Essentials of Complementary and Alternative Medicine (June 1999)

USE OF MEDICAL ACUPUNCTURE
Primary Therapy: Musculoskeletal Pain
In the United States, acupuncture has been most accepted and successful in the management of musculoskeletal pain. Acute musculoskeletal lesions, such as 
soft-tissue contusions, acute muscle spasms, musculotendinous sprains and strains, and the pain of acute nerve entrapments, are among the problems most 
frequently and successfully addressed with acupuncture. In these cases, acupuncture can legitimately serve as the initiating therapy.
Chronic musculoskeletal pain problems are also commonly and appropriately treated with acupuncture, although not usually as the only approach. Conditions likely to 
be responsive to acupuncture intervention include repetitive strain disorders (e.g., carpal tunnel syndrome, tennis elbow, plantar fasciitis), myofascial pain patterns 
(e.g., temporomandibular joint pain, muscle tension headaches, cervical and thoracic soft-tissue pain, regional shoulder pain), arthralgias (particularly osteoarthritic in 
nature), degenerative disk disease with or without radicular pain, and pain following surgical intervention (both musculoskeletal and visceral). In the management of 
chronic musculoskeletal pain, acupuncture is valuable as an adjunct to conventional therapy's pharmaceutical and invasive procedures. Other chronic pain problems 
commonly responsive to acupuncture include postherpetic neuralgia, peripheral neuropathic pain, and headaches from other causes.
Least Useful Indications
Although acupuncture has been established as an effective tool to treat many forms of musculoskeletal pain, its limitations must be recognized in dealing with the 
consequences of spinal cord injuries and cerebrovascular accidents. In these conditions, acupuncture's effectiveness is diminished, and the frequency of treatments 
is increased and protracted over a longer time. Furthermore, acupuncture is usually not useful for thalamically mediated pain and, apart from symptom management 
and general vivifying effects, is not of great value in the treatment of chronic neurodegenerative diseases.
Acupuncture as a sole therapy has not shown itself to be of substantial value in severe and chronic inflammatory and immune-mediated disorders, such as ulcerative 
colitis, asthma, rheumatoid arthritis, and collagen-vascular diseases, especially if those conditions have advanced to require systemic corticosteroid medication. 
Likewise, it is not appropriate to rely on acupuncture as the primary intervention in chronic fatigue states or HIV disease. There can be general value, however, for the 
symptom control and vitality-promoting effects of acupuncture in all of these conditions. In malignancies, acupuncture can be considered as an additional therapy to 
combat the secondary effects of conventional therapy, and as an adjunct in pain management.
Adverse Effects
In the hands of a medically trained practitioner, acupuncture is a fairly safe and forgiving discipline. It is difficult to introduce new and lasting problems with an 
acupuncture treatment, even if the treatment is not designed as skillfully as an experienced provider would desire. Many patients report a sensation of well-being or 
relaxation following an acupuncture treatment, especially if electrical stimulation has been used. That sense of relaxation, however, sometimes evolves into a feeling 
of fatigue or depression that lasts for several days. Other transient psychophysiological responses can be lightheadedness, anxiety, agitation, and tearfulness.
The possible risks and complications of an acupuncture treatment are undesirable consequences of penetrating the body with a sharp instrument: syncope, puncture 
of an organ, infection, a retained needle. These risks can be reduced by scrupulous sterilizing or using disposable needles, acquiring good clinical skills, 
understanding surface and internal anatomy, and executing responsible clinical judgment. Pneumothorax is the most frequently reported and the most easily produced 
serious visceral complication of acupuncture needling. Pneumoperitoneum, hemothorax, cardiac tamponade, and penetration of the kidney, bladder, and spinal 
medulla have been reported, although infrequently.
Contact dermatitis to stainless steel needles, local inflammation, and bacterial abscesses can occur, as well as chondritis from needling points on the ear. Outbreaks 
of hepatitis B documented in Europe and America have been traced to single practitioners reusing unsterilized needles (
5
). There have been a few reports of HIV 
transmission through acupuncture, but these can be avoided with proper use of sterile and disposable needles.
Preventive Value
Perhaps the most fertile ground for acupuncture intervention is for disorders in their premorbid state, for problems commonly encountered by primary care providers 
but rarely associated with positive laboratory findings, definitive medical diagnoses, or successful therapies. These states often can be described within acupuncture 
diagnostic paradigms, and then modified by activating the appropriate level of energy circulation. These disorders can be loosely categorized into three groups: 
aesthenic states, autonomic dysregulation disorders, and immune dysregulation disorders.
Aesthenic states include ill-defined fatigue (e.g., “tired all the time,” “low energy”), mild depression, stress-related myofascial symptoms (e.g., upper thoracic and 
cervical myofascial pain, muscle tension headache), and early functional disturbances (e.g., diminished libido).  Autonomic dysregulation disorders may manifest as 
anxiety, sleep disturbances, and bowel dysfunction.  Immune dysregulation disorders include recurrent infectious and inflammatory states without underlying frank 
immunodeficiency: sinusitis, pharyngitis, bronchitis, gastroenteritis, and viral illnesses.

