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MEDICAL HERBALISM THE SCIENCE AND PRACTICE OF HERBAL MEDICINE DAVID HOFFMANN, FNIMH, AHG author of The Complete Illustrated Holistic Herbal MEDICAL HERBALISM MEDICAL HERBALISM The Science and Practice of Herbal Medicine David Hoffmann, fnimh, a hg G Heai„ . gAj Healing Arts Press One Park Street Rochester, Vermont 0S767 www.InnerTraditions.com Healing Arts Press is a division of Inner Traditions International Copyright © 2003 David Hoffmann All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or me- chanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Note to the reader: This book is intended as an informational guide. The remedies, approaches, and techniques described herein are meant to supplement, and not to be a substitute for, professional medical care or treatment. They should not be used to treat a serious ailment without prior consultation with a qualified health care professional. Library of Congress Cataloging-in-Publication Data Hoffmann, David, 1951- Medical herbalism : the science and practice of herbal medicine / David Hoffmann, p. ; cm. Includes bibliographical references and index. ISBN-978-089281749-8 (hardcover) 1. Herbs—Therapeutic use. 2. Medicinal plants. [DNLM: 1. Phytotherapy—methods. 2. Holistic Health. 3. Plants, Medicinal. WB 925 H711m 2003] I. Title. RM666.H33H6444 2003 615'.321—dc22 2003017536 Printed in India 10 9 8 7 6 Text design and layout by Priscilla Baker A Traian as display typefaces This book was typeset in Janson, with Agenda a DEDICATION For Lois Stopple, What can I say, after 600 odd pages (odd pages indeed), I'm tongue tied! You have healed me heart and soul, with the celebration of life and joy that you are. This book may have been written by me, but it was midwifed by you. Sweet blossom come on under the willow We can have high times if you'll abide We can discover the wonders of nature Rolling in the rushes down by the riverside She's got everything delightful She's got everything I need A breeze in the pines in the summer night moonlight Crazy in the sunlight, yes, indeed —THE GRATEFUL DEAD (WHO ELSE ...) ACKNOWLEDGMENTS My deepest appreciation to Cheri Quincy, DO, for the continuing encouragement and support. Thank you for your confidence in me, even when I couldn't even spell the word! It is with love and gratitude that I acknowledge my friends and colleagues in the North American community of herbalists for making this escapee from Thatchers' Britain so welcome. The ideas in this book have been gestating over the years in discussions with many, many herbalists. The U.S. herb world is blessed with an at- mosphere of openness and mutual support that is unique and deeply nurturing. We can thank Rosemary Gladstar for so very much . . . There is so much I could say to each of you, so I'm copping out and simply "naming names." No special order, I love you all: Cascade Anderson-Geller, Paul Bergner, Jane Bothwell, Mark Blumenthal, Don Brown, Ryan Drum, Rosemary Gladstar, Mindy Green, Christopher Hobbs, Tori Hudson, Feather Jones, Gail Julian, Kathi Keville, Tierona Low Dog, David LaLucerne, Rob McCaleb (and everyone at the Herb Research Foundation), Anne Mclntyre, Terence McKenna, Bill Mitchel, Pam Montgomery, Rob Montgomery, Michael Moore, 7 Song, Ric Scalzo, Ed Smith, Sara Smith, Paul Stamets, Jill Stansbury, Autumn Summers, Jonathan Treasure, Gail Ulhrich, Roy Upton, Marty Wall, David Winston, Linda Wolf, Tom Wolf, Matthew Wood, Dusty Yeo. This book is much better than it deserves to be because of the superlative guidance of herbalist/editor ex- troadinaire Evelyn Leigh. Thank you for being so knowledgeable, insightful, literate, and understanding of this aging deadhead. You made the process pleasant, rewarding (or is that rewording?), and even entertaining. To Jeanie Levitan, the first editor to give me her toothbrush! All authors should hope to be blessed with guidance from someone with your erudition and warmth. To Jamaica Burns for editorial help above and beyond the call of duty. Sorry about