V. Schulz R. Kinsel V.E. Tyler

Rational Phytotherapy A Physicians' Guide to Herbal Medicine

Springer Berlin Heidelberg New York Barcelona Hong Kong London Milan Paris Singapore Tokyo

Volker Schulz Rudolf Hansel Varro E. Tyler

Rational Phytotherapy A Physicians' Guide to Herbal Medicine

Fourth edition, fully revised and expanded

With 90 figures and 50 tables

Springer

Prof. Dr. med. Volker Schulz Oranienburger Chaussee 25 13465 Berlin, Germany

Prof. Dr. rer. nat. Rudolf Hansel formerly Institut fur Pharmakognosie und Phytochernie der Freien Universitat Berlin Private address: WestpreuBenstraBe 71 81927 Munchen, Germany

Prof. em. Varro E. Tyler, Ph. D., Sc. D. Purdue University Present address: P.O. Box 2566 West Lafayette, Indiana 47996, USA

Translator: Terry C. Telger 6112 Waco Way Fort Worth, TX 76133, USA

ISBN-13: 978-3-642-98095-4 DOT: 10.1007/978-3-642-98093-0

e-ISBN -13: 978-3-642-98093-0

Library of Congress Cataloging-in-Publication Data Schulz. Volker, Prof. Dr. med. [Rationale Phytotherapie. Englishl Rational phytotherapy : a physician's guide to herbal medicine / Volker Schulz, Rudolf Hansel, Vano E. Tyler. - 4th ed., fully rev. and expanded. p. cm. Includes bibliographical references and index.

1. Herbs-Therapeutic use.!. Rudolf, Hiinsel, 1920- . II. Tyler, Vano E. III. Title. RM666.H33 S3813 2000 615.321-dc21

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Springer-Verlag Berlin Heidelberg New York a member of BertelsmannSpringer Science+ Business Media GmbH

© Springer-Verlag Berlin Heidelberg 2001

Softcover reprint of the hardcover 4th edition 2001

The use of general descriptive names, registered names, trademarks, etc. in this publications does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any infonnation about dosage and application contained in this book. In every individual case the user must check such infonnation by conSUlting the relevant literature.

Production: PRO EDIT GmbH, 69126 Heidelberg, Germany Typesetting: AM-productions GmbH, Wiesloch Printed on acid-free paper SPIN: 10757112 14/3133Re - 5 4 3 2 1 0

Preface to the Fourth German Edition

Rational Phytotherapy continues to add a truly significant dimen­sion to the practice of evidence-based herbal medicine. Prepara­tion of a new edition, so short a time after publication of the pre­vious English version, was necessitated by the rapid increase in the number of scientific and clinical studies attesting to the safe­ty and utility of phytomedicines. The results of these recent inves­tigations are now incorporated in the revised text of this volume.

Comprehensive, updated information on scientific studies and clinical trials of the therapeutically useful botanical drugs is now placed before interested readers worldwide.

Even the most CurS01Y acquaintance with phytotherapy, herbal treatment, botanical medicine - whatever you choose to call it -causes one to recognize that throughout most of the world, and especially in the United States and the United Kingdom, the prac­tice is at best still an imperfect art. In Germany, the use of plant drugs is a science. There are many reasons for this. Tradition can certainly not be discounted. However, the principal reason is, without question, the enlightened system of laws and regulations governing the sale and use of such products in that country.

Basically, the regulations in Germany permit phytomedicines to be sold either as self-selected or prescription drugs provided there is absolute proof of their safety and reasonable certainty of their efficacy. The words "reasonable certainty" are extremely important here. They require that some scientific and clinical evi­dence be provided prior to approval, but the requirements are not the same as would be necessary for a new chemical entity. Because patent protection is not ordinarily available for these ancient drugs, pharmaceutical companies are generally unwilling to invest the hundreds of millions of dollars required to prove them effective by the same standards applied to totally new, syn­thetic drugs. They are, however, willing to invest more modest amounts in the scientific and clinical testing needed to establish reasonable certainty of efficacy.

That has been and continues to be done in Germany. Data regarding safety and efficacy submitted to a special scientific body designated Commission E of the German Federal Health Agency (now the Federal Institute for Drugs and Medical Devices) have resulted in judgments validating the utility of several hundred dif­ferent phytomedicines. The brief summaries of these Commission

v

E findings, as well as its conclusions on about 100 different botan­icals that were not approved, were originally published in Ger­man in the Bundesanzeiger, the counterpart of the u.s. Federal Reg­ister, but they have now been published in English translation by the American Botanical Council in Austin, Texas. The Commission E monographs are based, in part, on proprietary information so, unfortunately, they are not referenced. If one wants to review the detailed information which they summarize - or to examine addi­tional studies conducted since their publication - one must seek elsewhere. Presentation and comprehensive analysis of such data, resulting from pharmacological studies in animals and, especially, from clinical trials in humans, is the unique dimension provided by this book.

