Modern Phytotherapy - American Herbalists Guild

Modern Phytotherapy:
lntegrating Scie ntific Data and Methodology
with Traditional Herbal Practice
by Kerry Bone, FNIMH, FNHAA,
Many herbalists have reservations about the way scientific methodology and specifically evidence-based
medicine is encroaching on herbal practice. In many
instances, these are indeed valid concerns. UK herbalist Ned Reiter posted the following discussion point on
herbal medicine, a system best encompassed by the
term 'phfotherapy'. As such, phyotherapy defines a
new medical paradigm that combines the wisdom of
an ancient tradition with the cutting edge of current
research. However, scientific rigour must not be com-
the PToIPN Web site:
promised.
"Is Western herbai medicine becoming too scientific?
As the profession marches towards statutory regulation
there is a growing amount ofconventional research on
herbal remedies. Descriptions of herb actions are often
about herbs and herbal medicine contain misleading
information because of excessive extrapolation from
scientific publications, be they in vitro, animal or clinical studies, or because ofvague allusions to traditional use. While it is appropriate to speculate on new uses
made in terms reminiscent of allopathic drugs, and
many would like to see the justification of remedy
Kerry Bone
choice to be couched in the language ofpharmacology.
Are we in danger of losing, as it were, the 'art and soul'
Kerry Bone was an
experienced research and
industrial chemist before
studying herbal medicine in
the UK where he graduated
as a member
MCPP, A.H'G.
of the
National Institute of
l\,4edical Herbalists. He is
currently a practicing
herbalist, and Technical
Director of MediHerb.
His articles are regularly
published in Austraiia
and overseas in herbal
medicine journals.
ofherbal therapy - or is this a necessary modernization
and refinement of traditional herbal medicine?"
It may surprise many to learn that this debate is at least
130 years old. In 1865, a leading herbalist of the
Physiomedical school warned his colleagues "that the
old-fashioned methods of Dr Thomson cannot continue to be popular . . . changes are going on; and now the
practical question is, shall we cling tenaciously to
"changes are going on," "cling tenaciously" (to past
practices) and "turn the changes to our own advantage." Changes are going on: Herbs supported by sci-
entific evidence become very popular and are demanded by patients. We certainly need to rediscover our traditional roots, but does that mean we can cling tenaciously to the past? We should turn the changes (and
the scientific data) to our own advantage. I believe that
we can both honor tradition and incorporate science to
the advantage ofour clinical effectiveness.
In my preface to my recent book collaboration with
Simon Mills (Principles and Practice of Phl'totherapy)
I wrote (Mills and Bone, 2000):
"The authors of this book are (through our original
training in herbal medicine) steeped in the AngloAmerican tradition. But we also recognize the importance of the considerable scientific endeavour that has
been applied in recent times to the study of medicinal
plants. The successful blending of tradition with science is leading to a new robust system of Western
Spring/Summer 2O02
for herbs, such speculation should be
transparent.
Hypotheses should not be presented as fact and all
sources ofinformation, be they traditional or scientific, should be clearly cited. Anecdotal information that
has no traditional basis shouldbe heavily discounted."
The successful integration of science with tradition in
the practice of modern phytotherapy requires us to
define where science stops and when tradition starts. I
believe this is actually readily accomplished both from
a theoretical perspective and in practice.
a
course that will drive away our own friends, or shall we
turn the changes to our own advantage" (Berman and
Flannery, 2001). Phrases here that are highly relevant
to the current dilemma of modern herbal practice are:
34
If science is an integral part of phltotherapy, then it should be good science. Too many texts
There are three essential elements of any traditional
system of medicine, and western herbal medicine is no
exception. These are:
I
A belief in a vital energy or force which really does
the healing. The fundamental aim of any treatment
is to assist the healing power ofthe vital force.
2 An
acceptance
of the value of traditional knowl-
edge, in particular the knowledge
ofhow herbs
are
selected and prescribed for particular health issues.
3
Treatment of the patient as an individual case.
It is this last element, the emphasis on treatment of the
individual patient, which is most valuable in defining
where science should stop in the consulting room and
where traditional considerations should take over.