the obscure Chinese citations. I want to thank the many groups of students I have had the honor of working with over the years. You all know who you are. In case you've forgotten, you went to one (or more!) of the following institutions: the California School of Herbal Studies, the Rocky Mountain Center of Botanical Studies, Bastyr University, National College of Naturopathic Medicine, California Institute of Integral Studies, and the National College of Phytotherapy. Sonoma County reference librarians have been a great help during the writing of this book. What would we do without libraries? To Sasha Shulgin, Grant Morrison, Hakim Bey, Jerry Garcia, and Ozric Tentacles for the help with sanity maintenance (and furtherance . . .). CONTENTS c^V, Introduction Part One INTRODUCTION TO PRINCIPLES AND PRACTICES 1. Herbs, Holism, and Science 6 Science and Phytotherapy, 17 • Pharmacognosy and Ways to Assess Herb Quality, 19 • The Conservation of Medicinal Plants, 26 2. Classification of Medicinal Plants 30 The Linnaean System of Classification, 32 • Derivation of Botanical Names, 33 3. An Introduction to Phytochemistry 36 Primary and Secondary Plant Metabolites, 37* Commonly Used Terms and Concepts, 40 4. Carbohydrates 41 Monosaccharides, 42 • Polysaccharides, 43 • Glycoproteins, 47 • Glycosides, 48 • Gums and Mucilages, SO 5. Lipids 54 Fatty Acids, 54 • Lipids Containing Glycerol, 58 6. Terpenes 62 Monoterpenes, 62 • Iridoids, 66 • Sesquiterpenes, 67 • Sesquiterpene Lactones, 69 • Diterpenoids, 71 • Saponins, 74 • Triterpenoid Saponins, 79 • Cardenolides and Bufadienolides, 83 • Phytosterols, 83 • Nortriterpenoids, 84 • Plant Exudates, 85 • Resins, 85 • Oleoresins, 86 • Balsams, 87 • Gum Resins, 87 7. Polyphenols 90 Simple Phenols and Phenolic Acids, 92 • Phenylpropanoids and Cinnamic Acids, 94 • Coumarins, 95 • Quinones, 96 • Xanthones, 99 • Stilbenoids, 99 • Flavonoids, 100 • Flavones and Flavonols, 101 • Isoflavonoids, 106 • Flavanones, 107 • Dihydrochalcones, 107 • Biflavonoids, 108 • Lignans and Neolignans, 112 • Tannins, 114 8. Alkaloids 120 Pyrrolidine and Piperidine Alkaloids, 122 • Tropane Alkaloids, 122 • Pyrrolizidine Alkaloids, 123 • Purine Alkaloids, 124 • Isoquinoline Alkaloids, 125 • Indole Alkaloids, 127 • Ergot Alkaloids, 127 • |3-carboline Alkaloids, 128 • Quinoline Alkaloids, 130 • Quinolizidine Alkaloids, 130 • Diterpenoid Alkaloids, 130 • Steroid Alkaloids, 131 • Miscellaneous Alkaloids, 131 9. Pharmacology 134 Pharmacodynamics, 135 • Phytoestrogens, 142 • Pharmacokinetics, 144 • Immunomodulators, 152 • Inflammation and Anti-Inflammatory Agents, 154 • Cancer and Plant Constituents, 159 • Antiviral Agents, 164 • Antioxidants and Free Radical Scavengers, 165 • Cardiac Glycosides, 168 • Nonsteroidal Cardioactive Plant Constituents, 169 • Cholesterol and Lipid-Lowering Activity, 170 • Hypertension and Hypotensive Agents, 171 • Platelet Function and Cardiovascular Disease, 173 • Herbs and the Liver, 175 • Hypoglycemic Agents, 178 10. Toxicity, Contraindications, and Safety 186 Evaluating Causality in Adverse Events, 187 • Toxicology, 192 • Oxalic Acid, 198 • Terpenes, 199 • Glycosides, 199 • Polyphenols, 200 • Alkaloids, 202 • Polypeptides, 205 • Lectins, 206 • Photosensitivity, 209 11. The Formulation and Preparation of Herbal Medicines 216 Herbal Medicines, 216 • Infusions, 219 • Decoctions, 221 • Tinctures (Tincturae), 223 • Fluid Extracts (Fluid Extracta), 224 • Syrups, Elixirs, and Emulsions (Emulsiones), 225 • Juices (Succi), Linctuses (Lincti), Mucilages, and Oxymels, 226 • Waters (Aqua), 227 • Capsules, Pills, and Tablets, 227 • Lozenges (Trochisci) and Pastilles (Pastilli), 228 • Baths (Balneotherapy), 228 • Douches and Enemas, 229 • Ointments and Suppositories, 230 • Liniments, 231 • Gargles (Gargarisma) and Mouthwashes, 231 • Inhalants (Vapors) and Spray Solutions (Nebulae), 231 • Oils, 232 • Compresses and Poultices, 232 • Incompatibility , 232 Part Two TREATMENT APPROACHES BY BODY SYSTEM 12. A Model of Holistic Herbal Medicine 236 Phytotherapeutic Selection Criteria, 237 • Dosage and Formulation Criteria, 252 • Outline of Treatment Chapters, 256 13. The Digestive System 258 Flatulence, 262 • Constipation, 263 • Laxatives, 264 • Diarrhea, 266 • Aphthous Ulcers, 267 • Periodontal Disease, 268 • Esophagitis and Gastroesophageal Reflux, 269 • Gastritis, 271 • Peptic Ulcers, 272 • Hiatus Hernia, 274 • Functional Dyspepsia or "Indigestion," 275 • Irritable Bowel Syndrome, 276 • Inflammatory Bowel Disease, 279 • Ulcerative Colitis, 279 • Diverticulitis, 280 'Jaundice, 283 • Chronic Hepatitis, 283 • Viral Hepatitis, 285 • Cirrhosis, 286 • Cholecystitis, 287 • Cholelithiasis, 288 • Hemorrhoids, 289 14. The Cardiovascular System 291 Tonics for the Cardiovascular System, 292 • Cholesterol, 300 • Hypertension, 302 • Arteriosclerosis, 307 • Congestive Heart Failure, 309 • Angina Pectoris, 310 • Peripheral Arterial Occlusive Disease, 311 • Varicose Veins, 312 15. The Respiratory System 316 Coughs, 322 • Acute Bronchitis, 323 • Chronic Bronchitis, 326 • Pertussis, 329 • Asthma, 330 • Emphysema, 334 • The Common Cold, 336 • Influenza, 338 • Hay Fever, 339 • Sinusitis, 340 • Laryngitis, 341 • Tonsillitis, 342 16. The Nervous System 344 Managing Stress: An Overview, 349 • Depression, 354 • Insomnia, 355 • Withdrawal from Benzodiazepines, 361 • Anorexia Nervosa, 363 • Headache, 364 • Migraine, 367 • Neuritis, 371 • Tinnitus, 372 • Motion Sickness, 373 • Shingles, 373 17. The Urinary System 375 Frequency, 377 • Dysuria, 378 • Hematuria, 378 • Edema, 379 • Cystitis, 379 • Urinary Calculus, 381 18. The Reproductive System 384 Emmenagogues, 385 • Amenorrhea, 386 • Dysmenorrhea, 387 • Premenstrual Syndrome, 388 • Menopause, 391 • Pregnancy, 393 • Herbs to Avoid During Pregnancy, 394 • Uterine Fibroids, 403 • Endometriosis, 404 • Fibrocystic Breast Disease , 405 • Benign Prostatic Hypertrophy, 406 19. The Musculoskeletal System 408 External Applications for Musculoskeletal Problems, 416 • Myalgia, 417 • Osteoarthritis, 418 • Rheumatoid Arthritis, 421 • Osteoporosis, 424 • Gout, 426 • Bursitis and Tendinitis, 427 • Restless Leg Syndrome, 428 20. The Skin 430 Herbs for Topical Application, 431 • Eczema and Dermatitis, 432 • Psoriasis, 435 • Acne, 438 21. The Immune System 441 General Support Protocols, 446 • Detoxification, 446 • Postoperative Recovery, 448 • General Guidelines for Treating Infection, 451 • Vaginitis, 452 • Prostatitis, 454 • Boils, 455 • Fungal Skin Infection, 455 • Cancer, 456 22. The Endocrine System 461 Hypothyroidism, 461 • Hyperthyroidism, 462 • Diabetes Mellitus, 463 • The Adrenal Glands, 465 23. Phytotherapy and the Elderly 467 Toning and Nurturing Health in Elders, 468 • Prevention and Treatment of Disease in Elders, 469 24. Phytotherapy and Children 473 Measles, 474 • Mumps, 474 • Colic, 475 • Constipation, 476 • Diarrhea, 477 • Indigestion, 477 • Nausea, 478 • Otitis Media, 478 • Attention Deficit Disorder, 479 • Diaper Rash, 480 • Cradle Cap, 481 • Impetigo, 481 25. Herbal Actions 483 Adaptogen, 483 • Alterative, 484 • Anticatarrhal, 485 • Anti-Inflammatory, 487 • Antimicrobial, 491 • Antirheumatic, 493 • Antispasmodic, 494 • Astringent, 496 • Bitter, 498 • Cardiac Remedies, 501 • Carminative, 502 • Cholagogue, 503 • Demulcent, 505 • Diuretic, 506 • Emmenagogue, 509 • Expectorant, 511 • Hepatic, 513 • Hypnotic, 515 • Hypotensive, 516 • Nervine, 517 • Stimulant, 519 26. Materia Medica 522 APPENDICES 1. Glossary 604 2. Selected Examples of Binomial Meanings 622 3. Herbs by Latin and Common Names 626 4. Pharmacy Terms 636 5. Weight and Measure Conversion 638 6. Herbal Information Sources 639 7. Taxonomy Hierarchy 646 Bibliography 652 Index 655 INTRODUCTION T his is an exciting and very challenging time to be herbal practice in 1978, I have seen that Western herbal involved in herbal medicine. There is a growing medicine is based upon a body of knowledge and experi- openness to the insights of clinical herbalism ence that has as much clinical value as any other field of from practitioners of other health care modalities, and a medicine. Thus the guidelines for protocol