Some conscientious patients consult the acupuncture practitioner with what may be considered from an allopathic perspective as minor symptoms, and request 
assistance to attain better health and vitality. In these cases, the general characteristics of the patient, the presenting symptoms, the patient's past and family medical 
histories, and the acupuncture examination allow the acupuncturist to identify minor imbalances in the energetic activity of the organs and energy axes. This level of 
subtle pathology, for which allopathic medicine has little more than lifestyle counseling to offer, is commonly overlooked in a conventional setting. The acupuncture 
diagnostic and therapeutic system, however, usually allows for an understanding of the patient and the early disturbances, and an appropriate intervention can be 
formulated. This form of preventive maintenance is a valuable dimension of the subtle aspects of acupuncture.
Scope of Practice
Medical acupuncture is a highly adaptable discipline and is of potential therapeutic value in many pain and general medical conditions. Its use as either a primary or 
complementary therapy depends on the nature and severity of the presenting problem and on the training, orientation, and practice environment of the provider. The 
physician trained in medical acupuncture who sees patients early in the course of their disturbances can initiate treatment of a pain or medical problem with 
acupuncture, and introduce additional therapies if acupuncture proves insufficient as the sole treatment. The physician who receives cases later in their evolution and 
after conventional treatments have been initiated can add acupuncture to assist, and sometimes replace, conventional treatments.
Many patients seeking attention from acupuncture providers demand acupuncture or other unconventional interventions as the starting treatment and agree to 
conventional methods only later in their management. Other patients and many physicians wait until conventional therapies have been exhausted and then resort to 
acupuncture intervention. Acupuncture therapy is not miraculous. It has its appropriate range of applications and, like other medical interventions, yields good results 
in well-selected early problems and less successful results when chronicity and complexity of the presenting problems increase. Usually, the best moment to initiate 
acupuncture therapy is early in the evolution of a problem; however, the flexibility and adaptability of acupuncture allow it to be integrated at almost any stage of 
treatment.
In addition to the treatment of acute and chronic musculoskeletal pain and premorbid or functional problems, medical acupuncture can be used successfully to 
address many diagnosable medical conditions, although it may need to be used in collaboration with other therapies, conventional and unconventional. In the United 
States, the four divisions of medicine that appear most responsive to acupuncture intervention are respiratory, gastrointestinal, gynecologic, and genitourinary.
Respiratory ailments potentially accessible to acupuncture intervention include allergic rhinitis, sinusitis, and bronchitis. Gastrointestinal ailments include gastritis, 
irritable bowel, hepatitis, and hemorrhoids. Gynecologic problems include dysmenorrhea and infertility. Genitourinary problems include irritable bladder, prostatitis, 
male infertility, and some forms of impotence.
Acupuncture, particularly when applied to the external ear, has shown to be valuable in managing substance abuse problems and reducing prescription narcotic 
analgesics. This application for acupuncture—one of the most socially visible—has gained the respect of rehabilitation programs internationally (
6
).
For mental and emotional disturbances, acupuncture can be useful as a transient aid in early and acute emotional states, such as anxiety, excitability, worry, early 
stages of depression, and fearful states. Acupuncture should not be considered as a primary or ongoing therapy for deep-seated or chronic psychoemotional illness 
because its effect on these conditions is not enduring.
Adaptability: Acupuncture as Complement and Complements to Acupuncture
Acupuncture's adaptability to the changing requirements of the patient's condition extends to its adaptability when combined with other modalities of health care. This 
integration is an expression of the training, orientation, and creativity of the practitioner. Acupuncture can be used as the initiating therapy for many common medical 
problems, and it can be combined with other modalities and disciplines according to the needs of the patient and the availability of other services. In addition to 
allopathic pharmaceutical and surgical interventions, there are medical modalities that particularly complement the effects of acupuncture or that acupuncture can 
complement. These modalities include physical medicine techniques in pain management, osteopathic manipulation, movement training, herbal therapy, homeopathic 
remedies, and psychiatric or psychological intervention.
Management of chronic musculoskeletal pain offers many occasions in which therapeutic modalities can be combined. A physical therapist experienced in myotherapy 
can extend the impact of an acupuncture treatment directed at relaxation of contracted muscles and fascial tension patterns. The conventional spray and stretch, 
trigger point infiltration, and transcutaneous electrical nerve stimulation techniques of physical medicine combine well with acupuncture therapy. Osteopathic 
manipulative therapy and its subspecialty of cranial therapy can also be productively combined with the musculoskeletal applications of acupuncture. Hatha Yoga 
postures assist patients with biomechanical rehabilitation and maintenance of results, and the breathing exercises assist with relaxation and stress reduction. 
Movement therapy, such as the Feldenkrais, Alexander, and Aston approaches, can also be useful adjunctive activities during rehabilitation.
With chronic medical problems, the traditions of herbal therapies and homeopathic remedies can be usefully combined with acupuncture treatments. Chinese herbal 
formulae, when prescribed according to the classical patterns of disharmony of internal organs, can serve as protopharmaceutical substrates to enhance and prolong 
the effects of acupuncture treatments. Herbal formulae can accomplish lasting change or maintenance that cannot be achieved with needles alone (see 
Chapter 12
).
Homeopathic remedies are generally used in low-potency form to treat acute problems, middle-potency form to treat chronic medical problems, and high-potency form 
to treat problems that have a core psychoemotional disturbance. These remedies can be used to specify and enhance the acupuncture treatments and can have 
capability in high potency to effect enduring changes in the patient's emotional configuration. It is sometimes necessary to work in collaboration with a psychiatrist or 
psychotherapist who is sensitive to the acupuncture process and who can serve in a guiding role for the patient.
ORGANIZATION
Training and Quality Assurance
In the United States, acupuncture is performed by physician and nonphysician practitioners. In 35 states, the acupuncture practice is included within the scope of a 
physician's medical or osteopathic license, and no regulations or restrictions are imposed on medical practitioners. The other 15 states require physicians practicing 
acupuncture either to demonstrate evidence of participation in training programs of 200 to 300 hours or simply to register with the board of medicine with evidence of 
formal training. From these loose regulations of physician practitioners, it is clear that the degree of acupuncture training and experience among physicians varies 
from state to state and individual to individual.
The American Academy of Medical Acupuncture (AAMA) represents the education, legislation, and professional interests of physicians who are well trained in 
acupuncture. Full membership in the AAMA requires 220 hours of formal training and two years of clinical experience. This standard follows the physician-training 
guidelines established in the constitution of the World Federation of Acupuncture-Moxibustion Societies, an international society guided by the World Health 
Organization. The AAMA has established a proficiency examination as the first of a two-part board certification examination. Membership eligibility in the AAMA has 
become the standard of physician credentialing for state registration, hospital privileges, liability insurance, and third-party reimbursement. It is likely that the 
proficiency examination will also become a requirement for participation in managed care programs (
7
).
The practice of acupuncture by nonphysicians is regulated in at least 33 states, and another dozen states have statutes pending. The educational prerequisites and 
training requirements vary widely from state to state and have been in a flux of improvement during the past decade. There are approximately 30 colleges accredited 
by the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine (NACSCAOM). Most of the programs span three years of 
didactic and clinical training. All states except California and Nevada that license nonphysician acupuncturists recognize the national examination developed by the 
National Commission for the Certification of Acupuncture and Oriental Medicine. There are two main national societies together with dozens of regional, state, and 
local organizations that represent the interests of the licensed acupuncturist communities (
8
).
The World Health Organization has adopted guidelines on basic training for physician and nonphysician providers, standards for safe practice, and clinical indications 
for acupuncture. The training guidelines reflect the minimum hours expected in most member nations and are consistent with regulations enacted in the United States: 
2500 hours for nonphysician acupuncturists and 200 hours for physicians. The basic curriculum is founded on the classical tradition of acupuncture, requiring a firm 
knowledge of the acupuncture points and channels and the traditional models of diagnosis and treatment. A basic knowledge of Western biomedical science is also 

