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CHAPTER ONE

Drawing from the deep pool: the history, scope and core principles of herbal medicine in the West

History and origins

As stated in the introduction, the origins of herbal medicine worldwide have an unknown lineage into archaic time and in other-than-human-beings. It is with the development of writing that ideas about health and disease, and the plants used as medicines, began to be recorded from oral traditions. Western herbal medicine, as practised by modern herbalists and members of the National Institute of Medical Herbalists today, has an eclectic and global heritage. Starting with information from oral cultures such as Ancient Greece, Ancient Egypt and beyond; concepts, theories and practical medicine of ancient times eventually became written texts.¹ The Roman Empire enabled the spread of these texts, and the collection of new ideas. Romanised physicians such as Dioscorides wrote their own works on medicine and the practical application of medicinal plants and of surgery. Pedianus Dioscorides (c. 40–90 CE) was originally from Greece, and his most famous work De Materia Medica was a precursor to modern pharmacopoeias (a technical book identifying and describing the preparation and use of medicines).

The ancient Greeks and Romans hailed the source of inspiration and knowledge of healing as coming from the Ancient Greek god Asclepius. It is thought by some scholars that Asclepius, also known as Thoth or Hermes Trismegistus could be based on the Ancient Egyptian architect Imhotep, although there is no evidence that he was a physician. Hiero-glyphic carvings from Imhotep's stepped pyramid at Saqqara however state that Merit-Ptah was the ‘chief physician’, and so she would have existed about 2700 bce, making her possibly the earliest recorded female physician.²

The Arabic scholars of the 9th–11th centuries then revived many of these texts, providing us with copies of works by Hippocrates and Galen, for example. Many of these Arab physicians, including people such as Avicenna, added to this information, practised medicine and surgery, and formed medical schools and hospitals that were very advanced for their time. Their work translating and adding to ancient texts meant that the knowledge and written work was picked up by the monastic traditions, copied and practised by monks and nuns (such as Hildegard of Bingen), and it also found its way to the original and first universities of Europe (and to medical practitioners of that time such as Trotula).

Works copied into Latin by monasteries and also new works from the early universities have allowed very ancient texts (such as Hippocrates and Dioscorides) to survive today in the form of ‘herbals’, eventually being written in the English language (a key purpose of Nicholas Culpeper). Each culture left its mark on the work, so that many copies of the same book exist—in different languages and with slight variations.

Let's look at some of the key people from the history of Western herbal medicine.

Hippocrates c. 460–377 BCE was the son of a Greek physician, who, at that time were part of the rhizotomi or root gatherers. Rhizotomi were also known as Asclepiadiae after Aesclepius the Greek god of medicine (see above). Hippocrates is probably the most famous of all the Ancient Greek physicians and is known to this day as the father of medicine. The Hippocratic oath was named after him.

A number of different texts on medicine were originally ascribed to Hippocrates, but are now believed to have been written and edited by at least two different authors over approximately two centuries.

Texts include:

Ancient medicine: This text emphasises the importance of balance within the body, and how essential it is to health. This is a forerunner to the modern-day concept of homeostasis in the body.

Airs, waters, places: In this text physiological systems are aligned with definitions of body, soul and cosmos. This text also showed an in-depth understanding of the importance of the impact of environmental factors on health.

The nature of man: This text expands on the theme of humoral medicine and how important it is to balance the humours within the individual for optimal health.

There are at least 50 other texts in this body of work. Hippocrates emphasised treating the physical body alongside emotional and mental states: an early record of holistic thinking perhaps.

It is far more important to know what person has the disease than what disease the person has.

—Hippocrates

Definition—Holistic: The term holistic was actually coined by General J. C. Smuts in 1926, and refers to the practice of looking at whole systems rather than breaking things down into their individual component parts (a mechanistic viewpoint). Holon is from Greek meaning ‘whole’—holos (masculine) holi (feminine).

Galen of Pergamon, 130–201 ce was born in the vibrant, intellectual Roman centre of Pergamon. His father had a dream given to him by the god Asclepius himself that Galen should study medicine. His 10-year training took him on to Smyrna and then Alexandria where he learned theories of medicine from ancient writings including those of Hippocrates, and more practical medicine such as surgery. His first job was as chief physician to the Roman gladiators, and this gave him much-needed experience in human anatomy. He went on to become personal physician to the Roman emperor Marcus Aurelius (ruled 161–180 CE). Galen published a huge corpus of works on language, logic, philosophy and many medical works on subjects such as diet, pharmacology, anatomy and physiology and surgery.

Galen was particularly influenced by the theory of the four humours, and he elevated this theory by attributing it to Hippocrates himself. He was also a practical observer and experimenter, and is considered to be the originator of the experimental method in medicine. This extended into pharmacology where he also suggested a method to observe the properties of herbal ‘drugs’. He became so well known for this that he was often sent medicines from far around the Roman Empire to test. Some of his physiological observations were new for his time and were accurate (such as proving that urine is formed by the kidney not the bladder).

Galen also believed in individualised medicine, and that any medical training should be accompanied by the study of philosophy. The quotation, ‘The best doctor is also a philosopher’ is attributed to Galen. He was much admired and 400 years later his ideas were taken up by other great ‘philosopher doctors’ of the Arabic world such as Maimonides (1135–1204 CE). The ‘medical logic’ of Galen was subsequently absorbed by the new universities of Europe. These were founded as theoretical institutions based on Greek, and Arabic medical works translated into Latin, the dominant language of that time.

Galen's influence was such that after he died his works and theories became heavily modified, re-invented and re-interpreted and led to a sort of Galenism, that remained the predominant form of medicine practised in Europe right up to the 1600s.

It took 1500 years, until the Renaissance, for Galen's theories to be successfully challenged. First to do this was the Flemish anatomist Andreas Vesalius (1514–1564) who realised Galen's anatomy (based on animal dissection) was not always correct (in the ancient world, dissection of humans was forbidden). Then, William Harvey (1578–1657), credited with the discovery of the circulation of the blood, challenged and condemned Galen's inaccurate theory of blood, although it should be remembered that Harvey himself thought his own discovery proved humoural theory, and even he did not fully complete our understanding of the circulation.

Galenism, the dogmatic, rigid and sometimes just plain incorrect application of Galenic ideas, did much to discredit Galen into our modern time. He was however a polymath, a keen observer and empiricist, a thinking physician and surgeon, who believed in listening deeply to the patient as an individual.

Official plant medicines once found in the British Pharmacopoeia alongside chemical medicines up until the 1970s and 1980s, were known as ‘Galenicals’. This has perhaps not helped the acceptance of modern phytotherapy among conventional doctors who may remember herbs being referred to in this way, and who think of Galen(ism) as holding back the progress of ‘modern’ medicine.

Probably the most famous of the Arabic scholars was Avicenna (Abū ‘Alī al-usayn ibn ‘Abd Allāh ibn Sīnā), (980–1037 CE) another polymath, physician and philosopher. Avicenna was born in what is now present-day Uzbekistan and lived during what has been called the Islamic Golden Age. At this time the West was going through what we now refer to as the Dark Ages (a mediaeval period of history), and medical knowledge from the Middle-East was significantly advanced by comparison. Muslim scholars had access to many sources of knowledge including that of Ancient Greco-Roman, Byzantine, Indian, Egyptian and Persian civilisations. It was the late middle ages before this wealth of knowledge became available to the West.

