Herbal approaches to system dysfunctions 207

SCOPE

Apart from their use to provide non-specific support for recuperation and repair, specific phytotherapeutic strategies include the following.

Treatment of:

inflammatory catarrhal conditions of the upper respiratory mucosa (e.g. common colds, rhinitis, sinusitis, otitis media); acute bronchial and tracheal infections; allergic rhinitis; nervous coughing patterns.

Management of:

chronic obstructive pulmonary diseases (e.g. chronic bronchitis, bronchiectasis, emphysema, silicosis); asthma; chronic tracheitis; coughing due to persistent local irritation.

Because of its use of secondary plant products, partic- ular caution is necessary in applying phytotherapy in cases of known allergic reactions to specific medicinal plant products.

RATIONALE AND ORIENTATION

To the Chinese the lungs were the internal organs most in contact with the exterior. So as well as ascribing to them the source of the body's rhythm and the site of the catalysis of vital energies, they were seen to be :he organs in charge of defences. In earlier times the role of the respiratory system was obvious; the first cry was generally taken to be the first sign of life, the bronchial gasp on the deathbed the last, and every- where like a never-ending nightmare was the hacking bloody cough of consumption or tuberculosis, the dis- ease that once cast its baleful influence over the popu- lar imagination like cancer and AIDS now do, the constant reminder of how fatal debility followed weakening of the lungs. It was obvious that the lungs, even more than the stomach, were prey to contagion, the expressive medieval precursor to viruses and bac- teria. It was also obvious that the key to resistance lay not in attacking the alien invaders but in strengthening innate resources. Traditional strategies for treating respiratory disease were notably founded on support- ive and tonifying remedies. Given that the modern virus remains as elusive as it ever was, an emphasis on supporting defences may seem appropriate again.

Tlic~e are very few modern endorsements of early tre,~t~ncnt strategies. Modern medical science, which at first embraced such agents in the earlier part of this century, now sees no role for their use. For example, modern editions of Mnrtiizdnlc's Extrn Plrnrnzncoyoeiu claim that: 'There is little evidence to show that expec- torants are effecti1.e'. Some modern drugs may have expectorant activity, such as bromhexine, but they are usually referred to as 'rnucolytic'. The impact of traditional remedies on the respiratory system is rela- tively poorly researched. Reliable external measures of change in mucosal functions are elusive; many respira- tory diseases are either self-limiting or are among some of the most persistent conditions in the clinic. Even in asthma, where peak flow rates provide a sim- ple measure of benefit, the complexity of the condition and the usual presence of confounding and vioient influences makes easy characterization of the condi- tion and the measuremelit of all but the most powerful across-the-board remedies unreliable.

A sense that traditional approaches should be rele- gated to history is possibly reinforced in the medical psyche by the knowledge that one of the most dra- matic advances of modern drugs was in controlling at last the old scourge of tuberculosis. However, this dismissal is not as conclusive as once thought. Tuberculosis is making a serious comeback on the world stage, attacking first the very impoverished and malnourished as it always did. As modern drugs struggle with this new manifestatjon, there may once again be value in looking at the lessons from the past, that treatment should be based on supportive remedies in a regime of convalescence. With the luxury of choice, with the option of taking modern drugs where these are necessary but also being able to select more sup- portive strategies at other times, there is real value in reviewing the treatments forged out of desperate but not always unsuccessful battles with disease in earlier times. These lessons are fortunately quite well learnt. ,.

The dominant feature of respiratory conditions is how readily changes in their behaviour are appreci- ated subjectively. The often immediate effects of eating and drinking different foods and drinks, of tempera- ture and humidity changes and of the various treat- ments used through history have been the main guide in determining therapeutic strategy. From such experi- ence has come the 1-iew of the respiratory mucosa and musculature as being particularly sensitive to reflex responses, notably from the upper digestive tract, from the pharynx to the stomach. There is a persistent tradition in many cultures that respiratory problems

:ims ~ractj61 clinical guider

are extensions of digestive dysfunctions. Embryology supports such links, with the bronchial tree starting as a diverticulum of the pharyngeal zone of the alimentary duct and sharing common vagal innerva- tion, and recent associations between asthma and H, receptors in the stomach' add further support to such connections.

PHYTOTHERAPEUTICS

Part of the problem with expectorants probably arises from confusion over their definition. Another aspect of the dismissal of expectorants stems from the difficulties involved with measuring their efficacy.

The four definitions of expectorants given below highlight the difficulties. The dictionary meaning is only concerned with the actual oral production of phlegm or sputum. Since the majority of mucus pro- duced from the lungs is swallowed, this definition is clearly unsatisfactory. Definitions from the pharmacol- ogists Boyd and Lewis are more useful but probably the best definition comes from Brunton, a 19th century pharmacologist.

If expectorants can render this catarrh more fluid and/or assist in its expulsion, then a clinical benefit should be achieved.

Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways (such as tenacious abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the tra- chea and larger airways. The sensitivity progressively decreases in the finer ainvays and in the very fine air- ways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex, whereas for tra- cheitis the stimulus is strong.) By clearing abnormal mucus or by changing its character and making it more demulcent, expectorants can allay cough and are therefore antitussive.

From the incomplete scientific case and lack of a consensus orthodox view, it is clear that in the respira- tory system the traditional therapeutic case dominates. In many instances however, the traditional case is strong and consistent across cultures and aeons. It includes mechanisms that are rational and which are usually immediately apparent. The following are cate- gories of herbal remedies acting on the respiratory tract.

Definitions of expectorants Topical agents

Oxford Dictionary - 'Promoting the ejection of phlegm by coughing or spitting.'

Boyd (1954) - 'An expectorant may be pharmaco- logically defined as a substance which increases the output of demulcent respiratory tract fluid.'

Lewis (1960) - 'Expectorants increase the secretions of the respiratory tract and so reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the presence of increased quantities of fluid mucus, expectorants produce a "productive cough" which is less exhausting and less painful to the patient.'