encouraged in the curriculum (
9
).
Reimbursement Status
Although there is no national standard for the third-party insurance industry regarding acupuncture, many policies recognize acupuncture as a legitimate and 
reimbursable procedure. Because of the popular and professional demand for acupuncture services, it is likely that insurance reimbursement will become more 
uniform with time. Medical acupuncture, particularly as practiced by an experienced medical provider, integrates creatively into many medical disciplines. Traditional 
Chinese medicine integrates less smoothly into conventional settings because the herbal diagnostic model that is fundamental to traditional Chinese medicine is alien 
to most Western physicians' thinking.
PROSPECTS FOR THE FUTURE
The potential for medical acupuncture is just beginning to be understood. Future clinical research and utilization evaluations should clarify how best to integrate it into 
the conventional health care system. Medical acupuncture offers the opportunity to expand contemporary medicine in treating conditions for which current 
interventions are either ineffective or have undesirable secondary effects. Because of its usefulness and adaptability to so many aspects of allopathic medicine, it is 
probable that medical acupuncture will be integrated with increasing creativity into private and institutional practices.
C
HAPTER
 R
EFERENCES
1.
Reston J. Now about my operation in Peking. The New York Times 1971; July 26:1, 6.
2.
Helms JM. Acupuncture energetics: a clinical approach for physicians. Berkeley: Medical Acupuncture Publishers, 1995:3–17.
3.
Stux G, Pomeranz B. Acupuncture: textbook and atlas. Berlin: Springer–Verlag, 1987:1–26.
4.
Helms JM. Acupuncture energetics: a clinical approach for physicians. Berkeley: Medical Acupuncture Publishers, 1995:71–78.
5.
Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years 1981–1994. J Altern Complement Med 1996;2(2):291–297.
6.
Culliton PD, Kiresuk, TJ. Overview of substance abuse acupuncture treatment research. J Altern Complement Med 1996;2(1):149–159.
7.
American Academy of Medical Acupuncture (AAMA), 5820 Wilshire Boulevard, Suite 500, Los Angeles, CA 90036, 213 937 5514 /fax [phone].
8.
American Association of Acupuncture and Oriental Medicine (AAAOM), 433 Front Street, Catasaugua, PA 18032, 610 266 1433 /fax [phone]. National Acupuncture and Oriental Medicine 
Alliance (NAOMA), 14637 Starr Road SE, Olalla, WA 90359, 206 851 6896 /fax [phone].
9.
Helms JM. Report on W.H.O. consultation on acupuncture. Medical Acupuncture 1997;7(1).

CHAPTER 20. P
HYTOMEDICINE
Essentials of Complementary and Alternative Medicine
CHAPTER 20. P
HYTOMEDICINE
Tieraona Low Dog
Background
 
Definition
 
General Considerations
History and Development
Principal Concepts
Therapy and Outcomes
 
