic and antipyretic Achillea is one of the most commonly used herbs in the West for common colds, influenza, and fever. It is not an important herb for these disorders in China, although one text cited in the Chinese Herbal Medical Dictionary listed A. millefolium to clear Wmd and to promotes sweating. Anticatarrhal and alterative Achillea is an important herb in the West to treat catarrhal states of the respiratory system,

179

especially when associated with Wind invasion. This use is not listed in the Chinese Herbal Medical Dictionary. The alterative use of Achillea is more important in,China, and yang shi dio is said to clear Heat and Toxin and treat ulcers and boils. General tonic and bitter digestive tonic The use of Achillea as a tonic is far more common in the West than in China. However, one text cited in the Chinese Herbal Medical Dictionary listed Achillea as a tonic, and another text listed it for Deficient Ym 'steaming bone syndrome: Circulatory stimulant and antihypertensive Although the Chinese Herbal Medical Dictionary listed Achillea as harmonizing the Blood, for example, for traumatic injuries, this herb is not commonly used in China for circulatory disorders. Astringent and antihemorrhagic In the West, Achillea is frequently used as an astringent or antihemorrhagic for a wide range of disorders, including nosebleeds, bleeding hemorrhoids, diarrhea, leukorrhea, and menorrhagia. Achillea is listed as an astringent in the Chinese Herbal Medical Dictionary, for example for bleeding hemorrhoids, but it does not appear to be frequently used. Emmenagogue Achillea is not used as a primary emmenagogue in recent Western tradition, but is commonly used as a secondary herb to treat a variety of womens' disorders. Yang sm dio is listed as a herb for irregular menstruation, but is not often seen in Chinese formulas for gynecological disorders. NATIVE AMERICAN USE OF ACHILLEA Achillea has been widely used by the Native Americans, and it is interesting to classify some of these uses in terms of Chinese actions and to speculate on their basis in phytochemistry.

Native American use and Chinese actions In the table below, the data on·Native American use comes from Plants of the Pacific Northwest Coast by Pojar and MacKinnon:53 Native American use and phytochemistry

As part of ongoing studies on the herbal remedies of the Micmac and Malecite Indians, the sterols and triterpenes of Achillea were investigated. ~-sitosterol was identified as the major sterol and a-amyrin as the major triterpene of this plant. The authors suggested that the effectiveness of Achillea may be partly due to the presence of these compounds, since many sterols and triterpenes exhibit a wide range of pharmacological effects.54

180

Combining Western Herbs and Chinese Medicine NATIVE AMERICAN USE

19. Kasaj D. Krenn L. Prinz S.et al. Z Naturforsch 56(7-8):521-525 (2001}::::•.• -

-chi~;s~':~citk;~":::'~~;:"~;~6f '~'~;'="'Tri6e(i)~~":::: clears Exterior Wind

colds

Klallam

clears Heat

colds and coughs measles

NU~hah-nulth

Squamish

---;-:;~~

..•~

20. Pailer M, Kurnp WG.Arch. Pharm 293:646-654 (1960)

21. Steinegger E. Hansel R. T13 (1988) [cited in Bradley PR (ed). British:~

~:~~~::~.e~~:i<:~d~:~i:~~)7erbalMedicine ASSOCiation,. ,_~~.~~.~·.:.·~~.l .,.,~.

22. Orzechowski G. Pharmazie in unserer Zeit 1:43 (1972) 23. Barel S. Segal R, Yashphe J. J EthnopharmacoI33(1-2):187-191 (1991)

clears Phlegm clears Retained Heat

bronchitis

Nuxalk

blood purifier

Cowichan

24. Pattnaik S, Subramanyarn YR, Bapaji M et al. Microbios 89(358):39-46

"'lo.--

QuinaUlt Sqaxin

astringent, stops bleeding

styptic diarrhea sore throat gargle

Saanich Snohomish Tsimshian

27. Zitterl-Eglseer K, Jurenitsch J, Korhammer S et al. Planta

childbirth

Ditidaht, Makah

28. Al-Hindawi MK. AI-Deen IH, Nabi ~H et al. J Ethnopharmacol

26. Bradley PR (ed). British Herbal Compendium. vol. 1. British Herbal ~edicineAssociation. Bournemouth. United Kingdom

···~t~.

(1992) ~ed

29. Gomez ~A. Saenz ~T. Garcia MD et al. Z Naturforsch [C] 54(11):937-941 (1999) 30.

~ustafa

EH,Abu ZM,Abdalla S. Gen PharmacoI23(3):555-560 (1992)

31. Asgary S, Naderi GH, Sarrafzadegan N et al. Drugs Exp Clin Res

~Unchen,~any(1960)

2. Perry L~. ~edicinal Plants of East and Southeast Asia. The MIT Press, Cambridge, United Kingdom (1980) 3. Jiangsu New Medicine Institute. Chinese Herbal Medicine Dictionary (Zhong yao da ci dian) Science and Technology Press, Shanghai, China (1975) 4. Chandler RF, Hooper SN, Harvey MJ. Botany 36:203-223 (1982) 5. Hofmann L. Fritz D. Nitz S et aI. Phytochemistry 31 :537-542 (1992) 6. FaIkAJ. Bauer L, Bell CL et al. Uoydia 37:598-602 (1974) 7. Formacek Y, Kubeczka K. J. Wiley. Chichester (1982) [cited in Bisset

26(3):89-93 (2000) 32. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983) 33. ~abey R. The Complete New Herbal. Elm Tree Books, London, United Kingdom (1988) 34. Chabrod E et al. Soc Bioi 108:1100 (I931)

35. Tozyo T. Yoshimura Y, Sakurai K et al. Chem Pharm Bull 42(5):10961100 (1994) 36. Montanari T. de Carvalho JE. Dolder H. Contraception 58(5):309-313 (1998) 37. Rucker G,Manns D.Breuer J.Arch Pharm 324(12):979-981 (1991)

NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn.

38. Tisserand R, Balacs T. Essential Oil Safety: A Guide for Health Care

Medpharm. Stuttgart, Germany (1994). from 2nd German edn. Wicht! ~ (ed) (1989)]

Professionals. Churchill Livingstone, Edinburgh, United Kingdom

8. Grieve~. A ~odern Herbal, vols. 1 and 2. Dover Publications, New York. New York (1971)

39. Von Bingen H. Hildegard von Bingen's Physica. Healing Arts,

9. Christopher JR. School of Natural Healing. BiWorld, Provo, Utah (1976)

40. Tabernaemontanus JT. Krauterbuch (1731). Reprinted by Verlag

10. British Herbal Pharmacopoeia. British Herbal ~edicine Association. West Yorks, United Kingdom (1983)

41. Gerard J. The Herbal or General History of Plants: The complete 1633

11. Stearn WT. Botanical Latin, 4th edn.. Timber Press. Portland, Oregon (1992) 12. Carnat AP, Larnaison JL. Phytotherap 24:238 (1990) 13. Oswiecimska M. Planta ~ed 25:389-395 (1974) 14. Haggag ~Y, Shal'aby AS. Verzar-Petri G. Planta Moo 27:361 (1975) 15. Kastner U etal. Sci. Pharm 60:87 (1992); 61:47 (1993) 16. Cuong B, Gacs-Baitz E, Radics L et al. Phytochemistry 18:331-332 (1979)

,.'.

57(5):444-446 (1991)

26(2):163-168 (1989)

1. Dioscorides P. Kreutterbuch (1610). Reprinted by Verlag Konrad Kolbl,

~.

25. Aljancic1, Vajs Y,Menkovic N et al. J Nat Prod 62(6):909-911 (1999)

general tonic stomach tonic

...References

;~

......

(1997)

tonifiers and moves Spleen and Uver Qi

regUlates Uterus

.i!~L

(1995)

Rochester, Vermont (1998)

Konrad Kolbl, MUnchen, Germany (1993) Edition as Revised and Enlarged by Thomas Johnson. Dover Publications, New York, New York (1975) 42. Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. ~eyerbooks, Glenwood, Illinois (1990) 43. Ellingwood F. American Materia Medica, Therapeutics and Pharmacognosy, 11 th edn. ( 1919). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1994) 44. Mills S. The Essential Book of Herbal ~edicine. ArkanalPenguin Books, London, United Kingdom (1991)

17. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn.

45. Kloss J. Back to Eden, 5th edn. (1939). Reprinted by Lifeline Books, - Santa Barbara. California (1975) .

~edpharm, Stuttgart Germany (1994), from 2nd German edn. Wicht! ~ (ed) (1989) .

46. Weiss RF. Herbal Medicine, English edn. Beaconsfield Publishers. Beaconsfield, United Kingdom (1988)

18. Ulubelen A, Okusuz S, Schuster A. Phytochemistry 29:3948-3949 (1990)

47. Fox W. The Working ~an's ~odel Family Botanic Guide to Health, 7th edn. Wtlliam Fox. Sheffield, United Kingdom (1878)

;~(f~f~:

..,i

Achillea 48. Felter HW, lloyd )U. King's American Dispensatory, vols. 1 and 2, 18th edn. (1898). Reprinted by Eclectic Medical Publications. Sandy, Oregon (1983) 49. Lyle TJ. Physio-Medical Therapeutics. Materia Medica and Pharmacy. Originally published Ohio (1897). Reprinted by the National Association of Medical Herbalists of Great Britain. London, United Kingdom (1932)

.....

...

50. Blumenthal M (ed). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council, Austin, Texas (1998)

181

51. Lonicerus A. Kreuterbuch (1697). Reprinted by Verlag Konrad Kolbl. MUnchen. Germany (1962) 52. Yaniv Z. Dafni A. Friedman Jet ai. J Ethnopharmacol19(2):145-151 (1987) 53. Pojar J. MacKinnon A. Plants of the Pacific Northwest Coast: Washington, Oregon. British Columbia and Alaska. Lone Pine Publishing. Redmond. Washington (1994) 54. Chandler RF. Hooper SN. Hooper DL et al. J Pharrn Sci 71(6):690-693 (1982)

-It'

Althaea Botanical name Althaea officinalis L. Family Malvaceae Pharmaceutical name Althaeae radix Part dried peeled roots collected in the autumn from plants at least 2 years old English marshmallow German Eibisch French guimauve Mandarin A. officinalis 1. is not used shU kui gen (Ij is the root of A. rosea

list the meridians entered. This suggests that this herb was not in frequent use in China.

What is special about Althaea In terms of Chinese medicine, Althaea can be said to be a cool, sweet, and slightly bitter herb that has its main internal effects on the Lung, Stomach, Intestines, and Bladder.

**)

The key to understanding Althaea is that it is a cooling and moistening mucilaginous herb with demulcent and emollient actions. It can be used especially to treat inflammatory conditions associated with patterns of Deficiency Heat in the Lungs, Stomach, Intestines, and Bladder, partly by clearing the Heat and partly by tonifying Yin.

Use in the West

Althaea officinalis This perennial herb is native to Europe and Western Asia, growing in damp locations. The therapeutic properties of Althaea have been known since antiquity and possibly from prehistoric times. A flower of an Althaealike plant was found in a Neanderthal grave in Iraq with other plants with potentially therapeutic effects.· The family name, Malvaceae, was derived from the Greek malake, meaning soft, referring to the therapeutic properties of the mallows in softening and healing. 2 Its generic name Althaea was derived from the Greek word altho, meaning to cure. All mallows contain much mucilage, and in past times, Arabian doctors used the leaves as a poultice for inflammations.

CHINESE ACTIONS In terms of Chinese medicine, Althaea, as used in the West, can be said to have four main groups of actions:

1. stop cough clear Lung Deficiency Heat tonify Lung Ym

Althaea rosea Hollyhock is a native of China. According to II. clear Stomach Deficiency Heat tonify Stomach Ym

Lyle,3 the roots and flowers of hollyhock are demulcent and have been substituted for A. officinalis". He wrote that A. rosea does not contain as much mucilage as A. officinalis, but it has a greater effect on the bladder and kidneys.

III. clear Intestines Heat moisten the Intestines

Use in China The entry in the Chinese Herbal Medicine Dictionarl for A. rosea (shu kui gen) is brief and does not

IV. clear Bladder Heat or Damp Heat tonifyKidneyYm

183

184

-----._".c,~

Combining Western Herbs and Chinese Medicine

The main Western actions of Althaea are shown here in terms of its four main Chinese actions: Chinese actions I. stop cough, clear Lung Deficiency Heat, and tonify Lung Yin

..

Limitations ofAlthaea

WESTERN ACTIONS

. -, Western actions ' antitussive respiratory demulcent anti-inflammatory

II. clear Stomach Deficiency Heat and tonify Stomach Yin

demulcent anti-inflammatory sweet nutritive tonic

III. clear Intestines Heat and moisten the Intestines

demulcent anti-inflammatory

IV. clear Bladder Heat or Damp Heat, tonify Kidney Yin

urinary demulcent anti-inflammatory

...

_~;

',",'~ .'.~

TEMPERATURE Althaea is classified as cool in this book. It can be used. ";]l.~ for hot, warm, or neutral conditions. -. ;:~¥

TASTE Althaea is classified in this book as sweet and slightly bitter. Its sweet taste can be associated with a nutritive and.:'" moistening Yill tonic action, rather than with adaptogenic or ,',,::' energizing effects as in Panax ginseng. Althaea more closely resembles Ophiopogon (mai men dong) in its taste properties and actions. The slight bitter taste of Althaea may contribute to its' 'I cooling, anti-inflammatory action, but this herb does not': have appreciable bitter digestive tonic effect. .::~~~= ~,

WESTERN USES, The Western uses of Althaea can be related to its four main Chinese actions:

ACTIONS Anti-inflammatory The anti-inflammatory action of Althaea is of the demulcent type, which is a result of the high mucilage content of this herb. Althaea is not so much """"t,. antimicrobial anti-inflammatory, like Berberis, or an astringent anti-inflammatory, like Potentilla. The demulcent antiinflammatory action of Althaea is especially felt on the . -..c-, mucosa of the respiratory, gastrointestinal, and urinary sys~ tems.

a.n'·

I. stop cough, clear Lung Deficiency Heat, and tonify Lung Yin

dry sore throat, irritant dry cough, bronchitis

II. clear Stomach Deficiency Heat and tonify Stomach Yin

gastritis, gastric ulcer

III. clear Intestines Heat and moisten the Intestines

enteritis, colitis, dry constipation

IV. clear Bladder Heat or Damp Heat, and tonify Kidney Yin

urinary tract inflammation, prostatitis

DIRECTION OF ENERGY Althaea does not have a marked directional effect on the movement of energy.

TYPICAL CASE EXAMPLE Signs and symptoms The patient has recurring dry sore throat, dry irritant cough, gastritis, dry constipation, and cystitis. Diagnosis The patient has generalized Deficient Yill with Deficiency Heat, affecting specifically the Lung, Stomach, Intestines, and Bladder.

Antitussive Althaea has an antitussive action via its moistening, demulcent, and anti-inflammatory properties, rather than via antispasmodic or sedative effects, like Prunus or Lobelia. Although Althaea is sometimes listed as an expectorant, it does not seem to have anticatarrhal action or the ability to initiate coughing, as does Lobelia. Laxative Althaea is sometimes listed as a laxative, but this laxative action may derive from its moistening and antiinflammatory effects on the bowel, rather than a direct laxative effect. Vulnerary Althaea can be used for wounds, burns, and inflammatory skin conditions, but it does not have the strong astringent and antihemorrhagic effect of high-tannin herbs, such as Potentilla. Rather, it may assist wound healing by forming a protective mucilaginous layer on the surface.' -' .-- ~

•

Choice of Althaea This herb can tonify the Yill of the Lung and Stomach, especially to clear Deficiency Heat in those organs, and it can also clear Heat in the Intestines and Bladder.

.

.. " '.·.1'1 ~~

.'

Althaea paired with other herbs::;~!}~ ;'

A discussion of the limitations of each ofthc{n-i~ih''. actions of Althaea can be useful in clarifying just what'this":" ,

'

•••.. , ";;(l:;..f<,

--

Althaea herb can and cannot do. However, suitable combination with other herbs can extend the range of use of Althaea beyond its limitations. The basic unit of herb combination is the herb pair. Six pairings of Althaea are briefly explained below.

CAUTION

Before using any of the herb pairs below, it is important to be familiar with the cautions listed for each herb in the pair. Althaea + Viola tricolor

Cystitis Both herbs are anti-inflammatory demulcents, which can be used for dry sore throat, dry irritant cough, and cystitis with burning urination associated with Damp Heat or Deficiency Heat in the Bladder. Althaea contains more demulcent mucilage, and Viola contains salicylate anti-

185

Althaea is a moistening, cooling demulcent as a result of its mucilage content, and Marrubium is an expectorant and antispasmodic, which is associated with the bitter constituent marrubiin. This pair can be used for bronchitis with nonproductive cough. Althaea + Potentilla

Diarrhea These herbs are very different and complement each other's actions. Althaea is a typical mucilaginous, demulcent anti-inflammatory, and Potentilla is a classic high-tannin astringent and antihemorrhagic. Althaea has the reputation of moderating any potentially irritant effects of the tannins. These herbs can be combined for intestinal or colonic inflammations.

AJ~aeaconabUnations

inflammatories in addition to mucilage. .--i

Four Althaea combinations are discussed in detail below: Althaea + Polygonum

Colitis Both herbs are listed by the BHP as mucilaginous demulcents, and they both have tannin. However, Althaea has more mucilage and less tannin, and Polygonum has less mucilage and more tannin. Althaea and Polygonum can be paired for inflammatory disorders of the colon with diarrhea, which can benefit from the combination of demulcent and astringent actions. Althaea + Glycyrrhiza

Laryngitis + dryness Both herbs are moistening anti-inflammatories, which can soothe dry sore throat and treat hoarseness or loss of voice. They can also be combined to treat gastritis or peptic ulcers, and enteritis or ulcerative colitis. Althaea + Ophiopogon

Gastritis These herbs are similar. Both are sweet and slightly bitter, and can act as moistening, cooling Yin tonics to treat Deficiency Heat in the Lung or Stomach. They can be combined for dry sore throat, dry cough, gastritis, and gastric ulcers. Both herbs can have a tonic effect to treat emaciation associated with Deficient yoffi. Althaea + Marrubium

Chronic cough Both herbs are antitussive but via different mechanisms.

1. dry cough

Lung Deficiency Heat + Lung Deficient Yin

2. gastritis

Stomach Deficiency Heat + Stomach Deficient Yin

3. colitis

Intestines Heat

4. cystitis

Bladder Heat + Kidney Deficient Yin

CAUTION

Before using any of the combinations below, it is important to be familiar with the cautions listed for each herb in the combination. ALTHAEA AS A DECOCTION Mucopolysaccharides are the key constituents of Althaea, and they are more effectively extracted in water than in alcoholic tincture. Therefore, Althaea is not used as a tincture in the four combinations belo\v. Also, in cases of inflammation and dryness, the higher fluid intake of the decoction is preferable to the minimal fluid intake of the tincture. In combination Nos. 2 and 4, all the herbs are decocted. In the other two combinations, Althaea is first prepared as a decoction, and then the other herbs in the combination are mixed together as tinctures and added to the Althaea decoction. This is partly because some of the herbs are generally used as an infusion rather than a tincture and others are better prepared as a high-alcohol tincture to extract the resins.

186

Combining Western Herbs and Chinese Medicine

1. Dry cough

sweet taste is associated with the moistening and Ym tonk function, and the bitter taste is associated with clearing Heat.

Lung Deficiency Heat + Lung Deficient Yin Herb

Ratio

.Temperature

Althaea Viola trio Prunus

10 approx. 1 1

cool cool neutral

Marrubium Ophiopogon Glycyrrhiza

1 1 1

neutral cool neutral-cool

Taste sweet, sl. bitter sour, sweet, bitter bitter, aromatic bitter sweet, sl. bitter sweet

GENERAL

This combination is for Lung Deficiency Heat with Lung Deficient Yin. The overall temperature is cool to treat warm conditions. For hot conditions, a cold respiratory herb, such as Asclepias, would need to be added. The dominant taste is sweet, associated with moistening and demulcent effects. The bitter taste is secondary, and is associated with cooling and anti-inflammatory effects. USE

USE

• gastritis or gastric ulcer with burning sensation or pain in the epigastrium PRACTICAL NOTES

The herbs are put in a pan containing about 750 ml of cold water, and the mixture is brought to a boil and simmered very gently for 15 minutes. The decoction is strained and the remaining liquid pressed out of the herbs in the pan. This provides 1 day's supply of decoction. which can be taken, when cool, in three individual doses of one cup. The combination can be used short-term for acute episodes, but it can also be taken long-term, at halfdose, for chronic conditions, unless the use of Glycyrrhiza needs to be restricted for a particular patient (see Glycyrrhiza). 3. Colitis

• dry, irritant, nonproductive cough, maybe with a dry, sore throat and thirst

Intestines Heat ~ ~."

;"'''''l-''.>:.:_

-.• ~.'.;' or.

Herb

PRACTICAL NOTES

Dried, cut Althaea root can be made as a decoction (see Dose), and 5 ml of a mixture of the tinctures of the other herbs can be added to 1 cup of the Althaea decoction for each of the three daily doses. This combination can be used for acute conditions, but there is usually an underlying chronic condition. Therefore, the combination may need to be taken for 1 to 2 months.

Caution This combination contains the moist, sweet herbs Althaea, Viola, Ophiopogon, and Glycyrrhiza. It is therefore not appropriate for patterns of accumulated Damp and Phlegm in the Lung.

Stomach Deficiency Heat + Stomach Deficient Yin

-H~b'~'-Y'0r:!;~o~il~d~:~~,··\:(:cT~:~~~riiture Glycyrrhiza Hydrastis

";/.::

10 approx. 1 1 1 1

0.5

.

.

:~.-. -';;'.:;.\:l"!.;:.~.~?;'?'Xi;'~:-r~-:,; :'~'~_ ~:~~?~!:-'?r~-: ;~ ;;~,?, :~t~

.. Temperature '.:.Taste '.' cool cool neutral-cool cool cool neutral-cool

.

sweet, 51. bitter sour, sl. bitter sour, 51. bitter bitter bitter sweet

GENERAL

This combination is for patterns of Heat or Damp Heat in the Intestines. The overall temperature is cool to treat warm or hot conditions. The sweet taste is associated with the demulcent action, the sour taste with the astringent action, and the bitter taste with anti-inflammatory and antimicrobial actions. USE

2. Gastritis

Althaea Ophiopogon

Althaea Polygonum Hamamelis Calendula Hydrastis Glycyrrhiza

•

. Ratio -

12 g 8g 4g 1-2g

cool cool neutral-cool cool

.·:.T~st~ sweet, sl. bitter sweet, sl. bitter sweet bitter

GENERAL.,' "':..':~" :·:('."i,

Thisco~binationis for Stomach Heat with Stomach Deficient Yui';The overall temperature is cool, and thus it can be used for warm or hot conditions. In this combination, the

• colitis with bleeding or mucus-containing diarrhea PRACTICAL NOTES

Dried, cut Althaea root can be made as a decoction (see Dose), and 5 ml of a mixture of the tinctures of the other herbs can be added to 1 cup of the Althaea decoction for each of the three daily doses. There is then approximately ten times as much Althaea as each of the other herbs in the mixture. This combination can be used for acute conditions, but there is ~sually an underlying chronic condition. Therefore, the combination may need to be taken for 1 to 2 months.

Althaea ..

Y::::~:: '.~:: _~:'~'~c J;;.~' ~;:::

4. Cystitis

Bladder Heat + Kidney Deficient Yin '''I

187

Daily do~e

Herb

Temperature

Taste

"

Althaea Viola trio Zea Agropyron Ophiopogon Arctostaphylos

3g 3g 3g 3g 3g 3g

cool cool neutral neutral cool cool

sweet, sl. bitter sour, sweet, bitter sweet sour, sl. sweet sweet, sl. bitter bitter, sour

GENERAL

This combination is for patterns of Heat or Damp Heat in the Bladder, with Kidney Deficient Yin and Kidney

Herb" """, Ratio

Ijerb'_

Althaea Viola trio Prunus Marrubium Ophiopogon Glycyrrhiza

10 approx.

Althaea

1 1 1 1 1

Ophiopog~n

-:" ......;'~~,'>._- ;,>:-...::.~:~_~::.~.s:;:~

Glycyrrhiza Hydrastis

~~_})aily'_d_q.:'.~,~

12 g 8g 4

g

1-2 g

1. Althaea, Viola and Glycyrrhiza are moistening, demulcent, anti-inflammatory, and antitussive herbs to treat dry cough. Prunus and Marrubium are antitussive, antispasmodic, and expectorant herbs, and Prunus has a mild tranquilizing effect. Ophiopogon and Glycyrrhiza can tonify Lung Yin and Fluids, supported by the other two moist herbs, Althaea and Viola.

Deficiency Heat. The overall temperature is cool to treat warm conditions. For hot conditions, neutral Agropyron would need to be replaced by colder herbs, such as Hydrastis or Berberis. The sweet taste is associated with the 'lm tonic and the demulcent actions, the sour taste with the astringent action, and the bitter taste with anti-inflammatory and antimicrobial actions. USE

• urinary tract inflammations and infections, accompanied by tiredness, restlessness, and sensations of heat

2. Prunus and Marrubium direct the previous combination to the Lung. Combination No.2, however, is specific for _gastric inflammation. Glycyrrhiza can increase the rate of mucus secretion by the gastric endothelium, and together with the mucilage in Althaea, this can assist in the formation of a protective layer on the gastric mucosa. Althaea, Ophiopogon, and Glycyrrhiza together can tonify Stomach 'lm, and Hydrastis can clear Stomach Heat. 3. Colitis

4. Cystitis

Intestines Heat

Bladder Heat + Kidney Deficient Yin

'--. PRACTICAL NOTES

The herbs are put in a pan containing about 750 ml of cold water, and the mixture is brought to a boil and simmered very gently for 15 minutes. The decoction is strained and the remaining liquid pressed out of the herbs in the pan. \-,

This provides 1 day's supply of decoction, which can be taken, when cool, in three individual doses of about one cup.

Herb

Ratio

Althaea Polygonum Hamamelis Calendula Hydrastis Glycyrrhiza

10 approx. 1 1 1 1

0.5

Althaea Viola trio Zea Agropyron Ophiopogon Arctostaphylos

3g

3g 3g 3g

3g 3g

The combination can be used short-term for acute episodes, but it can also be taken long-term for chronic conditions.

Caution

Since all the herbs but Arctostaphylos can act as

sweet tonics, this combination may be unsuitable for patients with patterns of Spleen Deficiency and Stagnation with accumulation of Damp and Phlegm, manifesting as obesity, catarrhal conditions, and lethargy.

COMPARISON OF THE FOUR ALTHAEA COMBINATIONS 1. Dry cough

2. Gastritis

Lung Deficiency Heat + Lung Deficient Yin

Stomach Deficiency Heat + Stomach Deficient Yin

3. The sweet herbs Althaea and Glycyrrhiza both have a demulcent anti-inflammatory and Yin tonic actions. The sour herbs Polygonum and Hamamelis, with higher tannin content, are both antidiarrheal and antihemorrhagic, supported by resin-based Calendula with its antimicrobial, antiinflammatory, and vulnerary action. Hydrastis is a bitter antimicrobial and anti-inflammatory, which can normalize mucus membrane function to treat colitis. 4. Whilst the previous combination is designed to treat colon inflammation, this combination is made specific for the urinary system by the soothing urinary anti-inflammatory herbs Zea and Agropyron, and the strong urinary antimicrobial, anti-inflammatory herb Arctostaphylos. All the herbs except Arctostaphylos are sweet in nature, and can combine to tonify Kidney 'lm.