As another polymath, Avicenna is known to have written over 450 works including 40 on medicine. Possibly his most famous work on medicine is The Canon of Medicine which became one of the standard texts in medical universities in the mediaeval West.

There are no incurable diseases—only the lack of will. There are no worth-less herbs—only the lack of knowledge.

—Avicenna

9th-century Arabic electuary for a cough caused by catarrh.

Equal parts of:

•Flax seed (Linseed) ground into a powder

•Sweet raisin (free from seed) pounded into a paste

•Pine nuts ground into paste

•Liquorice root ground into a powder

•Mix with honey (bereft of broth)

It is taken in the morning and at bedtime, it helps, God willing.

Adapted from The Medical Formulary of Aqrabadhin of Al-Kindi (c. 800–870 CE) Arabian physician and philosopher.

Works by Greek, Roman and Arabic physicians and others were preserved by the practice of monastic manuscript copying and translation.

Many ancient texts survive because of this painstaking practice, and fuel the popular association between monks and herb gardens. Uniquely in Britain, records were kept on Anglo-Saxon medicine and so we can see the influence of Latin texts on traditional Leechbooks from around the 9th century CE (leech was the term for a doctor in those times) such as the Leechbook of Bald.^3,4 Bald was a monk, and set about recording and copying contemporary medicine into a written document that survives to this day. Monastic life also allowed for the development of new ideas within health and medicine, an example being the Abbess Hildegarde of Bingen whose writings on health and, uniquely, womens health, contributed to this corpus of knowledge.

Hildegarde of Bingen, (1098–1179) abbess of Eibingen Abby, near Bingen, Germany. In addition to being one of the most important musical compos-ers of the period, Hildegarde wrote extensively about health and medicine.

Her books on many subjects including Physica written during the period 1150 to 1158 and Cause et Curae were originally combined in Liber subtilitatum diversarum naturarum creaturarum (the Book of the Subtleties of the Diverse Nature of Creatures).

According to Hildegard of Bingen, disease is not a process, but an absence of process, a failing in the course of nature. Thus, from a holistic perspective, the presence of disease suggests a shortfall that can be improved upon. Her works describe over 2000 herb recipes, as well as ways of eating, and Hildegarde also had advice on wellness and living, that is regarded as a forerunner to the strong tradition of herbal medicine and naturopathy in Germany, and Northern Europe. These can be translated as:

•Viriditas—The drawing of energy from nature's ‘greenness’ and life force.

•Healthy and balanced nutrition found from the healing power of food.

•Regeneration of strained nerves with healthy sleep and dream regulation.

•Finding the harmonious balance between work and leisure.

•Removal of waste products and purification with regular fasting and sweat baths.

•Optimism of mind and strength of psychological defences.

Monastic preservation of medical texts provided an intellectual starting point for the study of medicine or physic in the first universities. In Padua, Salerno, Bologna, Oxford and throughout Europe, medicine was taught and pharmacy was demonstrated in the physic garden—some of these physic gardens remain open to visitors today.

Another contributor from this time was the medical practitioner and scholar Trotula—we do not know her full name. There are three books largely attributed to her that also contain new ideas for the time about health, and about women's health and wellbeing.⁵

The Christian requirement for charity throughout the Middle Ages was expressed in the formation of hospitality for pilgrims, and thus the formation of ‘spittals’ or ‘hospitals’, which cared for and treated those in need.

Medico-archaeology such as that at Soutra Aisle close to the Scottish border, reveals the use of medicinal plants on a large scale (as well as other medical interventions of the time such as blood-letting). Archaeological evidence found at Soutra Aisle, such as well-preserved seeds of Valeriana officinalis L. and Hypericum perforatum L. (still formed into a bolus), has been linked to contemporary 12th-century recipes in manuscripts from around the time of the hospital such as ‘The armpit package of St Columba’ a possible remedy for swollen lymph glands made from these plants.⁶

As the printing press took over from handwritten manuscripts, herbals began to be printed and circulated. An extraordinary number of herbals are still available to us today and many of them repeat and elaborate on information from existing or even long lost manuscripts. The popularity of herbals has ensured the survival of many for our continued enjoyment and learning. Familiar names include: John Gerard, Nicholas Culpeper, William Turner and John Parkinson.⁷

Two types of herbal knowledge existed; Latin texts for those wealthy enough to be educated, and secondly, a folk tradition, often in the form of practical medicine infused with some exotic remedies from Latin texts right alongside native and local plants. In the UK, some resources survive, often in the form of recipes, of the people's everyday herbalism. For example recipes from Wales and the physicians of Myddfai,⁸ and 20th-century information collected from the country folk of England^9,10 and Scotland.¹¹

One significantly negative outcome from this period of history in Europe was the witch-hunt genocide (gendercide). In Europe during the Middle Ages, many women (and some men) were persecuted supposedly for being witches. It has been regularly suggested that many of these so-called witches who were put to death, were in fact herbalists or simply people offering other people healing or midwifery services. The link between herbalists and witchcraft is still resonant today—albeit jokingly.² A brief read of the Malleus Maleficarum (Hammer of the Witches) by Heinrich Kramer in 1487—the work that sparked the notorious witch trials of Europe and early settlers of America, reveals a far more sinister misogyny at work.

Matilda Joslyn Gage, suffragette, has said that

The persecution of witches had nothing to do with fighting evil or resisting the devil—it was simply entrenched misogyny, the goal of which was to repress the intellect of women. A witch was not wicked, did not ride a broomstick naked in the dark nor consort with demons. She was instead likely to be a woman of superior intellect.

—Matilda Joslyn Gage

As a thought experiment Matilda suggested that for ‘witches’ we should instead read ‘women’, for their histories run hand in hand.

The witch trials had undoubtedly a suppressive effect on a living tradition of plant medicine throughout Northern Europe, and continues to lend an unfortunate negative association with herbal medicine and women healers.

Wealthy and literate women of the 16th–19th centuries continued to keep and record recipes for food, medicine and medicinal foods, for use within the home. Meanwhile paid professionals went on to create and protect the title of doctor, leading to the formation of medical societies.

The steady development of chemistry as a profession enabled the evolution of a whole new area of drug development, which orthodox medicine fully embraced. However, plant-based medicines were still recommended as part of the pharmacopoeia well into the 20th century. The British Pharmacopoeia of 1932 lists ointment of capsicum, gum of tragacanth, tincture of ginger, tincture of valerian, common tincture of rhubarb, and tinctures of myrrh, gentian, quassia and lobelia, to name just a few. The British Pharmaceutical Codex of 1954 included tincture of lemon, squill, rose fruit, rosemary oil, and peppermint in its list of recommended substances for medicines. The British National Formulary (BNF) of 2016 still includes peppermint oil as one of its recommendations, among a list of medicines that are otherwise overwhelmingly mono-chemical in nature.