Treatment Evaluation
 
Description of Treatment: Herbal Therapeutics
 
Other Herbal Preparations
 
Concluding Remarks on Herbal Preparations
Organization
 
Training and the Legal Status
 
Reimbursement Status
 
Quality Assurance
Prospects for the Future
Chapter References
BACKGROUND
Definition
Phytomedicine, or herbal medicine, is the science, art, and exploration of using botanical remedies to treat illness. The term  phytotherapy describes the therapeutic 
application of plants. This term was coined by the French physician Henri Leclerc (1870–1955), who published numerous essays on the use of medicinal plants (
1
). 
Many consider herbal healing the oldest form of medicine. It has been used by all races, religions, and cultures throughout the world. Prehistoric records show that 
people of that period collected and used herbs and plants for food and medicine, and the documented use of herbal medicine dates back at least 5000 years.
General Considerations
Medical herbalism is thriving in Europe and the United States. The sale of herbal medicines in the United States is one of the ten fastest growing industries, with more 
than 1 billion in sales annually. Phytomedicines are sold in health food stores, pharmacies, and even grocery stores. The media coverage is extensive, and there are 
magazines devoted to this form of medicine. Numerous factors explain this increased use of medicinal plants for self-treatment. Although the tremendous benefits of 
technology that produce dramatic and specific effects (e.g., innovative drug therapies) in medicine are well recognized, the dangers of medical technology and the 
indiscriminate use of chemicals (e.g., preservatives, coloring agents, drugs, and chemical pollution to the environment) is straining the adaptability of our complex 
bodies and the environment. There appears to be a growing distrust of technology-based medicine, which has given rise to the “back to nature” movement prevalent 
in the United States today. Science is a double-edged sword, and its enormous influence means that we must begin to realize and address the long-term 
consequences of technology and its impact upon the environment and inhabitants of this world. Rising interest in herbal medicine reflects the public's attempt to 
create a more gentle and ecologically sensitive medicine than has been created with technology-based medicine. Yet both technology and nature must be combined 
wisely. Hopefully, as we learn from the past, we can take the wisdom gained to help guide our future.
When tracing the history of herbal medicine, it is difficult to distinguish it from that of medicine in general. Ancient physicians treated the sick with herbs. Their 
pharmacopoeias were filled with elixirs, ointments, teas, and poultices. Phytomedicine is an ancient profession that laid the foundations for what we now call modern 
medicine, botany, chemistry, and pharmacology. The following section covers some of the most influential historical figures of Western phytomedicine. However, the 
names of the unsung, unpublished, rural, and lay herbalists who kept much of the knowledge and tradition alive throughout the darkest periods of Europe are lost 
forever in the sands of time.
HISTORY AND DEVELOPMENT
The Egyptian Papyri Antiquarium is a 22-yard document dating from 3000 
BC
 that contains an extensive materia medica. It is one of the oldest Western documents 
that lists specific conditions and specific treatments with herbal medicines. The Rig Veda, a text from India, dates from the same time period and contains 
approximately 750 medicinal plants. In China, the Pen T'so provided detailed information on 366 plants. The history of Chinese and Ayurvedic medicine is explored in 
other chapters of this book.
Around 1500 
BC
, the Aztecs documented in the Badianus Manuscript the use of datura, tobacco, cotton, passionflower, cochineal, and other herbs, all of which have 
been adopted in both European and American pharmacopeias (
2
). Mayan medicine included guaiacum, capsicum, and chenopodium, and South American Indians 
were well versed in the use of coca, curare, ipecac, and cinchona (
3
). Native North American people's knowledge of their flora was so complete that they used all but 
about a half a dozen of the indigenous vegetable drugs. Over 200 drugs that were used by one or more Indian nations have been in the United States Pharmacopeia 
or National Formulary (
4
).
When considering the history of medicine in ancient Europe, most historians usually begin with the Greek culture, which can be traced back to Helen of Troy, who is 
believed to have lived around 2000 
BC
. There was an extensive herbal pharmacopoeia during this time, much of it geared towards pain relief.
It was between 460 and 370 
BC
 in ancient Greece when Hippocrates learned, wrote, and taught extensively about herbal medicine and healing. Blood, urine, feces, 
and phlegm were observed and described in terms of their substance, quality, and color. These four body fluids would come to be known as the  four humors of Greek 
medicine. Hippocrates believed that there were two approaches to disease: to eliminate the symptoms that are present and to restore the patient to health. 
Hippocrates viewed symptomatic healing as separate from the restoration of health, or what many would now call holistic medicine. Although Hippocrates knew more 
than 400 herbal and drug therapies, his primary approach to medicine was preventive in nature.
Pedacius Dioscorides was the author of De Materia Medica. Dioscorides was a Greek army surgeon in the service of Nero (54–68 
AD
) who used the opportunity of 
travel to study plants. His extensive  materia medica describes more than 600 plants and plant principles. He was the first to write on medical botany as an applied 
science.
Another prominent figure in herbal history was Pliny the Elder (23–79 
AD
) who wrote 12 texts solely on medicine. These texts were part of his  Natural History, an 
extensive compilation of all that was known in his time of anthropology, botany, zoology, mineralogy, geography, plants, and drugs.
Galen (131–201 
AD
) is considered the greatest of ancient Greek physicians after Hippocrates. He instituted an elaborate system of herbal polypharmacy and was a 
prolific writer, authoring more than 30 books on pharmacy. Galen was one of the first to provide a truly intelligent description on the uses of opium, hyoscyamus, 
hellebore, colocynth and many other herbs. It is because of his vast contribution to herbal medicine that the term  galenicals is still used today to describe herbal 
simples.
When the Roman Empire fell, much of the knowledge and wisdom gained from the Greeks was lost as Europe entered the Dark Ages. The period of monastic 
medicine (500–1000 
AD
), during which the studies of Greek medical writings were taught only at European monasteries, became the only preservation of the herbal 
knowledge of Hippocrates, Pliny the Elder, and Dioscorides available in Europe. During the time of the great plagues of Europe, monastic medicine became more 