Brunton (1885) - 'Remedies which facilitate the removal of secretions from the air passages. The secre- tion may be rendered more easy of renioval by an alteration in its character or by increased activity of the expulsive mechanism.' Brunton's functional definition best explains the various ways in which medicinal plants can act as expectorants.

Why expectorants?

Throat applications

The surfaces at the back of the mouth and pharynx are the first point of contact for ingested or inhaled pathogens and irritants; the dense masses of lymph- atic tissue in the region confirm their important role in defence. The use of gargles, lozenges and cough drops to mobilize local defences can be an effective way to encourage the body's response to a wide range of respiratory infections. LII the case of sore throats, demulcent remedies, e.g. licorice and marshmallow,2 and astringents such as Rubus (blackberry leaf) and Hamamelis (witchhazel) could at least reduce irritation and there are a range of remedies with more substan- tial reputations as topical antiinflammatories. These can be used as levers to improve resistance and recov- ery in rhinitis, sinusitis and otitis as well as treating more local inflammations. Rather than attempting local antisepsis, remedies such as tinctures of Calendula and myrrh, sage and thyme, balm of Gilead, propolis and Tolu balsam appear to mobilize activity in the surrounding lymphatic tissues, through the mildly provocative effect of their resins and essential oils.

Many respiratory conditions are characterized by Inhalations abnormal mucus (catarrh) which can narrow airways. This abnormal mucus may be thick and tenacious and The obvious topical applications for the respiratory hence very difficult to clear from the airways. mucosa, traditional approaches included smoking

Herbal approaches to system dysfunction

(Datura for asthma, for example, a high-risk treatment not recommended today), inhaling steam from herbal infusions to relieve congestion and simple humidifica- tion. When the technology for extracting essential oils was developed medical inhalations were frequent applications. Most apparent activity is found with the oils from mints (especially menthol), Eucalyptas, cam- phor, the Melaleuca family (tea tree - M. alt~~rll~folia, cajaput - M. lellcadendron, niaouli - M. viridiflorn) and the pine family (turpentine - Pinus palustl.is, P. syluestris, P.-excelsa) and these were widely used for symptomatic relief of respiratory congestion, although in the case of menthol there are doubts as to the real benefits.3 It is possible that some volatile principles could exert antiinflammatory effects (steam inhaled from chamomile flower infusions in some allergic rhinitis and pine oils in bronchitis, for example). Small doses of volatile oils may have a complex combination of activities, either reducing or stimulating ciliary activity%r mucosal secretions.5

Stimulating (reflex) expectorants

These are remedies that provoke increased mucociliary activity by reflex stimulation of the upper digestive wall. The classic examples were originally used as emetics. It was noted that this drastic action was accompanied by a noticeable expectoration. In fact, tra- ditional practitioners in Britain used emesis as a tec11- nique to clear the lungs in chronic bronchitis until quite recent times. Application of these remedies in subemetic doses was thus a consistent feature in all major herbal traditions. Herbs like ipecacuanha, squills and Lobelia have been standards in Western medicine. There is some limited modem investigation of mecha- nisms involved. For example, ipecac-induced emesis is thought to be mediated through both peripheral and central 5-HT, receptors.6 Other plants have been used as stimulating expectorants although not used as emet- ics; members of the Primula, Bellis, Saponaria and Polygala genuses are often included in this category in Western traditions. High saponin levels seem to be a common feature of this group.

chilli peppers were used for this purpose, although generally taken to be too drying in most cases. The effect of the pungent spices probably includes increased blood flow to the respiratory mucosa, a reflex irritation of the upper digestive mucosa (as with the stimulating expectorants) and, especially in the sul- phur-containing garlic and mustard family, a decrease in the thickness of mucus by altering the structure of its mucopolysaccharide constituents; the sensation usual- ly is of a clearing of catarrh and the shifting of conges- tion up from the lungs.' A simple infusion of fresh ginger and cin~~amon remains one of the most effective home treatments for the common cold.

Respiratory demulcents

These herbs contain mucilage and have a soothing and antiinflammatory action on the lower respiratory tract. Although the mechanism is not clear, an opposite effect to that of the stimulating expectorants has been postulated; i.e. the effect is a reflex one from the demulcent effect of the pharynx and upper digestive tract, again involving common embryonic origins and vagal innervation.

The major respiratory demulcent herbs are Althaea officinalis (marshmallow root or leaves) and other members of the Malvaceae (mallows), Ulmus spp (slip- pery elm), members of the Plantago genus, Cetraria islandica (Iceland moss) and Chondrus crispus (Irish moss). Tussilago (coltsfoot) and Symphytum (com- frey) were very widely popular before concerns about pyrrolizidine alkaloids constrained their sales.

Pronounced antitussive activity has been demon- strated experimentally with oral doses of 1000 mg/kg body weight of extract of Althaea officinalis (marshmal- low), with comparable effects at 50 mg/kg of the iso- lated polysaccharides.8 These animal studies might suggest enormous doses necessary for clinical effect but if, as implied, the effect is a mechanical one, then it is likely that only marginal increases in dose would be necessary to have similar impact in larger animals like humans.

Respiratory demulcents were popular for children's cough and generally for dry, irritable and ticklish coughing. They were seen as intrinsically contraindi-

Warming expectorants and mucolytics cated in wet, damp chest problems, although they can - -

sometimes be quite well suited to these if-thereis an Many of the spices were highly prized in the cold damp

irritable element. climates of northern Europe for their apparent ability to counteract associated chest problems. In particular, gin- ger had an almost mythical reputation; where this or

Respiratory spasm~lytics

imported cinnamon, aniseed, fennel and cloves were Respiratory spasmolytics relax the bronchioles of the not available, Europeans resorted to garlic, mustard lungs. Traditionally they included the Solanaceous and horseradish for the same ends. Even cayenne or plants (the nightshade family) with powerful atropine-

Practical clinical gu id~s

related antiparasympathetic constituents: Iiatura, Atropa and Solanum were the prominent antiasth- matics of early history. As could now be explained pharmacologically, these remedies tended also to dry up the mucosa and had other less desirable effects so less powerful remedies were also popular. Epkedrn sini- ca (ma huang) from Asia was popular when it reached

ptic action. Europe and works through a sympathomim, Other gentle remedies include culinary herbs like hys- sop and especially thyme,' horehoultd and the North American gumplant, Griizdelia comporurn.