During the 19th century, the success of the American Botanical Movement led to the formation of the National Association of Medical Herbalists (NAMH) in the UK in 1864, eventually becoming the National Institute of Medical Herbalists (NIMH).

Coat of Arms, National Institute of Medical Herbalists.

There is acknowledgement (as can be seen from the former coat of arms of the NIMH pictured here), that the corpus of knowledge from the ancient and new worlds has informed what we today call modern herbal medicine, and phytotherapy. It also represents the strong connection to and yet difference from, conventional medical origins.

The influence from America cannot be underestimated. The pio-neers from the old world had to live and survive in the unfamiliar newly settled lands of America. The survival of these early settlers can be seen as a direct result of First Nations peoples’ knowledge of medicine and medicinal plants. Many European settlers were helped by them, then they copied and formalised herbal medicine techniques from those native peoples of Canada, and of North and South America. This new influence upon European herbal medicine set in motion a clear distinction between conventional and herbal medicine, and a revival in the use of plant medicines in contrast to the growing popularity of chemical medicines among most professional doctors.

In the 18th and 19th centuries, use of bleeding, mercury, opiates, arse-nic, emetics and purgatives by regular doctors in America and Britain often resulted in the death of the patient. This influenced the creation of a strong alternative medicine system, which borrowed heavily from First Nations’ sweat baths, herbal practice, and also from New England folk remedies.

Samuel Thomson (1769–1843), a New Hampshire farmer, formalised his system of medicine that was similarly ‘heroic’ but much less toxic and extreme than the current conventional options, and relied on medicinal plants. The principle that ‘heat is life and cold is death’ was behind a simple system of steaming and purging remedies, and the use of many herbs familiar to Western herbalists today such as chilli, ginger, prickly ash bark, yarrow, lobelia, bayberry, skullcap and boneset can be traced back to Thompsonian medicine.¹²

Thompson's original theory was later supplanted and developed into Physiomedicalism by Alva Curtis (1797–1881). This sectarian medical school, at its height in the 1880s in the USA, drew from energetic theories similar to Traditional Chinese Medicine and promoted a study of the patients’ constitution and relevance of organ systems in the practice of herbal medicine.

The most resilient of the medical-botanical schools to emerge in the 19th century were the eclectic physicians founded in 1820 by Wooster Beach (1794–1868).¹³

The eclectic physicians introduced many American botanicals to the herbal pharmacopoeia of the UK, including echinacea (Echinacea angustifolia DC and E. purpurea (L.) Moench), wild indigo (Baptisia tinctoria (L.) R.Br.), black cohosh (Actaea racemosa L. formerly known as Cimicifuga) and golden seal (Hydrastis canadensis L.). Huge numbers of patients were treated and data about herbal interventions recorded.

John Milton Scudder MD (1829–1894) enhanced and continued the eclectic medical system. Its key features were the use of specific indications in herbal medicine practice. The patient was seen as an individual, and their unique symptoms were investigated using pulse, tongue and differential and physical diagnostics. Herbal medicines, conventional medicine, homoeopathy and hydrotherapy could be employed to help the patient.¹⁴

The history of Western herbal medicine in the UK in the 20th century is full of twists and turns. In 1941, against a backdrop of pharmaceutical ‘wonder drugs’ being continually discovered, the wartime government rushed the Pharmacy and Medicines Act onto the statute books. Overnight, members of the National Association of Medical Herbalists found that they could no longer supply herbal remedies directly to their patients. In effect it became illegal to practice as a consulting medical herbalist in the UK. Public reaction to this was generally hostile. NAMH members continued to practice and there were no prosecutions.

The 5th July 1948 is generally recognised as the birth of the National Health Service (NHS) in the UK. Its primary aim was to make healthcare available to everyone, not just to those who could afford it. Access to free healthcare, the fast-developing world of pharmaceutical companies and the accompanying enthusiasm engendered by the concept of ‘magic bullet’ medicine, and the 1941 Pharmacy and Medicines Act, all conspired to suppress the practice of Western herbal medicine in the UK.

This situation continued until 1964 when (in the wake of the thalido-mide tragedy) the newly formed British Herbal Medicines Association (formed by Frederick Fletcher Hyde and Frank Powers) was ultimately successful in overthrowing the 1941 Pharmacy and Medicines Act.

Albert Orbell FNIMH, medical herbalist and president of the NIMH in its centenary year, played a pivotal role in founding the Hospital for Natural Healing (HNH) in Stratford, E14, in 1934, and was the Chairman of the Hospital Board for most of its 40-plus years existence. A chari-table enterprise, the HNH was a most ambitious project, providing professional herbal health care to the people of London's deprived East End, regardless of their ability to pay.

The HNH also played a key role in the survival of the herbal profession in the UK during the difficult post-war years, when NIMH membership dropped to double figures. In an agreement with NIMH, the HNH provided professional training for herbal students from the 1950s until its closure in 1975. When it closed, the sale of the premises provided a substantial tranche of funds for the NIMH's Education Fund, a charity enabling the purchase of a building in Tunbridge Wells that established the School of Herbal Medicine run by Hein Zeylstra for the next 25 years or so.

Modern practitioners of herbal medicine, and members of the National Institute of Medical Herbalists, recognise the important discoveries and advancement of our understanding of the practical application of herbs due to the various American botanical movements, and their native First Nations’ teachers. Established in 1864, the National Association of Medical Herbalists (now the NIMH), still aims to use herbal medicines (in association with areas such as advice on diet and lifestyle changes) to heal and relieve suffering. The NIMH has continued to educate and provide professional membership ever since its inception. This was formalised into University-based BSc and MSc qualifications in the late 1990s, and continues as equivalent professional training to the present day.

We shall continue to treat each person as a unique entity and prescribe according to our judgement as to his needs.

—Fred Fletcher Hyde, Presidential address to the NIMH

The UK legislative provisions for herbal medicine are to be found in the Medicines Act 1968, and they were successfully prevented from being removed in 1993, and again in 2011, by, among others, the courageous and indomitable medical herbalist and past-president of the NIMH, Michael McIntyre. Although he was not successful in gaining statutory regulation for herbalists in 2017, this was at least partly because herbal medicine poses so little threat to public safety. The European Herbal and Traditional Practitioners Association founded at the request of the UK government maintains a record of political events regarding herbal practitioners via their website.

The National Institute of Medical Herbalists maintains a register and professional standards for modern medical herbalists and liaises with government bodies and departments on matters pertaining to professional herbal treatment. Although herbal medicine in the UK is legislated for, it is currently outside of National Health Service funding and is therefore sometimes misunderstood in terms of its scientific rigour and professional standards. In some ways, the state-funded NHS has created a situation where any form of healing that is not conventional biomedicine is in some way pseudo-scientific or ineffective. Different countries worldwide have their own rules on herbal medicine provision, and in many countries other forms of healing are valued and integrated, including herbal medicine and naturopathy.

Some historical sources and people who have influenced the practice of Western herbal medicine are listed below for your information:

Greco-Roman

Dioscorides 50–80 CE, Pliny the Elder c. 23–79 CE, Galen of Pergamon c. 130–200 CE, Pseudo-Asclepeius 5th century CE.