focused on the spiritual protection of the saints than in exploring the richness of the botanical medicines available. The women in the villages kept herbal medicine 
alive as they tended the sick and delivered the babies. Many of these village women were burned at the stake as witches because of their healing talents;  herbista, 
meaning female herbalist, is an old term for a witch. Scientific exploration of medicine was in a dark slumber throughout Europe.
Meanwhile, in the Islamic world, medicine and research were flourishing. The Golden Age of Arabia (750–850 
AD
) was rich in the study of medicine and art. Botanical 
gardens were planted and herbal remedies extensively studied and harvested to supply both pharmacies and physicians. The Mohammedan era, as this period is 
referred to, would last until 1100 
AD
. In Europe, Hildegard of Bingen (1098–1179), an abbess, was carrying the torch in the darkness. Her medical writings are 
considered by many to be the most important scientific contribution of the Middle Ages. Hildegard of Bingen described the function of 485 plants and blended the spirit 
world, prayer, and medicine into a tapestry unique for her time.
The seventeenth century brought the migration of many Europeans to the New World. Although many early immigrants transported medicinal plants and seeds from 
their homeland to treat their ailments, they incorporated much of the indigenous  materia medica into their own pharmacopoeia.
Samuel Thompson (1769–1843), an early American, is reputed to have learned herbal medicine from Mrs. Benton, a wise woman versed in Native American herbal 
lore. Thompson, who was raised on a farm in New Hampshire, became so impressed and inspired by the effectiveness of the remedies that he spent his life teaching, 
doctoring, and writing about herbal medicine. The Thompsonian approach to healing became widespread with its followers being primarily the common, rural folk, who 
gained much benefit from his simple philosophy of treatment. Samuel Thompson strongly advocated a return to the vitalist approach to medicine.
During the 1800s, drug preparations were primarily made of flowers, leaves, and roots. Medicine and botany were still closely allied. In 1850, in both Europe and 
America, 80% of the medicines used were derived from plants. (Today, less than 30% of our drugs are of plant origin.) The eclectic physicians of the United States 
were highly skilled in the use of botanical remedies and wrote detailed pharmacopoeias. Harvey Felter, John Uri Lloyd, and John King were among those well known 
for their teachings and writings in this area.
By the late 1800s, United States pharmaceutical companies began to gain a strong foothold in the field of medicine. As knowledge of chemistry increased, synthetic 
chemical drugs were developed. Aspirin was introduced by Bayer, and pharmaceutical science expanded at a rapid pace. Chemists were interested in studying 
chemical compounds that could be analyzed precisely and dosed in exact milligrams, with effects that could be accurately measured physiologically. The study of 
herbal medicine began to fall into neglect. Proprietary products became popular, and fewer physicians relied on making their own medicines. The pharmaceutical 
companies persuaded doctors to buy and prescribe their products conventional medicine organized around these concepts, and suppression of other practitioners, 
including herbalists, was intensified.
After 1910, medical schools were restructured to focus primarily on physics, chemistry, and pathology. Medicine was to become a branch of “higher” learning, 
available only to those who could survive the lengthy and expensive university training. Many of the medical schools that catered to minorities and women with an 
emphasis on herbal medicine, homeopathy, and holistic healing were closed. Fortunately, medical schools today are reconsidering the importance of psychology, 
sociology, and the humanities when selecting their student body, and a number of medical schools are revisiting holistic approaches and patient-centered medicine.
PRINCIPAL CONCEPTS
In phytomedicine, pathological understanding of illness is very similar to Western allopathic pathology. However, herbalists view illness within the context of the 
healing capacity of the whole person and then choose herbs that support the specific organ systems under stress. Most Western-trained herbalists believe that the 
body is a self-healing organism and that herbs should be chosen to support wellness, not simply to relieve symptoms or treat diseases. According to Simon Mills, “If 
we see the body, mind and spirit as a complex whole, applying a constant self-corrective force to maintain a homeostatic balance in spite of wildly varying 
environmental pressures, then we should use different medicines, and even redefine the term. The search is on for those agents that support homeostatic efforts, 
which help the body help itself” (
5
). Thus, therapy is directed at helping to strengthen the weakened areas of the body, often with emphasis on supporting the adrenal 
and nervous systems.
D
IAGNOSIS
The ability to “diagnose” an illness depends on each individual herbalist's training. In the United States, most consumers who are seeking the services of an herbalist 
have already received a diagnosis from their health care provider and are in search of an alternative way to treat the problem. Because most lay (unlicensed) 
herbalists do not have access to laboratory tests or radiological or pathological studies, they rely fairly heavily on an exhaustive review of systems and history of the 
presenting complaint; the initial appointment with a patient often lasts between 1 and 2 hours. Physical examination may include a systematic approach to the body, 
including auscultation of the heart and lungs, palpation of the abdomen, and examination of the ears, nose, and throat. Some herbalists employ unorthodox 
techniques, such as applied kinesiology and iridology. Again, this depends on the type of training the herbalist has received, and training varies considerably by 
country. For example, in Europe, conventionally trained physicians frequently use herbs; whereas in the United States, this rarely is the case. In many Asian and 
Indian countries, herbal training is part of conventional medical education.
D
ISEASE
 C
LASSIFICATION
Disease classification in phytomedicine is essentially the same as that in Western medicine. Dysmenorrhea is called just that, and herbs that support the uterus, 
enhance blood flow to the area, and reduce discomfort are chosen to address the problem. If the woman had significant stressors in her life, herbs for the nervous 
system would be included, supporting her body's overall attempts to rebalance. Therapeutic recommendations often include basic lifestyle and dietary 
recommendations. Some herbalists include the use of vitamins and minerals. However, the primary focus is on using herbal remedies to restore health.
As herbalist Michael Moore states, “Herbal remedies represent far more than a holistic fad or a total rejection of traditional medicine. They help to fill the 
overwhelming void between health and acute disease” (
6
). Herbal therapy is best suited for addressing a number of chronic complaints that are incompletely 
addressed by conventional medicine, and the many everyday minor complaints in which people seek relief from a bottle of pills. Herbalists design their protocols 
around assisting the body in its search for wellness rather than only blocking processes that produce disease.
David Hoffman, a British-trained herbalist, gives an example of a therapeutic approach for hypertension. He begins with the assumption that organic causes for 
hypertension have been explored and that the individual is living with essential hypertension. He outlines a number of herbs with hypotensive action that may be 
chosen based not only around their ability to reduce blood pressure, but also with an understanding of the secondary actions of the plant that may be relevant to the 
particular individual. For example, black cohosh ( Cimicifuga racemosa) is hypotensive but also has antiinflammatory and antispasmodic properties and is useful for 
women who are suffering from hot flashes and menopausal complaints. This herb may be more suited for a 50-year-old woman with arthritis entering her menopausal 
years than an herb such as linden. Hoffman also discusses the use of cardiac tonics for strengthening and toning the entire system that is under “pressure.” 
Peripheral vasodilators and diuretics are mentioned to reduce the resistance within the peripheral vessels and maintain renal perfusion. Nervines are included for 
addressing any stress or anxiety that may contribute to the hypertension. He then creates a formula of herbs that address these particular aspects and chooses herbs 
that best match a particular individuals' needs (
7
).
Many herbs have hypotensive properties and, through the combination of herbs addressing different aspects of the problem for a particular individual, a holistic and 
unique approach is created. For this reason, many herbalists do not use premade proprietary products. They create protocols based around each individual's 
particular need. For example, the following is a formula that might be used for a 50-year-old perimenopausal woman with hypertension and arthritis:
Black Cohosh (Cimicifuga racemosa): 2 parts
Hawthorn (Crataegus spp): 1 part
Cramp bark (Viburnum opulus): 1 part
Motherwort (Leonurus cardiaca): 1 part