;;r._

188

Combining Western Herbs and Chinese Medicine

OTHER ALTHAEA COMBINATIONS Other combinations that contain Althaea include the following:

• Arctostaphylos: vaginitis • Gentiana: digestive weakness + gastrointestinal inflammation

Research CONSTiTUENTS • mucopolysaccharides • flavonoid glycosides • other Mucopolysaccharides Althaea contains 5-10% mucopolysaccharides, consisting of a mixture of arabinans, glucans, arabinogalactans, and galacturonorhamnans. 5 Flavonoid glycosides These include the glucosides of hypolaetin and isoscutellarein.6 Other Althaea also contains starch (37%), pectin (11%), sucrose (10%), fat (1.7%), up to 2% asparagine/ tannins,s small amounts of phenolic acids such as caffeic acid,6 and a small amount of sterols. 9 PHARMACOLOGICAL AND CLINICAL RESEARCH • • • •

anti-inflammatory immunoregulatory antitussive hypoglycemic

Anti-inflammatory An ointment contalning aqueous Althaea root extract (20%) and dexamethasone (0.05%) was superior to the two individual substances in reducing skin irritation in rabbits. 10 Althaea root extract stimulated phagocytosis and released oxygen radicals and leukotrienes from human neutrophils. 11

-

C-'::Ii

muco::_.-~f'ir-

Hypoglycemic Intraperitoneal administration of polysaccharides isolated from Althaea root reduced plasma · mlce. . 15 g1ucose 1eve1s m

~~"":"

-

MECHANISM OF DEMULCENT AND EMOLLIENT ACTIONS Demulcents Traditionally, demulcents were defined as herbs, often with a high content of mucopolysaccharides, which have a soothing and protective effect on inflamed mucus membranes. The demulcent effects can be said to be of two types:

• direct demulcent effect • indirect or reflex demulcent effect

on the gastrointestinal system on the respiratory or urinary systems

Direct demulcent effect It is thought that the mucilage from herbs like Althaea root covers the mucosa, especially of the mouth and pharyngeal cavity, to give protection from local irritants. 16 Mucilage from the leaves of Plantago major has been shown to have protective effect against aspirin-induced gastric ulcer in rats. Ii

Indirect, reflex, demulcent effect It has been demonstrated that oral administration of Althaea preparations can reduce the amount and intensity of coughing. 13 Since mucopolysaccharide molecules are too large to be absorbed and transported to the respiratory system, the question of how demulcent herbs exert their anti-inflammatory effects on the respiratory mucosa and musculature has been raised. Mills and Bone ls have suggested that the soothing effect of the mucilage on the upper digestive tract can produce a reflex effect on the tracheobronchial muscles, possibly mediated by the vagus nerve. A similar effect is known to work in reverse, in which acid reflux from the lower esophagus can trigger coughing or nocturnal asthma. Mills and Bone proposed that a similar mechanism may explain the use of mucilagecontaining herbs for inflammatory conditions of the urinary system.

Immunoregulatory Althaea root extract induced the release of cytokines, interleucin 6, and tumor necrosis factor from monocytes. Isolated mucopolysaccharides from Althaea root increased the phagocytic activity of macrophages in mice when administered intraperitoneally at 10 mglkg.12

Emollients These substances were defmed as having a soothing anti-inflammatory effect at the surface of the body. Some emollient herbs, such as Althaea and Symphytum, contain mucopolysaccharides. Other emollients are oilbased, such as olive, linseed, and flaxseed oils.

Antitussive Oral administration of either Althaea root extract or isolated mucopolysaccharides reduced the intensity and amount of coughing in cats. 13 A cold macerate of Althaea root inhibited mucociliary transport in isolated frog, ciliated, esophageal epithelium. 14

RESEARCH VERIFICATION OF TRADITIONAL ACTIONS There is research evidence for the general anti-inflammatory, topical anti-inflammatory, and antitussive actions of

-

,-."..

.... -

Althaea Althaea, but there is no clear mechanism for the demulcent effect in the respiratory system. There is research evidence for protection against gastric irritation and ulceration by Althaea and its isolated mucopolysaccharides, and in this sense, there is evidence for the gastric demulcent action of Althaea. I have not seen evidence to support demulcent antiinflammatory action in the intestines or in the urinary system. The evidence for a nutritive tonic action for Althaea root is based on both its imrnunoregulatory effects and the fact that it has been used as food throughout the centuries.

189

flammatory skin conditions or as a poultice for wounds and ulcers. Vaginal bolus Dried powdered Althaea root is included in Christopher's vaginal bolus combination for vaginal inflammatory conditions. 20

Cautions Western contraindications None reported.

Additional uses suggested by research Hypoglycemic action has been demonstrated by research, as discussed above.

Chinese contraindications None reported, but since this is a moist nutrient herb, I would not generally prescribe it for patients with marked patterns of Damp. Pregnancy and lactation No adverse reports.

TOXICOLOGY I have not found data showing toxic effects by this herb.

Side effects None reported. Overdose No adverse reports.

f.~

Dose Dried herb per day. 19

Interactions According to one text, absorption of other drugs taken simultaneously may be retarded. 16

The BHP listed 2-5 g of dried root, three times

Regulatory status

Decoction I recommend that about 15 g of dried Althaea root is soaked in about 750 ml of cold water for 1 hour. The water is brought to a boil and simmered very gently for about 15 minutes. The decoction is strained, and the remaining material is pressed to release more liquid. The dose is 1 cup of warm decoction taken three times per day. According to Felter and Lloyd, since 'the decoction soon decomposes or becomes mouldy and acid, it should always be made in small quantities, not more than one or two pints at a time, according to the temperature of the weather.' Cold infusion According to the wording of the German Standard License, cited in Wichtl, about 150 ml of cold water is poured over a tablespoon (15 g) of dried Althaea root, allowed to stand for 30 minutes with frequent stirring, and then strained. One cup can be drunk. several times per day and should be freshly prepared each time. The tea can be gently warmed before drinking. Liquidextract The BHP listed 2-5 ml of 1:1 extract in 25% alcohol, three times per day.

Initial dose Can start at the standard dose. Duration Can be taken on a long-term basis. Topical uses

Can be used as an ointment (5-10%) for in-

Please read the Regulatory status section in the chapter on Safety. Althaea is on the UK General Sale List (Statutory Instrument Order 1977 No. 2129 to the Medicines Act 1968). Althaea is not included in Part 4 of Schedule 4 of the Therapeutic Goods Act Regulations of Australia. Althaea is not currently listed by the FDA (USA) as a prohibited substance, as subject to an import alert, or as a substance with a warning on its use.

Traditional sources PROPERTIES Temperature Some of the older texts did not practice what they preached with respect to their classification of the temperature of Althaea. Hildegard von Bingen21 classified marshmallow, which she called ybischa, as hot and dry, but recommended it for fever. According to Lonicerus,22 marshmallow is hot, but he listed it for burns to remove the heat. Tabernaemontanus23 wrote that marshmallow root is 'warm and dry in the beginning of the second degree: but then listed it for burning urination and for thirst. Culpeper4 classified the roots of mallows in general as temperate in heat, but listed them for hot agues and for hot choleric disorders. Also,

190

Combining Western Herbs and Chinese Medicine

according to Culpeper, mallows are governed by the planet Venus. This implies that they are moist and cool in nature. The main entry in the Chinese Herbal Medicine Dictionary classifies Althaea rosea root (shU klii gen) as cold, although one text cited listed it as slightly cold. Althaea officinalis root is classified as cool and moist in this book since it is specific for dry inflamed conditions of the mucous membranes. Tierra25 also classified this herb as cool in temperature. Taste

Taste in the mouth The BHP listed the taste of Althaea root as sweet. I found that a sample of the dried root tasted sweet and slightly bitter, and gave a mucilaginous sensation in the mouth. Taste properties The Chinese Herbal Medicine Dictionary classified A. rosea root (shu kill gen) as sweet. Tierra listed A. -officinalis root as sweet and bitter. In terms of Chinese medicine. the taste properties of A. officinalis root, as used in the West, are listed in this book as sweet and slightly bitter. associated with the tonic and antiinflammatory actions, respectively.

ORGANS In terms of Chinese medicine, the root of A. officinalis, as used in the West. can be associated mainly with disorders of the following organs: Organ

Examples ·of uses.

Source:

Lung

cough, laryngitis respiratory catarrh with irritating cough gastritis excoriations of the bowels, abdominal pain enteritis dribbling and painful urination cystitis

Christopherl° BHp 19

Stomach Intestines

Bladder Uterus

BHP Culpeperl4 BHP Dioscorides 26 BHP

inflamed swellings of the genitals Dioscorides vaginal irritation Christopher

The Chinese Herbal Medicine Dictionary did not list the meridians entered for A. rosea root (shU klii gen).

ACTIONS AND USES The main Western traditional actions of this herb are: • respiratory demulcent and antitussive • gastrointestinal demulcent • urinary demulcent and diuretic • emollient (topical demulcent)

• nutritive tonic

--

• other

..... .u --~

Respiratory demulcent and antitussive Lonicerus wrote that marshmallow seed cures coughs that are due to heat, helps to expectorate phlegm, and treats tightness of the chest. According to Tabernaemontanus, marshmallow leaves simmered in milk and consumed warm are good for all different types of coughs. Culpeper listed marshmallow for pulmonary tuberculosis, pleurisy, and other diseases of the chest and lungs due to heat. Christopher recommended Althaea for hoarseness, cough, and bronchitis. Wichtllisted Althaea root as an antitussive, especially for irritable coughs and catarrhal inflammation of the throat. Gastrointestinal demulcent Dioscorides recommended marshmallow seed decoction for diarrhea and dysentery. Culpeper wrote that mallows can treat abdominal pain coming from hot, choleric or offensive humors. and Gerard stated that marshmallow could treat bloody diarrhea and its associated pain. According to Felter and Lloyd,27 Althaea root can treat gastrointestinal irritation and inflammation, dysentery and diarrhea. Christopher recommended Althaea not only for diarrhea and dysentery, but also for chronic constipation. The BHP listed Althaea root as specific for peptic ulcer. and the BHC listed it for gastroenteritis, peptic ulcers, enteritis. and common and ulcerative colitis. Urinary demulcent and diuretic According to Dioscorides, marshmallow can be used to treat dribbling and painful urination, and urinary stones. Lonicerus said that marshmallow root can increase urination and that the seeds can help to expel kidney stones and soothe burning urination. Culpeper wrote that mallows may ease the pain of kidney and bladder stones by opening the passages and making them more slippery, so that the stone may descend more easily. Felter and Lloyd described Althaea as a demulcent and diuretic for inflammation of the kidneys or bladder. for painful and difficult urination. retention of urine. and hematuria. The BHP listed Althaea leaves for cystitis, urethritis. and urinary gravel or stones. Emollient (topical demulcent) Dioscorides used marshmallow preparations for wounds. insect bites, burns. swellings, abscesses, and ulcers, and for heat-type swellings of the anus or genitals. Lonicerus recommended marshmallow simmered in vinegar as a mouthwash for teeth and gum problems, and applied to the skin for acne. According to Felter and Lloyd. Althaea poultices applied to wounds. accompanied by internal use of the decoction, can help to prevent gangrene. The BHP listed Althaea leaf combined with Ulmus in fomentation, poultice. or ointment for wounds. ulcers, boils, and eczema.

'.~'"

-

.. Althaea

191

Nutritive tonic Christopher listed Althaea as a nutritive for weak digestion and malnutrition. Tierra listed this herb as a nutritive and a Yin tonic. Althaea is one of the herbs in common use in the West that can be regarded as a sweet Yin tonic, comparable to Chinese Ym tonics such as Ophiopogon (mil.i men dong). According to Grieve, the roots of Althaea and of other mallows have been used as food by the Egyptians, Romans, and Chinese.

6. Gudej J. Planta Medica 57:284-285 (1991)

Other Lonicerus recommended simmering the root with wine and drinking it to cure fractured bones or internal damage that are a result of beatings and punches.

10. Beaune A. Balea T. Therapie 21:341-347 (1966)

7. Benigni R. Capra C, Cattorini PE.l:51-52[Tl] (1962). {cited in Bradley PR (ed). British Herbal Compendium, vol 1. British Herballvledicine Association. Bournemouth. United Kingdom (1992) I 8. Bieloszabska FW, Czhucha K. Farm Polska 22:173-176 (1966); abstract found in ChemAbstr 65:8671 (1966) 9. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn. Medpharm. Stuttgart Germany (1994), from 2nd German edn. Wichd M (ed) (1989)

11. Scheffer J, Konig W. Phytotherapie-Kongress, Lubeck-Travemunde Oct 3-6 Abstract P9 (1991) 12. Wagner H. Proksch A. Irnmunostimulatory drugs of fungi and higher

COMPARISON OF WESTERN AND CHINESE USE OF ALTHAEA SPECIES Whilst A. officinalis is one of the main demulcent antiinflammatory herbs used in the West, A. rosea (shu klii gen) seems to be only of minor importance in Chinese medicine. The actions of A. rosea are listed in the Chinese Herbal Medicine Dictionary as clearing Heat and cooling the Blood. A. rosea does not appear to be used as a moistening nutritive herb to tonify Ym and clear Deficiency Heat, as is A. officinalis in the West. Unlike A. officinalis, A. rosea does not appear to be used for respiratory problems. Although A. rosea is used in China for hematemesis, this m~y not be identical to its use in the West as a demulcent for gastritis and gastric ulcer. The use of A. rosea for intestinal inflammatory disorders is not listed in the Chinese Herbal Medicine Dictionary. However, this text listed A. rosea for urinary problems and hematuria, which is similar to the Western tradition for A. officinalis.

plants. In: Wagner H. Hikino H. Farnsworth NR (ed). Economic and Medicinal Plant Research. vol. 1. Academic Press, London. United Kingdom 113-153 (1985) 13. Nosal'ova G. Strapkova A, Kardosova A et al. Pharmazie 47:224-246 (1992) 14. Mi1ller-Limmroth W,Frohlich H-H. Fortschr Med 98:95-101 (1980) 15. Tomoda M.Shimizu N, Oshima Y. Planta Med 53:8-12 (1987) 16. Althaea. In:Hansel R. Keller K. Rimpler H et al. (ed). Hagers Handbook. 5th edn. voL 4: Drogen A-D. Springer-Verlag, Berlin-Heidelberg, Germany. pp 233-239 (1992) 17. Obolentseva GV. Khadzhai Yal, Vidyukova Al et al. Bulletin of Experimental Biology and Medicine 77:256-257 (1974) 18. Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone, Edinburgh. United Kingdom (2000) 19. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks. United Kingdom (1983) 20. Christopher JR. School of Natural Healing. BiWorld. Provo, Utah (1976) 21. Von Bingen H. Hildegard von Bingen's Physica. Healing Arts. Rochester. Vermont (1998)

References 1. Lietava I. J EthnopharmacoI35(3):263-266 (1992) 2. Grieve M. A Modern Herbal, vols. 1 and 2. Dover Publications. New York. New York (1971) 3. Lyle TJ. Physio-Medical Therapeutics, Materia :-'ledica and Pharmacy. Originally published Ohio (1897). Reprinted by the National Association of Medical Herbalists of Great Britain. London. United Kingdom (1932) 4. Jiangsu New Medicine Institute. Chinese Herbal Medicine Dictionary (Zhong yao da ci dian) Science and Technology Press, Shanghai. China (1975) 5. FranzG. Planta Med 14:90-110 (1966)

22. Lonicerus A. Kreuterbuch (1679). Reprinted by Verlag Konrad Kolbl, Miinchen. Germany (1962) 23. Tabernaemontanus IT. Krauterbuch (1731). Reprinted by Verlag Konrad Kolbl. Miinchen, Germany (1993) 24. Culpeper N. Culpeper's Complete Herbal & English Physician Enlarged. Meyerbooks, Glenwood, Illinois (1990) 25. Tierra M. Planetary Herbology. Lotus Press. Twin Lakes, Wisconsin (1988) 26. Dioscorides P. Kreutterbuch (1610). Reprinted by Verlag Konrad Kolbl. Miinchen. Germany (1960) 27. Felter HW and lloyd IU. King's American Dispensatory, vols 1 and 2, 18th edn. (1898). Reprinted by Eclectic Medical Publications. Sandy, Oregon (1983)

-,...

--

Anemone Botanical name Anemone pulsatilla L. (Pulsatilla vulgaris Miller), or Anemone pratensis L. (Pulsatilla pratensis Miller) Family Ranunculaceae Pharmaceutical name Anemonae herba (Pulsatillae herba) Part dried aerial parts English pasque flower, wind flower German Kiichenschelle French anemone pulsatilla Mandarin A. pulsatilla L. is not used bai tou weng is the root of Pulsatilla chinensis Bge. (Anemone chinensis Bge.) Use in the West A. pulsatilla is a small perennial native to Europe and parts of Asia, which has had centuries of herbal use in Europe. However, it is essential to distinguish between the use of the fresh plant. which releases protoanemonin upon crushing, and the use of the dried plant, in which the protoanemonin is converted by the drying process to anemonin. Protoanemonin can be an irritant and is potentially toxic in high doses, whereas anemonin does not appear to have these adverse effects. There appear to be two different traditions: one using the fresh plant, and the other using preparations of the dried plant. However, it is not always clear whether writers are referring to the use of fresh or dried material.

chewing the fresh plant or using its juice.ln the late 19th and early 20th century. American Eclectic authors, such as Felter and Lloyd3 as well as Ellingwood,4 clearly recommended the use of fresh material. Tierra5 followed this tradition by using the instructions given by Felter and Lloyd for making a tinc. ture of the fresh plant

Use of preparations from dried material Recent British texts, such as the BHP,6 BHC/ and Mabey,S recommended the use of preparations from dried material. The BHP noted that the fresh plant should not be used. and Mabey described the fresh plant as poisonous. Dose is all-important. Both Ellingwood as well as Felter and Lloyd used small doses of tincture or fluid extract made from fresh material. These low doses, for example, 1-15 drops of the fluid extract, were used to avoid the adverse effects that can occur at high doses. Since I have only used preparations from dried plant material, the descriptions of properties, herb pairs, and combinations in this chapter refer to the dried material unless otherwise stated.

Homeopathic tradition During the late 19th century. Anemone (Pulsatilla) was used by the homeopathic practitioners for conditions such as fearfulness, anticipation, and dread of calamity, and fear of trouble or death. Some of the indications given by the Eclectics for preparations of the homeopathy. fresh material seem to have been adopted Practitioners currently using the dried material need to

from

Use ofpreparations from fresh material European writers in the 16th and 17th century, such as Culpeper l and Gerard2 appear to have been using the fresh material, for example,

be aware that indications given for Anemone in the literature

193

..........

,

:~.

194

"'~~"I

Combining Western Herbs and Chinese Medicine

may be relevant to homeopathic or fresh preparations, but may not necessarily apply to the dried material.

Nomenclature

The names Anemone or A. pulsatilla are used in this chapter to indicate material from either A. pulsatilla or A. pratensis. In addition, the term "anemonin» referred to by earlier writers such as Ellingwood or Grieve9 appears to be not anemonin, but the acrid irritant protoanemonin. Use in China The Chinese Herbal Medicine Dictionary'° has an entry for bai tou weng, the root of Pulsatilla chinensis (Bge) Reg. (Anemone chinensis Beg.) This herb is mainly used in China for diarrhea and dysentery associated with Damp Heat or Heat Toxin.

Calm Kidney fear Fear from Deficiency, instability, or·;·~~· overstimulation of the Kidney can destabilize Heart Spirit - ~.~;...... and can also result in Stagnation of the flow of Qi through the Kidney and Bladder channels, and the channels of the.~.c: male and female reproductive systems. This can result in .!~ menstrual irregularities, painful conditions of the male or female reproductive systems, or sexual difficulties associated with nervous tension and fear. Actions on other organs Anemone can be used to treat headache and migraine. It may do this as much by calming the Heart and by acting as a general sedative, antispasmodic, and analgesic as by calming Liver Hyperactive Yang. Similarly, Anemone can be combined with other herbs to treat asthma, but may do this more by calming Kidney fear and Heart anxiety, than by having a direct relaxing effect on the bronchial muscles and moving Stagnation of Lung Qi.

What is special about Anemone WESTERN ACTIONS In terms of Chinese medicine, A. pulsatilla, as used in the West, can be said to be a cold, bitter herb that has its main effects on the Heart and Kidney.

The main Western actions of Anemone are shown here in terms of its two main Chinese actions: .

The key to understanding Anemone is that it is a herb with tranquilizing, antispasmodic. and analgesic actions, which is specific to calm nervous tension linked to anxiety or fear, and to treat spasms or pain associated with this nervous tension. It is also specific for conditions of insomnia, restlessness, overexcitement, or hyperactivity linked to sensations ofheat. CHINESE ACTIONS In terms of Chinese medicine, A. pulsatilla, as used in the West, can be said to have two main actions: I. calm Heart Spirit Disturbance II. calm Kidney fear Calm Heart Spirit Disturbance Anemone can calm Heart Spirit Disturbance in general, but especially when associated with the following two patterns:

..../ .-

.Chinese actions I. calm Heart Spirit Disturbance

tranquilizer sedative

II. calm Kidney fear

tranquilizer

Tranquilizer and sedative action Anemone is not a sedative in the sense that it dulls the consciousness so that physical activities are impaired, nor does it induce sleep by causing stupor. It appears to have its effects by calming nervous tension, so that the best categorization of its action might be as a tranquilizer, rather than a sedative.

WESTERN USES The main Western uses of Anemone can be related to its two main Chinese actions: Chinese actions

• Heart Excess or Deficiency Heat • Kidney fear The pattern of Heart Heat is generally associated with mental and physical restlessness, hyperactivity, and sensations of heat. It may be associated with the unpleasant feelings of anxiety and mental disturbance, with the temporarily more pleasant feelings of overexcitement and overenthusiasm, or with alternations between the two. These emotions or mental states may be accompanied by physical Heart signs, such as chest pain, arrhythmias, or palpitations, and stammering or other speech difficulties.

Western uses

..

~

I. calm Heart Spirit Disturbance

restlessness with sensations of heat, menopausal hot flashes, insomnia, overexcitement, hyperactivity, bipolar disorders, anxiety, panic attacks

II. calm Kidney fear

menstrual irregUlarity, headache. asthma associated with fearfulness. fright, or shock; feelings of desperation and mental pressure associated with excessive ambition, fear of failure, or loss of control

DIRECTION OF ENERGY Anemone can reduce disturbed upward movement of Qi

Anemone from Disturbance of Heart Spirit, Kidney fear, or Liver Hyperactive Yang.

TYPICAL CASE EXAMPLE Signs and symptoms The patient has had chronic anxiety, palpitations, and insomnia, with sensations of restlessness and heat both day and night. These have become worse with the onset of menopause, and the hot flashes with sweating have become severe. She has had a history of occasional chest pain and severe dysmenorrhea, and a tendency to periods of overenthusiasm, during which she can overload herself with work and projects, resulting later in feelings of desperation due to the pressure of overwork. The pulse is rapid and slightly irregular, and is thin and wiry especially in the Heart and Kidney positions. The tongue is thin with a red tip and red spots.. Diagnosis The patie~t has ~o~c patterns of: • Deficiency Heat linked to Deficient Y"m of the Heart and Kidney • Disturbance of Heart Spirit linked to both Heart anxiety and Kidney fear • Stagnation of Qi in the Heart and Kidney Choice of Anemone This herb is specific for Heart Spirit Disturbance linked to Heart Heat and can treat chronic restlessness, insomnia, anxiety, and overenthusiasm linked to these patterns, especially when accompanied by sensations of heat. It can also treat painful conditions, such as chest pain or dysmenorrhea, linked to Stagnation of Qi in the Heart or Kidney channels due to fear.

ACTIONS Tranquilizer Anemone can have a strong calming effect and can treat insomnia, restlessness, .and hyperactivity linked to overexcitement, anxiety, or fear. I consider this herb specific for Heart Spirit Disturbance linked to Heart Heat. I do not use this herb for the following conditions unless it is combined with other herbs: • patterns of Cold and Deficiency • depression, unless accompanied by restlessness and signs of Heat • Liver Hyperactive Yang linked to Stagnation of Liver Qi rather than to Heart Spirit Disturbance Antispasmodic and analgesic I do not use Anemone as a general-purpose antispasmodic and analgesic, as I would, for example, Lobelia. While Anemone has a tradition of use for spasms and pain in the head, chest, and reproductive system, it has not been used as much for pain in the gastrointestinal system or in the muscles of the limbs.

Anemone paired with other herbs Discussion of the limitations of each of the main actions of Anemone can be useful to clarify just what this herb can and cannot do. However, suitable combination with other herbs can extend the range of use of Anemone beyond its limitations. The basic unit of herb combination is the herb pair. Twelve pairings of Anemone are briefly explained below.

Limitations ofAnemone

,.

CAUTION TEMPERATURE

.

195

In this book, Anemone is classified as cold. It is specific for Heart Spirit Disturbance associated with Heart Excess or Deficiency Heat. However, for Heat in other organs, other herbs are more suitable.

TASTE The bitter taste of Anemone can be associated mainly with its capacity to clear Heat and calm the Heart. There is also tradition of use as an antimicrobial, thus linking the bitter t~ste -to the capacity to drain Damp Heat and clear Heat Toxin-In the case of Anemone, the bitter constituents do not seem to act as tonics or regulators of the gastrointestinal or hepatobiliary systems.

a

Before using any of the herb pairs below, it is important to be familiar with the cautions listed for each herb in the pair. Anemone + Crataegus

Emotional lability Crataegus can stabilize both physical and emotional manifestations of Heart Qi disturbances to stabilize the heartbeat, energy, and mood. Anemone can calm the Heart Spirit and clear Heart Heat so that this herb pair can be used to treat bipolar disorders, emotional lability, or menopausal hot flashes with palpitations. Anemone + Convallaria

Palpitations

196

Combining Western Herbs and Chinese Medicine

Convallaria can stabilize the physical function of the Heart to treat arrhythmias and palpitations associated with heart disease or exhaustion. Anemone can calm the Heart so that this pair can be used to treat arrhythmias or palpitations with nervous tension or nervous exhaustion. Anemone + Leonurus

Menopausal neurosis Both herbs are specific for menopausal problems and complement each other's actions. Leonurus is more for exhaustion. cardiac weakness, and emotional lability, and Anemone is more for restless overexcitement or anxiety with hot flashes.

Anemone + Rnta

._ _--

_.•... .._........

Dysmenorrhea

~

--;,O::.1r

Ruta can move Stagnation of Kidney Qi. and Anemone can reduce the Kidney fear that may give rise to this Stagnation. Ruta also has an effect on the reproductive system so . _-~~ that this pair can be used to treat amenorrhea, infertility, irregular menstruation, dysmenorrhea, or sexual difficulties associated with nervous tension. The pair can also be used for headache, especially those associated with premenstrual or menopausal syndromes. Anemone + Hypericum

Menopausal disorders + depression Anemone + Passiflora

Insomnia Both herbs can be used for restless insomnia with dreamdisturbed sleep, anxiety or panic attacks, and palpitations or headache associated with nervous tension. Anemone is stronger in both its calming and cooling effects.