These days we hear a lot about evidence-based medicine (EBM). Historically, evidence in medicine (and
herbal medicine) was based on case sfudies and practitioner observation. EBM was pioneered by researchers
at McMaster University, Canada. They defined EBM
as the conscientious, explicit andjudicious use ofcurrent best evidence in making decisions about the care
of individual patients. EBM at its best combines the
integration of an individual practitioner's ability and
judgment based on practical experience with the best
available evidence from clinically relevant, and most
-n
I
particularly, patient-oriented research. EBM is not limited to randomized controlled clinical trials, although
it holds such sfudies in highest regard considering
them the 'gold standard'of modern medicine.
At first glance it
appears that EBM is centered on
treating the patient as an individual. But there is an
inherent flaw in its capacity to do so, because of its
heavy reliance on the "gold standard".
A key person in the planning of a clinical trial is the
statistician, whose role is to ensure that the probability
of a meaningful outcome is high. One way to achieve
this is to use large patient numbers. (In fact, the most
common criticism of clinical trials of herbal medicines
is that the patient numbers are too few.) A direct consequence of statistics is that the contribution from the
individual patient
is lost. Indeed, medical
abhors the unpredictable nature
science
of the individual, and
of statistical analysis is to neutralize the
effect of individual variations. The implications of this
can be best illustrated by some examples. If a clinical
trial gives a 70% success rate for a drug and a 40ok
success rate for placebo, and the difference is statistically significant, then a medical scientist would conclude the drug to be a successful featment for the condition in question. However, the treatment will fail for
thirty patients in every one hundred, and is therefore
unsatisfactory for these individuals. Why this might be
so cannot be answered by the current models of medical science. In another example, if the drug success
rate is 600/o and placebo success rate is 50%, and
patient numbers are not enough to show a statistical
significance, then the conclusion will be that the drug
has no value. But what if this difference between active
and placebo is in fact a valid reflection of the true situation? An effective treatment for ten individuals in
every one hundred will go undetected. So the 'gold
standard'ofEBM breaks down at the point ofpredicting the response ofan individual to a particular therapy. But this is where the traditional approaches should
be strong since they aim to understand the needs ofthe
individual. What is the constitutional approach other
than a method of individualization? Traditional techniques such as pulse, tongue, urine and more recently
iris diagnosis, all provide valuable information which
leads to the selection of a particular treatment.
Whether the approach used is energetics, humoral
medicine or astrology, it is all a process ofunderstanding the needs of the patient in front of you. So the
boundary between science and tradition is generally
when we come to the level of treating the individual.
Put in practical terms, science may tell us that eight
herbs are good for the liver, but traditional dictates can
guide us as to which of these eight herbs (if any) we
select for a particular patient.
one purpose
Lncrapcuiircs
The lmportance of Treating the Cause
When I was a student of herbal medicine in the UK,
the style of clinical teaching was generally by example. We would observe how our teacher approached the
various patients who presented at the training clinic.
Being cursed with an analltical mind
I
attempted to
arrive at an understanding of why the teacher was
selecting particular treatment approaches and resultant
herbs, with the aim of defining this unspoken system
which appeared to be followed. I concluded that the
teacher was generally trying to understand the cause of
the patient's health problems. The question which was
being asked at the outset and through all stages of
treatment was: "What is the cause of disease in this
individual?" As perception and understanding of the
patient's problem improved one came closer to the
'real' cause. Often there was a chain ofcausal events,
and the approach I observed was usually to treat all the
links in the chain which were amenable to treatment
and were active at the time of treatment.
Traditional constitutional approaches and diagnostic
techniques can provide information about causes, but
so can modern science. I feel that this is a particularly
valuable contribution which science has made to phy-
on
totherapy. Recent research
the organism
Helicobacter pylori, involved in peptic ulcers provides
severai useful illustrations of this point. Although
many now think that gastric ulcers are just an unluclcy
infection with this bug, research is now demonstrating
that stress could increase our susceptibility to infection
by this organism (and others) (Bosch et a1., 2000). So
the role of the organism becomes secondary and the
therapeutic focus should be on stress reduction. Many
patients with chronic skin diseases such as chronic
urticaria, pruritis and rosacea test positive for
Helicobacter and improve when the presence of this
microorganism is treated (Shiotani et al., 2001). Even
the hereditary version
of
angioneurotic edema
improves when Helicobacter ts erudtcaled (Farkas H et
a1.,2001). Treating the digestion to improve a chLronic
skin condition? They sound like herbalists!
There is a wealth of such scientific information which
can assist in providing treatment guidelines for otherwise perplexing conditions. Take autoimmune disease,
for example. Ever since my training as a
medical
herbalist I have maintained a particular interest in the
cause and treatment of autoimmune disease. The term
"autoimmune" is applied to a very wide spectrum of
human disease, sometimes tentatively. However, many
of these diseases tend to share common factors in their
pathophysiology.