The dose would be 5 mL of tincture taken three times daily. This formula provides the following:
Hypotensives: Black Cohosh, Hawthorn, Cramp bark
Cardiac tonics: Hawthorn, Motherwort
Diuretic: Hawthorn
Nervines: Motherwort, Black Cohosh
Peripheral vasodilator: Cramp bark
Antiinflammatories: Black Cohosh, Cramp bark
Estrogenic: Black Cohosh
The formula would help this woman's hypertension, perimenopausal complaints, arthritic joints, and it would help her to rest better and feel calmer throughout the day. 
Simultaneously, it would strengthen and protect her heart and vessels from the long-term stress of hypertension. Herbalists use the fact that one plant can have three, 
four, or more actions on the body. Although this often seems to frustrate pharmacists and physicians, many physicians often choose pharmaceutical medications in a 
similar fashion. When deciding what antidepressant to prescribe, a physician may choose the drug amitriptyline instead of fluoxetine for an depressed individual who 
is suffering with neurogenic pain. Fluoxetine is probably better suited for an obese individual with depression and an eating disorder. Herbalists and physicians both 
should attempt to know their materia medica so well that they know the intricacies of each substance they prescribe.
THERAPY AND OUTCOMES
Treatment Evaluation
Most people evaluate treatment effectiveness by the way they feel when taking an herb. Most herbalists believe that the longer the condition has existed, the longer it 
will take to restore balance or cause change within the body. Clients who are placed on “tonifying” herbs are commonly told that they should notice some change 
within 8 to 12 weeks. In other conditions, such as constipation and insomnia, relief may be seen in a few days. Again, because herbalists mainly treat common 
complaints and chronic disorders, treatment assessment is based on the reports of symptom reduction and improved quality of life from the client. If the client presents 
complaining of migraine headaches, treatment efficacy is determined by the individual's report of change in frequency, intensity, and duration of headaches. If suitable 
results are not obtained, the herbalist usually will modify the formula.
S
CIENTIFIC
 V
ALIDATION
For the past 40 years, researchers have been interested in trying to isolate the “active” constituent of a plant, which can then be studied using the same methods 
applied to the study of other chemical compounds. As a result, the exact mechanism of action for a number of plants has been elucidated and the understanding of 
phytomedicines expanded. This field of research, appropriately termed  phytochemistry, is growing in many European countries. As science validates the use of herbal 
medicine, a revival of interest has occurred in both Europe and the United States. With the ability to standardize herbs—that is, to accurately measure the exact 
percent of active constituents within a herbal product—a new range of herbal medicines is now available to the public. Many practitioners feel more confident 
recommending a product if they know the exact amount of the active principle and the number of milligrams that should be prescribed daily.
As can be seen from the forgoing example, however, it may be impossible to elucidate the mechanism of action of a particular plant by analyzing all its active 
constituents in an isolated form on multiple conditions. Most plants contain hundreds of constituents that may be acting in concert, not individually, to create the 
physiological effects in those consuming them. Clinical trials that study the whole plant's activity, accounting for nature's complexity and effects on several outcomes, 
must be designed. This requires a shift of thinking in Western research—a movement away from the reductionist approach, looking at herbs as complete products in 
which the “whole is more than the sum of its parts.” The study of herbal compounds, many of which contain 7, 10, or even 20 different herbs, has been even more 
difficult. Herbal practitioners believe that phytomedicines work synergistically and that through proper combination, the effect of a group of plants is more significant 
than the use of a single herb. Again, clinical trials must be conducted to evaluate the herbal “mixtures,” without becoming overly fixated on identifying and evaluating 
each single active principle.
Little research on herbal medicine is conducted in the United States. Drug therapeutics in the United States is powerfully influenced by a large pharmaceutical 
industry, with the primary goal being the ability to create and market synthesized, patentable, highly active chemicals that affect the body in a specific way. Medicine 
that cannot be patented cannot obtain the multimillion dollar investment required for research, regardless if the substance works (
8
). Unfortunately, many herbs that 
have been used effectively for centuries by herbalists and the public remain “unproven,” which many professionals incorrectly equate as “ineffective.”
Most of our current research on herbal medicine is coming from Europe and Asia, where there are far fewer political, economic, or regulatory reasons for rejecting 
traditional (i.e., phytomedicinal) remedies. These countries deem it important to scientifically explore natural therapies, embracing or rejecting them as the data 
indicate (
8
). The German Commission E Monographs are a good example of the current research conducted on phytomedicinal remedies. These monographs provide 
proper identification, therapeutic use, expected side effects, and safety issues of more than 100 plants. Although traditional use and medical experience is important, 
it is clear that we cannot rely solely on the fact that a plant was used in a certain way by Dioscorides 1000 years ago. According to Heinz Schilcher, “Uncritical 
acceptance of traditional reports and ancient herbals used as a revived materia medica will do more harm than good to the cause of phytotherapy” (
9
). He also states, 
“Phytotherapy in particular is a field where medical and pharmaceutical historians found much to surprise them. Tracing traditions back to their source revealed not 
only errors in passing on information. More often than not a plant name used today referred to a completely different species in antiquity or the Middle Ages. Exact 
botanical identification and description of the medicinal plant in question was the exception rather than the rule” (
9
).
Description of Treatment: Herbal Therapeutics
Herbal medicine can be used to treat, augment treatment, or alleviate side effects of allopathic medicines for most conditions other than serious acute illness. The 
following five herbs are but a few examples of some of the more popular plants and the research behind them. These herbs can help treat the following conditions: 
depression, anxiety, muscular tension, restlessness, insomnia, hypertension, cardiac insufficiency, upper respiratory infections, poor wound healing, sluggish immune 
system, intermittent claudication, impaired mental function, peripheral vascular insufficiency, vascular and Alzheimer's dementia, vertigo, macular degeneration, and 
Raynaud's syndrome.
S
T
. J
OHN
'
S
 W
ORT
St. John's wort (Hypericum perforatum) has received a great deal of attention lately from the media. A meta-analysis of 23 clinical trials conducted on more 1757 
outpatients with mild-to-moderate depression was published in the  British Medical Journal in 1996, showing that St. John's wort extract was more effective than 
placebo and equally as effective as standard synthetic antidepressants (
10
). Following this publication, many health care practitioners in the United States have been 
more willing to use St. John's wort in the management of mild-to-moderate depression. Although the herb has been classified by the  German Commission E 
Monographs as a monoamine oxidase inhibitor, newer studies suggest that the plant's main antidepressant effect may also be through serotonin reuptake inhibition 
(
11
). In addition to the plant's antidepressant effects, it also possesses antiretroviral activity in both in vitro and in vivo studies. It appears that hypericin and 
pseudohypericin interfere with the development of viral components and also directly inactivate mature retroviruses (
12
). This is being investigated for its possible 
benefit for patients with HIV. In most of the studies for depression, the dose of St. John's wort was 300 mg taken three times daily, with products standardized to 
contain 0.3% hypericin (
13
). Pediatric dosage for children 6 to 12 years of age is 250 mg daily of standardized product (
14
). Occasionally patients experienced 
gastrointestinal side effects. In light-skinned people who are sensitive to the sun, photosensitivity is a theoretical side effect. In general, St. John's wort is well 
tolerated and quite effective for the treatment of depression. Caution is needed when used with other psychoactive drugs, such as antidepressants and sedatives.