Anticatarrhals

There are a range of popular herbal treatments for a range of respiratory mucosal conditions whose action still remains mysterious. indications for their use range f ~ q m catarrhal congestion to some types of mucosal hypersensitivity such as hayfever and allergic rhinitis.

Antitussives

Antitussives are remedies that allay coughing. Some may work through soothing irritability (respiratory demulcents); others are claimed to relieve coughs at source, by removing congestive mucus or other mobile provocations (expectorants).

However, the term 'antitussive' is often used specifically to refer to remedies that depress the cough reflex and in particular, in herbal terms, to those with appreciable levels of cyanogenic glycosides. The notable example in Western tradition is Prunlis serotina (wild cherry). Another tradition was to use opiates and the gentle version of that strategy, Lactuca (wild lettuce), is still applied to the problem in some tradi- tions. Such cough suppressants are not ideal treat- ments and could even be counterproductive if they reduce cleansing of the lungs. However, there are many cases where they provide helpful relief and they may be the only solution for coughing not due to mobilizable irritants (e.g. nervous cough on the one hand, tumours on the other).

Antiallergic herbs

The principal antiallergic herbs for respiratory tract allergies are Ephedra, Albizzia and Sc~rfellarin bnicalen- sis (Baical skullcap). Urtica (nettles) is another herb with antiallergic properties which can sometimes be useful, especially for allergic rhinitis.

Multipurpose remedies

contain several active components or a group of active components are acting in several different ways. For example, Verbascum (mullein) contains saponins which are expectorant, mucilage which is demulcent and iridoids which are anticatarrhal. Lobelia, although an emetic and stimulating expectorant, was used as primarily a relaxant remedy in 19th century North America; it thus has a broad-spectrunl of effects on the respiratory system. Probably the broadest acting remedy in common use, however, is Glycyrrhiza (licorice) which combines a saponin stimulant effect, a s~othing effect and appreciable antiinflammatory properties.

STIMULATING EXPECTORANTS

Plant remedies traditionally used as stimulating (reflex) expectorants

Cephaelis (ipecacuanha), Lobelia inflatn (lobelia), Urginea (squills), Primllln ueris (cowslip), Bellis (daisy), Saponaria (soapwort), Polygnln senega (snakeroot), Glyryrrhiza (licorice).

Indications for stimulating expectorants

Cough linked to bronchial congestion Bronchitis, emphysema

Other traditional indications for stimulating expectorants

In some cases as emetics in higher doses (x10 expectorant dose)

Contraindications for stimulating expectorants

Although there is no firm evidence of unsuitability, as gastric irritants they can transiently upset some individ- uals (immediately relieved by withdrawing or chang- ing the remedy). In addition, the use of stimulating expectorants should be kept under review in cases of:

dry and irritable conditions of the lungs; asthma; young children; dyspeptic conditions.

Application

Stimulating expectorants are best taken in hot infusions or as tinctures or fluid extracts, before food.

As can be seen from the above, some herbs may fall Long-term therapy with stimulating expectorants is into several categories. This is either because they appropriate in the management of chronic bronchial

Herbal approaches to system dysfunctio

conditions as long as digestive functions are not RESPIRATORY DEMULCENTS affected.

Advanced phytotherapeutics

Plant remedies traditionally used as respiratory demulcents

Stimulating expectorants may also be usefully Althaea (marshmallow), Tussilago (coltsfoot), applied in some cases (depending on other factors) of Plantago SPP (rlbwort and plantain), V~bascum rheumatic ar.d connective tissue diseases. (mullein, esp. leaf), Chondrus (Irish moss), Cetraria

(Iceland moss), Glycyrrhiza (licorice).

WARMING EXPECTORANTS (MUCOLYTICS) lndications for respiratory demulcents -.

Plant remedies traditionally used as warming Dry, non-productive, irritable cough

expsctorants Coughing in children

Pimyinella anisum (aniseed), Cinnamomuill zeylalzicum Asthmatic wheezing and tightness

(cinnamon), Foeniculum (fennel), Zingiber (ginger), Allium sativurn (garlic), Angelica archange!icn (angelica). Other traditional indications for respiratory

demulcents lndications for warming expectorants

As mucilaginous digestive remedies (see p.169) Productive cough associated with cold The effects of dryness on the respiratory system Bronchitis, emphysema Profuse catarrhal conditions Contraindications for respiratory demulcents

Other traditional indications for warming The use of respiratory demulcents may be contraindi- cated or inappropriate in profuse catarrhal or

expectorants congestive conditions of the mucosa. As aromatic digestives (see p.171) Congestive chronic infections and inflammatory Traditional therapeutic insights into the use conditions of respiratory demulcents

Contraindications for warming expectorants As with other respiratory remedies, there is a close association between effects here and on the digestive -

The use of warming expectorants may be contraindi- tract. Respiratory demulcents are at their most appro- cated or inappropriate in gastrooesophageal reflux. priate if there are parallel indications in the gut: dry

inflamed conditions like gastritis and oesophagitis Traditional therapeutic insights into the use associated with hyperacidity, dry constipation and its

of warming expectorants various associated problems. - There is a close association in traditional medicine between catarrhal congestion and the digestive/assim- ilative functions. The warming remedies were seen to act seamlessly across both respiratory and digestive functions treating disturbances in either or both to- gether. Symptoms most often found with catarrhal con- ditions might include abdominal distension, loss of appetite and loose stools.