Arabic

Abn Sina (Avicenna) c. 980–1037 ce, Serapo the Younger (Ibn Wafid) 13th century.

Anglo-Saxon/late Middle Ages

The Old English Herbarium c. 1000, Macer 9th–12th century, The Salernitian Herbal 12th century, Hildegarde of Bingen 1098–1179, Physicians of Myddfai 14th–18th century.

Renaissance/early modern

Leonhart Fuchs 1501–1566, Pietro Andrea Mattioli 1501–1577, William Turner 1509–1568, Rembert Dodoens 1516–1585, Jaques D'Alechamps 1513–1588, Jean Bauhin 1541–1613, John Gerard c. 1545–1612, John Parkinson 1566–1650, Nicholas Culpeper 1616–1654.

18th-century sources

William Salmon 1710, John Quincy d. 1722, Joseph Miller d. 1748, John Hill 1714–1775, William Cullen 1710–1790.

19th-century American and British sources

Albert Isiah Coffin 1790–1866, William Fox, William Cook 1832–1899, Finley Ellingwood 1852–1920.

20th-century texts

Richard Cranfield Wren, Richard Hool, Maud Grieve 1858–after 1941, Wilhelm Pelikan 1893–1981, Rudolf Weiss 1895–1991, The National Botanic Pharmacopoeia 1921, Albert Priest and Lilian Priest, British Herbal Pharmacopoeia 1983, Thomas Bartram 1913–2009.

21st-century texts

Julian Barker, Kerry Bone, Dr Mary Bove, Peter Bradley, Andrew Chevallier, Alison Denham, Graeme Tobyn, Midge Whitelegg, David Hoffman, Elizabeth Williamson, Christopher Menzies-Trull, Simon Mills, Aviva Romm, Ruth Tricky and Matthew Wood.

Key concepts of Western herbal medicine

Medical herbalists study conventional medical science, but they also study and practice using key principles and concepts distinct from conventional medical thinking today. Herbalists study a functional and ecological approach to health and disease that informs their use of herbal medicines, and the advice that they give. These key principles and concepts are implemented alongside conventional medical diagnosis to analyse the individual's health, and in the application of herbal therapy. This deeper analysis of the patient and their symptoms, beyond the conventional diagnosis, ensures that herbal treatment remains person-centred.¹⁵ The plant medicines applied in this way have the capacity to act within us to restore specific tissues of the body and also therefore the function of our own bodies.

Definition—Medicine:

•The science or practice of the diagnosis, treatment and prevention of disease (in technical use often taken to exclude surgery).

•A drug or other (non-surgical) preparation for the treatment or prevention of disease.

•A spell, charm or fetish believed to have healing, protective or other power.

—Oxford English Dictionary

Throughout this book, we shall revisit these core principles and concepts and develop the themes of this ecological view of health and of the plants themselves.

Core foundational principles of herbal practice

•That wellness and illness are made up of a mosaic of factors, and time is needed to discover and respond to these in an individualised way.

•Symptoms and not just the diagnosis are seen as important.

•The consultation is conducted in a fundamentally positive setting.

•Lifestyle, diet and psychological wellbeing are recognised as significant in disease causation and treatment outcome. The herbalist is therefore acting as a health guide not just as a prescriber of plants as medicine.

•Humans have an innate vitality or resilience that can be negatively or positively impacted.

•Herbalists assess the individual using pattern recognition¹⁶ and a persistent theme within all traditions of herbal medicine is the assessment of a person's unique ‘constitution’.

•Our physiological functions act as an interconnected whole, and so the practice of herbalism is more like that of the science of ecology—the study of complex interconnected systems.¹⁷

•Some areas of human function are so fundamental as to be pillars of wellbeing. These ‘health drivers’ are good digestive function, restorative sleep, regular relaxation, and the promotion of circulation and tissue health. Improvement in these areas will positively impact other essential physiological functions such as the hormonal system, the immune system or the skin, and will act on the trophic state of tissues and organs.

•Restoring resilience or ‘bounce-back’ can be a result of correcting the pillars of health with diet and herbal medicine. In addition, herbalists recognise the concept of herbal tonics and adaptogens (a natural substance considered to help the body adapt to stress). Some herbs are considered to have tonic effects to the circulatory, or immune system, or the musculoskeletal system, for example, and others more broadly to our vitality and adaptive potential.

A summary of the core principles of the practical application of herbal medicines

To relieve suffering by addressing the following fundamentals of health:

•Positively influence digestive health (tissues, secretions, organs, microbiome)

•Assess and enhance elimination of metabolic waste products (at the tissue level, and via the organs of excretion)

•Assess and restore circulation (central and peripheral)

•Consider all aspects of the nervous system, its health and function

•Application of trophic herbs where needed

•Support adaptive potential with adaptogens

•Apply vulnerary and healing plants wherever needed¹⁸

The framework of the book

We will take a deeper look into the plants themselves and the compounds associated with them in Chapter 2. This book then dives into the study of our physical body and its interconnectedness. We have attempted to draw attention here to some of the fundamental differences between conventional and herbal medicine. Join us after this for an exploration of 15 key medicinal plants from the Western tradition (Chapters 4, 6 and 8). See how practical and helpful these herbal allies are, and observe how they have been examined in modern times to increase our understanding of how they can uniquely help us. We have included recipes and self-help measures so that you can experience each of these fantastic plants in a practical way. Herbal medicine, specifically the utilisation of whole plants such as bramble, nettle and oats, is often described as occupying the grey area between food and medicine. In Chapter 5 we will look more closely at this from the perspective of food, and how we can use the foods we eat to keep us healthy. Most of us will experience some form of health complaint at some time. Chapters 7, 9, 10 and 11 examine some of the commonest health issues that people might see their doctor for, and considers the herbalists’ perspective. This is illustrated throughout with case histories from our own practices. We consider research, safety and the role of herbal medicine in our modern technological (anthropocene) world. Finally we will draw together the key points from the book in Chapter 12, which sum-marises our thoughts and experiences, and our hopes for the future of this vibrant and supportive form of medicine.

But first, we would like to outline some key concepts from within herbal medicine about our plant allies. Once we start to look at anything in detail, we can all too easily lose the phenomenon as its true whole. We hope to retain that wholeness despite the analysis within this book.

Key concepts about medicinal plants

•Plants typically used in herbal medicine practice have multiple compounds that are of benefit to the plant, but also to human health, resilience and function.

•Plant constituents often demonstrate synergy, that is their interactions with each other produce therapeutic results beyond the merely additive.

•Co-evolution with many edible and medicinal plants has altered our genetics allowing us to tolerate medicinal plants to a greater degree than would be otherwise expected of mono-chemical drugs.

•Plants and humans have their own microbiome, or mini-ecosystem of commensal microorganisms.¹⁹

Definition—Microbiome: The microorganisms in a particular environment (including the body or a part of the body).