K
AVA
 R
OOT
Kava root (Piper methysticum) is found throughout the South Pacific islands, where it has been used as a slightly intoxicating, nonalcoholic beverage for thousands of 
years. The plant is used socially, medicinally, and ceremonially. Several clinical trials have demonstrated kava's effectiveness in easing stress, anxiety, and 
restlessness (
15
). The plant has also been used as a mild muscle relaxant and analgesic (
16
). The muscle-relaxing effects of kava are believed to be of supraspinal 
origin (
17
), and analgesia does not operate through opiate pathways because its effects are not reversed by naloxone (
18
). The exact mechanism of action is still not 
well understood and the active constituents not completely identified. The limbic system appears to be inhibited by the kavapyrones present in the root, with an 
associated dampening of emotional excitability and a definite enhancement of mood and clarity of thought (
19
). Kava has also been demonstrated to increase deep 
sleep without affecting REM sleep (
19
). Kava is a viable option in the treatment of anxiety and muscle tension before turning to benzodiazepines and the tricyclic 
antidepressants for easing anxiety and reducing muscle tension. Sedation is not seen in the therapeutic doses recommended (
20
). There are minimal side effects 
associated with the use of the root. Weight loss and a reversible skin condition known as kava dermopathy have been reported in long-term users who consume very 
high doses (
21
).The usual dose is 200 mg three times daily. Caution is needed when used with other sedatives and psychotropic medications.
E
CHINACEA
Echinacea (Echinacea spp.) is another popular herb in the United States and Europe. The plant is indigenous to North America and is widely exported to Europe for 
its medicinal uses. Echinacea is used as a stimulant to the immune system and is used for its antiviral effects. The plant's action upon the immune system is 
nonspecific and works primarily via the cell-mediated branch. There is an increased level of activity amongst macrophages and lymphocytes, and numbers of 
granulocytes are increased in the blood (
22
). The polysaccharides found within echinacea stimulate the secretion of tumor necrosis factor, interferon, and interleukin 
1 (
23
). The arabinogalactans found within the roots of  Echinacea purpurea have distinct antiviral properties. Echinacoside has bacteriostatic properties, whereas 
echinacin B promotes tissue granulation (
24
). Echinacea is a suitable herb for cold and flu-like symptoms. Physicians are reluctant to hand out antibiotics for obvious 
viral infections, yet there is tremendous pressure placed on the doctor to give something to the person who suffers such symptoms. Echinacea is an excellent 
recommendation. It stimulates the body's natural defense system and helps fight off viral infections both by direct means and through the stimulation of interferon. A 
meta-analysis of six double-blind, placebo-controlled and randomized studies showed an improvement in symptoms and decreased length of upper respiratory illness 
when echinacea was given. Echinacea for the prophylaxis of upper respiratory infections also showed positive results (
25
). Echinacea is well tolerated and there are 
few adverse reactions when applied topically to promote the healing of wounds or taken orally. The  German Commission E Monographs state that echinacea is 
contraindicated in those with “progressive systemic disease states, eg. tuberculosis, leukosis, collagenosis, multiple sclerosis, AIDS, HIV infection, and other 
auto-immune diseases” (
26
) because of its immune-stimulating properties. A few adverse effects have been reported. The usual dose for echinacea is 900 mg of the 
root extract, 2 to 4 times a day. Echinacea can be used for treating both children and adults.
H
AWTHORN
Hawthorn (Craetagus spp.) is a herb commonly used for the treatment of mild cardiac insufficiency (Stages I and II per the New York Heart Association classification), 
angina, and the aging heart that does not yet require a cardiac glycoside (
27
). The flavonoids and oligomeric procyanadins are believed to be the “active” 
constituents, but there are conflicting opinions about this (
27
). Hawthorn has positive inotropic, dromotropic, and chronotropic effects and negative bathmotropic 
effects upon the heart (
27
). Thus, it increases contractility, slightly increases heart rate, increases conduction velocity, and lessens the nervous-muscular irritability of 
the heart. The ability of hawthorn to dilate blood vessels, especially the coronary vessels, increases blood flow to the heart tissue and reduces peripheral vascular 
resistance. This mechanism is, in part, mediated through the inhibition of cAMP phosphodiesterase (
28
). The plant also reduces blood pressure and exerts 
angiotensin-converting enzyme activity (
29
). The antioxidative properties probably afford the heart a cardioprotective effect with prolonged use (
30
). Herbalists 
routinely recommend Hawthorn for those who have cardiac risk factors but are not yet on medication, and for those with mild hypertension. Hawthorn is considered a 
cardiac tonic, strengthening the heart and vascular system over time. The dose when standardized to hyperoside is 12 to 15 mg daily, or 300 to 900 mg of dried 
extract. When the product is standardized to the oligomeric procyanidin content, the dose is 45 to 90 mg daily, or 240 to 560 mg of dried extract. Hawthorn should be 
taken for at least 6 weeks and is best when given in two to three doses daily (
31
). If using the tincture of hawthorn fruit, flower, or both, the usual dose of a 1:3 tincture 
(1 kg of herb to 3 liters of water/alcohol) is 5 mL, taken 2 to 3 times daily. Caution is needed if used with other cardioactive drugs, such as digitalis.
G
INKGO
Ginkgo biloba comes from the leaves of the gingko tree, and it has been used and written about in the Orient for over 2000 years. The leaves have been studied for a 
wide number of indications, including dementia, poor memory, difficulties with concentration, cerebral insufficiency syndromes (including dizziness, headache, and 
tinnitus), intermittent claudication, Raynaud's syndrome, and asthma. The pharmacology of ginkgo is only partially understood. Ginkgo is an inhibitor of 
platelet-activating factor (PAF), which helps reduce platelet aggregation and plays a role in reducing the bronchoconstriction that accompanies asthma (
32
). Ginkgo 
also appears to have antioxidant properties, preventing lipid peroxidation, which may serve to protect vascular walls (
32
). Ginkgo inhibits catecholamine O-methyl 
transferase (COMT) and appears to stimulate the synthesis of serotonin receptors (
32
). This probably explains the subjective improvement in mood among elders who 
may have decreased serotonin receptors (
33
). Ginkgo prolongs the half-life of endothelium-derived relaxing factor (EDRF) (
34
), resulting in dilation of the arterial bed 
and improved peripheral circulation. A randomized placebo-controlled study found Ginkgo to be effective in increasing the pain-free walking distance in those 
suffering from intermittent claudication and peripheral arterial occlusive disease (
35
). A study published in Lancet in 1991 reviewed some of the clinical studies that 
evaluated the use of Ginkgo in cases of cerebral insufficiency. Several of the better designed studies showed an improvement in 8 of 12 symptoms: tiredness, anxiety, 
dizziness, tinnitus, headache, difficulties with concentration and memory, confusion, and lack of energy (
36
). In addition, several small trials have shown Ginkgo to be 
useful in the treatment of vertigo (
37
) and macular degeneration (
38
). There is no doubt that Ginkgo has a role to play in the health of an aging population. The plant 
is relatively free of side effects; however, it should be used with caution in combination with other antiplatelet agents (e.g., aspirin, garlic) because bleeding time can 
be prolonged. Almost all of the clinical studies have used products standardized to 24% ginkgoflavonoids and 6% terpenes; the dose ranges from 40 to 80 mg three 
times daily. Side effects are usually dose-related, and most people can safely use doses of 120 mg daily.
Other Herbal Preparations
In addition to the herbs just described, there are several other herbal preparations that are valuable in treating several common conditions and of which practicing 
physicians should be aware. The best summaries of the following information are in Murray's  The Healing Power of Herbs (1995, Prima Publishing) and Newall, 
Anderson, and Phillipson's  Herbal Medicines: A Guide for Health Professionals (1996, The Pharmaceutical Press).
G
ARLIC
A number of studies have documented the effects of garlic, including antimicrobial and antineoplastic effects, cholesterol- and blood pressure-lowering effects, and 
inhibition of platelet aggregation. Stability, quality control, and standardization of the content of several active ingredients is variable from product to product, however, 
making treatment effects unpredictable. In general, 900 mg/day of a 1.3% alliin content product may have cardiovascular prevention effects. Caution is needed with 
other antiplatelet and anticoagulants so as not to precipitate bleeding.
G
INSENG
As with garlic, a considerable amount of research has been conducted on the multiple effects of ginseng. Because of these multiple effects and the variability of 
products derived from multiple sources (for both panax and eleutherococcus ginseng) and prepared in various ways, the reliability of these effects in actual practice is 
quite unpredictable. Panax ginseng is most often used as an “adaptogen” or tonic for increasing the body's resistance to stress and fatigue, to increase endurance 
under heavy physical activity, or to improve well-being in age-related debilitation. One of its actions is stimulation of adrenocorticotropic hormone (ACTH) from the 
pituitary, which in turn influences a variety of hormone levels. The usual dosage for younger individuals is between 500 and 1000 mg of the panax root, taken on an 
empty stomach in divided doses. This is usually continued for two to 3 weeks, with a 2-week break between courses. For sick and debilitated elderly, the 
recommended dosage is 400 to 800 mg/day continuously. Ginseng may interact with MAO inhibitors, stimulants (e.g., coffee, antipsychotics), and sex hormones. 
Those with hormone-sensitive tumors (e.g., prostate, breast) should probably avoid its prolonged use. In addition, prolonged use of high doses of ginseng has been 
reported to produce a “ginseng abuse syndrome,” characterized by hypertension, euphoria, insomnia, nervousness, skin eruptions, and diarrhea (
39
).
S
AW
 P
ALMETTO