Hypericum can have a tonic action on the Kidney so that this pair can be used to treat nervous tension and exhaustion associated with depression. Both herbs are specific for menopausal conditions, especially those associated with hot· flashes from Deficiency Heat of Kidney and Heart. Anemone + Glycyrrhiza

Anemone + Lavandula

Anxiety + depression Lavandula is slightly warming. moving, and antidepressant so that it can complement and moderate the cooling and sedative actions of Anemone. This pair can be used to treat nervousness and anxiety concurrent with depression. This pair can also be used for headache, especially for cases in which Liver Hyperactive Yang is combined with Heart Spirit Disturbance. Anemone + Valeriana

Migraine Both herbs can calm Heart Spirit Disturbance, and Anemone can help Valeriana to calm Liver Hyperactive Yang. Since both herbs can clear Heat, they are specific for headache with sensations of heat in the head and face, accompanied by restlessness, overexcitement. or sensations of mental emotional tension and pressure.

Nervous tension + exhaustion Glycyrrhiza can tonify both the Kidney and Heart to assist in the treatment of Heart Spirit Disturbance associated with Deficiency. Its tonic action can moderate the sedating effect of Anemone, and the two herbs, usually in combination with others, can be used for nervous tension combined with nervous exhaustion. Anemone + Zingiber

Dysmenorrhea + sensations ofcold Zingiber is often paired with Anemone since its warming. stimulating actions balance the cooling, sedating actions of Anemone. Also, the diffusive diaphoretic action of Zingiber assists in the dispersal of disturbed Qi that has accumulated due to the stagnating effects of nervous tension. Anemone + Lobelia

Anemone + Mentha pulegium

Anxiety + fearfulness Both herbs can calm Heart Spirit Disturbance and Kidney fear so that the pair can treat restlessness, anxiety. panic attacks, nervousness, and feelings of tension, desperation, and fear. These psychological symptoms may be accompanied by physical manifestations, such as heart pain, headache, difficulty breathing, or dysmenorrhea. .

Asthma + nervous tensio'1 Both herbs are calming, antispasmodic. and analgesic. Lobelia has a specific effect on the bronchial muscles so that this pair can be used for asthma or other breathing difficulties associated with fear or nervous tension. The pair can also be used for dysmenorrhea associated with Stagnation of Kidney Qi due to chronic fearfulness or acute fright or shock.

Anemone

197

Anemone combinations Six Anemone combinations are discussed below. , . --.

Combination

Lavandula Anemone Schisandra Lobelia Prunus Ephedra Glycyrrhiza

Heart Spirit Disturbance

2. menopausalhotfiashes

Heart Heat + Heart Deficient Yin

3. asthma + anxiety

Heart Spirit Disturbance + lung Stagnant Qi

This combination is the same as Lavandula: asthma + anxiety and is discussed under that heading.

4. headache + anxiety

Liver Hyperactive Yang + Heart Spirit Disturbance

4. Headache + anxiety

5. exhaustion + fear

Kidney Deficient Qi + Kidney fear

Liver Hyperactive Yang + Heart Spirit Disturbance

6. dysmenorrhea + fear

Kidney Stagnant Qi + Kidney fear

CAUTION

Before using any ofthe combinations below, it is important to be familiar with the cautions listed for each herb in the com-

bination. 1. Insomnia

Herb Lavandula Valeriana Anemone Glycyrrhiza

Ratio·

Temperature

Taste

1 1 1

sl. warm cool cold neutrai-{;ool

aromatic, bitter, sl. acrid bitter, sweet bitter sweet

0.5

2. Menopausal hot flashes

Heart Heat + Heart Deficient Yin

Salvia off. Salvia mil. " Leonurus Anemone Ophiopogon Glycyrrhiza Valeriana

• !emperature

51. warm warm-cool warm cold cool neutral-cool hot

1 1 1 1 1 0.5 0.5

Taste

':~~"~;;:'h'

.'

aromatic, bitter, 51. acrid aromatic, acrid, bitter aromatic bitter bitter, sweet sweet acrid, aromatic

5. Exhaustion + fear

This combination is the same as Lavandula: insomnia and is discussed under that heading.

Herb

Lavandula Salvia off. Mentha pul. Anemone Valeriana Glycyrrhiza Zingiber

Ratio

This combination is the same as Lavandula: headache + anxiety and is discussed under that heading.

Heart Spirit Disturbance

I~

1 1 0.5 0.5

aromatic, bitter, 51. acrid bitter SOur acrid aromatic, bitter acrid, 51. bitter sweet

1. insomnia

Herb .::"

L..,;,:,,;"

sl. warm cold warm warm-{;ool neutral warm neutral-{;ool

1 1 1

Ratio

Temperature

Tas~e"

1 1 1 1 1 0.5 0.5

warm-cool cool neutral cold cool neutral-{;ool cool

aromatic, acrid bitter sour, sl. bitter bitter sweet, 51. bitter sweet bitter, sweet

This combination is the same as Salvia: menopausal hot flashes and is discussed under that heading. 3. Asthma + anxiety

Heart Spirit Disturbance + Lung Stagnant Qi

Kidney Deficient Qi + Kidney fear

Herb"".::~ Ruta Anemone Hypericum Serenoa Schisandra Ophiopogon Glycyrrhiza Zingiber

":' "

~,~~. ~-:-

.. ·~F -

-.,f~~"":--.'-::,"-':·~'":::::~~?·~::''.:~~_·,'~~·~~''''':'··-;'::l

Ratio

Temperature"

1 1 1 1 1 1 0.5 0.5

warm-cool cold neutral neutral 51. warm cool neutral-{;ool hot

-~Taste .

bitter, aromatic bitter sour, 51. sweet sweet, 51. sour sour sweet, 51. bitter sweet acrid, aromatic

This combination is the same as Ruta: exhaustion + fear and is discussed under that heading. 6. Dysmenorrhea + fear

Kidney Stagnant Qi + Kidney fear

:~r~!~~~~I~roe~~i~~;f~l~T~~~7~:::g;.~·7~~ Anemone 1 Ruta 1 Mentha pul. 1 lobelia 1 Viburnum 5PP. 1 Zingiber 1 Capsicum 5-20 drops

cold warm-cool warm warm-cool neutral hot hot

bitter _ bitter, aromatic aromatic acrid 51. sour, 51. bitter acrid, aromatic acrid

Combining Western Herbs and Chinese Medicine

198 GENERAL

This combination is for situations in which Kidney Qi has become Stagnant, resulting in lower back pain, difficult urination, amenorrhea, infertility, dysmenorrhea, or related Kidney organ or meridian disorders. This combination is specifically for situations in which Kidney Qi Stagnation is associated with obstruction of the movement of Qi in the Kidney and Bladder channels by fear. The overall temperature of the combination is warm so that it can be used for cool to cold conditions. Bitter, aromatic. and acrid herbs combine to calm the fear and move the Qi. USE

• dysmenorrhea with pain radiating to the back, maybe lower back pain, dysuria. depression, desperation, or fearfulness PRACTICAL NOTES

This combination can be taken as 5 ml of 1:5 tincture in quarter of a cup of warm water or in a cup of hot Mentha pulegium infusion three times per day. Capsicum can be given in a separate bottle so that the requisite number of drops of Capsicum can be added to each dose of the main medicine. The Mentha infusion is made by pouring one cup of boiling water over two teaspoons of dried Mentha and allowing it to steep in a covered vessel for about 7 minutes. This combination can be taken daily for 1 to 3 months, with appropriate breaks and modifications. The dose can be increased temporarily to 7.5 ml, three times per day, from about 3 days before menstruation to the time that menstruation pain ceases.

Caution This combination should not be taken if there is a chance of conception.

COMPARISON OF SIX ANEMONE COMBINATIONS 1. Insomnia

2. Menopausal hot flashes

Heart Spirit Disturbance

Heart Heat + Heart Deficient Yin

Herb

- Ratio

Lavandula Valeriana Anemone

1 1 1

Glycyrrhiza

0.5

Herb -. .

Ratio

Salvia off. Salvia mil. Leonurus Anemone Ophiopogon

1 1 1 1 1

Glycyrrhiza

0.5 0.5

Valeriana

1. In this effective symptomatic combination for insomnia, Anemone and Valeriana are the stronger calming herbs.

Lavandula contributes a tranquilizing effect, but it balances _.. _:~ this with mild tonifying and moving actions. The sweet· . heavy property of Glycyrrhiza emphasizes the sweet heaviness of Valeriana, but this grounding effect is moderated by the moving and lightening action of the Lavandula essential oils. 2. Both Salvias can clear Heart Deficiency Heat and help to tonify Deficient Heart Yin and Blood. They can also act as emmenagogues to regulate menstruation. S. officinalis is specific for menopausal sweating and combines with Leonurus and Anemone to treat menopausal disorders. Anemone and Valeriana can clear Heart Heat and calm Heart Spirit, and Ophiopogon and Glycyrrhiza combine to tonify Yin.

3. Asthma + anxiety

4. Headache + anxiety

Heart Spirit Disturbance + Lung Stagnant Qi

Liver Hyperactive Yang + Heart Spirit Disturbance

3. Lobelia, Prunus, and Ephedra combine to open the

Lung and relieve bronchial spasms. Lavandula and Anemone combine to calm the mind and emotions, supporting the antispasmodic herbs. Schisandra firms Lung and Heart Qi to calm anxiety and moderate the stimulating and dispersing effects of Ephedra on the energy of the Lung and Heart. 4. Lavandula, Salvia, and Valeriana are combined for headache associated with both Liver Hyperactive Yang and Heart Spirit Disturbance. Mentha and Anemone combine to treat nervous tension associated with Heart Spirit Disturbance and Kidney fear. Glycyrrhiza helps to stabilize the Heart and Kidney, and Zingiber helps to disperse Qi Stagnation resulting from nervous tension. 5. Exhaustion + fear

6. Dysmenorrhea + fear

Kidney Deficient Qi + Kidney fear

Kidney Stagnant Qi + Kidneyfear

Ruta Anemone

1 1

Anemone Ruta

1 1

Anemone

199

Protoanemonin A. pulsatilla may contain about 2.8%

Herb· Hypericum Serenoa Schisandra Ophiopogon Glycyrrhiza Zingiber

Mentha pul. Lobelia Viburnum spp.

1 1 1 1 0.5 0.5

Zingiber Capsicum

1 1 1 1 5-20 drops

5. Ruta and Anemone are paired to calm Kidney fear and the feeling of desperation that can be associated with selfimposed unrealistic goals and a fear of failure or loss of control. Hypericum, Serenoa and Schisandra possess the sour property to firm Kidney Qi, and these three herbs also possess the sweet property that can tonify Kidney Qi and Yin when assisted by Glycyrrhiza and Ophiopogon. 6. Ruta and Anemone are paired to calm Kidney fear as

in the previous combination. However, since the emphasis in this combination is on pain, rather than on exhaustion as in No.5, the tonic herbs in No.5 have been replaced in this combination by the antispasmodic herbs Mentha, Lobelia, and Viburnum. Zingiber and Capsicum assist the antispasmodic action of the other herbs and dear Stagnation of Qi in

ranunculin, and about 1% protoanemonin can be obtained by steam distillation. 12 However, protoanemonin is unstable, and as the plant material dries, it dimerizes to form anemonin. n

Anemonin The toxicity sometimes observed with fresh material from A. pulsatilla is due to ranunculin and protoanemonin, but this toxicity disappears as the material dries since anemonin is nontoxic.l~ Triterpenoid saponins The aerial parts of A. pulsatilla can contain 0.2-0.75% triterpenoid saponins. 1S According to Chang and But,16 the roots of P. chinensis have been reported to contain up to 9% triterpenoid saponins. The lupane-type triterpenic acid, pulsatillic acid, and the lupane-type triterpene saponins, pulsatilloside A, B, and C, have been isolated from the roots of Pulsatilla chinensis. 17• 18 Other The aerial parts of A. pulsatilla contain tannins,19 essential oil,l) the calcium salts of chelidonic arid succinic acids, and flavonoids. 7 The roots of Pulsatilla chinensis have been reported to contain the lignans pinoresinol and ~­ peltatin. 20

the Uterus due to Cold.

COMPARISON OF CONSTITUENTS OF OTHER ANEMONE COMBINATIONS Other combinations that contain Anemone include the following:

• Leonurus: menstrual disorders + anxiety • Ruta: chronic fatigue syndrome + palpitations • Ruta: nightmares • Thymus: enuresis

Research CONSTITUENTS

A. PULSATILLA AND P. CHINENSIS . Fresh material from both species contains protoanemonin, and dried material from both species contains anemonin. What is vital to determine are the relative amounts of protoanemonin and anemonin in preparations from dried material of different ages from A. pulsatilla herb and P. chinensis root. There appears to be a much larger amount of triterpenoid saponins in the root of P. chinensis than in the herb of A. pulsatilla, and various constituents have been reported for P. chinensis root that have not been noted in A. pulsatilla, such as the lignans pinoresinol and ~-peltatin, okinalin, and okinalein.

The following constituents have been reported: ·lactones • triterpenoid saponins • other Lactones

Ranuneulin 'Several species in the Ranunculaceae family contain the lactone glycoside ranunculin, which is present in the undamaged fresh plants. When the tissues are crushed, ranunculin is hydrolyzed enzymatically to the aglycone protoanemonin. 11

PHARMACOLOGICAL AND CLINICAL RESEARCH ON A. PULSATILLA The following effects have been reported: • antibacterial • antifungal • antipyretic • antispasmodic .• sedative • antimutagenic

Combining Western Herbs and Chinese Medicine

200

Antibacterial I have not found data on the antibacterial activity of A. pulsatilla extracts. Research on the antibacterial activity of the isolated constituents protoanemonin and anemonin is discussed in the section Pharmacological and clinical research on P. chinensis below. Antifungal Protoanemonin was reported to have antifungal activity,21 and protoanemonin, isolated from Pulsatilla alpina, was reported to have in vitro antifungal effect.22 Antipyretic Anemonin was reported to be the main compound responsible for the antipyretic activity of Pulsatilla alpina subsp. apiifolia. 23 Antispasmodic Early studies on A. pulsatilla reported antispasmodic activity,15 and according to Bruneton, I~ protoanemonin is thought to be antispasmodic. Sedative Early studies on A. pulsatilla reported sedative activity, IS and both anemonin and protoanemonin were reported to participate in the sedating effect of Pulsatilla alpina subsp. apiifolia.23 Antimutagenic Protoanemonin was identified as the factor responsible for the antimutagenic effect of Ranunculus and Anemone species against the strain E. coli B/rWP2trp.24

PHARMACOLOGICAL AND CLINICAL RESEARCH ON P. CHINENSIS The following effects have been reported: • antibacterial • antifungal • antiprotozoal • cardiotonic • anticarcinoma • antimutagenic

due to the breakdown of protoanemonin into anemonin. -~._ ~, =This implies that the breakdown is slow and that there may be variable amounts of protoanemonin in dried plant material. It is therefore necessary to obtain clearer data on: • whether anemonin has antibacterial action in A. pulsatilla or P. chinensis • how much protoanemonin remains in a decoction or tincture of the dried material of A. pulsatilla or P. chinensis Antifungal

This has already been discussed under

Pharmacological and clinical research on A. pulsatilla. In addition, P. chinensis preparations were reported by early Chinese study to have an effect against certain skin fungi. 31 Antiprotozoal Early research in China reported that P. chinensis preparations were effective against Trichomonas vaginalis. 32 P. chinensis preparations have been reported effective in clinical studies on the treatment of diarrhea due to Giardia lamblia or Trichomonas. 33 Cardiotonic Early studies reported that the aerial parts of P. chinensis have a cardiotonic action,34 and the cardiotonic constituents were reported to be okinalin and okinalein.35.36 Anticarcinoma An early study in China reported that intravenous injection of protoanemonin had an effect against squamous cell carcinoma, undifferentiated carcinoma, and melanoma of the lung. 37 In a more recent study, pulsatillic acid, a lupane-type triterpenic acid from P. chinensis, showed cytotoxic activity against P-388 Lewis lung carcinoma and human large cell lung carcinoma. 17 Antimutagenic

This has already been discussed under

Pharmacological and clinical research on A. pulsatilla. COMPARISON OF PHARMACOLOGICAL

Antibacterial

AND CLINICAL RESEARCH ON A.

Herb extracts The fresh juice,2s decoction,26 and alcohol

PULSATILLA AND

extract of Pulsatilla chinensis were reported to have antibacterial activity in vitro. A clinical study reported that a decoction of the fresh herb of P. chinensis was effective in the treatment of bacillary dysentery.28

P. CHINENSIS

The pharmacological and clinical research discussed above can be summarized to show the effects demonstrated for anemonin (A), protoanemonin (B), and dried material of A. pulsatilla (C) or P. chinensis (D):

Isolated constituents Protoanemonin has been reported to have antibacterial activity,29 but anemonin has been reported to lack antibacterial activity.30 However, according to Chang and But,16 both protoanemonin and anemonin have strong antibacterial activity. The BHC stated that protoanemonin is not found in dried material of A. pulsatilla. However, Chang and But reported that long dry storage renders P. chinensis less toxic

antibacterial

ari~i~ngal ~.':'tipr_~!~zoa~

._.

antipyretic.... __ . antispasmodic _.. - -----. ...._ _... - -

.. , •..

._.. _ ..__.

v

Anemone

;;,~"

sedative

..;

..;

..;

cardiotonic antimutag~nic

antitumor

..;

..; ..;

201

is a total of 6 doses. An individual dose is thus approximately 2.5-5 g. This is about twenty times greater than the individual dose of 0.12-0.3 g of dried A. pulsatilla listed by the BHP. (1 have not found clear data in Western texts on the dose in grams of fresh A. pulsatilla.) Dried herb

TRADITIONAL ACTIONS

A. pulsatilla I have not seen reports of adverse effects for preparations made from dried aerial parts of A. pulsatilla when taken in therapeutic doses.

The antimicrobial. antispasmodic, and sedative actions of either the dried herb or isolated anemonin or protoanemonin have been verified. The analgesic and emmenagogue actions have not yet been demonstrated for the dried material. nor have the nervine. antidepressant. and anticatarrhal actions. which. in any case. may only apply to the

P. chinensis According to Chang and But. both the decoction of P. chinensis and its saponins are of low toxicity. and no significant side effects have been reported for administration of the standard dose of the decoction. The LD 50 of the fluid extract of P. chinensis root in mice by intraperineal injection was reported as 60 glkg.38

RESEARCH VERIFICATION OF

fresh material. Additional effects d~monstrated by research Antimutagenic and antitumor effects have been reported for pro-

Dose

toanemonin.

TOXICOLOGY Protoanemonin The LD 50 of protoanemonin in mice was reported to be 190 mg/kg. 22 which is 11.4 g of protoanemonin for a 60 kg human. Fresh herb

A. pulsatilla According to Felter and lloyd. when preparations of the fresh material of A. pulsatilla are taken internally in overdose. there may be gastric irritation with a sense of rawness. burning. and pain in the stomach, attempts to vomit. and marked prostration. Toxic doses may produce stupor. coma. and convulsions. However. assuming that fresh A. pulsatilla contains about 1% of protoanemonin. then to ingest the 11.4 g of protoanemonin listed under Protoanemonin above. a person would have to consume about 1.14 kg of the fresh herb.

P. chinensis According to Chang and But. the crushed fresh P. chinensis emits a str~ng irritating odor due to the release of protoanemonin. which can strongly irritate the skin and mucosa. causing lachrymation. sneezing. and coughing. Ingestion ofthe crushed fresh herb may result in salivation. gastrointestmal irritation:vomiting. and abdominal pain. In severe cases. there Olay be nephritis. hematuria. heart faill;U'e. and death from respiratory failure. How~v~r. the therapeutic dose listed in the Chinese Herbal Medicine Dictionary for the fresh root of P. chinensis (bai t6u weng) is 0.5-1 liang. (15-30 g). Assuming that this amount of herb is a supply for 2 days, at 3 doses per day. this

Dried herb The BHP listed 0.12-0.3 g of dried herb. three times per day. Tmcture The BHP listed 0.3-1 ml of 1:10 tincture in 40% alcohol. three times per day.

Initial dose Can start at standard dose. providing cautions are observed. Duration Can be used for one month or more. providing cautions are observed.

Cautions Western contraindications I have not seen contraindications for preparations of the dried material when used in therapeutic doses. However. I do not use this herb for cases involving weakness with sensations of cold unless combined with a warming circulatory stimulant. such as Zingiber. Chinese contraindications Diarrhea and dysentery from Cold and Deficiency are contraindications for P. chinensis when used in Chinese therapeutic doses. which are about 20 times higher than those listed by the BHP for A. pulsatilla. Pregnancy and lactation No adverse reports are known for preparations of the dried material when used in therapeutic doses. The BHC contraindicated using the herb during pregnancy. but the fresh material was used during pregnancy by the Eclectics (see Traditional sources). Ability to drive and use machines No adverse reports.

Combining Western Herbs and Chinese Medicine

202

Side effects None reported, but see Western contraindications.

Overdose According to the BHC, overdose may irritate the stomach and cause vomiting, but this may be referring to the fresh plant rather than the dried material.

sweet. In this book, A. pulsatilla, as used in the West, is classi.:..'~~fi fied as bitter in terms of Chinese medicine, in the sensethat .~ it can be used to calm the Heart Spirit, especially in patterns of Excess or Deficiency Heat. ORGANS

Interactions None reported.

Regulatory status Please read the Regulatory status section in the chapter on Safety. Anemone (pulsatilla) is on the UK General Sale List (Statutory Instrument Order 1977 No. 2129 to the Medicines Act 1968). Anemone is not included in Part 4 of Schedule 4 of the Therapeutic Goods Act Regulations of Australia. Anemone is not currently listed by the FDA (USA) as a prohibited substance, as subject to an import alert, or as a substance with a warning on its use.

Traditional sources PROPERTIES Temperature The temperature listed for A. pulsatilla will depend on whether the author is referring to preparations from fresh or dried material. Gerard listed the temperature of the plant he called Pulsatilla vulgaris or pasque flower as hot and dry. From the entries on the anemones in both Gerard and Culpeper, it appears that the fresh material was used. According to Felter and Lloyd, an acrid volatile constituent is emitted when the fresh plant is bruised, which is sufficiently powerful to produce lachrymation or vesication if the plant material is kept in contact with the skin for an extended period. The main entry ·in the Chinese Herbal Medicine Dictionary classified the dried root of P. chinensis as cold. One subsidiary text cited listed it as cold, but did not specify the part used or whether it is fresh or dried. A. pulsatilla, as used in the West, is classified in this book as cold since it can be used for patterns of Excess or Deficiency Heat. Taste Taste in the mouth According to Felter and Uoyd, the fresh plant produces a numbing, tingling sensation when chewed. I found a 1:10 tincture of the dried plant in 25% alcohol to taste slightly sour, slightly bitter, and slightly acrid. Taste propertie~The main entry of the Chi~ese Herbal Medicine Dictionary classified the foot of P. chinensis as bitter, although one subsidiary text cited listed it as bitter and

In terms of Chinese medicine, Anemone, as used in the West, can be associated mainly with disorders of the following organ systems:

organ"':- i'Ei~~pie~'of"use's -.

Heart

Kidney

't

nervousness, hysteria hyperactive states, insomnia

Felter and Lloyd

unnatural fear

Felter and Lloyd

BHP

The main entry in the Chinese Herbal Medicine Dictionary listed P. chinensis as entering the Large Intestine, Liver,"and Stomach meridians, However, a subsidiary text cited listed the Heart and Kidney. ACTIONS Evidence from traditional sources for the following ..... actions of Anemone is discussed below: • antimicrobial • antispasmodic • analgesic • sedative • nervine • anticatarrhal • emmenagogue Antimicrobial Neither Felter and Lloyd nor Ellingwood _. listed preparations of the fresh plant as an antimicrobial. However, the BHP listed the dried material as antibacterial,recommended it for boils and skin eruptions associated with bacterial infection, and noted its combination with Echinacea or Baptisia for skin diseases and septicemia. Also, themain use of the dried material from P. chinensis in China is as an antimicrobial for bacterial or protozoal dysentery. Antispasmodic Felter and Lloyd listed the fresh material for asthma, whooping cough, and dysmenorrhea. The BHF listed the dried material as an antispasmodic and noted itt_ use for asthma and dysmenorrhea. Analgesic According to Felter and Lloyd, preparations 0 the fresh material can be used for painful conditions, espe-=-cially for those associated with debility, but also for thosp associated with acute inflammation. The BHP listed thl dried material as an analgesic and gave its specific indication .

Anemone as painful conditions of the male or female reproductive system. Sedative Ellingwood listed the use of the fresh material for hysteria or hysterical convulsions. Felter and Lloyd noted its use for sadness, depression, gloom, brooding over real or imagined troubles, tendency to look on the dark side of life, tendency to weep, nervous restlessness, unnatural fear, and real or imaginary cardiac conditions. The BHP listed the dried material as a sedative that can be used for insomnia, hyperactive states, and tension headache. Nervine The fresh material is said to have warming, tonic nervine, and antidepressant actions, but these actions are not listed for the dried material, which is more generally regarded as a sedative. Ellingwood noted the use of the fresh material for nervous exhaustion with feeble pulse, cold extremities, and generally relaxed physical condition. Felter and Lloyd wrote that, in therapeutic doses, the fresh material 'increases the power and regulates the action of the heart, and gives a better character to the pulse rate, particularly slowing the irritable, rapid and feeble pulse due to nervous depression.' Anticatarrhal Culpeper said that 'the leaves being stamped and the juice snuffed up the nose, purges the head mightily: so does the root being chewed in the mouth, for it procures much spitting, and brings away many watery and phlegmatic humours, and is therefore excellent for the lethargy.' Felter and Lloyd noted the use of the fresh material for thick discharges from mucous surfaces, stomach disorders from indulgence in fats and pastries, thick tongue coat with a greasy taste, acute nasal catarrh, frontal headache from nasal catarrh, chronic conjunctivitis with yellow discharge, and leukorrhea. Emmenagogue According to Felter and Lloyd, the fresh material can be used for amenorrhea or dysmenorrhea in nervous and anemic patients with chilliness as a main symptom. They recommended it for sluggish, ineffectual or weak labor pains, and Ellingwood wrote that preparations of the fresh material were excellent during pregnancy in small, frequent doses for nervousness or hysteria. The result is a feeling of general relaxation and an atonic condition, facilitating a normal and easy labor. The BHP recommended dried Anemone in combination with other herbs for menopausal disturbances.

203

dried root of Pulsatilla chinensis (Anemone chinensis): A. pulsatilla is mainly used for conditions with nervous tension, and P. chinensis is mainly used for bacterial or protozoal dysentery. A. pulsatilla The main use of A. pulsatilla dried material in the West is as a sedative, antispasmodic, and analgesic for fearfulness, restless insomnia, nightmares, anxiety, panic attacks, and hysteria, as well as for asthma, headache, and menopausal disorders or dysmenorrhea associated with nervous tension.