Much of the knowledge contained in Rational Phytotherapy is not available in other English language publications. Summaries of the numerous clinical trials on some of the popular phy­tomedicines will astonish many readers who were not only unaware of the results but in many cases were unaware that such studies had even been conducted. There is, of course, a reason for this lack of awareness. Studies on the botanical, chemical, and pharmacological aspects of plant drugs are often published in English, even in journals originating in non-English speaking nations. Those that do appear in other languages are rapidly made available in summary form through such publications as Chemical Abstracts. German medical literature, on the other hand, is much less available to English-only readers. Yet it is in just this literature where many of the clinical studies on phytomedicines are published. In the United States, even those who can read Ger­man have considerable difficulty in locating the journals, many of which are often unavailable in major libraries. Relatively few of the pertinent articles are currently indexed on MEDLINE. Person­ally, I have always found it much easier to request photocopies of such medical studies from colleagues in Germany rather than to attempt to acquire them here in the United States.

Of the hundreds of medicinal plants used therapeutically today, a relatively small number account for a very large percent­age of the total sales. Just 10 of them account for some 55% of the sales in the United States. Interestingly, those enjoying the greatest popularity are those which, by and large, have been most thoroughly investigated. These are the ones that are discussed in detail in this book. The tables in the Appendix provide details on the popularity of both individual and combination phytomedi­cines in Germany.

Members of the conventional medical community who are skeptical about the utility of phytomedicines often base their skepticism on the lack of human clinical trials for such products or, more precisely, on their lack of knowledge of those trials that have been conducted. Now, by turning to the pages of this book,

VI Preface to the Fourth English Edition

they can letrn just exactly how many therapeutic trials have been carried iout with capsules or tablets of, for example, garlic pow­der, the total number of patients involved, the dosage used, whether the studies were controlled, double-blinded, and the results compared with those obtained from using placebos. In short, all of the necessary clinical data, with references, are pro­vided here in addition to sound scientific information on the botany, chemistry, and pharmacology of the herb itself.

All of the numerous books on herbs written previously lack one or more of these essential components. English-language vol­umes usually are deficient in clinical information on the herbs considered. The few which do present some clinical details neg­lect other necessary aspects of botanicals. In the truest sense of the word, the first English edition of Rational Phytotherapywas the world's first qualitatively complete, science-based herbal in the English language. That distinction continues with this revision.

It is my belief that the information presented in this volume will continue to have a considerable impact on the therapeutic use of botanicals in the English-speaking world. Physicians, phar­macists, lawmakers, regulators, scientists, and interested lay per­sons will no longer be able to disregard the scientific and clinical evidence supporting herbal utility simply by claiming ignorance of data available previously only in a foreign language. The evi­dence recorded on these pages strongly supports the safety and efficacy of a substantial number of herbs and should facilitate their increased use as desirable conventional drugs for the pre­vention and treatment of a variety of conditions, syndromes, and illnesses.

For far too long, the use of botanicals in English-speaking countries has depended largely on folklore, hearsay, and even gossip. Now the broad spectrum of scientific and clinical evidence supporting the use of may such products has been collected, summarized, presented, referenced, and updated in a concise, intelligible form. Rational Phytotherapy will, without questions, continue to be a significant landmark, a milestone of achieve­ment, in the development of phytomedical science and its appli­cation to human health.

West Lafayette, Indiana, U.S.A. Varro E. Tyler

Preface to the Fourth English Edition VII

Preface to the Fourth English Edition

In 1997, phytomedicines comprised approximately 5% of all pre­scription drugs covered by health insurance plans in Germany, with total sales of over $2 billion. Two-thirds of the prescriptions were for single-herb products, i.e., products that contained only one medicinal herb. Just five herbs accounted for 60% of these prescriptions, and 27 herbs accounted for more than 90%. This is surprising when we consider that Commission E of the former German Federal Health Agency evaluated the therapeutic use of some 400 medicinal herbs from 1982 to 1994 and recommended approximately 300 of them. Clearly, the prescriptions written by present-day physicians no longer reflect the rich historical diver­sity of herbal remedies. Of course, family doctors also counsel their patients with regard to self-medication, and this more than doubles the yearly consumption of the leading phytomedicines. Nevertheless, the total number of medicinal herbs that are still used to a significant degree in modern medicine are but a frac­tion of the traditional botanicals that have been presented and described in classic textbooks of herbal medicine.