In contrast to garlic and ginseng, which have multiple effects and indications, saw palmetto is claimed to be useful for one primary indication—benign prostatic 
hypertrophy (BPH). The fat-soluble extract of the berries inhibits the conversion of testosterone to dihydrotestosterone (DHT) and has been reported to have 
antiandrogen and estrogenic effects. Placebo-controlled trials and direct comparisons with finasteride (Proscar) report significant reduction in BPH symptoms without 
reduction in prostate size. The dosage is 160 mg, twice daily, of the extract standardized to 85–95% fatty acids. Although few side effects are reported, given its 
antiandrogen and estrogenic effects, prolonged use may interact with hormone replacement therapy and affect hormone-sensitive diseases.
M
ILK
 T
HISTLE
Milk thistle, or  Silybum marianum, has been studied extensively in animals and humans for its hepatotoxic protective effects against various toxins, including alcohol. 
It appears to prolong life in advanced alcoholic cirrhosis and limit hepatic damage from viral hepatitis. The dosage is 140 mg of the standardized extract three times a 
day.
Concluding Remarks on Herbal Preparations
A number of other herbs have shown promising data on the importance of phytomedicine for common public health problems. Among these are:
Feverfew for prophylaxis of migraine headache
Ginger for motion sickness, nausea, and vomiting
Green tea for prevention of carcinogenesis
Valerian for improving sleep problems and anxiety, and to assist patients in withdrawal from dependency on benzodiazepines
Gugulipid for the reduction of cholesterol
Peppermint for the treatment of tension headache
Mistletoe for improving quality of life in cancer patients
Horsechestnut for the treatment of venous insufficiency
Evening primrose oil for the treatment of eczema, hyperactivity, and premenstrual syndrome
Learning about these herbs and their use, indications, contraindications, safety profile, drug-herb interactions, production character, dosing, side effects, and safety 
profile can help the practitioner to properly communicate with their patients about them. (See