—Oxford English Dictionary Online

Plants can positively impact a depleted human microbiome directly and also indirectly by having active compounds that correct gut function. It stands to reason then why care of our wider ecosystem is so important for everyone's health.

Synergy

Medicinal plants have many well-researched individual therapeutic compounds. These are considered to (and have often been shown to) act synergistically.²⁰ The use of whole plants with their multiple compounds, and multiple herb prescriptions, can result in better results than can be demonstrated by a single herb or single ‘active constituent’ research. This property is closely connected with the potential for herbal medicines to have properties beyond what can be described by solely looking at their compounds or pharmacology. A ‘greater than the sum of parts’ effect, known as synergy, is an example of a recognition of the dynamic nature of nature.

Examples of synergistic interactions would include the ability of one constituent to maximize the absorption of another constituent across the gut wall (pharmacokinetic synergy), or the multiple differing pathways by which the constituents of a plant exert their effects, coming together to provide broad based support for a system, and therefore resulting in better than expected outcomes (pharmacodynamic synergy).

This dynamic nature of nature can also be exemplified in the energetic approach of Ayurvedic and Traditional Chinese Medicine systems, and other traditions of the world. Many Western herbalists still consider this way of thinking as vital to the practice, some still refer to the humoral approach, the original ‘energetic’ approach of Western herbal medicine. We will revisit and expand this theme in later chapters.

A summary of the extra characteristics that herbalists recognise within plants:

Each characteristic has multiple potential layers of meaning.

Stimulating	Relaxing
Sedating	Astringing/condensing
Trophic	Adaptogenic
Nervine	Vulnerary

Key concepts of the approach of the Western medical herbalist

[Today, medical herbalists] critically evaluate both historical documentation and the latest empirical findings underpinning herbal prescribing.

—G. Tobyn, A. Denham and M. Whitelegg²¹

Modern Western medical herbalists (phytotherapists) value a detailed consultation and case history taking, allowing the person time to speak, to be heard, and time for the herbalist to ask about information concerning each and every body system, not just the current symptom or focus of primary diagnosis.

An emphasis is placed on the interconnectedness of all parts of our physiology, and the inherent vitality that can be suppressed in some people or some situations, and can therefore be supported and nourished with certain herbal interventions.

A timeline and chronology of events from wellness to un-wellness is mapped out, and areas of weakness, fragility or lack of function are identified. The aim is to direct focus and treatment to the perceived root causes, and to apply herbal medicines (and any other valued activity such as nutrition, exercise, lifestyle advice) to areas that need attention.

Each medicinal plant has multiple capacities, and so care in the selection of plants to suit the person and the situation is taken by the herbalist. Herbal therapy therefore may be, for example, ‘anti-inflammatory’, but also stimulating, relaxing or tonifying in nature. These actions may be attributed to plant compounds and our current pharmacological understanding of them, and also to traditional understanding or empirical sources from centuries of use.

Herbalists value a deep connection with the plants they enrol as medicines. Being a herbalist often results in a glorious life-long relationship with plants and nature.

Herbal therapy can be applied internally and/or externally and in a huge variety of forms—tea, tincture, capsule, syrup, pessary, ointment and so on, and thus individualised to the situation and/or to the patient and their requirements. We shall explore some home pharmacy recipes later in this book.

Evidence

One fairly common and misguided comment made concerning herbal medicine is the lack of research underpinning practice. Although there is undeniably a lack of well-structured quality human research specifically designed for the purpose of investigating whole plant remedies, it is untrue to say that there is no relevant research.

This is a misconception that we have striven to address where possible in the writing of this book. Research is out there; fragmented at times, but out there none the less. One aspect of this, however, is the thorny question of animal research. We do not believe that animal research involving the wilful harming of living creatures should be supported. This has in places led to us deliberately not quoting what could be seen by some as ‘relevant’ supportive research. We feel such research is profoundly in conflict with the spirit of a healing profession for which we both care deeply and strive to practice with integrity and love. The tenet of ‘do no harm’ should be adhered to at all times, and this includes all living creatures that come under the auspices of herbal medicine (which is to say—all living creatures).

What is evidence, particularly where any medicine is concerned? This often depends partly on whom the evidence is intended to inform. The research that produces evidence can be qualitative or quantitative, or even a mixture of the two.

The originators of the concept of evidence-based medicine defined it as:

The integration of best research evidence with clinical expertise and patient values.

—D. L. Sackett et al., 1996²²

There is a perceived hierarchy of evidence recognised today, that could be said to have developed because of its intrinsic link to the development and manufacture of drugs by companies looking for a market, and potential validation by government organisations. Any patient-centred intervention is likely to fall short of criteria designed to fit mono-chemical therapy applied to disease labels. A gradual realisation of the significance of more qualitative data, case reports and patient-centred medicine is growing within the medical community.

Levels of evidence include:

•Patients: often bring evidence in anecdotal form from previous cases that they have heard about that reflect their own.

•Clinicians: are interested in evidence that gives a probability of success or adverse effects, to guide their prescribing.

•Clinical researchers: want a comparison of one group against another with blinding and randomisation to eliminate placebo and nocebo effects. The randomised, placebo controlled trial (RCT's).

•Laboratory researchers: use experiments to identify causative factors and mechanism of action.

•Office-based researchers/clinical analysts: the highest regarded research currently for analysing clinical effectiveness is the meta-analysis and systematic reviews of groups of trials. This is the basis of government recommendations to clinicians. As we shall see, however, this is not always applied evenly.

Herbal medicine has been criticised for having a lack of RCT's, but, despite significant stumbling blocks such as lack of financial backing, some do exist. Conversely, despite a lack of RCT data showing efficacy for paracetamol (acetaminophen/tylenol) for clinical effectiveness for the pain of osteo-arthritis (OA), it continues to be the most prescribed medication by conventional UK practitioners for OA and is NHS funded.

Meta-analysis has been championed by the Cochrane review, but poorly designed trials on herbal medicines such as those on echinacea have produced results that suggest no clinical effectiveness. Concerns have been raised about the poor quality or quantity of plant material used in these RCT's.²³

Lack of evidence for efficacy is not the same as evidence for lack of efficacy.

—S. E. Edwards et al.²³

This short and seemingly simple statement belies a massive lack of understanding on the part of many people. If something has not been proved by accepted scientific methodology, this does not signify that it has actually been disproved. The confusion caused by the statement. ‘there is no scientific evidence for this’ or words to that effect are regularly taken as evidence of disproof. This misconception often lies at the heart of perfectly sound interventions being discarded or maligned.

It is important to be observant when herbal medicine research is being presented in the media, because often research trial data is discussed but ‘opinion’ pieces are tacked on to the end of the discussion, and presented as if they are as factual as the research itself. So even a positive herbal medicine outcome might also have the researcher comment that the public should still be wary of herbal medicine safety, for example. An alternative statement such as ‘refer to a qualified herbal practitioner’ would be more balanced reporting, and would be the equivalent to ‘seek advice from your doctor’.

Confusion about (or wilful muddling of) the distinction between herbal medicine and other complementary and alternative medicine (CAM) modalities also occurs, and can be used to ridicule herbal medicine as part of CAM. This is due to ideological beliefs that in order to further ‘rational science’, an opinion should be held that all past forms of medicine are based on flawed scientific thinking and must therefore be eradicated.