Despite its characterization as an "alternative therapy" in a 1976 German drug law, phytotherapy is in fact a scientifically tested and proven treatment modality in which modern phar­macotherapy has its roots . As with any medication, our knowl­edge of the safety and efficacy of a phytomedicine improves as the medicine is used more frequently. In preparing this fourth edition, therefore, we again focused our attention on the herbal constituents and products whose safety and efficacy are based not just on tradition but also on modern scientific testing. We have added considerable material since the 1994 edition, includ­ing new results on clinical pharmacology and toxicology, espe­cially for products made from ginkgo leaves, St. John's wort, kava rhizome, valerian root, garlic, ivy leaves, artichoke leaves, peppermint oil , saw palmetto berries, devil 's claw root, and echinacea. Chapter 8 has been reorganized under the title "Skin, Trauma, Rheumatism, and Pain" and includes new information on the therapeutic use of evening primrose oil, peppermint oil, devil 's claw root extract, and capsicum (paprika) extract. At the same time, products that are rarely used or whose safety and efficacy are not adequately documented have been given briefer mention or omitted entirely.

IX

Combination products consisting of several medicinal herbs are particularly difficult to evaluate from a scientific perspective. Most of these products are derived from traditional herbal medi­cine. With few exceptions, we cannot draw conclusions on the additive or potentiating effects of their individual constituents based on comparative clinical studies. Nevertheless, we gave due regard to practical physician experience with these multi-herb products and included those products that are among the 100 most commonly prescribed herbal medications listed in Table A3 of the Appendix.

We express our sincere thanks to Mrs. Monika Schmidt, who oversaw the technical organization of the book from the comput­er manuscript to the page proofs, and to our wives, who served as patient "copyreaders" during the course of our work.

Berlin and Munich, July 2000

X Preface to the Fourth German Edition

V. Schulz R. Hansel

Table of Contents

1

1.1

1.2

1.3 1.3.1 1.3.2 1.3.2.1 1.3.2.2 1.3.2.3 1.3.2.4

1.4 1.4.1 1.4.1.1 1.4.1.2 1.4.1.3 1.4.1.4 1.4.1.5 1.4.2 1.4.2.1 1.4.2.2 1.4.2.3 1.4.2.4 1.4.2.5 1.4.3 1.4.4

1.5 1.5.1 1.5.1.1 1.5.1.2 1.5.2 1.5.3 1.5.4 1.5.5 1.5.6

Medicinal Plants, Phytomedicines, and Phytotherapy . . . . . . . . . . . . . . . . . . . . . .

Common Roots of Pharmacotherapy

Making Medicines Safer by Isolating and Modifying Plant Constituents . . . . . . . . . . .

Pharmaceutical Preparation of Phytomedicines .. What are Extracts? ..................... . Standardization of Extracts ............... . Quality of the Herbal material . . . . . . . . . . . . . . Production Methods . . . . . . . . . . . . . . . . . . . . . Adjustment of Quality . . . . . . . . . . . . . . . . . . . . Analytical Quality Control . . . . . . . . . . . . . . . . .

Phytomedicines .... . . . . . . . . . . . . . . . . . . . . Liquid Dosage Forms ................... . Tinctures, Glycerites, and Related Products . . . . . Syrups ............................. . Medicinal Oils . . . . . . . . . . . . . . . . . . . . . . . . . Medicinal Spirits ...................... . Plant Juices . . . . . . . . . . , . . . . . . . . . . . . . . . . Solid Dosage Forms .................... . Granules ............................ . Uncoated Tablets ...................... . Coated Tablets . . . . . . . . . . . . . . . . . . . . . . . . . Capsules ............................ . Lozenges ............................ . Packaging ........................... . Herbal Combination Products ........... . . .

Phytotherapy .................. . ...... . Pharmacologic Characteristics ............. . Therapeutic Range ..................... . Onset of Action . . . . . . . . . . . . . . . . . . . . . . . . Pharmacologic and Clinical Research ... . . . . . . Indications for the Use of Phytomedicines ..... What Physicians Require from Phytomedicines .. Hopes and Expectations of the Patients ...... . Benefits and Risks of Phytomedicines Compared with Other Therapies ........... .