P. chinensis The main use of bai tou weng is for diarrhea and dysentery associated with Damp Heat or Heat Toxin. It is also noted in the main entry of the Chinese Herbal Medicine Dictionary for alternating fever and chills associated with dysentery, and for heat-type bleeding such as nosebleeds or bleeding hemorrhoids. Subsidiary texts cited listed swollen throat, lumps in the neck or abdomen, and boils as indicators.

References 1. Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. Meyerbooks. Glenwood, Illinois (1990) 2. Gerard J. The Herbal or General History of Plants: The Complete 1633 Edition as Revised and Enlarged by Thomas Johnson. Dover Publications, New York, New York (1975) 3. Felter HW, Lloyd JU. King's American Dispensatory, vols. 1 and 2, 18th edn. (1898). Reprinted by Eclectic Medical Publications, Sandy, Oregon (1983) 4. Ellingwood F. American Materia Medica, Therapeutics and Pharmacognosy,llth edn. (1919). Reprinted by Eclectic Medical Publications, Sandy. Oregon (1994) 5. Tierra M. Planetary Herbology. Lotus Press. Twin Lakes. Wisconsin (1988) 6. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks. United Kingdom ( 1983) 7. Bradley PR (ed). British Herbal Compendium. vol. 1. British Herbal Medicine Association, Bournemouth. United Kingdom (1992) 8. Mabey R (ed). The Complete New Herbal Elm Tree Books, London, United Kingdom (1988) 9. Grieve M. A Modern Herbal, vols. 1 and 2. Dover Publications. New York. New York (1971) 10. Jiangsu New Medicine Institute. Chinese Herbal Medicine Dictionary (Zhong yao da ci dian) Science and Technology Press. Shanghai. China (1975) 11. HillR. van Heyningen R. Biochem J 49:332-335 (1950

COMPARISON OF WESTERN AND CHINESE USE OF ANEMONE SPECIES

12. Pourrat A. Lejeune B. Besse-Bergier FX. J Pharm Belg 35:277-280 (1980) 13. Baer H. Holden M. Seegal BC. J Bioi Chern 162:65-68 (1946)

There is a marked difference between the use of preparations of the dried aerial parts of Anemone pulsatilla and the

14. Bruneton J. Pharmacognosy: Phytochemistry Medicinal Plants, 2nd edn. Lavoisier. Paris. France (1999)

.

_,

_. ....-.

~.

204

Combining Western Herbs and Chinese Medicine

15. Benigni R. Capra C. Cattorini PE. voU 1158-1164 (T1} {l964} 16. Chang H-M. But PP-H (cds). Pharmacology and Applications of Chinese Materia Medica. vols. 1 and 2. World Scientific Publishing. Singapore (1986) 17. Ye WC. Ii NN. Zhao SX et al. Phytochemistry 42(3):799-802 (1996) 18. Ye W. He A. Zhao S et al. J Nat Prod 61(5}:658-659 (1998)

28. Traditional Chinese Medicine Department, Xiaoxian People's Hospital._ " Anhui Yixue (Anhui Medical Journal) (2}:63 (1977) ~ .-~~

29. Blasco R. Wittich RM. Mallavarapu M et al. J Bioi Chem 270(49):

~-~-

29229-29235 (1995)

~.-.~'

30. Hifny Saber A. Mahran GH. EI-Alfy T. Planta Medica 16:231-238.:·?i. (1968)

- .:::.~~

19. Hagers Handbuch. Band VI A 975-978 (T II} (1977)

31. Cao RL et al. Chinese Medical Journal {l2}:781 (1962)

20. Mimaki Y.Kuroda M.AsanoT etaLJNatProd62(9}:1279-1283 (1999)

32. Pharmaceutics Section. Shanghai First Medical College. Abstracts of the 1959 symposium of Shanghai First Medical College p 41 (1959)

21. Mares D.Mycopathologia 98(3}:133-140 (1987) 22. Martin ML. San Roman L, Dominguez A. Planta Med 56(l}:66-69 (1990)

33. Chen WZ. Bulletin of Zhejiang College of Traditional Chinese

23. Martin ML, Ortiz de Urbina AY, Montero MJ et al. J Ethnopharmacol 24(2-3}:185-191 (1988)

34. Goto. Nihon Yakuho (6}:7 (1930)

24. Minakata H. Komura H. Nakanishi K et al. Mutat Res 116(3-4):317322 (1983) 25. Yan GH et al. Chinese Pharmaceutical Bulletin 8(2}:57 (1960) 26. WangWS et al. Chinese Pharmaceutical Bulletin 7(10}:522 (1959) 27. WangWSetal.ActaBotanicaSinica3(2}:121 (1954)

"'~7~

Medicine (4}:15 {l977}

35. Goto. Nihon Yakuho (7):5 (1930) 36. Kodama. Japan Centra Revuo Medicina 34:377 (1932) 37. Pilot Production Unit, Shanghai No 17 Pharmaceutical Factory. Pharmaceuticallndustry (6}:3 (1974) 38. Pharmacology Section. Henan Medical College. Acta Academiae Medicinae Henan (5}:19 (1959)

.,...;

Angelica

....

...

Botanical names Angelica archangelica 1. Family Apiaceae (Umbelliferae) Pharmaceutical name Angelicae archangelicae radix cum rhizomate Part dried roots and rhizomes English (garden) angelica German Engelwurz French angelique Mandarin A. archangelica 1. is not used bai zhl (a If.) is the root of A. dahurica Benth. et Hook. (or other species) diing gui (1; tf) is the root of A. sinensis (Oliv.) Diels. du huo W~ i~) is the root of A. pubescens Maxim. (or other species)

Use in China There is no entry for A. archangelica in the Chinese Herbal Medicine Dictionary.s The three Angelicas most commonly used in Chinese medicine are those listed above.

What is special about Angelica In terms of Chinese medicine, A. archangelica, as used in the West, can be said to be a warm herb with aromatic, bitter, and acrid properties, which has its primary effect on the Lung, Spleen, Stomach, Intestines, and Heart.

The key to understanding Angelica is that it is a warming, drying herb that can stimulate the respiratory, digestive, and cardiovascular systems to treat conditions associated with Interior Deficiency, Cold, Damp, and Phlegm. It can also help to clear Exterior Wind, Cold, and Damp.

Use in Europe Angelica is a biennial herb, native to Northern Europe and Asia, which is now naturalized in North America. The petioles are used as 'candied angelica' in confectionery, and the seeds with their aromatic and bitter taste are used in aperitifs such as Vermouth and liqueurs such as Benedictine and Chartreuse. Angelica has had medicinal use since ancient times. Dioscorides l used it to treat respiratory disorders and stomach problems, and this tradition of use has been continued to the present day. '---

Angelica can be used to: • stimulate the Spleen to transform Damp • stimulate the Lung to clear Phlegm and Damp • clear Phlegm and Damp from the head • clear Phlegm and Damp from the channels ofthe muscles and joints I use Angelica for phlegm in the lungs, and for phleg~ in the sinuses with nasal congestion, sinus headache, or postnasal drip. I also use it in combinations to treat a general body tendency to phlegm and obesity associated with Interior Deficien~~Q)ld, Damp, and Phlegm.

Use in North America A. archangelica has been more commonly used in Europe than in North America, where other species, for example, A. atropurpurea, 2.3 A. arguta, and A. pinnata\ have often been employed for indications that are similar to those ofA. archangelica.

205

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Combining Western Herbs and Chinese Medicine

206

.6~j~es~~ ~~Of!~'.~:~:~:-'~'::~~ .;;--'-'_:~~_~;~t~i~-~~~~-y7311 ~;~!'~

CHINESE ACTIONS

.:'U~

In terms of Chinese medicine, A. archangelica, as used in the West, can be said to have the following actions:

IV.

warm and move Intestines

V. warm and move Heart

1. clear Wind Cold Damp II. clear Lung Phlegm Cold IU. warm and tonify the Spleen to transform Damp and Phlegm IV. warm and move Intestines Stagnant Qi V. warm and move Heart Stagnant Qi Clear Wind Cold Damp Angelica can be said to clear Wind, Cold, and Damp from the: • body surface, especially from the head and sinuses • muscles and joints Warm and move Heart Stagnant Qi Angelica can be said to act as a circulatory stimulant to move Stagnant Qi and Blood, especially at the periphery of the body, and as a mild cardiotonic. It does not so much move Stagnant Blood to remove pain.

WESTERN ACTIONS The main Western actions of A. archangelica are shown here in terms of its five main Chinese actions: ~

... ' ~.- -":' . ',~" "\.:'"

cold extremities. general weakness

\-;; -_.~~::

DIRECTION OF ENERGY Dispersing effect

The aromatic and acrid constituents of

Angelica can be said to have a warming and moving effect, spreading the Qi in an outward direction. This dispersing effect is not only in the Interior, for example, to move Heart Qi, but also outwards to the surface as a circulatory stimulant, antirheumatic, and diaphoretic.

Comparison with Rosmarinus The dispersing effect of Rosmarinus is in the Interior rather than at the surface. Also, the stimulating, lightening, spreading and opening effect of,:=.}'.... Rosmarinus is greater on the mind and emotions than that·~:~~_ ' of Angelica, which has greater physical effect on the head by drying Damp and Phlegm and opening sinus obstruction. Also, Angelica can treat headache from sinus obstruction and invasion ofWmd Cold Damp. However, it does not have the control over upward movement as does Rosmarinus, which can treat headache due to Liver Hyperactive Yang.

:'..",-,v,;s;,-,:~:·~:-·,<,:

.Chinese actions '"

-.

Western actions

I. clear Wind Cold Damp

diaphoretic antirheumatic

II. clear Lung Phlegm Cold

expectorant anticatarrhal

III. warm and tonity the Spleen

to transform Damp and Phlegm

carminative bitter digestive tonic

warm and move Intestines Stagnant Qi

carminative antispasmodic

IV.

Stagnant Qi

V. warm and move Heart

Stagnant Qi

circulatory stimulant cardiotonic

TYPICAL CASE EXAMPLE Signs and symptoms A patient has chronic bronchitis and sinusitis, with debility and recurring influenza. The patient feels cold in limbs and body, dislikes cold and damp, and has a heavy sensation in the head, poor appetite, slow digestion, and tendency to weight gain. In addition, starchy or greasy foods seem to increase the amount of phlegm in the nose and chest. The pulse is generally slippery arid flooding with underlying emptiness at the Spleen and Lung positions. The Heart pulse is empty and slightly wiry. The tongue is pale and slightly purple. with tooth marks and a moist white greasy

WESTERN USES

coat. The main Western uses of A. archangelica are shown here in terms of its five main Chinese actions: ..f....-':.w~"""..-__:.. ,-... .-.~ ....... w-

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II. clearLuqg ~hl~grTl Cold.('~ III.

warm and tonity the Spleen to transform Damp and Phlegm

influenza with sinusitis. rheumatism sinusitis. bronchitis digestive weakness. general weakness. anorexia nervosa, obesity

•

intestinal colic. flatulence

Diagnosis

The patient has:

• Deficient Spleen Qi, allowing accumulation of Damp and Phlegm • Deficient Lung Qi, allowing easy invasion of the Lung by Wind Cold and Damp and resulting in accumulation of Phlegm Cold in the Lung • Heart Deficient Qi and Heart Stagnant Qi, which can both be associated with sensations of cold in the body and limbs

Angelica Choice of Angelica This herb can clear both Wind Cold and Damp from the Exterior. and accumulated Phlegm Cold from the Lung. It can tonify, warm, and dry the Spleen to tonify the Qi and Blood, and also transform Damp and Phlegm. It can warm and move Heart Qi to improve the circulation.

Limitations ofAngelica TEMPERATURE Angelica is a warm herb that is specific for cool patterns. It is not warm enough to treat cold patterns unless it is combined with hot herbs such as Capsicum, Cinnamomum, or Zingiber. Angelica is not appropriate for warm patterns unless it is balanced by cool or cold herbs, and it would not generally be used for hot patterns.

TASTE Acrid Angelica is acrid in the sense of clearing Wind, Cold, and Damp from the surface, and also in the sense of warming the Interior. In Western terms, it is both a warming diaphoretic and a circulatory stimulant, and therefore not appropriate for patterns ofWind Heat. Aromatic The essential oil constituents of Angelica may be involved in its diaphoretic, circulatory stimulant, carminative, and antispasmodic actions. However, Angelica does not seem to have the mental stimulant and antidepressant actions of Rosmarinus or Turnera, or the sedative action of Lavandula. Bitter Angelica is a moderately bitter herb. It is not as bitter as, for example, Artemisia. Genticma, or Hydrastis. Nor does Angelica have such a strong effect on the hepatobiliary system as do those three herbs.

207

Circulatory stimulant Angelica is warm. but not hot. So for cold conditions it would need to be combined with hot herbs. It is specific for poor circulation with digestive weakness and chronic bronchitis, especially in cases where there is an accumulation of Cold. Damp, and Phlegm. It would not be appropriate for someone with cold extremities who also has Deficient Yin and Dryness. Carminative and antispasmodic Angelica can relax intestinal spasms and reduce Damp and Phlegm, but it is neither strongly sedative nor antidepressant. If abdominal discomfort and obesity are associated with anxiety or depression. it would need to be combined with other antispasmodic herbs. such as Rosmarinus for depression or Lavandula for anxiety. Bitter digestive tonic and regulator Angelica is only a moderately strong bitter, so if strong bitter tonic action is requir.ed, Angelica would need to be combined with Cinchona or Centaurium. for example. Also, it is a warming bitter tonic and therefore may not be appropriate for mixed conditions of Deficiency and Heat, such as digestive weakness associated with gastrointestinal inflammation, for which Gentiana would be more suitable.

Angelica paired with other herbs Discussion of the limitations of each of the main actions of Angelica can be useful to clarify just what this herb can and cannot do. However, suitable combination with other herbs can extend the range of use of Angelica beyond its limitations. The basic unit of herb combination is the herb pair. Six pairings of Angelica are briefly explained below.

CAUTION ACTIONS Diaphoretic action Angelica is a warming, drying diaphoretic for Wind Cold Damp patterns, but which is not suitable for Wmd Heat or Wmd Dryness.

Before using any of the herb pairs below, it is important to be familiar with the cautions listed for each herb in the pair. Angelica + Achillea

Influenza + sinusitis Expectorant action Angelica is a warming, drying expectorant and anticatarrhal for Lung Phlegm with Cold and. Damp. It is therefore not appropriate for Lung Phlegm with Heat and Dryness. For example, it would be inappropriate for a dry, irritant cough. with scanty, yellowish sputum. However, it is an excellent herb for chronic bronchitis ~th . debility associated with digestive or circulatory weakness, provided that there are no signs of Heat or Dryness.

Being paired with Achillea emphasizes the diaphoretic action of Angelica so the two herbs can be used to treat colds and influenza with moderate fever. Angelica emphasizes the anticatarrhal action ofAchillea and directs this activity especially to the head and sinuses. Accordingly, these herbs can . be used together for acute sinus congestion or sinus headache accompanying influenza.

----Combining Western Herbs and Chinese Medicine

208

Angelica combinations

Angelica + Thuja

Chronic bronchitis + cold sensations Angelica and Thuja have both expectorant and circulatory stimulant actions so that they can be paired for bronchial congestion with poor peripheral circulation. In terms of Chinese medicine, they can clear Lung Phlegm Cold and warm, tonify, and move Heart Qi. Both herbs can be used for rheumatism with poor peripheral circulation and Interior Damp and Phlegm. Angelica + Zingiber

Digestive weakness + flatulence The acrid constituents of Zingiber can combine with those of Angelica to induce sweating and clear Exterior Wind Cold conditions, and the aromatic constituents of both herbs can combine to relax muscle spasms in the intestines. The unique combination of bitter, aromatic, and acrid constituents makes Angelica an ideal herb for Spleen Deficiency with Cold and Damp. Angelica and Zingiber can also have a warming expectorant action in patients with patterns of Lung Phlegm Cold. Angelica + Zanthoxylum

Arthritis + cold sensations Both herbs are circulatory stimulants. which can be used to strengthen peripheral circulation. Angelica emphasizes both the surface-active and the anticatarrhal actions of Zanthoxylum. As a result, these herbs can be combined to treat rheumatism or arthritis associated with a combination of Exterior and Interior Cold and Damp. Angelica + Phytolacca

Chronic sinusitis + obesity Both herbs can have a drying action to clear Damp and Phlegm, but Angelica is warming, whilst Phytolacca can have a cooling effect. These herbs can be paired for catarrhal conditions of both the sinuses and bronchi, and for Phlegm and Damp obstructing the channels, as in some forms of rheumatism and arthritis. They can also assist weight loss, providing the patient also adopts suitable exercise and nutritional regimes.

..

..

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Six Angelica combinations are discussed below:

Wind Cold Damp

1. influenza + sinusitis

2. chronic bronchitis + cold sensations Lung Phlegm Cold + Spleen Deficient Yang

3. digestive weakness + flatulence

Spleen Deficient Qi + Damp + Phlegm

4. arthritis + cold extremities

Stagnant Qi and Blood + Cold in the channels

5. sinusitis + obesity

Lung Phlegm Damp + Spleen Damp

6. depression + obesity

Heart Stagnant Qi + Spleen Damp

CAUTION

Before using any ofthe combinations below, it is important to be familiar with the cautions listed for each herb in the combination.

1. Influenza + sinusitis

Wind Cold Damp Herb

Daily -dose Temperature Taste_

3g 3g 3g Sambucus 3g Euphrasia Zingiber (fresh) 3 slices

Achillea Angelica arc.

warm-eool warm cool neutral-eool hot

acrid. bitter bitter. acrid, aromatic acrid, sl. bitter acrid, sour, bitter acrid, aromatic

This combination is the same as Achillea: influenza + sinusitis and is discussed under that heading.

2. Chronic bronchitis + cold sensations

Lung Phlegm Cold + Spleen Deficient Yang

Angelica + Rosmarinus Taste _

Chronic depression Culpeper wrote that Angelica can strengthen the heart and fortify it against poison, and Rosmarinus can refresh the spirits, make them lively and active, and drive melancholy 'vapors' from the heart. Although Angelica is not a primary herb for depression, it can help Rosmarinus warm, move, and disperse Heart Qi, especially when it is obstructed by Phlegm and Damp.

Commiphora Thymus Angelica arc. Prunus Lobelia Glycyrrhiza Zingiber Capsicum

1 1 1 1 1

0.5 0.5 5-20 drops

warm

bitter, acrid

warm-cool warm

aromatic bitter, acrid, aromatic

neutral

bitter, aromatic

warm-eool neutral-cool

acrid

hot

sweet acrid, aromatic

hot

acrid

.. ,·,Angelica This combination is the same as Commiphora: chronic bronchitis + cold sensations and is discussed under that heading. 3. Digestive weakness + flatulence

Spleen Deficient Qi + Damp + Phlegm "~~ ~ "':~;"'~..,~:'"

Herb

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. Ratio

Juniperus Angelica arc. Artemisia abs. Gentiana Citrus (ripe peel) Zingiber

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209

may also be some Deficient Yang of the Lung and Spleen. The overall temperature is warm-hot to treat cool or cold conditions. Capsicum can be omitted, if required, to reduce the overall temperature of the prescription. The acrid and aromatic properties combine to warm and move the Qi of the Lung and Spleen to transform and disperse Damp and Phlegm.

.. ':,:-:~~."', •.r:.

Temperature :~aStey"'; -; of

'1

1 1 1 1 0.5

sl. warm warm warm-cool neutral-cool warm

aromatic, 51. acrid, sl. sour aromatic, bitter, acrid aromatic, bitter bitter acrid, aromatic, bitter

0.5

hot

acrid, aromatic

This combination is the same as Juniperus: digestive weak+ flatulence and is discussed under that heading.

n~s

4. Arthritis + cold extremities

Stagnant Qi and Blood + Cold in the channels

USE

• chronic sinusitis and/or bronchitis with one or more of the following: - lethargy, sensations of heaviness in body and limbs - mental cloudiness and dullness - catarrhal deafness - cloudy discharges -edema PRACTICAL NOTES

This combination can be taken as 5-7.5 ml of 1:5 tincture in quarter of a cup of warm water three times per day. This combination is designed for long-term use.

Caution This combination is warm-hot in temperature

This combination is the same as Zanthoxylum: arthritis + cold extremities and is discussed under that heading.

and is not suitable for either Heat patterns or mixed patterns of Heat and Cold. The patient should be monitored for appearance of adverse Heat signs, and if these occur, the prescription should be stopped or modified. Also, see the cautions for all the herbs in the prescription. This combination is in no way suggested as a treatment for obesity. Rather, it is designed to treat an overall pattern of Lung Phlegm Damp and Spleen Deficient Qi with accumulation of Damp and Phlegm, of which obesity may be one of many signs.

5. Sinusitis + obesity

6. Depression + obesity

Lung Phlegm Damp + Spleen Damp

Heart Stagnant Qi + Spleen Damp

1 Zanthoxylum (bark) 1 Populus Harpagophytum 1 1 Angelica arc. 1 Angelica sin. 0.5 Zingiber 5-20 drops Capsicum

..

hot

acrid, aromatic, bitter

neutral-cool cool warm warm hot hot

bitter, sour bitter bitter, acrid, aromatic sweet, aromatic, bitter acrid, aromatic acrid

I

-.

Herb'c .-":.-:',

.,

Angelica arc. Zanthoxylum (berries) Juniperus

1 1

warm hot

bitter, acrid, aromatic acrid, aromatic, bitter

1

51. warm

Phytolacca Thuja Myrica Zingiber Capsicum

1 1 1

cool warm-cool warm hot hot

aromatic, 51. acrid sl. sour acrid acrid, aromatic, bitter acrid, sour, bitter acrid, aromatic acrid

0.5 5-20 drops

.

- '~'

Angelica arc. Zanthoxylum (berries) Juniperus

Ratio'

Temperature ' Taste

-

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.

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1 1

warm hot

bitter, acrid, aromatic acrid, aromatic, bitter

1

51. warm

aromatic, 51. acrid, sl. sour aromatic, bitter, acrid bitter, aromatic, acrid sweet, sl. bitter, acrid, aromatic acrid

Rosmarinus 1 Turnera 1 Panax gin. 1 Zingiber 0.5 Capsicum 5-20 drops

warm warm sl. warm hot hot

GENERAL

GENERAL

This combination is for Lung Phlegm Damp and Spleen Deficient Qi with accumulation of Damp and Phlegm. There

This combination is for Heart Stagnant Qi, Heart Deficient Qi, and Spleen Deficient Qi with accumulation of Damp

::;5-.-;' ..

:~

.- .....

Combining Western Herbs and Chinese Medicine

210

and Phlegm. There may also be some Deficient Yang of the Heart and Spleen. The overall temperature is warm to treat cool or cold conditions. Capsicum can be omitted, if required, to reduce the overall temperature of the prescription. The acrid and aromatic properties combine to warm and move the Qi of the Heart and Spleen to transform and disperse Damp and Phlegm. USE

• chronic depression, sadness, and loneliness, with one or more of the following: - sensations of cold -lethargy, sensations of heaviness in body and limbs - mental cloudiness, mental dullness -edema PRACTICAL NOTES:

This combination ~ be taken as 5-7.5 ml of 1:5 tincture in quarter of a cup of water, three times per day. This combination is designed forlong-term use.

~cc

~~

1. All the herbs in combination No.1 can clear Exterior·: -~:~ . Wind, especially When this is associated with obstruction of .."~

the sinuses by Phlegm. Angelica and ZiI1giber are warming herbs to clear Wind Cold, and Angelica is a drying antica~ _. tarrhal herb for Lung Phlegm Damp. -~:-::.!"",-

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2. Combination No. 1 is specific for clearing Wind Cold from the surface and Phlegm Cold from the sinuses. Combination No.2 has more of an effect on the Interior. Commiphora combines with Angelica to clear Lung Phlegm and warm and tonify both Spleen and Heart. Prunus, Lobelia, Glycyrrhiza, and Thymus combine to give expectorant yet antispasmodic and antitussive actions.

3. Digestive weakness + flatulence

4. Arthritis + cold extremities

Spleen Deficient Qi + Damp + Phlegm

Stagnant Qi and Blood + Cold in the channels

Juniperus Angelica arc. Artemisia abs. Gentiana Citrus (ripe peel) Zingiber

Zanthoxylum (bark) Populus Harpagophytum Angelica arc. Angelica sin. Zingiber Capsicum

warm

Caution

This combination is warm-hot in temperature and is not suitable for either Heat patterns or mixed patterns of Heat and Cold. The patient should be monitored for appearance of adverse signs of Heat, restlessness, or irritability, and if these occur, the prescription should be stopped or modified. Also, see cautions for all the herbs in the prescription. This combination is in no way suggested as a treatment for obesity. Rather, it is designed to treat an overall pattern of Heart Stagnant Qi and Spleen Deficient Qi with accumulation of Damp and Phlegm, of which obesity may be one of many signs.

ANGELICA COMBINATIONS 1. Influenza + sinusitis

2. Chronic bronchitis + cold sensations

Wind Cold Damp

Lung Phlegm Cold + Spleen Deficient Yang

3g 3g 3g 3g 3 slices

Commiphora Thymus Angelica arc. .: Prunus Lobelia Glycyrrhiza Zingiber Capsicum

1 1 1 0.5 0.5

1 1 1 1 0.5 0.5

5-20 drops

3. Juniperus and Angelica are warming, drying aromatic herbs that are used here for the loss of appetite with digestive weakness, tiredness, and phlegmy cough. Artemisia and Gentiana are bitter herbs to stimulate the appetite; they are supported by the bitter constituents of Angelica. Citrus and Zingiber help the Spleen to transform Phlegm and to treat phlegmy cough.

COMPAR.ISON OF THE SIX

Achillea Angelica arc. Sambucus Euphrasia Zingiber (fresh)

1

1 1 - 1 1 1 0.5

0.5 5-20 drops

4. All the herbs in combination No.4 can be used to treat arthritic and rheumatic disorders. Zanthoxylum, A. archangelica, Zingiber, and Capsicum make this combination specific for cases involving Wind, Cold, Damp, and Phlegm, with poor peripheral circulation and sensations of cold. Both Angelicas can move Stagnant Qi and Blood. However, A. archangelica is relatively more for clearing Exterior Wind from the channels of the muscles and joints, and A. sinensis is relatively more for tonifying Blood to prevent further entry of Exterior Wind. Harpagophytum and Populus can act as general-purpose antiarthritics for inflammation, pain, and immobility, but they are also specific for patterns involving Wind Cold Damp, and Damp Heat. They enable this combination to be used for mixed patterns of Cold and Heat.

.

...-.

Angelica 5. Sinusitis + obesity

6. Depression + obesity

Lung Phlegm Cold + Spleen Damp

Heart Stagnant Qi + Spleen Damp

Angelica arc. zanthoxylum

Angelica arc. Zanthoxylum

1 1

(berries)

(berries) Juniperus Phytolacca Thuja Myrica Zingiber Capsicum

1 1

Juniperus

1 1 1 1

Rosmarinus Tumera

0.5

Panax gin. Zingiber

5-20 drops

Capsicum

1 1 1 1

0.5

tial oil content of A. sinensis as 0.2-0.4%, of which 45% is ligustilide.