Journal of the American Herbalists
Guild
35
In order to better treat autoimmune disease, it is necessary to have an understanding of its causes. This in
lurn would lead to a systematic approach to defining
the key causative and sustaining factors operating in
each case. For each individual it is likely that the
autoimmune process has been precipitated by a unique
and complex interaction of causative events. What we
therefore need is a multifactorial model which allows
us to individualize treatments, yet at the same time
takes into account the most likely factors operating in
each particular disease.
In
1986 two American scientists, Fred Westall and
Robert Root-Bernstein published a paper inthe Lancet
entitled "Cause and prevention of postinfectious and
postvaccinal neuropathies in light of a new theory of
autoimmunity" (Westall and Root-Bernstein, 1986).
The authors were most interested in the incidence of
postinfectious neuropathies such as Guillain-Barr6
syndrome, and postvaccinal neuropathies such as the
potential reaction to measles vaccination. But they also
linked this interest to a new theory about the development of autoimmunity in general. As far as I know this
paper did not cause much lasting interest in scientific
circles, but their theory provides the basis for a practi-
cal multifactorial model for the treatment of autoimmune disease.
The basic rationale for this theory comes from experi-
mental animal models of autoimmunity. Take, for
example, experimental allergic encephalomyelitis
If
(EAE), an autoimmune disease of the brain. myelin
basic protein (a brain protein) is injected into an animal it does not cause EAE, no matter how often it is
injected. The development of EAE only occurs when
the myelin basic protein is injected together with
Freund's complete adjuvant. Freund's complete adjuvant is a water in oil emulsion containing antigen in
the aqueous phase, in this case myelin basic protein,
and dead tuberculosis bacteria in the oil phase.
Extending this model to humans, their basic hypothesis was that three requirements must be met to induce
autoimmune disease:
There must be an antigen present which is the same
as, or similar to, some fragment of self-tissue. We
I
2
can call this the primary lesion.
There must be a second antigen which is chemically complementary to the first antigen (for EAE this
is the tuberculosis bacteria).
causes an inappropriate response to the first antigen.
Once this process is triggered it becomes self-sustain-
ing due to the inflammation and tissue damage which
occurs. (This aspect is known as the 'Hit and Run
Hypothesis' of autoimmunity.) This tendency for the
immune system to respond inappropriately can be
called a state of immune dysregulation. The immune
system is confused but this need not always be due to
a complementary antigen. is possible that other
It
of immune confusion.
Therefore in this adapted model we require a primary
lesion and a state of immune dysregulation to be operating at the same time.
inputs can cause
I
a
state
have used this model to great advantage in the treat-
ment of various autoimmune diseases. In particular it
emphasizes the role of infecting organisms (which
confuse the immune system by a phenomenon known
as molecular mimicry) and disordered bowel flora
(which can create a state of dysregulation of the
immune system). It also provides a rationale for the
of immune-enhancing herbs (actually a better term
in this context is immune modulating) such as echinacea (Echinacea sppi) for the treatment of autoim-
use
mune disease.
It is now recognized that molecular mimicry may be an
important factor in the etiology of autoimmune disease
(Shoenfeld and Isenberg, 1989). An immune reaction
directed against the microorganism cross-reacts with a
similar self-antigen.
Another example, the similarity between a Klebsiella
protein and HLA 827, and its implications for the
autoimmune disease ankylosing spondylitis, is supported by other considerable research. The incidence
of ankylosing spondylitis (AS) shows a high correlation with HLAB}7. More than 90% of patients with
AS are HLA B27-positive. Research has demonstrated
that a substantial proportion of patients with AS have
antibodies in their blood which react to the epitope
shared by HLAB27 and Klebsiella pneumoniae nrfrogenase (Schwimmbeck and Oldestone, 1989). Thete
was no reaction from antibodies in control subiects.
Moreover antibodies to Klebsiella, but not to other
bacteria, have been shown to be present in patients
with active AS by seven different techniques (Ebringer
and Cox, 1988). In this context HLAB27 may be the
Both antigens must be present and immunologically
active in the host al the same time.
self-antigen which is the site of the cross-reactivity.
The particular sites of inflammation in AS are also the
tissues which can express a relatively higher concentration of HLA B2l as a swface antigen.