Applications

Warming expectorants are best taken immediately before meals. They are particularly effective taken in hot aqueous infusions.

Long-term therapy with warming expectorants is usually acceptable.

Application

Respiratory demulcents are best taken before meals. They are particularly effective taken in cold aqueous infusions.

Long-term therapy with respiratory demulcents is usually well tolerated.

RESPIRATORY SPASMOLYTICS

Plant remedies traditionally used as respiratory spasmolytics

Ephedra (ma huang), Datura stramonium (jimson weed), Atroya belludoizizn (deadly nightshade), Solanum dulca- marn (bittersweet), Hyssopus (hyssop), Thymus vulgaris

tical clinical guides

(thyme), Lobelia inflata (lobelia), Marrubittrn vulgare (horehound), Grindelia camporurn (gumplai~t), Euphorbiu hirta (pill-bearing spurge), Coleus forskohlii, Glycyrrl~iza (licorice), lnula (elecampane).

lndications for respiratory spasmolytics

Tight, breathless, non-productive coughing Wheezing and other asthmatic symptoms

Other traditional indications for respiratory spasmolytics

Many of the gentler remedies were used as relaxants. The Solanaceous plants have potent neuroactive properties.

Contraindications for respiratory spasmolytics

The use of respiratory spasmolytics may be contraindicated or inappropriate in the following:

in the case of solanaceous plants: glaucoma, urinary retention, paralytic ileus, intestinal atony and obstruction in the case of ephedra: appetite disorders, glaucoma, prescription of MAOl-inhibitors

Application

Respiratory spasmolytics may be taken at any time of the day as required for immediate effect.

Long-term therapy with respiratory spasmolytics is acceptable in the case of the gentler examples but not for the solanaeous plants or Ephedra, and in all cases, there shoul'd be attention to treatment of underlying causes rather than relying on symptomatic relief.

ANTICATARRHALS

Plant remedies traditionally used as .

anticatarrhals

Euphrasia spp (eyebright), Plantago lanceolata (rib- wort), Sambucus nigra (elder), Nepeta hederacea (ground ivy), Solidago zlirgaurea (goldenrod), Verbascum thapsis (mullein flowers) and Hydrastis canadensis (goldenseal).

lndications for anticatarrhals

Catarrhal conditions, especially in the upper respiratory tract

Sinusitis, otitis media Allergic rhinitis and other hypersensitivity conditions

Contraindications for anticatarrhals

Anticatarrhals are generally regarded as gentle and safe.

Application

Anticatarrhals are best taken before meals. Long-term therapy with anticatarrhals is usually

well tolerated.

ANTITUSSIVES

Plant zemedies traditionally used as antitussives

Prunus serotina (wild cherry bark), Lactuca (wild lettuce).

lndications for antitussives

Non-productive, severe or persistent cough refractory to expectorants Nervous cough Cough due to external irritation or obstruction (e.g. tumour)

Contraindications for antitussives

Antitussives should be used only as needed and limited as soon as practical.

Application

Antitussives are best taken before meals. Long-term therapy with antitussives is not

advisable.

PHYTOTHERAPY FOR RESPIRATORY CONDITIONS

Allergic and non-allergic rhinitis

Rhinitis is an inflammation of the lining of the nose characterized by one or more of the following symp- toms: nasal congestion, nasal discharge, sneezing and itching. Acute infectious rhinitis (and sinusitis) is usually due to the common cold and the appropriate treatment is described later in this chapter. Chronic infectious rhinitis is treated using the same approach as described under chronic sinusitis. Allergic rhinitis is

Herbal approaches to system dysfunctions 213 --

triggered by inhaled allergei~s and may be perennial or seasonal (hayfever). Non-allergic or vasomotor rhinitis has no identified medical cause, although in naturopathic traditions it is understood as being caused or exacerbated by diet. Rhinitis may also be drug induced by overuse of nasal sprays containing decongestants.

In the herbal treatment of rhinitis, it is important to identify whether or not inhaled allergens are involved, since this determines the approach to treatment.

Treatment

The approach to the herbal treatment of rhinitis is to control symptoms and remove causes. Avoidance measures to reduce exposure to aeroallergens should be part of this treatment.

Dietary exclusions should be tried for both allergic and non-allergic rhinitis. Herbalists believe that diet can create a state of hypersensitivity and catarrh of the mucous membranes which predisposes to rhinitis. The dietary components which contribute to this process do not necessarily give a positive reaction on the RAST or skin prick test. They include dairy products, wheat, salt and refined carbohydrates. Excessive consumption of these should be avoided by sufferers of rhinitis and complete exclusion of one component, e.g. dairy, should be tried for at least 1 month.

Essential aspects of treatment are as follows.

Immune-enhancing herbs such as Echinacea. This is especially the case for allergic rhinitis.

~ n t i a l l e r ~ i c herbs, e.g. Albizzia, only in the case of allergic rhinitis.

Upper respiratory anticatarrhal herbs for both types of rhinitis, e.g. Euphrasia, Hydrastis and Plantago lanceolata.

When treating seasonal allergic rhinitis, treatment must be commenced 6 weeks before the season starts and continued through the season. Any helpful dietary exclusions should also follow this time pattern.

Stress can exacerbate rhinitis and should be treated if it is considered to be a factor with tonic herbs, nervine tonics, sedative herbs and adaptogens as appropriate (see p.231).

Treatment of rhinitis at a deeper level may involve the use of depuratives, e.g. Galium (cleavers), lymphatics, e.g. Phytolacca (poke root) and choleretics and hepatics.

Case history

A 30-year-old female patient with chronic persistent rhinitis. Symptoms wereworse in the morning with clear nasal discharge and irritated eyes. She was sensitive to house dust mite and had suffered tonsillitis, adenoids and otitis media as a child. She regularly took antihistamines. Treatment consisted of a dairy-free diet, protective measures against house dust mite and the following herbs.