Monoterpenes

Monoterpene hydrocarbons make up 8090% of the essential oil of A. archangelica, with the follOWing as the main components:8 • a-pinene, 14-31% • ~-phellandrene, 13-28% • a-phellandrene, 2-140/0

Sesquiterpenes Wichtllisted ~-caryophyllene,~-bisabo­ lene, bisabolol, and various macrocyclic lactones for A. archangelica.

5-20 drops

5. Combinations No.4 an.d No.5 have Angelica, Zanth-

oxylum, Zingiber, and Capsicum in common to warm and move Qi and Blood. However, combination No.5 also has Juniperus, Thuja, Myrica, and Phytolacca to transform and disperse Phlegm and Damp in the sinuses, bronchi, and body in general to treat chronic respiratory catarrh with obesity. 6. Combinations No.5 and No.6 have Angelica, Zanthoxylum, Juniperus, Zingiber, and Capsicum in common. However, instead of Phytolacca, Thuja, and Myrica to clear Lung Phlegm Cold, combination No.6 contains the antidepressant herbs Rosmarinus, Turnera, and Pan ax. Angelica can assist Rosmarinus to warm and move Heart Stagnant Qi.

""'--

211

Furanocoumarins Over 20 furanocoumarins have been listed for A. archangelica, including bergaptan, xanthotoxin, angelicin, and archangelicin.9 Bergaptan is also found in the roots of A. pubescens. 1o and A. dahurica. 11 Coumarins A. archangelica has been reported to contain. osthole and umbelliferone. 8 Ostholeis also present in A. pubescens. 12 Phenolic carboxylic acids Wichtl listed phenolic carboxylic acids as components of A. archangelica. Ferulic acid is a component of A. sinensis. 13 Other A. archangelica

This herb has been reported to contain the flavanone archangelenone, tannins, sitosterols, fatty acids, and saccharose.6

OTHER ANGELICA COMBINATIONS

A. sinensis According to Chang and But, A. sinensis con-

Other combinations that contain A. archangelica include the following:

tains 40% sucrose, sitosterol, vitamins A and E, vitamin B12, nicotinic acid, folic acid, folinic acid, and biotin. Recent studies have reported polysaccharides with gastrointestinal protective effects from A. sinensis. 14

• Juniperus: phlegmy cough • Myrica: chronic sinusitis

PHARMACOLOGICAL AND

Research CONSTITUENTS The following constituents have been reported: • essential oil ·furanocoumarins • coumarins • phenolic carboxylic acids • other Essential oil Wichtl6 gave the essential oil content of A. archangelica as 0.35-1.9%. Chang and Bue listed the essen-

CLINICAL RESEARCH The following effects have been reported for Angelica species or for isolated constituents: • antimicrobial • anti-inflammatory and analgesic. • antispasmodic • antiasthmatic and antibronchitic

• emmenagogue • sedative • cardiovascular effects • antiatherogenic • anticoagulant

212

Combining Western Herbs and Chinese i\1edicine

-~'~

--:--~:;:~~~ _.<.~

• antianemic • central nervous system effects • hepatoprotective • immunoregulatory • antitumor and antimutagenic Antimicrobial An antimicrobial effect was reported for an A. dahurica decoction,15 and a weak antimicrobial action was reported for an A. sinensis decoction. 16 An early study reported that the coumarin umbelliferone could inhibit Brucella Spp.,17 and a more recent study reported that umbelliferone may have potential as an antiviral agent. 18 Anti-inflammatory and analgesic

Furanocoumarins and coumarins An in vivo mouse study reported that the furanocoumarin bergapten from A. dahurica has an anti-inflammatory effect. 11 Bergapten and the coumarin umbelliferone from A. pubescens showed both anti-inflammatory and !'Jlalgesic_effeets!1~10 rng/kg, and the coumarin osthole and the furanocoumarin xanthotoxin showed anti-inflammatory activity. 10 Monoterpenes and sesquiterpenes a-pinene, ~-pinene,19 and a-pinene and ~-caryophyllene,2°were reported to have anti-inflammatory effects in animal studies. ~-caryophyllene was reported to inhibit induced gastric mucosal injuries in rats, whilst hardly affecting the secretion of gastric acid and pepsin. 21 Extracts and polysaccharides An A. archangelica extract was reported to have antiulcerogenic action against chemically induced gastric ulcers in rats, with reduced acid output, increased mucin secretion, and a decrease in leukotrienes. 11 An extract of polysaccharides from the root of A. sinensis was reported to prevent induced gastric mucosal damage in 14 rats. A further study found that A. sinensis crude extract enhanced gastric ulcer healing in rats and promoted wound repair in cultures of gastric epithelial cells. 23 Antispasmodic

Essential oils from Angelica root were

reported to have a relaxant effect on guinea-pig tracheal and ileal smooth muscles.24 The coumarin osthole isolated from A. pubescens had a relaxant action on guinea-pig trachea, which the authors concluded was a result of inhibiting cyclic-AMP and cyclicGMP phosphodiesterases. 25 Osthole isolated from A. pubescens was also reported to have a vasorelaxant effect on rat thoracic aorta, which the authors concluded was the result of the calcium-blocking properties of osthole and of raising levels of cyclic-GMP in the muscle. 12 Vasorelaxant activity was also reported for a methanolic extract of A. furcijuga and for khellactone-type coumarins

isolated from the plant. 26 An ethanol extract of the rootso!~ ~:.c~·::';·. A. keiskei and chalcones isolated from it were reported to reduce induced constriction in rat aortic rings.!7

_.;~

Antiasthmatic and antibronchitic An ether extract of A. sinensis was reported to be effective in the treatment of sta:~ . tus asthmaticus, with beneficial results appearing in 2-10 hours and control being established in 12-48 hours. 28 Beneficial results were also reported using an injection of A. sinensis root preparations in the treatment of bronchial asthma. 29 Another study reported the efficacy of oral administration of A. sinensis root extract in the treatment of chronic bronchitis complicated by pulmonary emphysema or pulmonary heart disease at the early or remission stage. 30 An A. pubescens decoction was reported to have antitussive and antiasthmatic effects: 7% had marked effects, whilst 66% showed some response. 31 Emmenagogue Experiments with A. sinensis root extracts showed a biphasic, regulatory effect on animal uteri. 32 essential oils inhibited contraction, and the nonvolatile fraction increased uterine contraction. The action of the herb on the uterus also depended on the state of the organ. Intravenous administration of ferulic acid, which is a component of A. sinensis, was shown to have an inhibitory effect on movement of rat uterus in situ. 33

The

Estrogenic activity In an early study in China, A. sinensis was reported to have no estrogenic action in mice, as judged by the vaginal smear examination, nor did uterine weight increase following use of the herb. 34 In a recent in vitro study, A. sinensis showed only weak binding to estrogen receptors, only weak effect on progesterone receptors, and only weak induction of the estrogen-inducible presenelin-2 gene in 530 breast cancer cells. 35 A double-blind, randomized, placebo-controlled trial was conducted to assess the effect of A. sinensis on vaginal cells and on endometrial thickness in postmenopausal women. It was concluded that used alone, A. sinensis does not produce estrogen-like responses in endometrial thickness or vaginal maturation, and was no more effective than the placebo in relieving menopausal symptoms. 36 Sedative An A. pubescens decoction was reported to have sedative and hypnotic effects when administered either intragastrically or intraperitoneally to mice or rats. 37 Both an ether extract of A. sinensis and the essential oils of this herb were reported to have a sedative effect. 38 Both the extract of Japanese Angelica rooe9 and ligustilide or butylidenephthalide extracted from this plant promoted sleep in mice. 40 Cardiovascular effects

Antiarrhythmic

Angelica injection was reported to have

,::_.--'-~

~.-

Angelica protective effect against arrhythmia in rats, using the myocardial ischemic reperfusion modeL H Antihypertensive An A. sinensis extract was reported to lower arterial blood pressure in dogs whilst at the same time reducing the resistance of the coronary, cerebral, and femoral arteries, and increasing peripheral blood flow. 42 The coumarin osthole, contained in A. archangelica and A. pubescens, was reported to have antihypertensive effects in vivo, ~3 and an extract of A. sinensis was reported to reduce pulmonary arterial pressure in patients with pulmonary hypertension.o\-I Antiatherogenic Injections of A. sinensis in rabbits were reported to inhibit aorta atherogenesis by decreasing the serum triglyceride concentration.~5 It has been reported that A. sinensis can protect human vascular endothelial cells from the effects of oxidized low-density lipoproteins in vitro, supporting the antiatherogenic effect of this herb. 46 Anticoagulant A. sinensis decoction was reported to suppress induced platelet aggregation in rats. ~7 It has been reported that osthole can inhibit platelet aggregation in vitro.~3 In vitro studies with an A. sinensis extract reported that this herb can reduce the aggregation, deformation, and osmotic fragility of human erythrocytes.-l8 !_.

Antianemic It has been suggested that the reported antianemic effect of A. sinensis may be partly due to its content of vitamin B 12, folic acid, nicotinic acid, and biotin. 49 Central nervous system effects Using the passive avoidance test, A. sinensis root extracts were reported to reduce amnesia in rats induced by various drugs.3{) Hepatoprotective The methanolic extract from the roots of A. furcijuga and its isolated coumarin and polyacetylene constituents were reported to have hepatoprotective effects and to inhibit nitrous oxide production in vitro. 51 It was found that A. sinensis polysaccharides can reduce induced liver injury in mice.5~.53 Immunoregulatory Ange1an, a polysaccharide from A. gigas, potentiated immune function. 54 A low molecular weight polysaccharide from A. sinensis showed antitumor activity in Ehrlich Ascites tumor-bearing mice and immunostimulating activities, both in vitro and in vivo.55 Antitumor and antimutagenic A carbon tetrachloride extract of A. japonica inhibited cell growth of human gastric adenocarcinoma (MK-l). Presumably the active constituents were the furanocoumarins. 56 Antimutagenic properties of A. archangelica

213

extracts were reported using the micronucleus test in murine bone marrow cells.57

RESEARCH VERIFICATION OF TRADITIONAL ACTIONS The following traditional actions of Angelica have been supported by research: antiulcer, expectorant, emmenagogue, hepatic, and antitoxin. It should be pointed out that the evidence for these actions comes from research on Angelica species other than A.archangelica~This means that there is as yet no evidence to support any of the traditional actions for A. archangelica specifically. Additional effects demonstrated by research The following additional effects have been reported for Angelica species or for their isolated constituents: antimicrobial, antiinflammatory, analgesic, sedative, antispasmodic, antiasthmatic, antiarrhythmic, antihypertensive, anticoagulant, antilipemic, antianemic, immunoregulatory, and anticancer. It would seem that the clinical uses of the Angelica species can be greatly expanded.

TOXICOLOGY An important distinction A careful distinction needs to be made between the use of: • therapeutic doses of Angelica as an infusion, decoction, or tincture • Angelica essential oil • isolated components ofAngelica, such as bergaptan Reports of toxic or adverse effects for pure constituents from Angelica, or for its essential oil, do not necessarily apply to the use of infusions, decoctions, or ethanolic tinctures of the root of this plant, when used in the recommended therapeutic doses. This is because the pure constituents and the essential oil represent much higher levels of a potentially toxic constituent than are found in the herb itself, and because other constituents in the herb may protect against potentially toxic effects. A. archangeIica root preparations I have not found information on toxicity or adverse effects of preparations of A. archangelica when taken within the recommended dose range. According to the German Commission E monograph,58 no contraindications and no herb-drug interactions are known for this herb.

Photosensitivity I have not Seen research evidence to show that preparations of A. archangelica root can cause photosensitivity when taken within the recommended dose range.

214

Combining Western Herbs and Chinese Medicine

However. the furanocoumarin bergaptan has been reported to have phototoxic effects. although it has been suggested that due to the negligible solubility of furanocoumarins in water, no risk of phototoxic effects is likely from the tea. 59 If the practitioner prefers. the patient can be advised to avoid prolonged sunbathing or other exposure to intense UV irradiation during the period of treatment with preparations of this herb, as recommended in the Commission E monograph. However, to keep a sense of perspective, the amount of furanocoumarins in A. archangelica root appears to be about the same as in a lemon peel, which is commonly used to flavor foods and drinks. A. archangelica oil In phototoxicity tests, distinct positive results were obtained with as little as 3.125% oil. 60 The International Fragrance Association recommended that if Angelica oil is applied to the skin in preparations containing over 3.9% of the oil, the skin must not be exposed to sunlight or sunbed rays for 12 hours. 61 Phototoxicity is primarily due to the presence of bergapten. Isolated constituents The furanocoumarin bergaptan has been reported to have phototoxic effects,62 and may increase the damaging effects of ultraviolet light, although it can also protect against them. 63

"-

Pregnancy and lactation No adverse effects reported, but .'~ Moore 4 suggested avoidance of Angelica in pregnancy, - 'c:,~ although he considered it 'not particularly a stin,lulant to the ,.,~ uterus: -,.~:7 Side effects None reported, but see Photosensitivity and,,' . ',_ ':'-:'.:£. Duration above. A~

-.:.'M'

Overdose No adverse reports, but see Duration above. Interactions No adverse reports for A. archangelica. There has been one report that A. sinensis significantly increases the anticoagulant effect of warfarin in rabbits. 65 However, the dose levels of A. sinensis used were far in excess of the human therapeutic dose.

.:-.:........... ,

_.,-

Regulatory status

.-

on SafetY'°:t~ A. archangelica (angelica root) is on the UK General Sale List (Statutory Instrument Order 1977 No. 2129 to the Medicines Act 1968). Angelica root is not included in Part 4

~=

i'Jfl-~ ---o:c.

Australia. Angelica root is not currently listed by the FDA (USA) as a prohibited substance, as subject to an import alert, or as a substance with a warning on its use.

Traditional sources

Tincture The BHP listed 0.5-2 ml of 1:5 liquid extract (in 50% alcohol), three times per day.

There is no entry for A. archangelica in the Chinese Herbal Medicine Dictionary. The values of the properties of

Can start at the standard dose. A. DAHURICA baf zhl

A. PUBESCENS

du hu6

A. SINENSIS dang gul . ~...':~,;,' ,~,?~::-~

Properties (range of opinion)

.-

.';.

Temperature

Western contraindications

None reported.

Chinese contraindications A. archangelica is not listed in the Chinese Herbal Medicine Dictionary, but since I consider this herb to be both warming and drying, I would avoid its use for persons with patterns of Heat and/or Dryness, especially in the Lung.

_2~

of Schedule 4 of the Therapeutic Goods Act Regulations of-,=~

SPECIES USED IN CHINESE MEDICINE

Cautions

.--

. ~:~r:l.

Dried herb The BHp6-l listed 1-2 g of the dried root, three times per day.

Duration I have not seen any restrictions recorded in texts, but I would avoid prolonged use of this herb for persons with sensations of heat and/or dryness in the head and face.

~

. -=-C'..::j::-;,

Please read the Regulatory status section in the chapter::'T~

Dose

Initial dose

..

>'-~-o:

main text subsidiary texts

warm

wann 1. neutral 2. slightly warm 3. slightly cool

warm 1. slightly warm 2. very warm

acrid acrid, slightly sweet

bitter. acrid sweet

sweet, acrid 1. sweet 2. bitter

LU, Sp' ST 1. ST. LR. LU 2. LV, ST, LR

KI. BL 1. KI, HT 2. LU,KI 3. SI, UB, LV, KI 4. HT, LV, KI, US

HT, LV, SP 1. PC, SP. LV 2. HT. LV. LU

Taste main text subsidiary texts

Meridians main text subsidiary texts

Angelica the three species most commonly used in Chinese medicine are listed in the species comparison table below. Note For each herb, the Chinese Herball·yfedicine Dictionary often included material not only from one main text, but also from various subsidiary texts. Values from both the main text and the subsidiary texts used by Chinese Herbal Medicine Dictionary are given in the table (next page, top) to show the range of opinions. It can be seen from the table that there is a considerable range of opinions on the values for the temperature, the taste, and especially the meridians entered. PROPERTIES OF A. ARCHANGELICA Temperature According to Dioscorides, the roots, leaves, and seeds of Angelica have warming properties, and Culpeper66 recommended it for cold disorders. Both Lonicerus67 and Gerard 68classified A. archangelica as hot and dry in the third degree, but Tabernaemontanus69 considered it to be hot in the third degree and dry in the second. It is classified in this book as warm rather than hot because it does not have a strong heating effect on the body. Taste in the mouth The BHP described the taste of A. archangelica root as sweet, becoming slightly bitter and astringent. According to Wichtl, the taste is 'first aromatic, then acrid, bitter, and lastingly pungent' I found samples of both the dried root and a 1:5 tincture in 45% alcohol to be slightly sweet and mucilaginous, slightly sour and astringent, definitely aromatic, bitter, and with a lingering pungent taste and tingling sensation on the tongue. The tincture was relatively more aromatic and the dried material was relatively more bitter. Taste properties

Aromatic A. archangelica is classified in this book as aromatic because it can be used as a warming and drying carminative to stimulate the digestive system and treat flatulence and colic. Acrid This book classifies A. archangelica as acrid since it can have both a warming diaphoretic action at the surface of the body and a warming action in the interior. Bitter A. archangelica is used as a bitter digestive tonic in European tradition. Mills70 suggested that the bitterness of the fur3?ocoumarins provides the digestive tonic action. Sweet A. archange1ica is not classified as sweet in this book. It does have saccharose as a constituent, but A. archangelica does not smell or taste as sweet as A. sinensis, and is not generally used as a nutritive tonic. A. archangelica is classified as drying whilst A. sinensis is relatively more moistening.

215

ORGANS In terms of Chinese medicine, Angelica, as used in the West, can be associated mainly with disorders Of the following systems: Examples of use

Source ..

Spleen. Stomach

bitter digestive tonic

Wichtl

Intestines

intestinal flatulence and colic

Commission E monograph

lung

expectorant and antispasmodic for bronchial asthma

BHP

Heart

peripheral vascular disease

BHP

Uver

problems of the liver

Gerard. Culpeper. Kloss

Organ

There is no entry for A. archangelica in the Chinese Herbal Medicine Dictionary. ACTIONS The following traditional actions are discussed: • diaphoretic • cardiotonic • circulatory stimulant • antirheumatic • carminative • anticatarrhal • expectorant and antiasthmatic • bitter digestive tonic • emmenagogue • diuretic • hepatic • antitoxin Diaphoretic Dioscorides recommended Angelica for fever, and Gerard said that it could be used for infections from 'evil and corrupt air: driving them out by urine and sweat. Lyle71 wrote that the seeds of A. atropurpurea have diaphoretic and antiperiodic action and can be used for acute fever and colds. Both Grieve72 and Mills listed A. archangelica as a diaphoretic for feverish conditions, Mabey3 recommended it in hot infusion as a diaphoretic for colds, and TierraH listed it as a warming diaphoretic for colds and influenza. Cardiotonic Gerard wrote that Angelica is beneficial to the heart, and Tabernaemontanus said that Angelica root strengthens the heart if it is weak due to cold. Culpeper wrote that Angelica 'resists poison by defending and comforting the heart, blood and spirits: and Parkinson echoed this statement. Kloss also wrote that Angelica can strengthen the heart.

..~.~~ ..

216

Combining Western Herbs and Chinese Medicine

Circulatory stimulant Lonicerus wrote that Angelica warms the body. According to Tabernaemontanus, Angelica can be used for internal injuries due to trauma from falls or blows, since 'it breaks congealed blood and removes it: He said that Angelica can 'warm the head and brain and prevent a stroke in old, cold people: Angelica is listed in Mabey as a circulatory stimulant to warm cold hands and feet and for anemia. The BHP listed it to treat peripheral vascular disease. It is interesting that research on A. sinensis has reported that this herb can increase peripheral blood flow and treat early stage thromboangiitis obliterans and anemia. Antirheumatic Culpeper wrote that Angelica eases all pains and torments coming from cold and wind, and Felter and Lloyd as well as Grieve recommended this herb for chronic rheumatism and gout. The BHP listed Angelica for rheumatic diseases. Carminative Dioscorides recommended Angelica for flatulence, and Lonicerus listed it for stomach aches due to cold. Culpeper wrote that Angelica can warm a cold stomach, help digestion, and relieve the results of overeating. According to Tabernaemontanus, Angelica can increase the appetite and is good for dampness in the stomach, heartburn, stomach acidity, and pain in epigastrium or abdomen. The BHP listed Angelica for flatulent dyspepsia, and Mabey stated that this herb warms and stimulates digestion and treats indigestion, colic, and flatulence. Anticatarrhal I have not found reference to an anticatarrhal action in traditional texts. However, I use A. archangelica as a warming, drying, aromatic herb to: • stimulate the Spleen to transform Damp • stimulate the Lung to clear Phlegm and Damp • clear Phlegm and Damp from the head • clear Phlegm and Damp from the channels of the muscles and joints I use A. archangelica not only for phlegm in the lungs, but also for phlegm in the sinuses with nasal congestion, sinus headache, or postnasal drip. I also use it in combinations to treat a general body tendency to phlegm and obesity, associated with Interior Deficiency, Cold, Damp, and Phlegm. Expectorant and antiasthmatic Gerard said that A. archangelica attenuates and thins tough phlegm, and helps asthma by dissolving ~d expectorating the phlegm. Tabernaemontanus wrote that Angelica can treat chronic coldtype coughs, wheezing, and shortness of breath because it softens and loosens thick phlegm, allowing it to be easily expectorated. Culpeper recommended Angelica for all dis-

_~-

-~' '. .

---.;".-.

• .-"'C.;;'.,

...•..

, ..-

.

-. -'~.~·~i _. .. eases of the lungs, including pleurisy, cough, and shor·tri~~.=::.. ,.-,l!'@

of breath. ::.,::' Felter and Lloyd listed A. archangelica as a stimulant to_~~' the respiratory mucous surfaces to treat chronic bronchitis~··'d..~ The BHP listed it as specific for bronchitis with vasculaD. deficiency, and it is interesting to note that A. sinensis has~-~¥i been reported to help chronic bronchitis complicated by ..~__ pulmonary heart disease. '/c",,' _.~

Bitter digestive tonic According to both Gerard and Tabernaemontanus, Angelica can increase the appetite, and both Gerard and Culpeper wrote that A. archangelica opens obstructions of the liver and spleen. Tabernaemontanus said that powdered Angelica root can warm the liver and treat .. '" congestion in this organ. Wichtl stated that Angelica stimulates gastric and pan-"':f:fji _.. creatic secretions. The BHP listed it for anorexia nervosa.·,;-~ ". According to Mills, 'there is probably no better convalescel1~;.;~;'.~ remedy in the Western materia medica: .• -,:~ ;: --.-.,.~

Emmenagogue Dioscorides, Lonicerus, Tabernaemontan~ us, and Culpeper all listed Angelica as a herb to induce menstruation. In addition, Tabernaemontanus noted its use in helping with difficult labor and postnatal pains, and Culpeper recommended it to expel the afterbirth. Lyle recommended a hot infusion of A. atropurpurea for dysmenorrhea, especially in nervous women. According to Mabey, the antispasmodic action of Angelica can assist the treatment of dysmenorrhea, and it can gently promote the onset of menstruation. I do not use A. archangelica as a primary emmenagogue. Diuretic Dioscorides recommended Angelica for edema and for diseases of the kidneys and bladder. Lonicerus listed this herb for dribbling urination, and Culpeper noted the use of Angelica for the stranguary or the stoppage of urine. The BHP listed it as a diuretic, and its traditional use in Germany as a diuretic is noted in Wichtl. Hepatic Tabernaemontanus recommended Angelica for conditions of cold and stagnation in the liver, and Culpeper wrote that it opens obstructions of the liver and spleen. The German Commission E monograph listed the cholagogic action for this herb, and Wichtl noted that Angelica is included in German herbal combinations for the biliary system. Antitoxin Dioscorides listed Angelica for snake bites, and both Lonicerus and Tabernaemontanus recommended it to drive out poisons and to treat the plague. Culpeper wrote that Angelica could treat epidemic: diseases, and resist poisons. Interestingly, Yeung75 mentioned that A. dahurica has shown antimicrobial action and has been used in China as an antitoxin for snake bites.

Angelica

Comparison ofWestern and Chinese use ofAngelica species The actions and uses of A. archangelica, A. dahurica (bai zhl), A. pubescens (dti hu6), and A. sinensis (dang guI) are compared below, viewed through the perspective of taste.

TEMPERATURE All four herbs are classified as warm.

TASTE A. archangelica is classified in this book as aromatic, bitter, and acrid. There is some variation of opinion regarding the taste properties assigned to the three Chinese species, but generally A. dahurica is regarded as acrid, A pubescens as bitter and acrid, and A. sinensis as sweet, acrid, and bitter. Acrid

All four herbs are classified as acrid, but their acrid

properties can manifest in different ways:

A. archangelica • clears Wind Cold, Damp, and Phlegm from the surface, either from the sinuses and head (to treat influenza with sinusitis) or from the channels of the muscles and joints (to treat arthritis with sensations of cold)

L

• clears Interior Cold, Damp, and Phlegm associated with Deficient Qi and Yang of Lung, Spleen, and Heart to treat chronic bronchitis or sinusitis with digestive weakness or disorders of peripheral circulation

A. dahurica The acrid property can clear Wind, Cold, and Damp from the surface, especially in the head and face, to treat frontal headache and sinusitis.

A. pubescens The acrid property can clear Wmd, Cold, and Damp from the surface, primarily from the channels of the muscles and joints in the lower back and legs to treat arthritis, and secondarily from the head to treat acute headache.

A. sinensis A. sinensis is not used much as an acrid herb to clear the surface, although its acrid property can have a mild warming effect on the Interior. Acrid and aromatic constituents of A. sinensis may combine to produce the ability of this herb to treat circulatory disorders, menstrual irregularities, and painful injuries associated with the pattern of Stagnant Blood. Aromatic There is a distinct smell common to the four Angelica species, but in addition, each has its own characteristic aroma. These similarities and differences in fragrance

217

may be based on similarities and differences in the composition of the essential oils. Whilst only A. archangelica is classified as. aromatic, A. dahurica, especially, seems to combine aspects of both acrid and aromatic properties in that it can be used to clear Damp and Phlegm. For example, it is used to treat Damp Cold in the Lower Burner and phlegm congestion in the sinuses. A. archangelica manifests its aromatic property by its ability to: • warm, tonify, and move Spleen Qi to transform Damp and Phlegm and treat chronic sinus or bronchial catarrh with obesity and lethargy • warm and move Spleen Qi to treat flatulence and intestinal spasms Bitter The bitter property of A. archangelica manifests itself in its use as a bitter digestive tonic to treat poor appetite, anorexia nervosa, and digestive weakness. The traditional Western use of A. archangelica fa'r anemia may be associated partly with its cardiotonic action and partly with the bitter digestive tonic effect. Although A. pubescens and A. sinensis are listed as bitter, they have not had wide use in China in the treatment of digestive weakness. Sweet All four Angelicas can have some sweetness in the mouth, and both A. dahurica and A. pubescens have been classified as sweet or slightly sweet in property in some Chinese texts. However, the sweetest in the mouth and the Angelica species most commonly associated with the sweet property is A. sinensis. This herb is regarded as a sweet tonic for the Blood to treat a variety of chronic or recurring conditions based on Blood Deficiency, such as: • eczema from Deficient Blood with Wmd invasion • arthritis from Deficient Blood with invasion of Wind, Cold, and Damp • constipation from Deficient Blood with Intestines Dryness • amenorrhea from Deficient Blood with Stagnation of Qi and Blood in the Uterus

ORGANS AND CHANNELS A. dahurica

This herb is specific for acute sinusitis and

frontal headache due to Wind invasion of the Lung and of the Yang Ming (Large Intestine and Stomach) channels. A. pubescens This herb is specific for leg, back, and head pain associated with Wind invasion of the Bladder and Kidney channels.