1

1

2

4 5 5 6 6 7 8

9 9 9

10 10 11 11 11 12 12 12 12 13 13 14

16 16 16 16 17 19 20 22

23

XI

1.6 1.6.1

1.6.2 1.6.3 1.6.3.1 1.6.3.2 1.6.3.3 1.6.4 1.6.5 1.6.6 1.6.7 1.6.8

2

2.1

2.1.1 2.1.2 2.1.3 2.1.4 2.1.5 2.1.6

2.1.7

2.1.8 2.1.9

2.2 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.5.1 2.2.5.2 2.2.6 2.2.7 2.2.8

2.2.9 2.2.10

2.3 2.3.1 2.3.2 2.3.3

Medicinal Teas Today. . . . . . . . . . . . . . . . . . .. 25 Origin of the Word Tea. Medicinal and Nonmedicinal Teas ........... 25 Medicinal Teas and Their Actions .... . ...... 27 Various Forms of Medicinal Teas . . . . . . . . . . .. 30 Mixtures of Cut and Dried Herbs. . . . . . . . . . .. 31 Tea-bag Teas . . . . . . . . . . . . . . . . . . . . . . . . .. 31 Soluble Teas .......................... 31 Standard Approval for Tea Mixtures. . . . . . . . .. 31 Teas Compounded as prescribed by a Physician .. 32 Guidelines for Tea Preparation ............. 34 Teas for Infants and children. . . . . . . . . . . . . .. 35 Adverse Effects and Risks . . . . . . . . . . . . . . . .. 36

Central Nervous System. . . . . . . . . . . . . . . . .. 41

Ginkgo in the Treatment of Cognitive Deficiency .................. 42 Introduction .......................... 42 Botanical Description . . . . . . . . . . . . . . . . . . .. 43 Crude Drug and Extract .................. 44 Key Constituents, Analysis, Pharmacokinetics ... 44 Pharmacology and TOxicology . . . . . . . . . . . . .. 45 Clinical Efficacy in Patients with Cognitive Deficiency . . . . . . . . . . . . . . . .. 46 Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . .. 52 Therapeutic Significance . . . . . . . . . . . . . . . . .. 53 Drug Products . . . . . . . . . . . . . .. . . . . . . . . .. 54

ST. John's Wort as an Antidepressant. . . . . . . .. 57 Introduction .......................... 57 Botanical Description . . . . . . . . . . . . . . . . . . .. 57 Crude Drug and Extract .................. 58 Key Constituents, AnalYSiS, Pharmacokinetics ... 59 Pharmacology .. . . . . . . . . . . . . . . . . . . . . . .. 61 Biochemical Models . . . . . . . . . . . . . . . . . . . .. 61 Behavioral Models in Animals . . . . . . . . . . . . .. 63 Toxicology, Photosensitization . . . . . . . . . . . . .. 64 Clinical Efficacy in Depressed Patients ........ 64 Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . .. 70 Therapeutic Significance . . . . . . . . . . . . . . . . .. 72 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 73

Kava as an Anxiolytic . . . . . . . . . . . . . . . . . . .. 78 Introduction .......................... 78 Botanical Description . . . . . . . . . . . . . . . . ' . . .. 78 Crude Drug and Extract .................. 78

XII Table of Contents

2.3.4 2.3.5 2.3.6 2.3.7 2.3.8 2.3.9 2.3.10

2.4 2.4.1 2.4.1.1 2.4.1.2 2.4.1.3 2.4.1.4 2.4.1.5

2.4.1.6 2.4.1.7 2.4.2 2.4.2.1 2.4.2.2 2.4.2.3 2.4.2.4 2.4.3 2.4.4

3

3.1 3.1.1 3.1.1.1 3.1.1.2 3.1.1.3 3.1.1.4 3.1.1.5 3.1.1.6 3.1.1.7 3.1.1.8

3.1.1.9 3.1.1.10 3.1.2 3.1.2.1 3.1.2.2 3.1.2.3 3.1.2.4 3.1.2.5 3.1.3

Key Constituents, Analysis, Pharmacokinetics ... 79 Pharmacology and Toxicology . . . . . . . . . . . . .. 80 Clinical Efficacy . . . . . . . . . . . . . . . . . . . . . . .. 81 Side Effects and Risks . . . . . . . . . . . . . . . . . . .. 84 Indications and Dosages . . . . . . . . . . . . . . . . .. 85 Therapeutic Significance . . . . . . . . . . . . . . . . .. 85 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 85