I
have extended this theory by examining the role of
the second complementary antigen. The presence of
Dr Alan Ebringer of King's College Hospital, London,
decided to test this association clinically. Patients with
this antigen probably confuses the immune system and
AS were placed on a low starch and sugar diet, because
3
36
Spring/Summer 2Q02
Therapgeutilcs
it was postulated that this would reduce the number of
ter and their disease will be at least slowed down.
Klebsiella in the gut (Ebringer and Wrlson, 1996).
Most patients on this program had their disease
process halted, but the diet must be adhered to for at
Herbs can also be used in this way, although many are
too gentle to be of much use in this paradigm. Western
herbal therapeutics is based on a different paradigm
and we need more scientific research consistent with
this paradigm.
least six months.
Some additional examples of the association between
infection and the autoimmune destruction of tissue are
described below. This is not a comprehensive review
of
this topic. Guillain-Barr6 syndrome is viewed as
a
reactive, self-limited, autoimmune disease triggered by
preceding bacterial or viral infection. Campylobacter
a major cause ofbacterial gastroenteritis, is the
most frequent antecedent pathogen (Hahn, 1998). The
syndrome has also been linked to influenza vaccination in isolated instances (Ropper andVictoE 1998).
a
jejuni,
Patients with rheumatoid arthritis placed on a vegetarian diet for one year had a significant reduction in antiProteus mirabilis antibody levels which was correlated
with decreased disease activity (Kjeldsen-Kragh et al.,
1995). Patients with autoimmune tkombocy.topenia
(low platelet count) who also were positive for
Helicobacter pylori experienced a significant increase
in platelet count when the bacterium was eradicated
from their stomachs (Gasbarnni et al., 1998).
Eighty-nine per cent of patients with untreated celiac
disease were positive for the presence of human adenovirus serotype 12, an adenovirus isolated from the
human intestinal tracI, whereas the incidence in controls was 0 to 12.8% (Kagnoff et al., 1987). Amino
acid sequence homology (and potential for molecular
mimicry) was noted between a protein in gluten and
this virus. Infection with Coxsackie B viruses has been
linked to the development of insulin-dependent diabetes mellitus in children (Clements et a1., 1995).
Other viruses have been linked
to this
disorder
(Clements et a1., 1995).
A
case was reported of a woman who developed ulcer-
ative colitis during pnmary cytomegalovirus infection.
She subsequently developed chronic recurrent disease
(Lortholary et al., 1993). Retroviruses have been
implicated in the development of various autoimmune
diseases. For example, retroviral antibodies were
detected in patients with primary biliary cirrhosis and
other biliary disorders of unknown cause (Mason et
al., i998).
If
we must make the assumption that the normally
functioning human body is free from disease and capable of resisting disease, then it follows that a true
understanding of the cause and treatment of disease
should come from a consideration ofphysiology, the
normal functioning of the body, as well as pathology
and pathophysiology. An excessive focus on pathology
will
lead to a medical system which is interventionist
and directed towards compensating for the physiological deficiencies and imbalances which arise in disease,
without seeking a greater understanding of how they
arose in the first place. The basic strategy will be
superficial and short-term. This is increasingly the
orthodox medical system which we have today. While
it is a very useful system for advanced pathologies and
life-threatening states, it is incomplete.
In
contrast, those traditional medical systems which
are partially or completely based on herbal medicine,
concern themselves more with the underlying physio-
logical imbalances which led to and sustain the disease. As such they are more focussed on physiology
than pathology in that the treatment is aimed at physi-
ological support or correction, rather than just compensating for the chemical deficiencies or excesses
resulting from an abnormal physiology. The orthodox
approach of physiological compensation often requires
the constant presence of the medicine to achieve the
desired effect, whereas physiological support can, in
time, lead to a permanent correction of an abnormal
body chemistry
One group ofherbalists in the 19th century recognized
these considerations and, in an attempt to translate tra-
ditional herbal thinking into more modem concapts,
named their discipline'physio-medicalism'.
Obviously, other traditional herbal practitioners did not
and could not express their understanding ofphysiology in modern scientific theories, but this does not
detract from the value or elegance oftheir comprehension of the functioning of the human body.
A simple example of traditional
Promoting Health or Treating Disease?