Echinacea angustifolia 1 :2 30 ml Picrorrhiza kurroa 1 :2 5 ml Zingiber officinale 1 :2 5 rnl Euphrasia officinalis 1 :2 25 ml Scutellaria baicalensis 1:2 20 ml Albizzia lebbeck 1:2 15 ml

Tot al 100 ml

Dose 8 ml with water twice a day. Hydrastis 500 mg tablets, one tablet three times a day. After 3 months of herbs, her antihistamine use was greatly reduced and symptoms were very much improved.

Common cold and influenza

Viral infections of the respiratory tract can be minor self-limiting, frequent and recurrent or terminally dangerous. Their unpredictable course makes reliable treatment recommendations notoriously difficult. However, the often instant benefits following some remedies and the experience of improving resistance to frequent winter viral infections in some individuals does provide support for some of the recommendations below.

Treatment

The basic treatment approaches for the common cold and influenza are similar. However, in the case of more severe forms of influenza, treatment is more vigorous (e.g. higher or more repeated doses). Essential aspects of treatment are as follows.

Diaphoretics and heating remedies to manage and improve febrile responses. For the most direct agents, circulatory stimulants Zingiber (ginger, especially fresh grated) and cinnamon taken in hot water can dramatically improve mucosal symptoms and fend off the sensation of cold. For more gentle but sustained effects, especially in children, hot teas of Mentha piperita (peppermint), Euyntorium perfoliatum (bone- set), Nepeta cataria (catmint), Achillea (yarrow), Tilia (lime flowers) and Sambucus (elderflower) are well- established diaphoretic approaches which in the con- text of a cold can exert surprisingly different effects

-r*

?@$f&p Practical clinical guides '3 %

than when consumed at other times. Asclepias tuberosa (pleurisy root) is indicated if there are pulmonary or bronchial complications. Allium sativunz (garlic, taken raw) may also be useful as a general and warming defensive agent.

Immune-enhancing herbs such as Echinacea, Andrographis and Picrorrhiza to support the body's fight against the virus. Note that Astragalus and tonics such as Panax ginseng are contraindicated in the acute stage of infection.

Anticatarrhal herbs for upper respiratory catarrh, especially Euphrasia (eyebright), Sambucus (elder) and Hydrastis (golden seal). Traditionally, Hydrastis was said to be contraindicated in the acute stage of infection so its use may be best in the later stages of the secondary bacterial infection.

Hypericum (St John's wort) as an antiviral treatment for influenza.

Acute and chronic sinusitis

With sinusitis, the drainage of the sinuses is blocked, usually by congestion and mucosal oedema. This results in stasis which allows a bacterial infection to take hold. Pain is caused by either negative pressure (due to absorption of gases by the vasculature) or positive pressure of mucosal congestion.

Factors involved in the aetiology of chronic sinusitis include pollution, occupational dust expo- sure, tobacco smoke, adenoids, allergy (especially in children), rhinitis, cold and damp weather, dental problems, trauma and flying. A deviated nasal septum or other structural causes may be present. Herbalists also believe that dietary factors can cause excessive mucus discharge which may cause and sus- tain the disease. Particularly implicated are dairy prod- ucts, salt and wheat. Stasis and congestion may be aggravated if the patient has inadequate fluid intake.

Treatment

The treatment approaches for acute and chronic sinusitis are similar. For acute sinusitis the dose should be higher and given more frequently and treatment may need to be supplemented with diaphoretics, etc. as for acute rhinitis if fever is present.

Anticatarrhal (e.g. euphrasia) and decongestant (e.g. Ephedra) herbs to clear the stasis.

Musolytic herbs to clear the stasis such as Alliun~ safivlirn (garlic) and Armoracia (horseradish).

Particularly indicated is Hydrastis (golden seal) which has antimicrobial and anticatarrhal properties and is a mucous membrane trophorestorative. Regularly chewing a Hydrastis tablet can be very beneficial but they are exceedingly bitter.

A steam inhalation containing antimicrobial and antiinflammatory essential oils, e.g. tea tree, pine, aniseed oils, or chamomile flowers, may be useful.

Chronic sinusitis only

Chronic sinusitis may represent a vicarious elimination and this can be treated with depuratives, e.g. Galium (cleavers), and lymphatics, e.g. Phytolacca.

Exposure to the environmental factors listed above should be reduced and a dairy-free, low-salt diet should be tried for at least 3 months.

The sinuses are relatively inaccessible regions of the body and once a chronic infection has taken hold it can be difficult to eradicate. The following topical treatment can be beneficial.

Capsicum annuurn 1.3 20 ml Lobelia inflata 1 :8 20 ml Hydrastis canadensis 1 :3 20 ml Cornrniphora rnol-mol 1:5 20 ml Myrica cerifera 1:2 ' 20ml

Total 100 ml

Work over the affected sinuses for 10 minutes once to twice a day. Keep away from the eyes. Use a glove or wash hands after using. The Capsicum and Myrica act as decongestants, the myrrh is antiseptic and lobelia assists penetration. The properties of Hydrastis are given above. If Lobelia is unavailable, substitute with a saponin-containing herb such as Bupleurum or Aesculus (horsechestnut).

Acute and chronic sinusitis

Supporting the immune system in its fight against Patients with chronic sinusitis should avoid antihis- the bacteria with immune-enhancing herbs such as tamines and steroid-based decongestant drugs as Echinacea, Andrographis and Picrorrhiza. these will weaken immunity in the region further.

Herbal approaches to system dysfunctions 215

Case history

A male patient aged 36 presented with chronic sinusitis which fcllowed frcm a bout of the common cold. There was a history of allergic rhinitis with chronic use of antihistamines and nasal steroids. Antibiotics had failed to resolve the condition which had been present for 4 years. The patient had a high dairy intake and had been a cigarette smoker. Treatment consisted of the following.