218

Combining Western Herbs and Chinese Medicine

A. archangelica This herb can be used for sinusitis and for arthritis, but it is not specifically associated with the Yang Ming channels as is A. dahurica or with the Bladder and Kidney channels as is A. pubescens. A. archangelica can be said to enter the Lung, Spleen, and Heart, associated with its use for respiratory, digestive, and peripheral circulatory disorders. A. sinensis This herb is listed as entering the Heart, Liver, and Spleen, associated with its ability to tonify and move the Blood. In this book, it is also associated with the Uterus.

26. Matsuda H. Murakami T. Nishida N et al. Chern Pharm Bull 48(0);1429-1435 (2000) 27. Matsuura M. Kimura Y, Nakata K et al. Planta Med 67(3):230-235 (2001) 28. Nanguang District Office for Prevention and Treatment of Chronic Bronchitis et al. Abstracts on the Prevention and Cure of Four Diseases (Jiangsu Medical Association) (6):67 (1978) 29. Angelica sinensis Research Unit. Second Teaching Hospital of Hubei Medical College. Health Journal of Hubei (5):64 (1977) 30. Antibronchitis Pilot Area. Fanxian Health Bureau. Henan Zhongyi Xueyuan Xuebao (Journal of Henan College of Traditional Chinese Medicine) (2):30 (1978) 31. Wuhan Fourth Hospital. Wuhan Journal of New Traditional Chinese

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14. Cho CH.Medi QB.Shang Petal. Planta Med 66(4):348-351 (2000)

47. Yi ZZ. Acta Pharmaceutica Sinica 15(6):321 (980)

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205 (2001)

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SO. Hsieh MT. Lin IT. Lin YH et al. Am I Chin Med 28(2):263-272 (2000)

19. Lorente I, Ocete MA, Zarzuelo A et al. J Nat Prod 52(2):267-272 (1989)

51. Matsuda H. Murakami T. Kageura T et al. Bioorg Med Chern Lett

20. Martin S. Padilla E. Ocete MA et al. Planta Med 59(6):533-536 (993) 21. Tambe Y, Tsujiuchi H. Honda G et al. Planta Med 62(5):469-470 (996) 22. Khayyal MT. el-Ghazaly MA. Kenawy SA et al. Arzneimittelforschung 51(7):545-553 (2001) 23. Ye YN. Liu ES. Shin VY et al. Biochem PharmacoI61(1l):1439-1448 (2001) 24. Reiter M. BrandtW.Arzneimittelforschung 350A):408-414 (1985) 25. Teng CM. Lin CH. Ko FN et al. Naunyn Schmiedebergs Arch PharmacoI349(2):202-208 (1994)

8(6):2191-2196 (1998) 52. Ding H. Peng R.Yu I. Zhonghua Gan Zang Bing Za Zhi 9 (Suppl):50-52 (2001) 53. Ye YN. Liu ES. Li Yet al. Life Sci 69(6):637-646 (2001) 54. Han SB. Kim YH. Lee CWO Immunopharmacology 400 ):39-48 (1998) 55. Choy YM. Leung KN. Cho CS et al. Am J Chin Med 22(2):137-145 (994) 56. Fujioka T, Furumi K. Fujii H et al. Chern Pharm Bull 47(1):96-100 (1999)

-;+-,

,.---

Angelica

219

57. Salikhova RA. Poroshenko GG. Vestn Ross Akad Med Nauk (1):58-61 (1995)

67. Lonicerus A. Kreuterbuch (1679). Reprinted by Verlag Konrad Kolbl, Miinchen, Germany (1962)

58. Blwnenthal M (ed). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council.

68. Gerard J. The Herbal or General History of Plants: The Complete 1633 Edition as Revised and Enlarged by Thomas Johnson. Dover Publications. New York. New York (1975)

Austin. Texas (1998) 59. Schimmer O. Planta Med 47:79 (1983) 60. Opdyke DLJ. Food and Cosmetics Toxicology 13 (1975) [cited in Tisserand R, Balacs T. Essential Oil Safety: A guide for Health Care Professionals. Churchill Livingstone, Edinburgh. United Kingdom (1995)] 61. Tisserand R. Balacs T. Essential Oil Safety: A Guide for Health Care Professionals. Churchill Livingstone. Edinburgh, United Kingdom (1995) 62. Zaynoun ST et al. Contact Dermatitis 3:225-239 (1977)

69. Tabernaemontanus JT. Krauterbuch (1731). Reprinted by Verlag Konrad Kolbl, Miinchen. Germany (1993) 70. Mills S. The Essential Book of Herbal Medicine. Arkana. London, United Kingdom (1991) 71. Lyle TJ. Physio-Medical Therapeutics, Materia Medica and Pharmacy. Originally published Ohio (1897). Reprinted by the National Association of Medical Herbalists of Great Britain, United Kingdom (1932)

63. Young AR et al. Pigment Cell Research 1:350-354 (1988)

72. Grieve M. A Modern Herbal, vols. 1 and 2. Dover Publications. New York, New York (1971)

64. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983)

73. Mabey R (ed). The Complete New Herbal. Elm Tree Books. London. United Kingdom (1988)

65. Lo AC, Chan K. Yeung JH et al. Eur J Drug Metab Pharmacokinet 20( 1):55-60 (1995)

74. Tierra M. Planetary Herbology. Lotus Press.. Twin Lakes, Wisconsin (1988)

66. Culpeper N. Culpeper's Complete Herbal and English Physician Enlarged. Meyerbooks.. Glenwood, lllinois (1990)

75. Yeung H-C. Handbook of Chinese Herbs and Combinations. vol. 1. Institute of Chinese Medicine. Los Angeles.. California (1985)

Arctium

...,

\,;,.. .... --

Botanical name Arctium lappa L. (A. majus Bernh.) or A. minus Bernh. Family Asteraceae (Compositae) Pharmaceutical name Arctii radix (Bardanae radix = Lappae radix) Part air-dried root English burdock German GroBe Klette French bardane Mandarin niubanggen (4-1H~) istherootsofA.lappaL. niu bang zi (4=-f -f) is the seeds of A.lappa L.

I use the seeds more for conditions that are relatively more superficial, such as allergic urticaria associated with Wind Heat, and the root more for conditions that are relatively more interior, such as chronic psoriasis associated with Stagnant Blood and Phlegm. Use in China Niu bang zl refers to the seeds of A.lappa L. and is mainly used to clear Wind Heat and treat sore throat with the common cold; to promote the eruption of rashes in diseases such as measles; to clear Heat Toxin to treat boils, tonsillitis, or mumps; and to moisten the Intestines and treat constipation.

Use in the West Burdock is a biennial native to Europe and Asia which has become naturalized in North America. The main herbal use of burdock in the West has been as an alterative and diuretic to treat skin conditions and urinary disorders. I have happy childhood memories of throwing the clinging burrs of this plant onto the clothes or hair of the children in front of me on country walks, and it appears that Culpeper himself found this temptation irresistible.

What is special about Arctium In terms of Chinese medicine, Arctium, as used in the West, can be said to be a cool herb that has its main effects on the Lung, Large Intestine, Kidney, and Bladder. Arctium root is classified in this book as slightly acrid and slightly bitter, and Arctium seeds as acrid and slightly bitter.

The key to understanding Arctium is that it is an alterative herb that can be used to treat:

Parts used The parts used in the West have been the root and seeds, and to a lesser degree the leaves. European use has tended to emphasize the root, and early American use by the Eclectics emphasized the seeds. Since the root and seeds taste definitely different in. the mouth, the seeds being considerably more acrid, there may be a genuine difference between the two parts in constituents and in therapeutic effects, but no detailed research has yet been done.

• acute and chronic skin disorders such as urticaria, eczema, psoriasis; acne, and boils • inflammatory conditions such as arthritis, gout, rheumatism, and lymphadenitis • toxic conditions following cancer therapy, prolonged multimedication treatments, drug abuse, or overindulgence in food and drink

221

222

Combining Western Herbs and Chinese Medicine _.~.%?1_

Chinese '~ctions':;'-'-~-:~ ·····"·:;:Weslerri2.uses :- .-,----: -:~~:~:~~~,_~-'

CHINESE ACTIONS In terms of Chinese medicine, Arctium, as used in the West, can be said to have the following actions: I. clear Wind Heat and Retained Pathogen II. clear Heat Toxin III. assist the Kidney and Bladder to drain Damp Clear Wind Heat and Retained Pathogen In the West, Arctium has not been commonly used for treating acute throat conditions with fever, as in Chinese medicine. However, it can be used as in China to clear a combination of Wmd Heat and Heat Toxin from the skin,to remove rashes, sometimes by temporarily encouraging their expression. Clear Heat Toxin Arctium can be used to clear Heat Toxin or a combination of Heat Toxin with: • Wind Heat • Retained Pathogen • Damp Heat Assist the Kidney and Bladder to drain Damp This is only a secondary function of Arctium. but it contributes to its cleansing action since toxins can be cleared through increased urination.

WESTERN ACTIONS

Western actions

I. clear Wind Heat and Retained Pathogen

alterative dermatological agent

II. clear Heat Toxin

alterative anti-inflammatory dermatological agent antiarthritic

III. assist the Kidney and Bladder to drain Damp

recurring urticaria, allergic eczema

II. clear Heat Toxin

eczema, psoriasis, acne, boils, arthritis, rheumatism, gout, lymphadenitis, adjunct to cancer therapy

III. assist the Kidney and Bladder to drain Damp

secondary herb for cystitis or obesity with edema

diuretic urinary anti-inflammatory alterative

The alterative action is the primary effect of Arctium that is utilized in the West. especially the dermatological and antiarthritic aspects of the alterative action.

:~'\

--~~.

DIRECTION OF ENERGY In terms of Chinese medicine. Arctium can have two directional effects on the energy of the body. First, it can clear Wind Heat and Retained Pathogen from the surface. but not necessarily by diaphoresis alone. Rather. it may loosen the pathogens from their sites of entry or accumulation. and flush them from the tissues via the blood and lymph systems. In some cases. it can encourage rashes to the surface. thus clearing lingering conditions. Secondly. Arctium is a mild diuretic and laxative that can assist the clearance of toxins from the body via the urine and the stools by draining them downward. The surface-cleansing. diuretic. and laxative actions are integral parts of the overall alterative effect of

~-

this herb.

TYPICAL CASE EXAMPLE

The main Western actions of Arctium are shown here in terms of its three main Chinese actions: Chinese actions

I. clear Wind Heat and Retained Pathogen

Signs and symptoms The patient has acute urticaria. which is brief in duration but recurs regularly. mild but chronic arthritis, and occasional cystitis and dysuria. There is a history of recurring tonsillitis and of severe teenage acne. The pulse is slightly slippery. with a feeling of congestion rather than wiriness. especially in the third position. The tongue has red dots and a somewhat yellow coat. especially at the back. Diagnosis The patient has a combination of Wind Heat, Retained Pathogen. Heat Toxin. Stagnant Qi, and maybe Damp Heat. Choice of Arctium treat:

This herb is chosen because it can

• urticaria with Wind Heat, Retained Pathogen. and Heat Toxin

WESTERN USES

~ arthritis with Heat Toxin and Damp Heat

The main Western uses of Arctium are shown here in terms of its three main Chinese actions:

• dysuria with Bladder Stagnant Qi. Damp Heat, or Heat Toxin

,

.-.:.

223

Arctium

Limitations ofArctium

the mouth. especially when compared with defmitely bitter herbs such as Achillea. Cinchona, Gentiana, Hydrastis, or Rosmarinus.

TEMPERATURE In this book, Arctium is classified as cool and is more appropriate for warm conditions, although it can be used for hot, neutral, or cool conditions if it is suitably combined with other herbs. TASTE Both Arctium root and Arctium seeds are classified in this book as slightly bitter, in that they can act as mild antiinflammatories to clear Heat and also as mild bitter tonics for the digestive system. Arctium seeds are classified in this book as acrid in that they can help to clear pathogens from the surface of the body. Arctium root is classified as slightly acrid, and its surfac~-active effect may be weaker than that of the seeds. In my opinion, Arctium is a herb which is best used in combination with others, rather than as a single herb. ACTIONS Diaphoretic Although Arctium may in some circumstances assist in the manifestation of unexpressed rashes, its ability to clear surface pathogens may generally be accomplished by increasing the release of toxins into the local blood and lymph capillaries, rather than by a diaphoretic action out through the skin. Alterative In the West, Arctium is used as an alterative, which can clear Heat Toxin and Retained Pathogen specifically from the skin, joints, and lymph system. It does not have such a strong tradition of use to clear toxins from the Liver as do Taraxacum or Berberis. Diuretic Arctium has a long tradition of use to increase urination and clear obstruction and inflammation from the urinary system. However, I do not use it as a primary herb for these effects. Instead, I use it as a secondary herb to support other urinary herbs. Laxative Although Arctium seeds are used as a moistening laxative in Chinese medicine, probably because of their oil content, Arctium is only regarded as a mild laxative in the West. The mild laxative and diuretic actions of Arctium are mainly used in the West to support its primary alterative action. Tonic In the West, there is a tradition of use of Arctium as a tonic, but this use is of secondary importance. Neither Arctium seeds nor Arctium root taste particularly bitter in

Arctium paired with other herbs Discussion of the limitations of each of the main actions of Arctium can be useful to clarify just what this herb can and cannot do. However, suitable combination with other herbs can extend the range of use of Arctium beyond its limitations. The basic unit of herb combination is the herb pair. Twelve pairings of Arctium are briefly explained below. CAUTION

Before using any of the herb pairs below, it is important to be familiar with the cautions listed for each herb in the pair. Arctium seeds + Ephedra

Acute urticaria Both herbs can move Wind invasion from the surface of the body, specifically in the case of allergic or nonallergic urticaria or eczema. In addition, Arctium can assist clearance of Retained Pathogen and Heat Toxin, which are responsible for recurring acute episodes. Arctium + Urtica

Acute urticaria These herbs can combine to clear Wind Heat from the surface and to clear Retained Pathog~n and Heat Toxin. In addition, Urtica has had traditional use in the West to strengthen the Blood, and this can help to prevent further Wind invasion. Arctium + Mahonia

Chronic eczema Both herbs can help to clear Retained Pathogen and Heat Toxin from the body, and Mahonia is specific for clearing Liver-Gallbladder Damp Heat, which results in chronic Damp Heat eczema. Arctium + Harpagophytum

Chronic arthritis + heat sensations Harpagophytum is specific for rheumatism, arthritis, or gout linked to Damp Heat. It is assisted in this by Arctium. In addition, Arctium can help to clear Retained Pathogen and Heat Toxins from the joints, and to drain these pathogenic factors from the body via the urine.

Combining Western Herbs and Chinese Medicine

224 Arctium + Taraxacum

Detoxification regimes This has long been a traditional spring cleansing combination in Britain and can be used to augment detoxification programs. Both herbs are alteratives with diuretic and mild laxative action, which can be used to clear Damp Heat and Heat Toxins from the body in the treatment of: • joint or skin disorders • sequelae of drug abuse • sequelae of prolonged multimedication treatments • sequelae of radio- or chemotherapy for cancer Arctium + Iris

Skin disorders + constipation Iris is specific for chronic skin disorders associated with sluggish liver function and constipation, or, in Chinese terms, Liver Stagnant Qi with Intestines Stagnant Qi and accumulation of Damp Heat and Heat Toxin. Arctium and Iris combine for chronic skin disorders such as acne, boils, and eczema. Arctium + Rheum

Arctium and Viola together can be used: • for eczema, boils, and acne • for lymphadenitis • as an adjunct to cancer therapy Arctium + Phytolacca

Boils

_. - .... .,..~

Phytolacca is an alterative herb, which can move Stagnant Qi to clear accumulation of Damp, Phlegm, and Heat Toxin in the skin and tissues. Phytolacca and Arctiurn can be combined: • for chronic psoriasis, acne, and boils • for rheumatism and arthritis • as an adjunct to weight loss programs, providing a cleansing diet is also adopted Arctium + Baptisia

Boils + infection Baptisia is a strong antimicrobial and a lymphatic alterative herb, which can be combined with Arctium to treat infections associated with boils, throat disorders, or lymphadenitis.

Acute psoriasis Rheum can help to clear Heat in the Blood and Heat Toxins, and it can combine with Arctium seeds to treat acute psoriasis, eczema, or acne rosacea with red, hot, painful skin lesions. Rheum, assisted by Arctium, can help to clear Heat out of the body through the stool. Arctium + Scrophularia

Arctium combinations SixArctiurn combinations are discussed below: Combination

Arctium + Smilax

Chronic psoriasis Smilax is specific for acute or chronic psoriasis, and Arctium can assist it to clear Heat Toxin and Damp, thereby treating itching, dry, scaly skin. Arctium + Viola

Acne Viola tricolor or V. odorata can combine with Arctium to clear Heat Toxin, and the Viola species can also clear Damp Heat.

Chinese syndromes

1. recurring urticaria (acute phase)

Wind Heat + Retained Pathogen

2. recurring urticaria (remission

Retained Pathogen + Deficient Blood

Acute eczema Scrophularia is specific for acute skin disorders with Heat in the Blood and bright red rashes with sensation of heat and severe itching. Arctium seeds can combine with Scrophularia to treat acute eczema due to Heat in the Blood or chronic eczema due to accumulation of Heat Toxin.

-

phase)

3. chronic eczema

Damp Heat + Deficient Blood

4. acute psoriasis

Heat in the Blood + Heat Toxin

5. arthritis + heat sensations

Damp Heat in the channels

6. cancer therapy adjunct

Stagnant Qi + Damp Heat + Heat Toxin

CAUTION

Before using any of the combinations below, it is important to be familiar with the cautions listed for each herb in the combination. 1. Recurring urticaria (acute phase)

Wind Heat + Retained Pathogen

,~

Arctium

Arctium (seeds) Arctium (root) Hydrastis Echinacea Urtica Ephedra

1 1 1 1 1

0.5-1

225

Arctium (seeds) Mahonia

cool

acrid, sl. bitter

cool

sl. acrid, sl. bitter

cool cool

bitter acrid, bitter, sl. sweet

warm-cool

acrid

Angelica sin. Ziziphus

acrid, sl. bitter

GIycyrrhiza

warm

Urtica

Schisandra

GENERAL

This combination is for recurring skin disorders in the acute phase caused by an acute attack of Wind Heat in a person with chronic Retained Pathogen and possibly also some Heat Toxin and Damp Heat. The residual pathogenic factors present in the body surface, blood, and interior predispose the person to recurring acute episodes of red, itchy rashes that may quickly come and go. These are regarded as a manifestation of Wind Heat in Chinese medicine. The aim of this combination is to clear Wind and Heat from the surface, to relieve itching, and to begin to clear Retained Pathogen from the surface and body. The overall temperature of the combination is cool to treat warm or moderately hot conditions. Although Ephedra is a warm herb, it is included because it is specific for allergic disorders associated with Wind invasion of the body surface. The important properties are acrid to clear the surface and bitter to clear Heat. USE

..

•

• acute phase of recurring allergic or nonallergic urticaria or eczema with red, itchy rashes that may quickly come and go, and may be of variable location PRACTICAL NOTES

This combination can be taken as 5 ml of 1:5 tincture in quarter of a cup of water, three times per day. This combination is for the acute phase of the condition only, and as soon as the redness and itching have subsided, this combination can be replaced by a combination that treats the remission phase of the condition, such as combination No.2 below.

Caution • practitioners are reminded that there may be local restrictions on the use or dose of Ephedra, and should be aware of the cautions on the use of this herb • especially during the initial use of this combination, the precautions for the use of alterative herbs and co~binationsshould be observed-see chapter on

Safety: Cautions on the use ofalteratives. 2. Recurring urticaria (remission phase)

Retained Pathogen + Deficient Blood

1 1 1 0.5 0.5 0.5 0.5

cool

acrid, sl. bitter

cool

bitter

warm-cool

acrid

warm

sweet, aromatic, bitter

neutral neutral-cool

sweet sweet

warm

sour

GENERAL

The previous combination is for the acute phase of recurring skin disorders in which the dominant pattern is Wind Heat with underlying Retained Pathogen. This combination is for the remission or chronic phase of skin disorders, in which the dominant pattern is ;Retained Pathogen with Deficient Blood. The aims of this combination are to: • clear Retained Pathogen • clear Heat Toxin and Damp Heat • tonify Blood and Nutritive (Y"mg) Qi • tonify and firm Kidney and Lung Qi The overall temperature is neutral to cool to treat neutral or warm conditions. The acrid and bitter properties assist in the clearance of Retained Pathogen and Heat from the surface and interior of the body; the sweet property tonifies the Blood, Kidney, and Lung Qi; and the sour property firms the Qi of the Kidney and Lung. In Chinese medicine, an important principle in the treatment of skin disorders with Wind invasion is to strengthen the Blood and the Nutritive Qi, thereby strengthening the surface of the body in order to reduce the occurrence of Wind invasion. Also, many ca~es of chronic allergy with asthma, rhinitis, or skin rashes, have underlying Kidney Deficiency, so that strengthening and firming the Kidney can also strengthen the circulation of Defensive and Nutritive Qi at the body surface. USE

• remission or chronic phase of recurring allergic or nonallergic urticaria or eczema with red, itchy rashes that may quickly come and go, and may be of variable location PRACTICAL NOTES

This combination can be taken as 5 ml of 1:5 tincture in quarter of a cup of water, three times per day. This combination is for the remission or chronic phase of the condition, and can be taken for 1-2 months with appropriate breaks and modifications. Should the acute phase return, this remission phase combination is stopped, and the acute phase combination above is used until the symptoms are

·"'';;;;;;---

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Combining Western Herbs and Chinese Medicine

226

...

~

-_:~

considerably improved. Then the acute phase combmation is stopped, and the chronic phase combination can be resumed.

5. Arthritis + heat sensations

3. Chronic eczema

Damp Heat in the channels

Damp Heat + Deficient Blood Herb

Ratio

Herb

Temperature

Taste

cool cool cool cool warm-cool warm neutral-cool

acrid, sl. bitter bitter bitter sour, sweet, bitter acrid sweet, aromatic. bitter sweet

Arctium (seeds) 1 Mahonia 1 Iris 1 Viola trio 1 Urtica 1 0.5-1 Angelica sin. Glycyrrhiza 0.5

Harpagophytum Berberis Taraxacum Arctium (root) Filipendula Angelica sin. Glycyrrhiza

Ratio

Temperature

Taste: , , ,', "-',;~

1 1 1 1 0.5 0.5 0.5

cool cool cool-cold cool cool warm neutral-cool

bitter bitter bitter sl. acrid, sl. bitter sour, bitter sweet. aromatic. bitter sweet

."

-'

This combination is the same as Harpagophytum: arthritis + heat sensations and is discussed under that heading.