development plethora of peer-reviewed work on herbs being published given throughout the book are based firmly on this by the research community. Many new insights have been bedrock of Western herbalism. I have not rejected the put forth, and many traditional ideas are being reassessed clinical approaches of medical herbalism in favor of peer- and either rejected or embraced anew. reviewed research. Even acknowledging the wealth of Above all, this is a time of change for Western research occurring, there is not yet enough clinically rel- medicine, both holistic and orthodox. While herbs have a evant material to justify changing tried-and-true approaches, an issue that is explored throughout the book. unique and valuable contribution to make, no clear context has yet been defined for Western holistic medicine. The focus of the medicinal plant research commu- In such a rapidly evolving clinical and research milieu, a nity, however, is rarely on the protocols used in herbal book of this sort can at best serve as a building block, a medicine, but instead on the plants themselves as sources step on the road toward a more cohesive vision for the fu- of novel (and thus patentable) chemical structures. A dis- ture of Western holistic healing. quieting trend in North American herbalism is the ten- With this book I have endeavored to lay a foundation dency to be influenced by the marketplace and herbal for the skilled use of herbal medicine within a holistic fashion. I have made a point of avoiding such hype in the practice by bringing together the modern scientific treatment section of the book. The following statement, movement with traditional herbal practice. The book is made by the 19th-century Eclectic physician John King in writing about Grindelia squarrosa, is as relevant today as it intended for practitioners and students of medical herbal- was 100 years ago: ism, as well as practitioners of other modalities who are interested in the principles and practice of Western The fact is, that many physicians have a great proneness herbal medicine. to run after new remedies, especially when introduced A cursory look at the contents reveals two distinct under some pretentious name, and to place a marvelous sections of the book. credulity in the statements of interested parties, who are Part 1 surveys the scientific underpinnings of medical incapable of determining accurate conclusions as to the herbalism, the chemistry and pharmacology that may value of a remedy.1 help clarify the mechanisms of herbal activity and clinical Herbalism is a fundamentally conservative activity, al- efficacy. While this information may be unfamiliar and though I must say it is the only aspect of my life where challenging for many herbalists, I feel it is important for any trace of conservative tendencies will be found! traditional practitioners to have at least a rudimentary grasp of this subject as we move into the 21st century. Part 2 deals with the practical therapeutics of the OVERVIEW OF THE BOOK major body systems and the pathologies that affect them. PART 1 It is based on my own 25 years of clinical experience, the experience and knowledge accrued by the Eclectic and Chapter 1 Physiomedical physicians of the United States, and the Places Western herbalism in a philosophical, therapeutic, practices developed by the National Institute of Medical ecological, and multicultural context. This chapter intro- Herbalists in the United Kingdom. duces the relationship between science and herbal Despite the seeming dichotomy of these two major medicine, looking at the scientific method and the lan- sections of the book, I have attempted throughout to guage of research. A discussion of pharmacognosy is fol- marry biomedical theory with the clinical experience of lowed by a review of large-scale screening programs to as- the medical herbalist. As a clinician who began his own sess the therapeutic potential of the world's flora. The 1 2 INTRODUCTION importance of the conservation of medicinal plants and volved. The criteria for establishing