Complementary medicine is a misleading umbrella term for this cluster of unconnected theories and methods.

Osteopathy, chiropractic, acupuncture, herbal medicine, nutritional therapy, hypnotherapy? Their most obvious shared feature is their being absent from the medical curriculum.

—Professor David Peters

There are many conventional clinicians who find they have effectiveness gaps in terms of the treatment they can offer their patients in a real-life setting, and interest in complementary approaches and integrated medicine is growing among this sector.

There is inconsistency in terms of implementation of herbal medicine by governments, and dissemination of correct information to doctors about herbal medicine. Despite a Cochrane review demonstrating that St John's wort (Hypericum perforatum L.) was equivalent in efficacy to selective serotonin reuptake inhibitors (SSRI antidepressant drugs) in the UK, health claims for herbal medicines can only be based on ‘traditional use’, and so the efficacy data for St John's wort cannot be used as advice for doctors. It could be argued that this set up keeps herbal medicine in a ‘traditional use’ straight-jacket.²⁴

A large amount of pharmacological evidence for herbal medicine and its compounds exists, as does some clinical evidence. Although plants contain multiple compounds, and traditional use often mixes multiple plants, pharmacological evidence will often support traditional use. An example of this would be the growing body of research confirming improved bioavailability of phytochemicals resulting from the use of complex plant mixtures (a form of synergy in whole plant medicines).²⁵

Research data on herbal medicines can be found in journals such as:

The Journal of Herbal Medicine (Elsevier)

Phytotherapy Research

Planta Medica

Journal of Ethnopharmacology

Fitoterapia

Phytomedicine

Online searches via Pubmed/Medline and Google Scholar may also prove fruitful.

Herbal safety

Some examination of what we mean by safety, what we mean by adverse events and the case to answer is needed. Clarification of what is meant by placebo, and in terms of herbal safety what is meant by nocebo, is also required.

The common refrain ‘just because it is natural doesn't mean it is safe’ is often applied to herbal medicine. To some extent this is true. Plant identification by those wishing to harvest a herbal medicine from the wild has, and can, result in potentially dangerous misidentification. Unscrupulous companies marketing herbal products have and can sell defective, adulterated and occasionally poisonous ‘herbal’ products. Issues of quality have been and continue to be a very real problem, which means it can be difficult for those wishing to self-medicate for minor ailments with herbal medicine to do so effectively. Each European country has its own rules about quality, but companies based outside of the EU may have little or no regulation or pharmaco-vigilance.

In the UK, herbal products provided to practitioners of Western herbal medicine have the highest standard of good management practice ensuring the quality of the end product. A licensing scheme for over-the-counter products exists for herbal products in the UK not provided via a practitioner and these products clearly state they are licensed and contain a public information leaflet.

Once again reporting of herbal safety is not conducted using the same criteria applied to conventional medicine. Many adverse herbal medicine events occur as the result of excessive ingestion of a plant.

Definition—Adverse reaction: A response to a drug that is noxious and unintended and which occurs at normal doses for human use.

Even in the instance of such a plant being medicinal, most reported adverse reactions have occurred when significant overdoses were taken.

That does not mean that all herbs are safe, and herbalists are, and should be, hyper-vigilant. Medical herbalists have a yellow-card reporting scheme for herbal medicines, as exists for conventional medicines. We should always work from the assumption that any herbal remedy consumed is done so respectfully, and for a targeted purpose—to relieve suffering, to promote healing and wellbeing, and with an aim to restore resilience and function.

Particular care should be taken when people are taking conventional medicine, and/or mixing herbal medicines or taking herbs with vitamins and mineral supplements.

Medical herbalists are trained in pharmacology and are the experts in using plant medicines in a modern context of conventional drugs and over-the-counter remedies.

It has become increasingly clear that the UK government and the MHRA (Medicines and Healthcare Regulatory Agency) do not have any great concerns about safety with regard to the practice of herbal medicine by registered practitioners. Statutory regulation for herbal practitioners in the UK has been rejected several times, and lack of public risk is repeatedly given as a key reason for this.

Things to consider with regard to herbal safety:

a)Be aware of rare but known adverse reactions to some herbs (e.g., Actaea racemosa L. has been known to cause self-limiting but unwanted headaches in rare cases.)

b)Remain alert to issues of safety and observe any signs for potential harm to liver, kidney, heart or other body systems.

c)There are rare but occasional risks of phototoxicity or allergy with any substance.

d)Be mindful of vulnerable sectors of the population.

e)Be mindful of the small number of conventional medicines which are genuinely vulnerable to herb/drug interactions (this includes drugs that operate within a narrow therapeutic dose such as anticoagulants or immune-suppressant drugs).²⁵

Actaea racemosa (L.) was previously, and more commonly, known as Cimicifuga racemosa, or black cohosh. Concerns have been raised about this herb in connection with serious liver damage. Research into this issue has not, to date, been able to prove conclusively that the small number of cases of liver damage recorded are definitely attributable to Aceta racemosa (L.) and were in fact products made with a non-medicinal plant wrongly identified as Actea racemosa.

Another implication of herbal safety has arisen from plants that contain unsaturated pyrrolizidine alkaloids (PA's) such as comfrey (Symphytum officinale L.), coltsfoot (Tussilago farfara L.) and borage (Borago officinalis L.). Use of these herbs has been restricted or banned in some countries, despite concern that the animal and human case-study data used to inform and legislate may have been flawed. There are numerous PA's found in plants, they undergo complex metabolic change via liver pathways, and range from dangerous unsaturated PA's to the least toxic forms. Small amounts of the most toxic can be found in coltsfoot, large amounts of the least toxic in comfrey, while borage, (eaten widely as a vegetable in Europe) appears relatively benign all round. A person's liver health, drug and alcohol use, and nutritional deficiencies (such as antioxidants) that can impact on liver metabolism are therefore all essential factors in the safe use of these traditionally used herbs. PA's are not absorbed through the skin, so external use is safe. Internal use of these herbs should be avoided in pregnancy, as this is one situation where evidence of rare harm has been found.

Systematic reviews and multifaced case analysis studies were com-missioned by the National Institute of Medical Herbalists in 2016. The findings are now published and show that although establishing directly causality of poisoning by PAs, could not be established, adverse events arising from ingestion of these plants is a rare harm, and that a patient-specific risk: benefit analysis should always be conducted before these plants are prescribed.²⁶

By far the most common feature of herbal medicine adverse reactions we have observed in our practice setting is when a patient reports a (self-limiting) change to bowel movements early on in the treatment. Sometimes there can be temporarily increased diuresis, or other idiosyncratic reactions related to normal healing responses. Sometimes patients will report an increase in coughing, and expulsion of mucous from the nose when being treated for a cold for example. Mucous is produced by the body to both protect the membranes of the body and also as a vehicle to eliminate pathogens or the results of successful infection reactions. Producing more mucous more easily is exactly what the body needs to do to clear the respiratory tract of debris so that healing can occur. Here is a real case history showing the sort of thing that can happen.