GENERAL

This combination is for chronic or recurring patterns of Wmd Heat, Heat, or Damp Heat lodging in the skin, occurring with underlying Deficiency of Blood, Qi, or rm. The overall temperature is cool to treat chronic warm conditions. For cases of acute eczema associated with Heat in the Blood, this combination can be replaced by Berberis: acute eczema. The acrid and bitter constituents can clear Wind Heat, Heat, and Damp Heat, and the sweet constituents can tonify Deficiency. USE

• chronic or recurring eczema with dry skin, especially with a history of prolonged corticosteroid use PRACTICAL NOTES

Caution Especially during the initial use of this combination, the precautions for the use of alterative herbs and combinations should be observed-see chapter on Safety: Cautions on the use ofalteratives. 4. Acute psoriasis

Heat in the Blood + Heat Toxin

~~~~~2!~~~!~tit;~~;~J.~,~~;i~:;~" 1 1 1 1 1 1 0.5

--:.: .

cool cool cool cool cool-cold cool-cold neutral-cool

6. Cancer therapy adjunct

Stagnant Qi + Damp Heat + Heat Toxin

Thuja Viola odo. Phytolacca Hydrastis Taraxacum Arctium (root) Glycyrrhiza Zingiber

1 1 1 1 1 1 0.5 0.5

warm-cool cool cool cool cool-cold cool neutral-cool hot

acrid. aromatic sour, sweet. bitter acrid bitter bitter sl. acrid, sl. bitter sweet acrid, aromatic

adjunct and is discussed under that heading.

COMPARISON OF THE SIX ARCTIUM COMBINATIONS 1. Recurring urticaria (acute phase)

2. Recurring urticaria (remission phase)

Wind Heat + Retained Pathogen

Retained Pathogen + Deficient Blood

Arctium (seeds) Arctium (root) Hydrastis Echinacea Urtica Ephedra

Arctium (seeds) Mahonia Urtica Angelica sin. Ziziphus Glycyrrhiza Schisandra

',-' ~

sl. bitter sl. bitter acrid, sl. bitter bitter bitter bitter, sour sweet

~":".:;::'I':"-

.:;~.

This combination is the same as Thuja: cancer therapy

This combination can be taken as 5 ml of 1:5 tincture in quarter of a cup of water three times per day for 2-3 months with appropriate breaks and modifications.

Smilax Scrophularia Arctium (seeds) Mahonia Taraxacum Rheum' Glycyrrhiza

This combination is the same as Smilax: acute psoriasii~ and is discussed under that heading.~':·~

1 1 1 1 1 0.5-1

1 1 1 0.5 0.5 0.5

0.5

~:

Arctium 1. Arctium seeds are more for the surface and are paired here with Arctium root, which is more for the interior. Arctium seeds, Arctium root and Echinacea can clear Wind Heat, Retained Pathogen, and Heat Toxin. Hydrastis is included to clear Retained Pathogen and Damp Heat, specifically in cases of allergic skin disorders, especially with Heat in the Stomach, Intestines, or Liver. Urtica and Ephedra combine to clear Wmd from the surface in the specific case of acute allergic or nonallergic skin rashes.

2. The emphasis of the previous combination for acute urticaria is to clear Exterior Wind; therefore, Ephedra is an important herb in the combination. Since the emphasis of this combination is to tonify the Blood and Nutritive Qi, Angelica and Ziziphus are included. In addition, Glycyrrhiza and Schisandra tonify and firm Kidney Qi. Both combinations contain herbs to clear Retained Pathogen, Heat Toxin, and Damp Heat. Whilst the previous combination contains Hydrastis for its antiallergic action, this combination contains Mahonia to clear Damp Heat and Heat Toxins from the surface, Blood, and Liver. 3. Chronic eczema

4. Acute psoriasis

Damp Heat + Deficient Blood

Heat in the Blood + Heat Toxin

Herb';';

Arctium (seeds) Mahonia Iris Viola trio Urtica Angelica sin. Glycyrrhiza

Ratio 1 1 1 1 1 0.5-1 0.5

Herb

Smilax Scrophularia Arctium (seeds) Mahonia Taraxacum Rheum Glycyrrhiza

" Ratio.' 1 1 1 1 1 1 0.5

3. This combination is similar to the previous combination for the remission phase of urticaria. However, whilst the previous combination contains the tonics Ziziphus and Schisandra, this combination contains Iris to clear Damp Heat and Heat Toxins from the system via the Liver and Intestines, and Viola to clear Heat Toxins and Deficiency Heat. This combination for the chronic phase can also be compared with Berberis: acute eczema for acute skin disorders with Liver-Gallbladder Damp Heat and some Heat in the Blood. 4. Smilax makes this combination specific for psoriasis. Scrophularia, Taraxacum. and Rheum in combination are included to clear Heat in the Blood. Arctium and Taraxacum combine to clear Heat through urination, and Rheum and Taraxacum combine to clear Heat through the stools. All the herbs in this combination combine to clear Heat Toxin.

227

5. Arthritis + heat sensations

6. Cancer therapy adjunct

Damp Heat in the channels

Stagnant Qi + Damp Heat + Heat Toxin

Herb

_ Ratio' .

Harpagophytum Berberis Taraxacum Arctium (root) Filipendula Angelica sin. Glycyrrhiza

1 1 1 1

0.5 0.5 0.5

Herb

Thuja Viola odo. Phytolacca Hydrastis Taraxacum Arctium (root) Glycyrrhiza Zingiber

1 1 1 1 1 1 0.5 0.5

5. Harpagophytum is the leading herb for treating arthritis from Damp Heat in the joints. Berberis, Taraxacum and Arctium assist this by clearing Damp Heat from the Liver and from the body in general. Filipendula and Glycyrrhiza clear Stomach Heat associated with long-term use of nonsteroidal anti-inflammatory medications, and A. sinensis treats Deficient Blood associated with blood loss from gastric ulceration associated with the side effects of anti-inflammatory medications. 6. Thuja, Viola, and Phytolacca have a reputation for retarding the growth of tumors. Thuja, Viola, Phytolacca, Hydrastis, Taraxacum, and Arctium are alterative herbs that can help to clear Retained Pathogen, Damp Heat, and Heat Toxin, thus, helping to reduce the side effects of radio- or chemotherapy. Glycyrrhiza can assist detoxification and act as an anti-inflammatory and a tonic. Zingiber moderates the effects of the cooling herbs and helps to stimulate circulation and digestion.

OTHER ARCTIUM COMBINATIONS Other combinations that contain Arctium include the following:

• Calendula: lymphadenitis • Echinacea: boils + infection • Phytolacca: chronic acne • Smilax: arthritis + psoriasis

CONSTITUENTS The following constituents have been reported for A. lappa: • acetylenic compounds • terpenoids

228

Combining Western Herbs and Chinese Medicine

• phenolic acids ·lignans • other Acetylenic compounds The root of Arctium contains about 0.002% of acetylenic compounds of two types: • polyacetylenic Cll alkynenes, mainly trideca-lil-diene3,5,7,9-tetrayne 1 • sulfur-containing acetylenic compounds with two thiophene rings, mainly arctinone-a. together with related arctinols, arctinal, and arctic acids2 Terpenoids The roots of Arctium contain about 1% essential oil, containing over 60 compounds, especially the bitter sesquiterpene lactones dehydrocostus lactone and 11, 13dihydrodehydrocostus lactone.3 Phenolic acids The root contains 1.9-3.65% polyphenols, including caffeic, chlorogenic, isochlorogenic, and other acids. 4 Lignans The seeds contain lignan dimers and oligomers, mainly arctiin, with lesser amounts of artigenin,s and neoarctin B.6 The root also may contain arctiin. (Arctlin is broken down to its aglycone artigenin by rat large intestine flora.)' Other

Arctium root also contains:

• phytosterols, including sitosterol and stigmasterol4 • inulin up to 45%8 . • mucilage, including a xyloglucan of repeating oligosaccharide units9 • tannins4 • y-guanidino-n-butyric acid in small amounts8 Root, leaves, and seeds The different parts of Arctium appear to be characterized by different constituents:

• roots • leaves • seeds

acetylenic compounds arctiopicrin, a bitter sesquiterpene lactone of germacranolide type lO lignans

PHARMACOLOGICAL AND CLINICAL RESEARCH The following effects have been observed for A.lappa: • aritiniicrobiat • anti-inflammatory • hepatoprotective • antioxidant

.i.

• antidiabetic • diuretic • antiplatelet • antitumor and antimutagenic

-~

-

...

...__-.,...;;H;

...

~.

--_:.--~~ "7.~.::

Antimicrobial

According to Bruneton, II Arctium has' ".'

antimicrobial and antifungal actions that are linked to the polyacetyleneic compounds. No reference was given, but Bruneton may have been referring to the bacteriostatic action attributed to polyacetylenes reported by Schulte et al. 1

,.=

Anti-inflammatory Arctium seeds were reported to have protective effect against gastric ulcer. 12 Subcutaneous administration of Arctium extracts was reported to decrease carrageenan-induced rat paw edema. 13 Hepatoprotective The same study reported protection by .. , subcutaneous administration of Arctium extracts against carbon te~a~oride~~duced liver damage in rats. 13 Antioxidant The same study suggested that the antiinflammatory and hepatoprotective effects may be due to the antioxidative activity of Arctium. 13 A further study suggested that Arctium could reverse the decrease in glutathione or cytochrome P-450, associated with liver damage caused by carbon tetrachloride or acetarninophen. 14 Antidiabetic A hypoglycemic effect has been listed by Bensky and Gamble ls and by Yeung, 16 but no references were given. Arctium root extracts were reported to reduce blood sugar levels in rats and raise carbohydrate tolerance. 17 In one recent study, 6.25% by weight of Arctium was administered in the diet of normal and streptozotocin-induced diabetic mice for 28 days. After the administration of 200 mg/kg of streptozotocin, Arctium was reported to aggravate the diabetic condition. 18 Diuretic A diuretic effect is listed in Yeung, but no reference is given. Antiplatelet Arctium extract and various of its lignans were found to have inhibitory effect on the binding of platelet-activating factor to rabbit platelets. 19 Antitumor and antimutagenic The lignan arctiin, isolated from the seeds of Arctium and administered in the diet to rats at doses of 0.02% or 0.2% arctiin, was reported to have protective effect on induced carcinogenesis particularly in the mammary gland. However, arctiin may have a weak _ cocarcinogenic influence on induced hepatocarcinogenesis. 20 Arctium extracts showed antitumor activity against -~ human hepatoma HepG2 cells in vitro and against mouse

Arctium sarcoma 180 cells in vivo. Arctiin and arctigenin showed strong cytotoxicity against HepG2 cells.2\ Also, arctiin and arctigenin showed strong antitumor activity against induced mouse skin tumors, and arctigenin exhibited potential anti22 tumor activity in induced mouse pulmonary tumors. Finally, a factor isolated from Arctium reduced the mutagenicity of a range of mutagens. 23

229

USE OF ARCTIUM Western contraindications None reported. Chinese contraindications Arctium seeds are contraindicated in patients with diarrhea associated with Deficient Qi and in patients with open sores and carbuncles. IS Pregnancy and lactation No adverse reports. None reported, but see chapter on Safety:

Side effeCts RESEARCH VERIFICATION OF

Cautions on the use ofalteratives.

TRADITIONAL ACTIONS

Overdose

The following traditional actions of Arctium have been supported by research: diuretic, gastrointestinal anti-inflam-

No adverse reports, but see chapter on Safety:

Cautions on the use ofalteratives. Interactions

No adverse reports.

matory, and antitumor. Additional effects demonstrated by research The following additional effects have been reported as discussed above: antimicrobial, antioxidant, hepatoprotective, antidiabetic, antiplatelet, and antimutagenic. TOXICOLOGY I have not found information on the toxicity of Arctium.

Dose Dried herb The BHp24 listed 2-6 g of the dried root, three times per day. Both Lyle!5 and Christopher6 wrote that the seeds of Arctium are best crushed or ground just before decoction to increase the extraction of the constituents. Tincture The BHP listed 8-12 ml of 1:10 tincture (45% ethanol), three times per day. When I use Arctium tincture in combination with the tinctures of about five other herbs, the amount of Arctium tincture in each 5-10 ml of the mixture is about 1-2 ml. Initial dose

Please read the Regulatory status section hi the chapter on Safety. Arctium (burdock) is on the UK General Sale List (Statutory Instrument Order 1977 No. 2129 to the Medicines Act 1968). Arctium is not included in Part 4 of Schedule 4 of the Therapeutic Goods Act Regulations of Australia. Arctium is not currently listed by the FDA (USA) as a prolubited substance, as subject to an import alert, or as a substance with a warning on its use.

Traditional sources Nomenclature In the old sources, the Latin name for burdock are Arctium, Lappa, Personata, and Bardana; the older English names include burre docke, clot burre, and clod bur; and the older German name is generally Gross Kletten. PROPERTIES

Can start at the standard dose, but see

Cautions on the use ofalteratives in the chapter on Safety. Duration

Regulatory status

No restriction known.

Cautions USE OF ALTERATIVE HERBS Precautions for the use of alterative herbs and alterative combinations are discussed in the chapter Safety in Clinical Practice and in the appendix Healing Crises.

Temperature According to Lonicerus,27 the green leaves can clear Heat. Culpeper8 described the leaves as coolIng and moderately drying. Gerard!9 classified the root as slightly hot and the seeds as hot and dry. Arctium seeds are variously classified in Chinese medicine as cool15 or cold. 16 The root of Arctium is classified as cool in this book in line with its ability to clear Heat Toxin and treat such disorders as tonsillitis, boils, and inflammation of the joints. Taste

Taste in the mouth: seeds I found a 1:5 tincture of the seeds (mu bang zl) in 25% alcohol to be acrid and bitter, definitely

...

...

~

Combining Western Herbs and Chinese Medicine

230

.:.i~:i

:--~..

;

-c'::].:;:;::: _:~:13d

but not strongly, and also slightly sour. I found a sample of dried seeds (niu bang zl) to have a strongly acrid taste and slightly numbing sensation that lingered in the mouth and on the tongue. The seeds were also between slightly bitter and bitter in taste, and slightly sour. Grieve 30 described the roots as sweetish and mucilaginous, and the leaves as somewhat bitter. The BHP described the root as mucilaginous and slightly bitter, and the leaves as bitter. I found a 1:5 tincture of the root in 25% alcohol to be slightly sweet, slightly acrid, slightly bitter and slightly sour, and a sample of organically grown dried root to be mucilaginous, slightly sweet, slightly bitter, and slightly sour.

. Taste in the mouth: root

• respiratory anti-inflammatory

~

.. -:::-_-'::~

• tonic • other The two actions of Arctium most emphasized in the past and present in the West are the alterative and the diuretic actions. Alterative

Dioscorides33 recommended Arctium leaves as

a poultice to heal old ulcers, and Lonicerus wrote that the green leaves can be used to clear heat, and that burdock can be used 'to heal wounds with a lot of pus and rotten flesh: and 'to soften hard swellings and to pull out evil substances

fied in Chinese medicine as acrid and slightly bitter lS or acrid and bitter.16 Arctium seeds are classified in this book as acrid and slightly bitter.

and pus.' Felter and lloyd listed burdock root as an alterative for rheumatism, gout, venereal disease, and leprosy, and the seeds as a diuretic alterative for boils and styes on the eye~

used in the West, is classified as slightly acrid and slightly bitter, but since its acridity in the mouth is considerably less than the seeds, it may also follow that the surface-clearing acrid property of the root is less pronounced than that of the seeds. I use the seeds rather than the root for acute skin conditions involving Wind Heat, such as allergic urticaria.

In terms of Chinese medicine, Arctium lappa, as used in the West, can be associated mainly with disorders of the following systems:

feeble cutaneous circulation; scaly, dry' eruptions; and psoriasis. Lyle classified burdock root as a soothing, demulcent, tonic, alterative and lymphatic that could be used for all skin disorders. Christopher recommended burdock root for:

• lymphatic congestion • an aid for the removal of excess fatty tissue According to Priest and Priest,34 burdock is specific for

Examples of use

Source

skin

smooth beautiful skin styes on the eyelids

Lonicerus Felter and Lloyd 31

joints

gout rheumatism, sciatica

Felter and Lloyd Lyle

make the skin smooth and beautiful, Felter and lloyd listed burdock for impaired nutrition of the skin, and Grieve wrote

Kidney, Bladder

kidney stones edema

Tabemaemontanus 32 Grieve

that the influence of the seeds on the skin, restoring smooth-

Intestines

aperient

Christopher

mended the use of Arctium for skin disorders in children and wrote that it can improve poor skin following chicken

Niu bang zi, the seeds of A.lappa, are described as entering the Lung and Stomach in Chinese medicine. ls

ed burdock root for eczema, psoriasis, rheumatism, and gout.

Skin tonic Lonicerus recommended burdock ointment to

ness, is due largely to their oily nature. Julian ScouJ 5 recom-

pox.

Adjunct to cancer therapy Christopher listed burdock root ACTIONS

for cancer, and Mills and Bone36 noted the use of burdock in alterative combinations used as adjuncts to cancer therapy.

The following traditional actions are discussed: • alterative • diuretic • gastrointestinal anti-inflammatory

~-

• itches, rashes, eczema, psoriasis, boils, sores, wounds,

skin eruptions on the head, face, and neck, and the BHP listOrgan

....

lids, and for skin diseases. They listed burdock as specific for

and burns • rheumatism, gout, and sciatica

ORGANS

~­

.~~~

• laxative • diaphoretic

Taste properties: seeds Arctium seeds are variously classi-

Taste properties: root In this book, the root of Arctium, as

..

Diuretic Gerard quoted Apeleius as recommending the juice of the leaves to promote urination and to treat pains in the bladder. Culpeper noted the use of the seeds in breaking urinary stones and in assisting their expulsion in the urine.

-.-.

Arctium According to Felter and Lloyd, the seeds increase renal activity, relieve urinary tract irritation, and assist in the elimination of 'morbid products,' so that they can be used for edema and painful urination due to renal obstruction. The BHP listed A. lappa root as a diuretic that can be used for cystitis. This herb has also had traditional use as a diuretic in Germany4 and in France. 'l Gastrointestinal anti-inflammatory Gerard noted the use of burdock root for windy or cold stomach, and Felter and Lloyd recommended Arctium seeds for catarrhal and apthous ulcerations of the digestive tract, and for dyspepsia. Grieve wrote that an infusion of burdock leaves can strengthen and tone the stomach for chronic indigestion.

231

COMPARISON OF WESTERN AND CHINESE USE OF ARCTIUM

Actions----;'--- Western uses dermatological agent

rough dry skin, eczema, psoriasis, boils, ulcers

antiarthritic, antirheumatic

arthritis, gout, rheumatism, sciatica

other alterative

adjunct to cancer therapy

diaphoretic

Respiratory anti-inflammatory Tabernaemontanus noted the use of Arctium for wheezing and to cleanse the chest when coughing up blood and pus, and Gerard listed burdock for ulcers of the lungs and for spitting blood. According to Felter and Lloyd, the seeds can be used for bronchial irritation and cough, and Christopher wrote that the root can be used for pulmonary diseases. Laxative Some texts mention a tradition of use as a laxative (aperi~nt),4.11.26 but this has not been considered a primary action of this herb. Indeed, according to Lonicerus, burdock seeds can help to stop diarrhea and dysentery. Diaphoretic In the West, Arctium has not been used much as a diaphoretic and older texts, such as Lonicerus, Tabernaemontanus, Gerard, and Culpeper either do not mention or do not emphasize the diaphoretic action. Felter and Lloyd listed the use of Arctium seeds as a diaphoretic. but they did not describe any application of this action. Christopher mentioned the diaphoretic action of Arctium root or seeds, and listed the root for colds and fever. Tonic This is not a primary action of burdock and is only mentioned by a few authors. Gerard wrote that an extract of burdock root in wine strengthens the back, and according to Christopher, Arctium root can be used as a nutritive tonic. The BHP listed Arctium root for anorexia nervosa.

Chinese uses 15,16. boils due to Heat Toxin, incomplete expression of rashes

mumps or abscesses and ulcers of tongue and mouth due to Heat Toxin sore throat or tonsillitis due to Wind Heat + Heat Toxin

diuretic

secondary use for edema, cystitis

laxative

mild laxative action secondary to alterative use

constipation with Dryness

In Chinese medicine, the main actions of niu bang zi, Arctium seeds, are to clear Heat Toxin and/or Wind Heat to treat inflammations and infections of the throat and skin. In the West, there is a long tradition of using Arctium to clear heat and toxins from the surface of the body, as in China, but there is also a tradition of using Arctium seeds to nourish and moisten the skin. This is rather like the Chinese tradition of using the seeds to moisten the Intestines. In the West, there is a long tradition of using Arctium for urinary problems and for arthritic or rheumatic disorders, which is not well known in China. A Chinese tradition of use that is not emphasized in the West is that of using Arctium for inflammatory conditions of the throat, but there is an old tradition of use using it for bronchial conditions, which is not emphasized in China.

References 1. Schulte KE, Rucker G, Boehme R. Arzneim Forsch 17:829-833 (1967)

2. Washino T, Yoshikura M, Obata S. Agric Bioi Chern 50:263-269 (1986)

Other

3. Washino T, lwabuchi H, Yoshikura M et al. Nippon Nogeikagaku Kaisi 59:389-395 (1985)

Sexual tonic Gerard said that Arctium stalk 'increases seed

4. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn. Medpharm, Stuttgart. Germany (1994). from 2nd German edn. Wicht! M (ed) (1989)

and stirs up lust,' and Tabernaemontanus wrote that the root increases the hbido.

5. Sun WJ.ShaZH.Gao H.Yao Xue Xue Bao 27(7):549-551 (1992)

Nervine For7 wrote that Arctium seeds are a good nervine that can be used for spasms, convulsions, epilepsy, and fits.

6. Wang HY.YangJS. Yao XueXue Bao 28(12): 911-917 (1993)

Christopher listed Arctium seeds as a nervine, but did not discuss this use.

8. Mockle JA and Sr. Patrick de l' Assomption. Acta Phytotherapeutica 7:101-114 (1960)

7. Nose M, Fujimoto T. Takeda T et al. Planta Med 58(6):520-523 (1992)

232

Combining Western Herbs and Chinese Medicine

9. Kato Y. Watanabe T. Biosci Biotechnol Biochem 57(9):1591-1592 (1993) 10. Suchy M. Herout V. Sorm F et al. Collect Czech Chern Commun 22:1902-1908 (1957) 11. Bruneton J. Pharmacognosy: Phytochemistry Medicinal Plants. 2nd edn. Lavoisier. Paris. France (1999) 12. Os'kina OA. Pashinskii VG. Kanakina TA et al. Eksp Klin Farmakol 62(4):37-39 (1999) 13. Lin CC.Lu JM. Yang JJ et al.Am J Chin Med 24(2):127-137 (1996) 14. Lin SC. Chung TC. Lin CC.et al.Am J ChinMed 28(2):163-173 (200) 15. Bensky D. Gamble A. Chinese Herbal Medicine Materia Medica. Eastland Press. Seattle, Washington (1986)

25. Lyle TJ. Physio-Medical Therapeutics. Materia Medica and Pharmaq',_ Originally published Ohio (1897). Reprinted by the NationaE~.~ Association of Medical Herbalists of Great Britain. London. United .

"h .

.~"1'"

Kingdom (1932) 26. Christopher JR. School of Natural Healing. BiWorld. Provo, (1976)

tJ~~'::':: .•. ·;; ~.'. ....,:._:

27. Lonicerus A. Kreuterbuch (1679). Reprinted by Verlag Konrad Kolbl, Miinchen, Germany (l962)

".

.~.~;::,':~

',::iii '-, c;~

28. Culpeper N. Culpeper's Complete Herbal and English Physician:'i:'.-rEnlarged. Meyerbooks, Glenwood. Illinois (1990) ~~

i

29. Gerard J. The Herbal or General History of Plants: The Complete 1633 . '.:.:.L.,.r. '.." Edition as Revised and Enlarged by Thomas Johnson. Dover '''~''.

'·'et:.~~

Publications, New York. New York (1975)

16. Yeung H-C. Handbook of Chinese Herbs and Formulas. vol. 1. Institute of Chinese Medicine. Los Angeles, California (1985)

30. Grieve M. A Modern Herbal. vols. 1 and 2. Dover Publications, New

17. Lapinina O. Sisoeva TF. Farmatsevt. Zh. (Kiew) 19:52 (1964) [dted in Bi.~set NG (ed). Herbal Drugs and Phytopharmaceuticals. English edn. Medpharm. Stuttgart. Germany (1994). from 2nd German edn. Wichtl M (ed) (1989)]

31. Felter HW. Uoyd JU. King's American Dispensatory. vols. 1 and 2. 18th .. . ~f:..':."::" edn. (1898). Reprinted by Eclectic Medical Publications, sand:,_~L~::

18. Swanston-Flatt SK. Day C. Flat PR et al. Diabetes Res 10(2):69-73 (1989)

Oregon (1983)

.•

:~~

...,

32. Tabernaemontanus JT. Krauterbuch (1731). Reprinted by Verlag Konrad Kolbl, Miinchen, Germany (1993) 33. Dioscorides P. Kreutterbuch (1610). Reprinted by Verlag Konrad Kolbl, .

19. lwakarni S. Wu JB, Ebizuka Yet al. Chem Pharm Bull 40(5):1196-1198 (1992) 20. Hirose M, Yamaguchi T. Lin C et al. Cancer Lett 155(1):79-88 (2000)

';;'"

York. New York (1971)

Miinchen. Germany (1960)~t~L~ 34.

~~~:dA~:~:: ~~8~;rbal Medication. L.N. Fowler, Romford Essex,,~{~':lt .--.,~t"~

21. Moritani S. Nomura M, Takeda Yet al. Bioi Pharm Bull 19(11):15151517 (1996)

35. Scott

22. Takasaki M, Konoshima T. Komatsu K et al. Cancer Lett 158(1):53-59 (2000)

36. Mills S, Bone K. Principles and Practice of Pbytotherapy: Modern

23. Morita K. Kada T. Namiki M. Mutat Res 129(1):25-31 (1984)

J. Natural Medicine for Children. Unwin Paperbacks, London.,;:~

United Kingdom (1990) Herbal Medicine. Churchill Livingstone, Edinburgh. United Kingdom _'2~ (2000)

, '''''i-~. ·:';":.~:~f

24. British Herbal Pharmacopoeia. British Herbal Medicine Association. West Yorks, United Kingdom (1983)

37. Fox W. The Working Man's Model Family Botanic Guide to Health. 7th .• :~ :;~ edn. William Fox, Sheffield, United Kingdom (1878) ." .,'.~ !\".

~.

.....,.

Arctostaphylos Botanical name Arctostaphylos uva-ursi (1.) Spreng. (A. officinalis WlIIlIl1.) Family Ericaceae Pharmaceutical name Uvae ursi foliwn Part dried leaves English bearberry German Barentraube French busserole Mandarin A. uva-ursi (1.) Spreng. is not used

What is special about Arctostaphylos In terms of Chinese medicine, Arctostaphylos, as used in the West, can be said to be a cool, sour, and bitter herb that has its main effects on the Kidney and Bladder.

The key to understanding Arctostaphylos is that it is an antimicrobial, anti-inflammatory, and astringent herb that is specific for urinary tract infections, especially those with alkaline urine. It can also be used as an antimicrobial, anti-inflammatory, and astringent for prostate, vaginal, or uterine disorders.

Use in the West A. uva-ursi is a low-growing evergreen shrub found throughout the Northern hemisphere in America, Europe, and Asia. According to Grieve,1 it was used in the 13th century by the Welsh physicians of the Myddfai, and in the 18th century by Gerhard of Berlin. However, I could not fmd reference to this herb in Dioscorides,2 Lonicerus,3 Tabernaemontanus,4 Gerard,S or Culpeper,6 and the common use of this herb to treat urinary problems may have been introduced to Europe from America in the late 19th century. The Northwestern Native American group, the Haida, used the leaves of Arctostaphylos as a diuretic in kidney diseases and urinary tract infections, 7 and this herb was used by Physiomedical and Eclectic practitioners to treat urinary problems at least since the early 19th century. In 1878 Fox8 wrote that uva-ursi 'has ~o equal in chronic inflammation of the kidneys and bladder:

CHINESE ACTIONS In terms of Chinese medicine, Arctostaphylos, as it is used in the West, can be said to have two main actions: 1. clear Damp Heat in the Lower Burner II. stop bleeding and discharges WESTERN ACTIONS The main Western actions of Arctostaphylos are shown here in terms of its two main Chinese actions: .."...,.."...._._-.~-

I. clear Damp Heat in Lower Burner

Use in China A. uva-ursi is not listed in the Chinese Herbal Medicine Dictionary,9 Perri,lo or Chang and BUt. 11

233

antimicrobial anti-inflammatory diuretic antilithic

234

Combining Western Herbs and Chinese Medicine

II. stop bleeding and discharges

astringent anticatarrhal antimicrobial anti-inflammatory

Anticatarrhal Arctostaphylos may help to reduce catarrh in the urogenital system, that iS,oversecretion and accumulation of phlegm with obstruction and/or discharge. However, this effect may be via the antimicrobial and antiinflammatory actions of Arctostaphylos, rather than by directly increasing the ciliary action of epithelial cells. It may also be that the astringent action of Arctostaphylos contributes to an anticatarrhal effect, and this herb has had a tradition of use as a tonic for the wall of the bladder and the passageways of the urinary system.

WESTERN USES

II. stop bleeding and discharges

·~·it·

Choice of Arctostaphylos This herb is specific for urinary _'~ tract infections, but whilst of value in the short-term treat-';'=ment of acute infections as an antimicrobial, other herbs will be needed for this patient for the long-term correction of the underlying causes of the Stagnation of Qi, which may be the" ~ origin of the accumulation of Damp Heat.

Limitations ofArctostaphylos TEMPERATURE In this book, Arctostaphylos is classified as cool, but can be used for hot, ~arm, neutral, or cool conditions if combined with appropriate herbs. It would not normally be sufficient to treat hot conditions unless combined with colder herbs, such as Baptisia.

TASTE

The main Western uses of Arctostaphylos can be related to its two main Chinese actions:

I. clear Damp Heat in Lower Burner

c:.::=-..:'3;"·,

urinary tract infections, prostate infections, vaginitis. cervicitis blood or mucus in the urine, abnormal uterine bleeding, leukorrhea

Arctostaphylos is classified as sour and bitter in this book. It is sour in the sense of being an astringent, rather than a tonic for the Liver, and it is bitter in the sense of dearing Heat, rather than acting as a bitter digestive tonic.

ACTIONS Antimicrobial and anti-inflammatory The primary use of Arctostaphylos is as an antimicrobial and anti-inflammatory, specifically for infections and inflammations of the urogenital system. For infections and inflammations of other systems, other herbs are generally more effective.

DIRECTION OF ENERG Y This herb does not have a marked directional effect on the circulation of energy in the body. It may act as a mild diuretic with an associated downward movement of Fluids, but it can also act as a mild astringent, helping to restrain discharge or bleeding from the urogenital systems.