Restlessness and Sleep Disturbances . . . . . . . . .. 87 Valerian ............................. 87 Medicinal Plant .......... . ........... . . 87 Crude Drug and Extract .................. 87 Key Constituents, AnalYSiS, Pharmacokinetics . . , 88 Pharmacology and Toxicology . . . . . . . . . . . . .. 89 Pharmacologic Effects in Humans and Clinical Efficacy in Patients . . . . . . . . . . . .. 91 Indications, Dosages, Risks, and Contraindications 96 Therapeutic Significance . . . . . . . . . . . . . . . . .. 97 Hops, Lemon Balm, Passion Flower, and Lavender 97 Hop Strobiles and Hop Glands ............. 98 Balm Leaves .......................... 99 Passion Flower ........................ 99 Lavender . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 100 Sedative Teas .... . ...... . ............. 102 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 103

Cardiovascular System. . . . . . . . . . . . . . . . . .. 107

Heart Failure and Coronary Insufficiency . . . . .. 107 Hawthorn ........................ . ... 108 Introduction .......................... 108 Medicinal Plant ........................ 109 Crude Drug and Extract .................. 109 Key Constituents, AnalYSiS, Pharmacokinetics ... 109 Pharmacology ......................... 110 Toxicology ........................... 113 Clinical Efficacy . . . . . . . . . . . . . . . . . . . . . . .. 114 Indications. Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . .. 117 Therapeutic Significance . . . . . . . . . . . . . . . . .. 118 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 118 Herbs Containing Digitaloids . . . . . . . . . . . . . .. 119 False Hellabore ........................ 120 Lily-of-the-Valley ....................... 120 Squill Powder ......................... 121 Oleander Leaves ....................... 121 Drug Products . . . . . . . . . . . . . . . . . . . . . . . . . 122 Other Cardioactive Plant Drugs ...... . . . . . .. 122

Table of Contents XIII

3.2 3.2.1 3.2.1.1 3.2.1.2 3.2.2

3.3 3.3.1 3.3.1.1 3.3.1.2 3.3.1.3 3.3.1.4 3.3.1.5 3.3.1.5.1

3.3.1.5.2

3.3.1.5.3 3.3.1.5.4 3.3.1.6 3.3.1.7 3.3.1.7.1 3.3.1.7.2 3.3.1.7.3

3.3.1.7.4 3.3.1.8 3.3.1.9

3.3.1.10 3.3.1.11 3.3.2

3.3.3

3.3.3.1

3.4 3.4.1 3.4.1.1 3.4.1.2 3.4.1.3 3.4.1.4 3.4.1.5 3.4.1.6 3.4.1.6.1 3.4.1.6.2 3.4.1.7

Hypotension and Hypertension . . . . . . . . . . . .. 124 Phytotherapy of Hypotension .............. 124 Caffeine-Containing Herbs and Beverages. . . . .. 125 Essential Oils . . . . . . . . . . . . . . . . . . . . . . . . .. 126 Phytotherapy of Hypertension. . . . . . . . . . . . . . 126

Atherosclerosis and Arterial Occlusive Disease .. 128 Garlic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 128 Historical Background ...... . ............ 128 Botanical Description . . . . . . . . . . . . . . . . . . . . 129 Crude Drug . . . . . . . . . . . . . . . . . . . . . . . . . .. 130 Key Constituents, Analysis, Pharmacokinetics ... 131 Experimental Pharmacology ............... 133 Effects on Atherogenesis and Lipid Metabolism . . . . . . . . . . . . . . . . . . . . 135 Effects on Vascular Resistance, Fibrinolysis, and Platelet Aggregation . . . . . . . . . . . . . . . . .. 135 Cardioprotective and Antioxidative Effects ..... 137 Other Actions ................... . ..... 137 Toxicology .. . ...... . .... . ............ 138 Clinical Studies ..... . . . ...... . . . .. . ... . 138 Reduction of Elevated Blood Lipids . . . . . . . . .. 140 Blood Pressure Reduction . . . . . . . . . . . . . . . .. 141 Inhibiting the Progression of Atherosclerosis in Humans .. . ...... . ... . ............. 142 Other Clinical Studies . . . . . . . . . . . . . . . . . . .. 144 Side Effects and Garlic Odor . . . . . . . . . . . . . . . 144 Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . " 146 Therapeutic Significance ... . ..... . . ... , . .. 147 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 148 Gingko Special Extract for Peripheral Arterial Occlusive Disease. . . . . . . . . . . . . . . .. 152 Other Herbs with Antiatherosclerotic Properties . . . . . . . . . . . . . . . . . . . . . . . . . . .. 155 Red Yeast Rice . . . . . . . . . . . . . . . . . . . . . . . .. 156

Chronic Venous Insufficiency . . . . . . . . . . . . . . Horse Chestnut Seed Extract . . . . . . . . . . . . . . . Introduction ........ .. .......... .. ... . Crude Drug and Extract . . ........... . ... . Chemistry and Pharmacokinetics of Aescin . . . . . Pharmacology ...... . . .. ..... . . . .. . . . . . Toxicology ..................... . .... . Actions and Efficacy in Subjects and Patients .. . Studies in Healthy Subjects . . . . . . . . . . . . . . . . Therapeutic Studies in Patients ... . ... . .... . Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . . .

158 158 158 159 160 160 161 161 161 161

165

XIV Table of Contents

3.4.1.8 3.4.2 3.4.3

4

4.1 4.1.1 4.1.2

4.2 4.2.1 4.2.1.1 4.2.1.2 4.2.1.3 4.2.1.4 4.2.1.5 4.2.2 4.2.2.1 4.2.2.2 4.2.2.3

4.3 4.3.1 4.3.2 4.3.3

4.4 4.4.1 4.4.1.1 4.4.1.2

4.4.1.3

4.4.2 4.4.3 4.4.3.1 4.4.3.2 4.4.3.3 4.4.3.4 4.4.4 4.4.5

4.5

4.6

Therapeutic Significance . . . . . . . . . . . . . . . . .. 165 Topical Venous Remedies . . . . . . . . . . . . . . . .. 166 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 167

Respiratory System . . . . . . . . . . . . . . . . . . . .. 169

Cold Syndrome (Flulike Infection) .......... 169 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . .. 169 Viruses and Host Defenses ................ 170

General Phytotherapeutic Measures .......... 171 Teas for Cold Relief . . . . . . . . . . . . . . . . . . . .. 171 Elder Flowers ......................... 171 Linden Flowers ........................ 172 Meadowsweet Flowers . . . . . . . . . . . . . . . . . .. 173 Willow Bark and Salicylates ............... 174 Tea Formulas ......................... 174 Essential Oils . . . . . . . . . . . . . . . . . . . . . . . . .. 176 Nasal Ointments and Nosedrops ............ 176 Inhalation Therapy . . . . . . . . . . . . . . . . . . . . .. 177 Lozenges, Troches and Gargles ............. 178

Herbal Cough Remedies . . . . . . . . . . . . . . . . .. 180 Mucilaginous Herbs ..................... 180 Essential Oils in Cough Remedies ........... 181 Ephedra ............................. 182

Herbal Expectorants. . . . . . . . . . . . . . . . . . . .. 184 Mechanisms of Action ................... 184 Reduction of Mucus Viscosity by Water ....... 184 Neural Mechanism Based on the Gastropulmonary Reflex . . . . . . . . . . . .. 185 Liquefaction of Secretions by Direct Action on the Bronchial Glands. . . . . . . . . . . . . . . . .. 185 Saponin-Containing Herbs. . . . . . . . . . . . . . . .. 186 Essential Oils as Expectorants .............. 189 Dosage Forms . . . . . . . . . . . . . . . . . . . . . . . .. 190 Cineole (Eucalyptol) . . . . . . . . . . . . . . . . . . . .. 192 Myrtol ............................... 192 Anise Oil and Anethole .................. 193 Licorice Root . . . . . . . . . . . . . . . . . . . . . . . . .. 194 Suggested Formulations .................. 195

Phytotherapy of Sinusitis ................. 197

Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 198

Table of Contents XV

5 Digestive System . . . . . . . . . . . . . . . . . . . . . .. 203

5.1 5.1.1 5.1.2 5.1.2.1 5.1.2.2 5.1.3 5.1.3.1 5.1.3.2 5.1.4 5.1.5 5.1.6

5.2 5.2.1 5.2.2 5.2.3

5.3 5.3.1 5.3.2 5.3.3

5.4 5.4.1

5.4.2 5.4.2.1 5.4.2.2 5.4.2.3 5.4.2.4 5.4.2.5 5.4.2.6 5.4.2.7

5.5 5.5.1 5.5.1.1 5.5.1.2 5.5.1.3 5.5.2 5.5.3 5.5.3.1 5.5.3.2 5.5.3.3

5.5.4 5.5.5

Anorexia and Dyspepsia . . . . . . . . . . . . . . . . .. 203 Introduction ........... . .............. 203 Bitter Herbs (Bitters) .................... 204 Wormwood (Absinth) . . . . . . . . . . . . . . . . . . .. 206 Other Bitter Herbs . . . . . . . . . . . . . . . . . . . . . . 207 Biliary Remedies (Cholagogues) ............ 209 Artichoke Leaves .. . . . . .. .............. . 210 Other Cholagogues . . . .. . ... . .......... . 213 Digestive Enzymes . . . . . . . . . . . . . . . . . . . . .. 214 Suggested Formulations .................. 215 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 217