Scientific information is a tool. Like a knife, how it is
used depends on the user. The current approach with
orthodox drugs is to treat disease using symptombased outcomes. The idea is if we chemically block
this or that process in the body the patient will feel bet-
versus orthodox, of
physiological support versus physiological compensation, can be seen in the treatment of bacterial infections. The traditional herbal approach is to support
immunify and to fine-tune the normal physiological
responses to infection such as fever. In contrast, the
orthodox approach is to suppress the fever and kill the
Journal of the American Herbalists
Guild
37
essential for
bacteria with antibiotics, thereby compensating for
It is important to note that synergy is not
weakened or overloaded bodily defences. The latter
approach has life-saving value, but will not prevent
infections from recurring. The traditional herbal
approach may see a higher rate of failure in acute situations, although this is debatable, but will lead to
justifuing the use of the plant as a whole; demonstration of additive effects from several different phytochemicals is sufficient to justify this. Which one do
improved immunity and a reduced rate of recurrent
infections. Clearly an important complementary role
for traditional herbal medicine can be argued.
The sort ofresearch which could improve our understanding ofthe physiological effects ofherbs is not difficult to do, because it requires administering herbs to
healthy people. Unfortunately there is little commercial imperative to undertake such research in the west.
Put another way, the best model for phytopharmacological research (research on whole herbs as medi-
you isolate as the drug ifthey all add to the effect?
The enhanced bioavailability of active phytochemicals
from whole plant extracts is one of the most compelling arguments for using plant extracts rather than
isolated chemicals. This most likely (and readily studied) example of synergy is where an inactive component(s) enhances the bioavailability of an active phytochemical(s). Established examples are:
kava lactones from Piper methysticum.
.
.
.
hypericin and pseudohypericin and OPCs from
Hlpericum.
daidzin from Pueraria lobata.
cines) is the 6-foot rat, i.e. you and I.
There are many opportunities
Science Can Provide Us
to
creatively devise
herbal research using human volunteers. Using this
kind of research many of the uncertainties are taken
into account, for example, extrapolation to the human,
bioavailabiliry dosage. Examples include:
. Pharmacokinetic and bioavailability studies.
. Ex vivo research on isolated cells. In this example
the person is given the herb and then cells such as
blood cells are removed from the person and studied
to ascertain if they have any different feafures to
those from someone who did not take the herb (that
is, a control).
Use of non-invasive techniques: EEG, ECG, ultrasound, PET:scans, polysomnography.
Change in physiological fi..rnction: hormone ievels,
urine output and quality, hepatic biotransformation,
immune function, gastric acid output etc.
Performance: memory, cognitive function, IQ,
With Better Tools
Herbalists can only be as good as the tools (the herbal
products) they use. Science has developed a system for
the manufacture of medicinal agents known as phar-
maceutical GMP (good manufacturing practice). I
believe that it is essential that herbal products are manufactured under pharmaceutical GMP. This is because
an herb is biologically rather than chemically defined
and:
.
.
.
may be incorrectly identified
may vary in chemical content
has a history and so may be contaminated with
unwanted substances
may be inappropriately assayed
processing may enhance or detract from quality.
Science Can Justify Our Existence
In addition, research can help us better understand the
complex quality issues for herbal products. The use of
standardized extracts is one controversial scientific
development which I have discussed in detail else-
You may say: "So what!" But the reality is that herbal-
where (Bone, 2001).
endurance, recovery.
ists operate in a competitive marketplace and many
patients are comforted by the knowledge that our med-
Conclusion
icines (at least some of them) are supported by scien-
Modern phl.totherapy is a flexible and all-inclusive
model which incorporates the best of traditional thinking and scientific information. The value of science
lies in using it as a tool within the philosophical constructs of the traditional herbal paradigm. In the context of herbal practice, science is a fwo-edged sword.
Without checks and balances, the wholesale incorporation of scientific methodology into herbal practice
could render it less than what it is today: a therapy
without a soul, devoid of insight and inspiration. In my
vieq the model of modern phytotherapy is the way
forward to re-establish the deserved prominence of
tific
evidence.
There are some aspects
of
research which many
herbalists agree are valuable. For example, a concept
often invoked by herbalists is synergy. Wth spergy,
the combined effect of two or more components is
greater than expected from their arithmetic combina-
tion. The opposite is antagonism. Additive
effects,
where several components are important for activity,
are likely to be more common in the context of phytopharmacology.
38
Spring/Summer
2OO2
herbalism as a self-contained therapeutic system. The
beauty of it is that none of the other approaches
described in this edition of the AHG journal are
excluded since they assist the all-important process of
treating the individual.
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