Echinacea angustifolia 1 :2 40 ml Euphrasia officinalis 1 :2 30 ml Hydrastis canadensis 1 :3 25 ml Phytolacca decandra 1 :5 5 ml

Total 100 ml

Dose 5 ml with water three times daily In addition, allicin-releasing garlic tablets (5000 rng fresh weight equivalent) three per day and Picrorrhiza 500 mg tablets, two per day, were prescribed. The patient was placed on a dairy-free and low-salt diet and advised not to use antihistamines and steroid decongestant drugs. The above sinus rub was also prescribed. After a period of 6 months of treatment, symptoms were considerably improved.

Chronic tonsillitis and chronic sore throat

Chronic sore throat may be a symptom of other disor- ders, e.g. sinusitis. However, it may exist in its own right as a chronic bacterial infection in a patient with or without tonsils.

Treatment

The approaches to the herbal treatment of chronic ton- sillitis and chronic sore throat are similar. The main aspects of treatment are as follows.

Immune-enhancing herbs. Being a chronic condi- tion, Astragalus may be used as well as Echinacea, Picrorrhiza and Andrographis.

Lymphatic and depurative herbs.

A local treatment such as a throat spray or lozenge using herbs such as:

Glycyrrhiza (licorice) - soothing, antiinflammatory, topically antiviral Salvia (sage) - astringent and antiseptic Propolis - antiseptic, healing and anaesthetic Kava - anaesthetic , Echinacea - immune enhancing, antiinflammatory Capsicum - stimulant, antiseptic Hydrastis (golden seal) - antiseptic, mucous

membrane trophorestorative Althaea (marshmallow root) - demulcent Myrrh - antiseptic, induces local leucocytosis

A dairy-free diet rich in fruit and vegetables should be observed.

Case history

A male patient aged 65 complained of a chronic sore throat which had been present for years. Other conditions were also being treated, but for the sore throat he was prescribed:

Echinacea angustifolia 1:2 5 ml once a day with water

A gargle consisting of: Echinacea angustifolia 1:2 40 ml Propolis 1:5 30 ml Salvia officinalis 1:2 30 ml

Total 100 ml

Dose 2 ml in 10 ml water as a gargle on the affected area of the throat twice a day. Swallow after use. After 8 weeks the sore throat was considerably improved. With continuing treatment it has almost gone.

Otitis media

Inflammation of the middle ear, or otitis media, can be divided into acute, chronic or serous.

Viral upper respiratory tract infection is most com- monly associated with the onset of acute otitis media, although the major infection present is bacterial. Symptoms can include pain, purulent discharge from the ear, hearing loss, vertigo, tinnitus and fever. Examination will demonstrate a red, dull and bulging or perforated ear drum.

Chronic otitis media with discharge from the ear can result from ineffectively treated acute or recurrent otitis media. The infection is clearly bacterial.

Serous otitis media or secretory otitis media (or 'glue ear') is an enigmatic disorder that usually occurs in children. Examination of the ear drum shows that it is retracted ('sucked in') and there is fluid in the middle ear cavity which can lead to con- ductive hearing loss. Allergy, nasal infection and chronic sinus infection may be involved and it is asso- ciated with increased frequency of respiratory infec- tions. Medical treatment can involve the use of grommets to drain the middle ear cavity. The overuse of antibiotics is probably ill advised, although bacteri- al infection may play a role in some patients with this disorder.

?!&ti ctical clinical guides

Treatment Treatment

The treatments of acute and chronic otitis media are similar to the treatments of acute and chronic sinusitis respectively (with the exclusion of the topical treatment containing Capsicum).

Secretory otitis media (SOM) should be regarded as an a!lergic disorder, as well as possibly a vicarious elimination. A dairy-free, low-salt diet should be tried or otherwise a full elimination diet. However, the presence of microorganisms which contribute to the inflammation or the malfunction of the eustachiali tube should also be considered. If adenoids are impli- cated, then the SOM should be treated similarly to ton- sillitis. The following herbs should be emphasized during treatment.

Antiallergic and decongestant herbs such as Albizzia, Ephedra and Scutellaria baicalensis.

Upper respiratory anticatarrhal herbs such as Euphrasia, Solidago, Hydrastis, Plantago lanceolata and Glechonza hederacea.

Depurative and lymphatic herbs such as Galium (cleavers) and Phytolacca.

Immune-enhancing herbs, particularly Echinacea and Astragalus, to correct the presence of allergy and possibly infection.

Chewing on a Hydrastis tablet (difficult for children because of its bitterness) will accentuate its mucous membrane trophorestorative and antibacterial effects on the upper respiratory tract.

Acute bronchitis

Acute bronchitis is an acute inflammation of the tra- chea and bronchi caused by bacteria. It commonly fol- lows the common cold, influenza, measles or whooping cough. Patients with chronic bronchitis are particularly prone to develop episodes of acute bron- chitis (where their sputum turns from grey or white to yellow or green). Other factors which can predispose to this kind of bacterial infection include cold, damp, dust and cigarette smoking.

Initially there is an irritating, unproductive cough which eventually progresses over a few days to copi- ous, mucopurulent sputum. Infection usually starts in the trachea and progresses to the bronchi and with this spread there is a general febiile disturbance with tem- peratures of 38-39°C. Gradual recovery should occur over the next 4-8 days. However, it may progress to bronchiolitis or bronchopneumonia.

Being an acute disorder, it is important to give fre- quent doses of herbs and, if possible, to follow the pro- gression of the infection, adapting the treatment to the various stages.

Antiseptic herbs such as lntila helenium, Thymus vul- garis and Allium sativum (garlic) should be prescribed throughout the course of the infection and preferably should be continued for 1 week into recovery to prevent relapse.