TYPICAL CASE EXAMPLE Signs and symptoms The patient has recurring bouts of acute cystitis with burning sensation and pain on urination, and frequent, though less severe, urinary discomfort between these bouts. The pulse is slightly wiry in the third positions, and this wiriness increases during the acute episodes, when the pulse rate may also increase. The tongue is slightly red with a slightly yellow, greasy coat, the redness and yellowness increasing during the acute periods. Diagnosis The patient has Damp Heat and Stagnation of Qi in the Lower Burner.

Astringent The secondary use of Arctostaphylos is as an astringent to tone mucous membranes, reduce excessive discharge, and reduce bleeding from the urogenital systems of_ ". both male and female. However, despite its relatively high tannin content, it does not have common use as a general astringent and antihemorrhagic for other systems. Anticatarrhal Arctostaphylos may help to reduce catarrh in the urogenital system that is producing obstruction and/or discharge. However, the anticatarrhal action is sec-·ondary to the antimicrobial and anti-inflammatory effects, and the anticatarrhal activity of this herb is mainly limited to the urogenital system.

Arctostaphylos paired with other herbs Discussion of the limitations of each of the main actions

f: Arctostaphylos of Arctostaphylos can be useful to clarify just what this herb can and cannot do. However, suitable combination with other herbs can extend the range of use of Arctostaphylos beyond its limitations. The basic unit of herb combination is the herb pair. Six pairings of Arctostaphylos are briefly explained below.

CAUTION

Any urinary condition with hematuria or female reproductive disorder with bloody or purulent discharge requires diagnosis and/or treatment from an appropriate specialist in conventional medicine prior to treatment with herbal therapy. Before using any of the herb pairs below, it is important to be familiar with the cautions listed for each herb in the pair.

235

or cystitis. Thuja can also be used to treat recurring respiratory infections with accumulation of phlegm and may have antiviral, anticatarrhal, and expectorant actions. Arctostaphylos and Thuja can be combined to treat urinary infections associated with respiratory infections. Arctostaphylos + Juniperus

Cystitis + arthritis Juniperus can have antimicrobial, anti-inflammatory, and diuretic actions, so that it can be paired with Arctostaphylos for urinary tract infections. Juniperus can also be used for recurring respiratory conditions or arthritis and rheumatism. Arctostaphylos + Rumex

Vaginitis + leukorrhea Arctostaphylos + Althaea

Cystitis + gastrointestinal inflammation Althaea is a demulcent anti-inflammatory that can be used for inflamed mucosa of the respiratory, gastrointestinal, or urogenital systems. Althaea can complement the antimicrobial, anti-inflammatory, and astringent actions of Arctostaphylos to treat urogenital inflammations, especially if there is generalized inflammation in the body, with gastrointestinal irritation, for example. Arctostaphylos + Echinacea

Urinary tract infections Echinacea is a general-purpose antimicrobial that can complement the urogenital system-specific antimicrobial action of Arctostaphylos. This pair can be used also when acute urinary infections are associated with acute respirato-

Rumex is an alterative that can be used for chronic infectionsand inflammations of the urogenital system associated with accumulation of Damp Heat and Heat Toxin. It can be combined with Arctostaphylos in oral preparations and in vaginal boluses or douches to treat vaginitis and leukorrhea.

Arctostaphylos combinations Six Arctostaphylos combinations are discussed below: .......

_----~--.,-

...... - ... ..."...••.. ,. _~-

'~~;.;,..:;.

1. urinary infection + heat sensations

Bladder Damp Heat

2. cystitis + hematuria

Bladder Damp Heat + Bleeding from Heat

3. cystitis

Bladder Heat + Kidney Deficient Yin

4. cystitis + recurring respiratory infection

Retained Pathogen + Bladder Damp Heat

ry infections. Arctostaphylos + Hydrastis

Urinary infections + hematuria Hydrastis is a general-purpose antimicrobial and antiinflammatory that can complement the specific action of Arctostaphylos on the urogenital system. Hydrastis is anticatarrhal and antihemorrhagic, and can combine with Arctostaphylos to treat conditions with:

..

Combination

5. prostatitis 6. vaginitis

+ infection

Damp Heat in Lower Burner Damp Heat in Lower Burner

CAUTION • mucus or blood in the urine • infection, inflammation, and discharge of the male or female genital areas Arctostaphylos + Thuja

Cystitis + respiratory infections Like Arctostaphylos, Thuja can have both astringent and diuretic actions. and the two herbs canbe used to treat enuresis

Any urinary condition with hematuria or female repro~ ductive disorder with bloody or purulent discharge requires diagnosis and/or treatment from an appropriate specialist in conventional medicine prior to treatment with herbal therapy. Before using any ofthe combinations below, it is important to be familiar with the cautions listed for each herb in the combination.

Combining Western Herbs and Chinese Medicine

236

1. Urinary infection + heat sensations

USE

Bladder Damp Heat

• acute urinary tract inflammations and/or infections with burning sensation on urination • acute urinary tract inflammations and/or infections

Arctostaphylos Baptisia Echinacea Hydrastis Zingiber

sour, bitter bitter acrid, bitter, sl. sweet bitter acrid, aromatic

cool cold cool cool hot

1 1 1 1 0.5

with bleeding PRACTICAL NOTES

This combination can be taken as 5 ml of 1:5 tincture in quarter of a cup of water, three times per day. If there is hematuria, as soon as this is consistently reduced, this com-

GENERAL

This combination is for Excess patterns of Damp Heat or Heat. The overall temperature is cool to treat hot or warm conditions. Zingiber has been included to disperse Heat to the surface, and to moderate the effect of the cool herbs in the treatment of mixed conditions of Heat and Cold, or of temporary Excess Heat with underlying Deficiency. Zingiber can be omitted or rep~;lced by Glycyrrhiza in purely Excess Heat patterns. if required. The dominant taste is bitter to clear Heat.

--

bination can be replaced with a more tonic combination. such as combination No.3 below.

Duration of prescription

If the hematuria is not improved within one week, the combination should be modified or a different combination may be required. If, for example, the pattern of bleeding proved to be one of Spleen Deficiency and Cold rather than one of Heat. then Arctostaphylos and . Hydrastis could be replaced by Astragalus and Cinnamomum bark.

USE

• acute urinary tract infections with feverishness or sensations of heat

3. Cystitis

Bladder Heat + Kidney Deficient Yin .' '~:.

PRACTICAL NOTES

This combination is for acute conditions, and can be taken as 5 m1 of 1:5 tincture in quarter of a cup of water, three times per day, for up to 1 week. As soon as the symptoms of burning pain on urination and sensations of heat are consistently reduced, this combination can be replaced with a less cool and more tonic combination. such as combination No.3 below.

_ ~'.'- :;'./';,'J; ~:;;:";;2:;.-:.r:~Y~\.::;,.~~ ~"~:-',::;:'~.,~,:j '.;;.~ ..... --:.:~-,~;--/~ .._:~

Daily dose ': Temperature: -Taste. , " : '--, :, . '_-.-.-,--, ,_

Herb

-

Althaea Viola trio Zea Agropyron Ophiopogon Arctostaphylos

3g 3g 3g 3g 3g 3g

-."

sweet, sl. bitter sour, sweet, bitter sweet sour, sl. sweet sweet, sl. bitter bitter, sour

cool cool neutral neutral cool cool

This combination is the same as Althaea: cystitis and is discussed under that combination.

2. Cystitis + hematuria 4. Cystitis + recurring respiratory infection

Bladder Damp Heat + Bleedingfrom Heat "',; >':'?::: ~:~

"'-,~_-', "-'~l -: "~.'.~,'-""j:;:'.:'--~'L!-:::';~";:.:~~~';_

Herb,

...

:~

Retained Pathogen + Bladder Damp Heat

',' .},~a~i?.:·Tempercltur~);Tast~:,:::

Arctostaphylos Hydrastis Polygonum Plantago Ian. (leaves) Equisetum Capsella

1 1 1 1 ,1 1

cool cool cool cool cool neutral

bitter, sour bitter sour, bitter sour, sl. bitter sl. bitter, sl. sweet sour

GENERAL

This combination is'forBia:clder Damp Heat with bleeding due to Heat. The overall temperature is cool to treat hot or warm conditions. The dominant tastes are bitter to clear Heat and Damp Heat. and sour to reduce bleeding by astringency.

Temperature Taste ..

Juniperus 1 Arctostaphylos 1 Thymus 1 Thuja 1 Echinacea 1 Hydrastis 1 Zingiber 0.5

51. warm cool warm-cool warm-cool cool cool hot

aromatic, sl. acrid, 51. sour sour, bitter aromatic acrid, aromatic, bitter acrid, bitter, sl. sweet bitter acrid, aromatic

This combination is the same as Juniperus: cystitis

+

recurring respiratory infection and is discussed under that heading.

Arctostaphylos

237

from the following six-herb combination, which is a modification of Christopher's vaginal bolus formula.

5. Prostatitis + infection

Damp Heat in Lower Burner

Ratio

Herb Herb

Ratio Temperature Taste

Thuja

1

warm-<:ool

acrid. aromatic. bitter

Arctostaphylos

1

cooi

1 1 1 1

51. warm

bitter. sour aromatic. 51. acrid, 51. sour

cool

bitter

neutral

bitter, sour 51. bitter, 51. sweet

Juniperus Hydrastis Hydrangea Equisetum

cool

This combination is the same as Thuja: prostatitis + infection and is discussed under that combination.

Arctostaphylos Althaea Hydrastis

1.5 1.5 1

Herb

Ratio

Mitchella Stellaria Rumex

1 1 1

The douche can be a decoction of a single herb such as Berberis. Hydrastis was commonly used in the past, but Berberis can be used as a much cheaper substitute.

COMPARISON OF THE SIX ARCTOSTAPHYLOS COMBINAT.IONS

6. Vaginitis

Lower Burner Damp Heat

Arctostaphylos Althaea Hydrastis Vinca Mitchella. Rumex Zingiber (dried)

1.5 1.5 1 1 1 1 1

cool

bitter. sour

cool

sweet. 51. bitter

cool

bitter

neutral

sour

neutral

51. sour

cool

bitter

hot

acrid. aromatic

1. Urinary infection + heat sensations

2. Cystitis + hematuria

Bladder Damp Heat

Bladder Damp Heat + Bleedingfrom Heat

Hertr~;1gr?1~Ratio "··r'·~·-···

Arctostaphylos Baptisia Echinacea Hydrastis Zingiber

1 1 1 1 0.5

GENERAL

This combination is for Damp Heat in Lower Burner with some Heat Toxin. The overall temperature is cool to treat warm, neutral, or mixed conditions. Fresh Zingiber is included to disperse Heat ounvard to the surface, and to moderate the cool herbs, especially in patterns with underlying Deficiency and Cold. The dominant taste is bitter to clear

Ratio'

Herb

-...., .

1 1 1 1 1 1

Arctostaphylos Hydrastis Polygonum Plantago Ian. (leaves) Equisetum Capseila

I. This combination is for acute, severe Excess patterns of Damp Heat or Heat and contains four cool, bitter antimicrobial herbs, moderated by Zingiber. This combination is only to be taken for up to a week, and as soon as symptoms of pain and heat are consistently reduced, it can be replaced by the next combination.

Heat, supported by sour to astringe discharge. USES

• inflammation and/or infection of vagina or cervix, with discharge • urinary inflammation and/or infection with discharge. • anogenital herpes simplex (acute phase)

2. This combination is to treat urinary inflammation and! or infection associated with Bladder Damp Heat, and to treat hematuria associated with Heat Arctostaphylos and Hydrastis are paired as antimicrobials; Polygonum and Plantago are paired as mucilaginous, demulcent, anti-inflammatory and antihemorrhagic herbs for the urinary system; and Equiseturn and Capsella are paired for their antihemorrhagic action.

PRACTICAL NOTES

This combination can be taken as 5ml of 1:5 tincture in about quarter of a cup of water, three times per day. It can be taken, with appropriate breaks and modifications for 2-4

3. Cystitis

4. Cystitis + recurring respiratory infection

Bladder Heat + Kidney Deficient Yin

Retained Pathogen + Bladder Damp Heat

weeks.

Bolus and douche This tincture may be accompanied by vaginal bolus and/or douche, as descnbed in the Examples section in the chapter Dose. The vaginal bolus can be made

Althaea Viola trI.

3g 3g

Juniperus Arctostaphylos

1 1

-

c~

Combining Western Herbs and Chinese Medicine.:=,ii.~ .

238

..

=:~

vmca.::'iif'

Zea Agropyron Ophiopogon Arctostaphylos

3g 3g 3g 3g

Thymus Thuja Echinacea Hydrastis Zingiber

acts as a demulcent anti-inflammatory. and Hydrastis. and Mitchella together have tonic. astringent. and anti-· ...' catarrhal effect on the mucus membranes of the reproductive system. Rumex is an alterative herb that can help to clear Damp Heat and Heat Toxins from the body. to reduce inflammation in the reproductive system.

1 1 1 1

0.5

3. Of the four strong antimicrobial herbs present in combination No. I, orily Arctostaphylos is retained in combination No.3. The strong antimicrobial herbs Baptisia. Echinacea. and Hydrastis are replaced by the anti-inflammatory herbs Althaea. Viola, Zea. Agropyron. and Ophiopogon. These anti-inflammatory herbs can help to tonify Kidney Ym and clear Deficiency Heat. This combination can be taken for 1-2 months, since Arctostaphylos is a small proportion of the whole and is moderated by the demulcent herbs. 4. Combination No.4 contains herbs for both the urinary and respiratory systems. All the herbs in this combination except Zingiber can have strong antimicrobial action. Arctostaphylos and Juniperus are specific for the urinary system. but Juniperus can also combine with Thymus, Thuja, and Echinacea to treat recurring respiratory infections due to Retained Pathogen. and to clear treat cough and bronchial obstruction due to Lung PWegm. 5. Prostatitis + infection

6. Vaginitis

Lower Burner Damp Heat

Damp Heat in Lower Burner

Research CONSTITUENTS The following constituents have been reported: • hydroquinone derivatives • polyphenols (tannins) • other Hydroquinone derivatives The main constituent is arbutin (hydroquinone mono-~-D-glucoside) which is usually 612%,12 but there is seasonal variation and it can be as high as 17%.13 There is also a smaller amount of methyl arbutin (up to 4%) and some free hydroquinone and methylhydroquinone. H Polyphenols These can be 10-15% and are mainly gallotannins, which are galloyl esters of glucose.1 5 There are also 16 ellagic acid, catechin. and anthocyanidin derivatives. Other These include the phenolic glucoside piceoside, flavonoids. phenolic acids. the iridoid glucoside monotropein, and triterpenes. 1i

Herb

..

-

Thuja Arctostaphylos Juniperus' Hydrastis Hydrangea Equisetum

Ratio 1 1 1 1 1 1

Herb Arctosta phylos Althaea Hydrastis Vinca Mitchella Rumex Zingiber (fresh)

Daily Dose 4.5 g 4.5 g

3g 3g 3g 3g 3 slices

5. This combination is for prostate inflammation and infection with signs of Heat and without appreciable Deficiency. Thuja. Arctostaphylos. Juniperus, and Hydrastis can have antimicrobial, anti-inflammatory, and anticatarrhal action on the urinary system, and Hydrangea, and Equisetum are specific for prostatitis. 6. Both combination No.6 and combination No.5 are for Damp Heat in the Lower Burner. But whilst combination No. 5 is for prostate infection. combination No.6 is for vaginal inflammation and/or infection. Arctostaphylos and Hydrastis have antimicrobial action, as in combination No.5, but in combination No.6, Althaea

PHARMACOLOGICAL AND CLINICAL RESEARCH The following effects have been reported: • antimicrobial • anti-inflammatory • urinary antimicrobial and anti-inflammatory • diuretic • nephroprotective • antidiabetic • antitussive • antimelanin Antimicrobial Arctostaphylos extract,18 and arbutin and hydroquinone. 19 have all shown antibacterial activity in vitro. The aglycone of piceoside. p-hydroxyacetophenone, 20 showed antibacterial action although piceoside did not. Anti-inflammatory Arctostaphylos extract has been reported to have an anti-inflammatory effect in mice. and both the Arctostaphylos leaf extract and arbutin isolated from it

Arctostaphylos increased the anti-inflammatory effect of prednisolone. 21 Arbutin also increased the anti-inflammatory action of indomethacin on carageenin-induced edema and adjuvantinduced arthritis.~2

Antidiabetic One study reported that consumption of a diet containing Arctostaphylos may counter some of the symptoms of streptozotocin diabetes in mice, but without affecting glycemic control.33

Urinary antimicrobial and anti-inflammatory

Antitussive Oral administration of arbutin at 50 mg/kg was reported to inhibit induced cough reflex. 34

Arbutin metabolism Arbutin may be the main constituent responsible for antibacterial activity in the urinary system.

-.

239

Arbutin is hydrolysed by the intestinal flora to its aglycone hydroquinone, which is in turn metabolized to its glucuronate and sulphate esters, which can then be excreted in the urine. 23 Arbutin and hydro quinone are not found in appreciable amounts in the urine. It has been suggested that, at an alkaline pH, the glucuronate and sulphate esters can release small amounts of hydro quinone, which has antibacterial effect.24

Antimdanin Both Arctostaphylos extract and arbutin have been reported to inhibit melanin synthesis by both tyrosinase and autoxidation. 35 It has been suggested that the leaves of Arctostaphylos species can be used as whitening agents for the skin. 36

RESEARCH VERIFICATION OF TRADITIONAL ACTIONS

Hydroquinone and urine pH The urine of a healthy individual on a diet including meat ranges from pH 4.5-6, although the pH of the urine of a vegetarian may be higher. Certain organisms associated with urinary tract infections, such as Proteus species or Klebsiella species,::; may produce a urine pH of >7 due to the degradation of urea with release of ammonia. 26 This pH may be high enough (about pH 8) to result in hydroquinone release and antimicrobial activity. Other bacteria responsible for urinary infections do not degrade urea and therefore do not raise pH appreciably. In such cases, it has been suggested that it may be beneficial to administer sodium bicarbonate27 or lJral28 along with Arctostaphylos in order to raise the pH sufficiently to ensure release of hydroquinone. This suggestion is based on the hypothesis that hydroquinone release in alkaline urine is the main cause of the antimicrobial action of Arctostaphylos, and although there is some evidence for this hypothesis,24 it has not yet been definitively confirmed. The only double-blind, placebo-controlled randomized clinical trial so far reported investigated the effectiveness of a combination of Arctostaphylos ,and Taraxacum to treat cystitis. 29 Although this combination was shown to be effective and without side effects, it cannot give information on the effectiveness of Arctostaphylos itself, since the activity may have been due to the Taraxacum. Diuretic One study reported that oral administration of Arctostaphylos infusion to healthy rats did not significantly increase urination or alter calcium and citrate levels,30 but another study reported that aqueous extracts of Arctostaphylos led to an increase in urine flow. 31 Nephroprotective It has been reported that an Arctostaphylos extract, at a dose of 25 mg/kg, had a marked antibacterial and nephroprotective effect in rats with acute bacterial pyelonephritis caused by E. coli. 32

The following traditional actions have been supported by research: antimicrobial, anti-inflammatory, diuretic, antidiabetic, and antitussive. The astringent and antilithic actions have not yet been supported by research. The BHC states that the high tannin content causes an astringent action, but does not support this statement with references. Additional effects demonstrated by research Arctostaphylos extracts have been reported to inhibit melanin synthesis, so that this herb may have the potential to treat hyperpigmentary disorders.

TOXICOLOGY An important distinction Whilst hydroquinone can have toxic effects at a high enough dose,37 a careful distinction needs to be made between the use of: . • therapeutic doses ofArctostaphylos as an infusion or tincture • arbutin as an isolated chemical • hydroquinone as an isolated chemical Although one model of the antimicrobial action of Arctostaphylos is based on the concept of release of small amounts of hydroquinone in the urine at high pH. a pilot clinical study found no free hydroquinone in the urine of volunteers. 38 Arctostaphylos According to the ESCOP monograph on Arctostaphylos, no toxicity data, reports of carcinogenicity, or reports of overdose are available for this herb, and it has been shown to be non-mutagenic in the Ames test and in the Bacillus subtilis rec-assay.39 According to Mills and Bone, short-term use of Arcto-

-~::~os~~IDw~huti~= ::::::O::::eros :~:::n::~::nt:atment ili~ beth an~:C. mili

· e th e urme. . 45 agents to alkaliniz

pregnancy and lactation.

Arbutin Arbutin did not induce mutations in concentrations of up to 10'2 M in a gene mutation assay, and there was no induction of micronuclei in bone marrow following oral administration of arbutin at 0.5-2 g/kg.-IO Hydroquinone

~

.,,~,a_

._"~

Duration According to the ESCOP monograph on Arcto- "~~. staphylos, treatment should be continued until complete_ ~:,o~~""'" ~. appearance of symptoms, up to a maximum of 2 weeks~ ~"': . Until more is known, it may be prudent to avoid the long-term .,:-....;:. ~ use of this herb at higher therapeutic doses, see Toxicology. '~'", ~ ..

LD;Q The oral LD so of hydroquinone in 2% aqueous solution has been reported as 320-550 mglkg in a variety of animals: l

Carcinogenicity and mutagenicity Hydroquinone is nonmutagenic in the Ames test, but can induce chromosome aberrations in eukaryotic cells, and, when administered by intraperitoneal injection in vivo, has induced raised micronucleus incidences.40 Topical use Whilst no side effects have been reported for topical creams containing Arctostaphylos, depigmenting creams containing hydroquinone may cause hyperpigmentation42 or allergic dermatitis. 43 Duration of use According to Mills and Bone, Arctostaphylos is not suitable for prolonged use due to its tarmin content. However, this statement is based on theoretical considerations of the potential effects of tarmins, rather than on research evidence for Arctostaphylos used within therapeutic doses.

Cautions ._,.'::

Western contraindications According to the German Commission E monograph,46 no contraindications are known for this herb. According to the BHC, this herb is contrain- ;~;i;~ ~ dicated for kidney disorders, but no references were given to<~ " support this. Indeed, there is a tradition of use to treat kidney~"1-. "1 disorders, and one research study has reported a nephro-..,· ' . 32 protective"effect for A r c t o s t a p h y l o s ..'~ ' ~.; y~; , - •••

Chinese contraindications

None known for A. uva-ursi.

Pregnancy and lactation Until more is known about the amount of hydroquinone released from Arctostaphylos in humans, it is prudent to avoid the use of this herb in pregnancy and lactation, see Toxicology.

-:~~ .....,...-..

Side effects According to Wicht!, this herb may cause nausea or vomiting in patients with delicate digestion.

~

The chemical that may give rise to greater toxicity concern than the tannins is hydro quinone. It is necessary to determine the amounts of hydroquinone and potentially toxic derivatives released in the body from arbutin. It is also necessary to determine whether these levels are sufficient to have toxic effects either long or short-term in humans. It may be that the amount of hydroquinone released from therapeutic doses of Arctostaphylos in the human body is toxic to the bacteria responsible for urinary tract infections, but not to humans. However, until more is known on this topic, it may be prudent to limit Arctostaphylos to relatively short-term use.

Overdose No reports on overdose known,39 see Toxicology.

Dose

Regulatory status

Dried herb The BHp H listed 1.5-4 g of the dried herb, three times per day.

Please read the Regulatory status section in the chapter. on Safety. Arctostaphylos is on the UK General Sale List, and it i~ not included in Part 4 of Schedule 4 of the Therapeutic Ci?0ds Act Regulations of Australia. Arctostaphylos is not currently listed by the FDA (USA) as a prohibited substance, as subject to an import alert, or as a substance with a warning on its, .. .... .. use.

Tincture The BHC listed 2-4 ml of 1:5 tincture in 25% alcohol, three to four times per day. Initial dose

Can start at the standard dose.

Method of administration

It may be beneficial to drink

6,

Interactions

• if the assumption that Arctostaphylos works best at an alkaline pH is correct, it would be better to avoid treatments that increase urine acidity whilst using Arctostaphylos as a urinary antimicrobial • theoretically, the high tannin levels in Arctostaphylos might interfere with the absorption of various nutrients, but this has not been reported for this herb in practice

~'.'

"

-,.

;;~t

i

--

Arctostaphylos

,

Traditional sources The recorded use of this herb seems to have begun with the early Eclectics, and to have been transferred from them to Britain and Europe.

• tonic astringent • diuretic • antilithic • antidiabetic • antitussive • other

PROPERTIES

Antimicrobial and anti-inflammatory

Temperature In this book, Arctostaphylos is classified as cool, associated with its antimicrobial and anti-inflammato-

Urinary disorders

ry properties. Taste

Taste in the mouth The BHP described Arctostaphylos as slightly bitter and astringent. I found a 1:5 tincture in 25% alcohol to be bitter and sour, with a slightly puckering astringent sensation in the mouth.

Taste properties Arctostaphylos is classified in this book as sour, associated with its astringent action, and bitter, relating to its antimicrobial and anti-inflammatory effect to clear Damp Heat in the lower body.

241

Fox recommended Arctostaphylos for inflammations and ulcerations of the kidneys and bladder, Felter and Lloyd listed it for chronic irritation of the bladder and for chronic disorders of the kidneys and urinary passages, and Ellingwood49 noted its use for cystitis, pyelitis, and pyelonephritis. Christopher recommended Arctostaphylos for kidney and bladder congestion or ulceration and for chronic nephritis, and the BHP listed this herb for cystitis, urethritis, and pyelitis, and gave its specific indication as 'acute catarrhal cystitis with dysuria and highly acid urine:

Reproductive disorders Felter and Lloyd listed Arctostaphylos for gonorrhea, and Christopher also recommended it for syphilis and uterine ulceration. Tonic astringent

ORGANS In terms of Chinese medicine, Arctostaphylos, as used in the West, can be associated mainly with disorders of the following organs:

Kidney, Bladder

back pain cystitis

Christopher" BHP

Uterus

leukorrhea uterine hemorrhage

Felter and L1oyd48 Christopher

Lung

cough bronchitis

Felter and Lloyd Christopher

A. uva-ursi is not listed in the Chinese Herbal Medicine

Urinary disorders According to Felter and Lloyd, Arctostaphylos is specific for urinary problems with: • 'feeble circulation and lack of innervation in the urinary tract' • mucous or bloody secretions • feeling of weight and dragging in the loins and perineum, when not due to prostatic enlargement According to Ellingwood, Arctostaphylos is specific for 'relaxed conditions of the bladder walls, to which it imparts tone and induces normal contraction: Felter and Lloyd also wrote that Arctostaphylos could be used for enuresis, and Christopher described two enuresis combinations including this herb.

Dictionary.

Reproductive disorders Both Felter and Lloyd and Christ-

ACTIONS

opher listed Arctostaphylos for leukorrhea and menorrhagia. Christopher also recommended it for prostate weakness.

The main tradition of use of Arctostaphylos has been as an antimicrobial, anti-inflammatory, and astringent herb primarily for the treatment of Urinary disorders, and secondarily for the treatment of certain reproductive disorders, such as leukorrhea, gonorrhea, uterine ulceration, and uterine hemorrhage. The following actions are discussed separately, although the antimicrobialJanti-inflammatory, tonic astringent, and anticatarrhal actions may work in combi