Bloating and Flatulence ............ . .... . 218 Definition and Actions of Carminatives. . . . . . . . 219 Typical Carminative Herbs ............ . ... 219 Suggested Formulations ......... . ........ 220

Gastritis and Ulcer Disease . . . . . . . . . . . . . . .. 222 Chamomile . . ... . .. . . . ....... . ........ 223 Licorice Root . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 224

Irritable Bowel Syndrome . . . . . . . . . . . . . . . .. 225 Symptoms, Epidemiology, and Approaches to Treatment ... . . . . . . . . . . . . . . . . . . . . . .. 225 Peppermint . . . . . . . . . . . . . . . . . . . . . . . . . .. 226 Crude Drug and Constituents ..... . ........ 226 Peppermint Oil ............... . ........ 226 Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . .. 227 Pharmacology ..... . ... . ..... . .. ... ...... 228 Therapeutic Efficacy . . . . . . . . . . . . . . . . . . . .. 228 Risks and Side Effects . . . . . . . . . . . . . . . . . . .. 239 Indications, Dosages, and Contraindications .... 230

Acute Diarrhea ...... ... ......... . . . ... 232 Tannin-Containing Herbs ...... . .......... 232 Green and Black Tea . . . . . . . . . . . . . . . . . . . . 233 Other Tannin-Containing Herbs . . . . . . . . . . . .. 234 Tannic Acid and Albumin Tannate . . . . . . . . . .. 235 Pectins .......... . . . ............ . .... 236 Live Dried Yeast ............ . ... . .. . ... 236 Pharmacology and Toxicology . . . . . . . . . . . . . . 237 Therapeutic Efficacy . . . . . . . . . . . . . . . . . . . .. 237 Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . .. 238 Other Herbal Antidiarrheals . . . . . . . . . . . . . . .. 238 Suggested Formulations ..... . ... ... ...... 240

Table of Contents

5.6 5.6.1 5.6.2 5.6.2.1 5.6.2.2 5.6.2.3 5.6.2.4 5.6.2.5 5.6.3 5.6.4 5.6.4.1 5.6.4.2 5.6.4.3 5.6.4.4 5.6.5 5.6.6

5.7 5.7.1 5.7.1.1 5.7.1.2 5.7.1.3 5.7.1.4 5.7.1.5 5.7.1.6 5.7.1.7

5.7.2 5.7.3

Constipation . . . . . . . . . . . . . . . . . . . . . . . . .. 241 Symptoms, Causes, General Measures ... .. . .. 241 Bulk-Forming Agents . ........ . . ... ... . .. 242 Mechanism of Action .. . ... . . . ....... .... 242 Linseed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244 Wheat Bran . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Psyllium Seed and Husk . . . . . . . . . . . . . . . . . . 247 Agar and Karaya Gum .. . ... ....... . .. . . . 248 Osmotic Agents . . . . . . . . . . . . . . . . . . . . . . .. 248 Anthranoid-Containing Herbs . .. .. . . .. . . .. . 249 Rhubarb Root . . . .. . .. ....... . ... . . .. . . 251 Buckthorn Bark . . . . . . . . . . . . . . . . . . . . . . .. 252 Senna Pods and Leaves ... ... .... . ..... . . 253 Aloe . . . .. .. ... .. .. . . .. . . .. . .. .. .. . .. 253 Castor Oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Suggested Formulations . .... . .... . . .. .. . . 255

Liver Diseases . ...... ... .. . .... . .. . .... 257 Milk Thistle Fruits, Silymarin . . . . . . . . . . . . . . . 258 Medicinal Plant and Crude Drug . . .. . .. . .. . . 258 Components and Active Constituents . . . . . . . .. 259 Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . 259 Pharmacology and TOxicology . . . . . . . . . . . . .. 259 Therapeutic Efficacy in Chronic Liver Diseases .. 260 Use in Mushroom Poisoning . . . . . . . . . . . . . .. 261 Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . .. 262 Soybean Phospholipids . . . . . . . . . . . . . . . . . .. 262 Drug Products . . . . . . . . . . . . . . . . . . . . . . . .. 263

6 Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . . .. 265

6.1 Inflammatory Diseases of the Urinary Tract . . .. 265 6.1.1 Uva Ursi Leaves. . . . . . . . . . . . . . . . . . . . . . .. 266 6.1.2 Petasite Rhizome .... . . . . . . . . . . . . . . . . . .. 268