During the dry, unprotective cough phase, demul- cents such as Althaea glycetract should be prescribed.

Diaphoretic herbs are indicated during the febrile phase, particularly Asclepias tuberosa (pleurisy root) which is almost a specific for acute lower respiratory tract infections. It is often combined with Zingiber to enhance its effectiveness. Other diaphoret- ics such as Tilia and Achillea can also be prescribed.

Expectorant herbs, which include Inula helenium, Thymus vulgaris, Polygala and other saponin-contain- ing herbs, Foeniculum (fennel), Pimpinella (aniseed) and Marrubium (white horehound) can be prescribed throughout the course of the disorder.

Anticatarrhal herbs, especially Verbascum, Plantago lanceolata and Hydrastis, may be indicated when the sputum is particularly copious or if the productive cough lingers beyond the acute stage.

Antitussive herbs should be used to help the cough, especially at night, and Pruntis serotina (wild cherry) is particularly indicated if tracheitis predominates.

Whooping cough

Whooping cough or pertussis is a highly infectious disease caused by Bordetella pertussis. About 90% of cases occur in children under 5 years.

The first stage consists of respiratory infection lasting about 1 week during which conjunctivitis, rhinitis and an unproductive cough are present. Diagnosis is difficult at this stage, since it resembles other respiratory infections.

The coughing stage follows and is characterized by severe bouts of coughing. Each paroxysm consists of many short sharp coughs, gathering in speed and duration and ending in a deep inspiration when the characteristic whoop ihay be heard. The paroxysms can end with vomiting. This stage can last from one to several weeks. The sputum is particularly tenacious and difficult to expectorate.

Herbal approaches to system dysfunctio

Treatment

The treatment approach is similar to acute bronchitis but different aspects of the treatment are emphasized.

Immune-enhancing herbs such as Echinacea and Andrographis and respiratory antiseptic herbs such as l~lula heleninm, Thymus vl~lgaris and Alliunz sativum (garlic) should be prescribed throughout to treat the infection and prevent complications.

Drosera (sundew) is a specific fm pertussis and has antispasmodic, derrtulcer~t and expectocant properties.

In the coughing stage expectorant herbs such as Inula heleizium, Thymus vulgaris, Lobelin inflata, Polygala, Glycyrrhiza (licorice) and other saponin- containing herbs, Foeniculum (fennel), Pimpinella (aniseed) and Marrubium (white horehound) should be emphasized to loosen the tenacious sputum.

Also, antitussive and demulcent herbs are required to dampen and soothe the cough reflex. If vomiting is occurring, these should be extended by gastrointestinal spasmolytics such as Vi'burizl~nz opulus.

Respiratory spasmolytics which also have expecto- rant activity, such as Grindelia and lnula helenium, should also be emphasized in the coughing stage. A combination of Inula, Glycyrrhiza and Lobelia is worth trying for the most severe symptoms.

Mucolytic herbs such as Allium sativum and Armoracia may be required to help loosen the tena- cious sputum.

Chronic bronchitis and emphysema

Although chronic bronchitis and pulmonary emphy- sema are distinct disorders, they often coexist in the patient and it can be difficult to determine the relative importance of each condition in the individual case. The term 'chronic obstructive pulmonary disease' (COPD) often applies to a combination of the two. In emphysema, the fine architecture of the alveoli is damaged, leading to impairment of ventilatory capacity. There is probably little that can be done to reverse this destruction (although some natural thera- pists feel that bioavailable silica and herbs rich in this mineral, such as Equisetum, can help restore lung architecture).

In contrast, chronic bronchitis is a syndrome which can develop in response to long-term exposure to various types of irritants to the bronchial mucous

membranes. These include cigarette smoke, dust and automobile or industrial air pollution, especially in conjunction with a damp climate. Acute infection is usually a precipitating or aggravating factor and chron- ic infection is usually present, with regular acute episodes. Hence, there are many factors in chronic bronchitis which are treatable and long-term herbal treatment can dramatically alter the course of chronic bronchitis.

In chronic bronchitis, ventilatory capacity is reasonably preserved but hypoxia, pulmonary hyper- tension and right ventricular failure occur early - 'the blue bloater'. In emphysema, the impairment of venti- latory capacity and exertional dyspnoea lead to the sufferer being labelled a 'pink puffer'. A mixed syn- drome is most common and all patients should be treated along the following lines, regardless of their clinical label. The treatment outcome will, however, depend on how much the changes in their lungs can be reversed.

Treatment

In chronic bronchitis there is overactivity of the mucus-secreting glands and goblet cells. The vast excess of mucus coats the bronchial walls and clogs the bronchioles. Exacerbating this, many ciliated colum- nar cells are replaced by goblet cells in response to the chronic irritation. Therefore the excessive mucus is also less able to be cleared from the lungs. Hence, the use of expectorants is emphasized in the treatment of chronic bronchitis, despite the fact that an easily pro- ductive cough can be a feature of this disease. (In some patients sputum may be scanty and tenacious, which also requires treatment with expectorants.)

Bronchial irritation must be avoided. Giving up smoking and a change in occupation or climate may be necessary. Mucus-producing foods such as dairy products and bananas should be reduced.

The chronic infection should be treated and acute infections prevented by immune-enhancing herbs, especially Echinacea and Astragalus (discontinue Astragalus during acute febrile infections). Many chronic bronchitis patients are constitutionally cold, so the cold herbs Picrorrhiza and Andrographis should be avoided. Heating herbs such as cinnamon may be help- ful and could be used in conjunction with these cold herbs.

Expectorant herbs, such as lnula helenium, Thymus vulgaris, Polygala, and other saponin-containing herbs, Foeniculum (fennel), Pimpinella (aniseed) and

218 -0 Practical clinical guides

Marrubium (white horehound) can be prescribed throughout the course of the disorder. The diffusive stimulant p~~pe r t i e s of Zingiber will potentiate the activity of expectorants.