dosage and formula- the work of organizations such as United Plant Savers is tion specifics are given, along with an outline of the struc- discussed. ture of the subsequent treatment chapters. Chapter 2 Chapters 13-24 Explores the diversity of medicinal plants through taxon- The therapeutic approach to each body system is ex- omy and the insights of the Linnaean system of nomen- plored in turn, focusing on prevention and wellness but clature—actually much more interesting than is often also addressing a range of conditions that may be ap- appreciated! proached herbally. Phytotherapeutic approaches to the health needs of the young and the elderly are also dis- Chapters 3-8 cussed. The holistic context is always emphasized. Where Plant chemistry is the basis of the therapeutic uses of lists or tables are given, the sequence of herbs reflects my herbs. In these chapters, I discuss the nature of primary opinion of relative importance. and secondary plant metabolites as a foundation for a re- I must emphasize that the suggested prescriptions are view of the main categories of constituents considered to NOT to be considered "herbal formulae." The impor- be of therapeutic importance. Each chapter includes an tance of their inclusion lies in the process of developing a overview of structure, botanical distribution, and general- treatment program that takes advantage of the strengths izations about pharmacology, followed by a discussion of of herbalism in addressing individual needs, not simply representative molecules described in the herbal litera- pathologies. I have emphasized the application of the ture. Important groups, such as sesquiterpene lactones, model and identification of any resulting patterns of rela- saponins, and flavonoids, are covered in depth. tionship between plant and pathology in an attempt to empower the reader as he or she faces clinical realities. Chapter 9 In practice, however, theory is often secondary to re- An introduction to the principles of pharmacology rele- ality. The suggested prescriptions come from personal vant to herbal medicine, covering the broad principles of observation of many herbally treated cases. Any conclu- pharmacokinetics and pharmacodynamics. Using herbal sions or ideas presented come from an interpretation of examples wherever possible, the chapter explores a range such observations and of the healing process in the peo- of pharmacological actions. ple who have honored me by allowing me to work with them. In instances where I have no solid foundation in Chapter 10 practice, I have referred to colleagues who do. An introduction to the basics of toxicology as they re- Chapter 25 late to issues concerning the safety and toxicity of medicinal plants. A discussion of contraindications and A review of the main herbal actions with an exploration of drug-herb interactions is followed by a review of toxic the mechanisms underlying their activity (where known). plant constituents. The primary herbal examples are given, along with a discussion of the other actions of these plants. Chapter 11 Chapter 26 Explores the formulation and preparation of herbal medicines. The various pharmaceutical forms are dis- An herbal materia medica, in the traditional sense, cover- cussed, with examples from official pharmacopoeias as ing 150 of the plants most commonly used in European well as folk medicine. and North American phytotherapy. A description of the structure used throughout these entries is presented at the beginning of the chapter. The traditional uses of the PART 2 plant are covered, along with relevant research data. Chapter 12 Appendices Presents a model of holistic herbal medicine that is ap- • Glossary of herbal, medical, and phytochemical terms. plied throughout the rest of the book, and describes the • Meanings of some Latin binomials. Here translations process of developing a protocol that addresses specific can be found into English of the meanings of the Latin pathologies while supporting the unique individual in- or Greek words used in botanical binomials.