Case history

Background

A 38-year-old woman presents with depression, recurrent colds and rhinitis following several miscarriages in the last 18 months. She is exhausted, and feels cold and miserable. She has a regular menstrual cycle but experiences heavy, painful periods. She eats a varied diet but is slightly overweight for her height. She has difficulty sleeping through the night, waking frequently, and feels anxious with occasional palpitations. She is pale, her tongue is pale, and she has a full ‘jumpy’ pulse despite a ‘normal’ blood pressure of 120/80 mmHg.

Herbal intervention

Herbal medicines included chamomile flowers (Matricaria chamomilla L.), ginger root (Zingiber officinale Roscoe), nettle leaf (Urtica dioica L.), yarrow herb (Achillea millefolium L.), echinacea root (Echinacea purpurea (L.) Moench) and raspberry leaf (Rubus ideaeus L.). She also had a night-time herbal medicine containing passionflower herb (Passiflora incarnata L.) and motherwort (Leonurus cardiaca L.). She was happy to include other herbal teas, especially chamomile and fennel, cinnamon and ginger, and oat flower and lemon balm.

Dietary advice

She was advised to try to avoid bread in her diet (she tended to eat bread for breakfast and lunch), and to try to find a non-wheat alternative. This was partly to create more variety in her diet. A multi-grain, seed, nut and fruit muesli with live plain yoghurt was suggested for breakfast, and a buckwheat and lentil tabbouleh with handfuls of green herbs (parsley, mint, coriander) with a tahini sauce was suggested as a possible lunch.

What happened next

The patient telephoned within a week of starting the herbal medicine feeling she was experiencing palpitations. On questioning, she was experiencing them mornings and evenings when going to bed and waking from sleep. She had reported palpitations at her first visit, and was reminded of this. She agreed that she had been anxious about allowing herself to sleep more, when she was already very tired during the day. The herbalist encouraged her to embrace the sleep, and allow her body to rest and re-charge.

The review consultation

The patient returned for a follow-up consultation 3 weeks later, reporting she was sleeping very well. So well, in fact, that the herbal medicine was now making her feel ‘drowsy’. She had begun to make changes to her diet, and was enjoying the new foods. The rhinitis was gone. She had had another menstrual period, this time heavy but much less painful than usual. She was encouraged to continue with the daytime and night-time herbs for another month/cycle.

Another review

Within that time her sleep continued to be good, the drowsiness gradually disappeared and her next menstrual cycle was moderately heavy with no pain. The palpitations had gone, except for some on the day of her period (a disappointment for this lady who wanted desperately to conceive). Her pulse was strong but less ‘jumpy’, and her tongue was more pink rather than pale. She felt less ‘depressed’ although she continued to suffer from a propensity to low mood. She went on to have two full-term pregnancies.

It can be seen from this complex but typical case history, that it is difficult to put all of the presenting symptoms into a single conventional diagnosis, or to conclude that improvements were down to any single intervention introduced by the herbalist, whether dietary or herbal. This case does illustrate the ideas of the perceived importance by the herbalist of restoring sleep, in this case by using herbal medicine (passionflower and motherwort), of improving circulation (yarrow and ginger), and the concept of ‘tonics’ (nettle, oat flowers, raspberry leaf). The extra nutrition achieved through dietary change and through the nourishing herbs can be delivered by the improved circulation, and improved digestive function. The tongue and pulse can be monitored and give extra information to what the patient reports in terms of symptoms. The patient reported mild ‘adverse effects’ (possibly nocebo effects), early in treatment, but was persuaded to continue, and the symptoms disappeared.

Placebo and nocebo

The placebo effect

Be enthusiastic. Remember the placebo effect—30% of medicine is showbiz.

—Ronald Spark

It is very likely that over the years you will find people who claim that all complementary medicine, including herbal medicine, works mainly by the placebo effect. Well, before we dismiss that, let's take a closer look at just what the placebo effect is.

The word placebo is derived from the Latin for ‘I shall please’. If you were living in medieval England a placebo would be someone who tells you what you want to hear, rather than telling you the truth: a sycophant.

Moving forward into the 1800s, a dictionary from 1811 defined placebo as a medicine designed more to please than benefit the patient. In the 20th century, placebos were thought of as a medicine that the doctor thought was beneficial, but which turned out to be ineffective or inert.

Of course doctors have (and still do in some parts of the world) given placebo medicines deliberately, and their beneficial effects have been documented in many cultures. So currently we view the placebo effect as a positive response to an inert medication.

If there can be positive responses to inert medications, there can also be negative ones. When a patient responds negatively to a medicine that subsequently turns out to be inert, this is termed a nocebo response.

Modern-day medicine has had the placebo effect on its radar for quite a few years now, as it is regarded as an irritating and confounding effect in drug trials of new pharmaceutical medicines that needs to be screened out as far as possible.

You are a placebo responder. Your body plays tricks on your mind. You cannot be trusted.

—Ben Goldacre

A lot of research has gone into trying to identify ‘placebo responders’ so that they can be excluded from clinical trials. This has turned out to be impossible, however. In the real world the meanings we ascribe to all sorts of things can play into healing and our responses to medicines. The term ‘placebo effect’ is quite correct when we are dealing with clinical drug trials, but in the real world what we are really talking about is meaning responses.

The anthropologist Daniel Moerman has studied this area for many years. In his book Meaning, Medicine and the Placebo Effect, Moerman states that:

A human being is simultaneously a cultural and a biological creature…what we think, say and know about the world can have a dramatic influence on our biology, as culture and biology overlap in powerful and important ways.

—Daniel Moermann²⁷

In our Western culture, the practice of medicine is very firmly rooted in a specific ‘cause and effect’ paradigm. We also operate in what may be described as a reductionist way of thinking.

Definition—Reductionist: The practice of analysing and describing a complex phenomenon in terms of its simple or fundamental constituents, especially when this is said to provide a sufficient explanation.

—Oxford English Dictionary

Breaking things down into their simplest parts so that we can understand them is at the root of Western medicine (think about the study of things like anatomy, microbiology, endocrinology etc). This has brought a fantastic understanding of human physiology on many levels, but is not very good at seeing the big picture, the phenomenon. Also, what about the things we cannot see?

Moerman lists three ways in which the human body responds to injury:

•Autonomous responses: Known biological mechanisms mobilized by the body for healing to take place (i.e. clot formation, white blood cell recruitment etc.).

•Specific responses: Interactions with medications (i.e. anti-inflammatories etc.)

•Meaning responses: Interactions within the context in which the healing takes place (i.e., blue pills are calming; the use of medical instruments and machines is viewed as very powerful). We ascribe certain meanings to the world around us and respond accordingly. Our world is full of meaning to us, some of it we are consciously aware of, and some of it is so ingrained that we are not aware of it.

Meaning responses are not just confined to medicines. Many other factors play significant roles in our response to healing. Consider the patient/therapist consultation. In consultation a) the doctor/therapist is very enthusiastic about the medicine she is prescribing. She has lis-tened carefully to all of the patients’ concerns, offered explanations and advice where necessary and is very confident that the medicine she is prescribing will be helpful.