Respiratory antiseptic herbs which also have expec- torant or mucolytic properties are particularly indicat- ed, such as 111llla helenium, Thyvrus vulgaris anc! Allium satizwm.

Since the goblet cells are oversecreting, anticatarrhal herbs such as Verbascum, Plantago laizceolata and Hydrastis can help to reduce this oversecretion.

If there is an unproductive cough at night, a sepa- rate formula containing demulcents such as Althaea glycetract and Glycyrrhiza and antitussives such as Glycyrrhiza and Bupleurum may be prescribed.

Inhalation of peppermint and eucalyptus oils com- bined can help loosen mucus and dilate airways to make breathing easier.

Bronchodilating herbs such as Coleus and Lobelia may be helpful. Ephedra should probably be avoided. Those with expectorant activity such as Grindelia can be chosen.

Since chronic inflammation is present, antiinflam- matory herbs such as Glycyrrhiza, Bupleurum and Rehmannia may be of value, as well as omega-3 fatty acids (as found in linseed oil).

Support for the heart and general circulation with Crataegus and Ginkgo (see p.202) may be required.

Case history

A male patient, 66 years, has received herbal treatment for chronic bronchitis for 7 years. During this time there has been considerable improvement in the patient's condition and friends often now comment on how well he looks. The frequency of acute episodes has substantially reduced and his lung function parameters have improved. Although treatment varied over this time period, a representative herbal treatment is as follows.

Immune formula (mainly) Echinacea angustifolialpurpurea 1 :2 45 ml blend Arctium lappa 1 :2 15 ml Achillea millefolium 1 :2 20 ml Withania somnifera 1 :2 20 ml

Total' 100ml Dose 5 ml tds

Lung formula Glycyrrhiza glabra lnula helenium Zingiber officinale Foeniculum vulgare Thymus vulgaris Grindelia camporum

Dose 5 ml tds.

1:l 15 ml 1 :2 20 ml 1 :2 10 ml 1 :2 15 ml 1 :2 20 ml 1 :2 20 ml Total 100ml

Bronchiectasis

The term 'bronchiectasis' describes an abnormal dilation of the bronchi which becomes a focus for chronic infection. In most cases it develops as a complication of a severe bacterial infection and then follows a chronic course. Clinical features include chronic cough, often with copious purulent sputum, and febrile episodes with malaise and night sweats which can last from a few days to weeks, and some- times haemoptysis. The disorder can be debilitating. Although continual use of antibiotics is inadvisable, many patients are placed on this regime.

Treatment

Essential aspects of the treatment of bronchiectasis are as follows.

Immune-enhancing herbs such as Echinacea, Andrographis and Astragalus.

Respiratory antiseptic herbs such as Inula helenium, Thymus vulgaris and Allillin sativum.

Diaphoretics such as Asclepias tuberosa (pleurisy root) during the febrile episodes.

Tonics such as Panax, Eleutherococcus or Withania if debility is present.

Anticatarrhal herbs, such as Verbascum, Plantago lanceolata and Hydrastis.

Expectorant herbs such as Ilzula helenium, Thymus vulgaris, Polygala and other saponin-containing herbs, Foeniculum (fennel), Pimpinella (aniseed) and Marrubium (white horehound).

Note that Astragalus, Panax and Eleutherococcus should be discontinued during any febrile phases.

Case history .

A male patient, 59 years, with bronchiectasis. He coughs up an egg cup of sputum every morning and experiences occasional febrile episodes and acute viral infections.

Herbal approaches to system dysfunctions 219 ,

Herbal treatment consisted of the following.

Echinacea angustifolia 500 mg tablets, two tablets 2-4 times daily. The Echinacea liquid disagreed with this patient hence the tablets. The higher dose was taken during febrile episodes and acute infections.

Aesculus hippocastanum 1:2 15ml Foeniculum vulgare 1:2 10 ml Thymus vulgariz 1:2 30 ml Ginkgo biloba standardized extract 20 ml lnula helenium 1:2 25 ml

Total 130 ml

Dose 8 ml twice a day.

The Ginkgo and Aesculus were mainly for circulatory problems hut kerculus also has expectorant properries due to i t s saponin content.

Garlic, 1-2 fresh crushed cloves per day. A dairy-free diet was followed.

Treatment over 2 years has resulted in a substantial improvement of this patient's condition. Febrile episodes and acute infections are rare, and his sense of well-being is greatly improved.

References

1. Gonzalez H, Ahmed T. Suppression of gastric H2-receptor mediated function in patients with bronchial asthma and ragweed allergy. Chest 1986; 89(4): 491-496

2. Kurz H. Antitussiva und Expektoranzien. Wissenschaftliche Verlagsgesellschaft, Stuttgart, 1989

3. Eccks R, Morris S, Tolley NS. The effects of nasal anesthesia upon nasal sensation of airflow. Acta Otolaryngolica (Stockholm) 1988; 106: 152-155

4. Dorow P. Welchen Einfluss hat Cineol auf die mukoziliare Clearance? Therapiewoche 1989; 39: 2652-2654

, 5. Lorenz J, Ferlinz R. Expektoranzien: Pathophysiologie und Therapie der Mukostase. Arzneimitteltherapie 1985; 3: 22-27

6. Minton NA. Volunteer models for predicting antiemetic activity of 5-HT3-receptor antagonists, British J o ~ ~ r n a l of Clinical Pharmacology 1994; 37(6): 525-530

7. Muller-Limmroth W, Frohlich HH. Effect of \,arious phytotherapeutic expectorants on mucociii?ry transport. Fortschritte der Medizin 1980; 98(3): 95-10?

8. Noslil'ova G, Strapkovli A, Kardoso\rli A et al. Antitussive action of extracts and polysaccharides of marsh mallow (Althea offici- nalis L., var. robusta). Pharmazie 1992; 47(3): 224-226