In consultation b) the doctor/therapist is apathetic in attitude, spends half her time typing on a computer, does not give any information about the medicine itself or how it will benefit the patient and does not appear to be actively listening to the patient. Both doctors/therapists prescribe the same medicine at the same dosage. Which one do you think will be more successful? Why? The patients’ faith in the practitioner and the practitioners’ faith in their remedies can be crucial to outcomes. Meaning responses are not confined to inert medicines: active medicines are also affected by them.

The act of diagnosing a condition is an intervention of a kind and can be filled with meaning. When a diagnosis (and prognosis) is good, it is most likely that things will improve. How does this compare with the psychological significances of a charm? If the diagnosis (and prognosis) is bad, things are more likely to deteriorate. How does this compare with the psychological significances of a curse? Where does ‘self-fulfilling prophecy’ come into all this? There are hard facts and there are also meaning responses. Untangling them may be harder than we think.

One thing that we can take from all this is that things that please us psychologically have a knock-on effect on our physiological responses. Conversely, things that worry or displease us can do the opposite. This is an excellent example of the mind-body connection.

It is important for us to acknowledge that there is no form of treatment (up to and including surgery) that is not affected by a meaning response. Therefore to claim that the placebo effect is the only reason that some interventions work is to show a lack of understanding of how ubiquitous meaning responses are. The advent of the clinical drug trial has put a negative spin on what is a positive and very powerful influence on therapeutic outcomes. Meaning responses are a natural corollary of being human and interacting with the world around us according to the facts as we see them.

Biology and culture interact. To turn ones eye away from such powerful human interactions is not only short sighted and foolish, but utterly unethical.

—Daniel Moermann²⁷

The nocebo effect

Although it was popularly accepted that approximately 30% of all patients treated would get better even with a ‘dummy’ treatment (intervention), it has now been shown that placebo benefits can occur in any proportion of a treatment group from almost none, to almost all, depending on the condition and circumstances.

It is not surprising therefore that such potency can also generate the opposite of a placebo—the adverse reaction, (even when a dummy pill has been given)—known as the nocebo phenomenon.

Most extraordinary of all is that adverse-placebo (nocebo) has been demonstrated in measurable physiological signs (altered blood test results) from the patients, not just reported symptoms!

In 1999 the liver enzyme alanine transaminase (ALT) was measured in a study monitoring 93 healthy volunteers all of whom were given a placebo (dummy) medicine over 14 days. During this time approximately 20% of them developed elevated ALT levels.

ALT is commonly used as a marker for liver damage, so this would have raised considerable concern if a real drug or herb was being tested.²⁸

The power of adverse suggestibility occurs when the patient expects adverse events, or when patients learn from previous experiences to expect adverse events. Anxiety, among other conditions, increases the likelihood of nocebo response. So under certain conditions patients are more likely to report, and sometimes more likely to actually experience, adverse reactions.

In our own practices, patients have self-selected themselves and probably thought long and hard about whether to invest their time, trust and money in seeing a medical herbalist instead of their doctor. In that scenario, we have found that people are prepared to ‘put up’ with some transient discomfort to achieve their aims. They may not have instant results and may have to spend more money with us ‘in faith’ that given time, improvements will be seen. They also may notice discomforts ranging from the nasty taste of the ‘unfamiliar’ medicine, mild indigestion sensations on using it, or even the occasional transient ‘healing crisis’ where symptoms may appear that show that the body is responding to treatment and mobilising the immune response. For example a cough may become more productive before clearing altogether.

But patients who have self-selected themselves for complementary medicine have probably already committed themselves and have a more positive and benevolent attitude to this unconventional treatment. This is a regular criticism we receive from doctors when we give presentations on herbal medicine—self-selection is thought to induce a more powerful placebo response. Conversely however anxiety about the possible dangers of stepping outside of the doctor's advice may elicit a nocebo response.

A mini case history

A patient seen for a first follow-up consultation was delighted at the significant improvements to their mood (they had presented with depression), improvements to energy levels, headaches and digestive symptoms but also wanted to report that they had experienced an adverse event. They reported that they had been repeatedly woken from their sleep at around 3am since using the herbal prescription, but they were prepared to continue the herbs because so many other symptoms had been relieved.

However, recorded in the notes from their first visit, one of their original symptoms was waking at 3am on a regular basis. The patient was amazed, and admitted they had forgotten that this symptom had been present before starting treatment. They also admitted that they could not conceive of a drug (even a herbal one) having no side effects—if it works, there must be adverse events—by definition.

Quick checklist for clinicians advising patients about the use of herbal medicine

These groups of people should seek the advice of a qualified medical herbalist rather than buy over-the-counter herbal medicines.

•Patients who are at higher risk of herb–drug interaction or idiosyncratic drug reactions.

•Patients using drugs that are within a high-risk therapeutic area.

•Patients who are self-medicating with herbal medicines without success.

•Patients who are using herbal medicines long term rather than for short-term or minor ailments.

•Patients who may be pregnant or be medically compromised through frailty, age or health.

The future

This introductory chapter places herbal medicine as practised in the UK within its own unique historical context. The ecological viewpoint of the modern herbalist is a unique lens through which to apply herbs therapeutically. Although the development of modern phytotherapy has run parallel with that of conventional biomedicine, it remains unique and different to it. The core principles of person-centred, individualised symptomatology and recognition of the complexity and synergy of plants as medicines make the herbalist also unique.

It has potentially made it all the more challenging in conveying to the public, the media, other health care professionals and researchers, what herbal medicine is. It places herbal medicines outside the normal scope for gold-standard research as is currently practised, and also makes it difficult therefore for governments and institutions to legislate for herbal medicine alongside conventional funded care. Nevertheless evidence in the areas of efficacy, quality and safety has matured, and progress continues.

time has allowed an evolution from a traditional medicine for coping with life-threatening illnesses, before ambulances, powerful modern synthetic medicines and hospitals, to one that can live alongside these services and meet their shortfalls.

—Simon Mills

We hope that you have enjoyed this brief introduction to what is a very complex and absorbing subject area. We have attempted to address some of the more poorly understood ‘thorny’ issues surrounding the practice of Western herbal medicine. In the following chapters we will look more closely at ‘how herbalists think’, and give you examples of how this thinking bears fruit.

Useful websites

https://www.henriettes-herb.com/

www.healthyhildegarde.com

https://pfaf.org

Greive, M. 1st edition, 1931. A Modern Herbal. Also available, in part, online: http://www.botanical.com/botanical/mgmh/mgmh.html

Professional organisations of medical herbalists:

The National Institute of Medical Herbalists

(est. 1864) www.nimh.org.uk Other UK based herbal professions are listed at: www.herbalist.org.uk

Where to train in the UK to be a medical herbalist:

Find out up to date information at:

https://www.nimh.org.uk/becoming-a-herbalist

Heartwood

heartwood-uk.net

Lincoln College, UK

https://www.lincolncollege.ac.uk/courses/bsc-hons-clinical-herbalism/

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