6.2 Benign Prostatic Hyperplasia .. . . ... .. .. ... 268 6.2.1 Saw Palmetto Berries .... .. .. . . . .. . . .. ... 270 6.2.2 Nettle Root .. .. . . ... . . . . .. ... .. . . . . .. . 274 6.2.3 Pumpkin Seeds . . . ... .... ... .. .. . .. . ... 275 6.2.4 Grass Pollens. . . . . . . . . . . . . . . . . . . . . . . . . . 276 6.2.5 Phytosterols from Hypoxis moperi . . . . . . . . . . . . 277 6.2.6 Pygeum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

6.3 Therapeutic Significance . . . . . . . . . . . . . . . . . . 278

6.4 Drug Products Other than Teas. . . . . . . . . . . . . 279

6.5 Bladder and Kidney Teas . . ... ... ... . . .... 280

Table of Contents XVII

7. Gynecologic Indications for Herbal Remedies. . . 285

7.1 Chasteberry . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

7.2 Black Cohosh .... .. ..... . . . . .. ........ 289

7.3 Phytoestrogens . . . . . . . . . . . . . . . . . . . . . . . .. 291

7.4 Other Herbs .... .... . .. .. . ... . ..... . .. 293

7.5 Therapeutic Significance. . . . . . . . . . . . . . . . .. 295

7.6 Drug Products. . . . . . . . . . . . . . . . . . . . . . . . . 295

8 Skin, Trauma, Rheumatism, and Pain . . . . . . . .. 299

8.1 Dosage Forms and Preparations. . . . . . . . . . . .. 299

8.2 8.2.1 8.2.1.1 8.2.1.2 8.2.1.3 8.2.1.4 8.2.2

Inflammations and Injuries of the Skin . ..... . 301 Chamomile Flowers ..... . ..... . . . .. . . . .. 301 Crude Drug, Constituents, and Preparations . . .. 302 Pharmacology and Toxicology . . . . . . . . . . . . . . 304 Therapeutic Efficacy . . . . . . . . . . . . . . . . . . . .. 305 Indications, Dosages, Side Effects, and Risks . . .. 305 Witch Hazel and Other Tannin-Containing Herbs . ... . .. . .. . ...... 306

8.2.3 Evening Primrose Oil . . . . . . . . . . . . . . . . . . .. 308 8.2.4 Other Dermatologic Herbs . . .... . ....... . . 310

8.3 Post-traumatic and Postoperative Conditions . .. 313 8.3.1 Bromelain . . . . . . . . . . . . . . . . . . . . . . . . . . .. 313 8.3 .2 Comfrey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314 8.3.3 Arnica . ... . ........ . ..... : ....... ;- . .. 314

8.4 Rheumatic Conditions and Degenerative Joint Diseases . . .... . . ... ... . .... . .. . . . 316

8.4.1 Devil's Claw . ..... . .... .. . . .. . . . .. . .. . 316 8.4.2 Willow Bark, Ash, Aspen .. . .. . ... . ... .. . . 318 8.4.3 Nettle Tops . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 8.4.4 BoswelJia serrata . .... .. .... . .... . . .. . ... 319

8.5 Treatment of Pain ... .. .... . .. ...... .. .. 320 8.5.1 Peppermint Oil and Tension Headache . .. .... 320 8.5.2 Capsicum (Paprika) for Local Pain Relief ... .. . 322

8.6 Formulations . . . . . . . . . . . . . . . . . . . . . . . . . . 325

8.7 Drug Products. . . . . . . . . . . . . . . . . . . . . . . . . 326

XVIII Table of Contents

9 Agents that Increase Resistance to Diseases. . .. 331

9.1 9.1.1 9.1.1.1 9.1.1.2 9.1.1.3 9.1.1.4

9.1.2 9.1.3 9.1.3.1 9.1.3.2 9.1.3.3 9.1.3.4 9.1.3.5 9.1.3.6

9.1.3.6.1 9.1.3.6.2 9.1.3.6.3

9.2 9.2.1 9.2.1.1 9.2.1.2 9.2.1.3 9.2.1.4 9.2.2 9.2.2.1 9.2.2.2 9.2.2.3 9.2.3 9.2.4

9.3

Adaptogens ... . ................. .... . . Ginseng ..... . . . ........... ... . ... .. . Plant, Crude Drug, and Constituents ........ . Pharmacology and Toxicology . . . . . . . . . . . . . . Clinical Studies in Humans ........ .... .. . . Indications, Dosages, Risks, and Contraindications . . . . . . . . . . . . . . . . . . . . Eleutherococcus Root . . . . . . . . . . . . . . . . . . . . Other Adaptogenic Drugs . . ..... . . ....... . Cordyceps .................. .. .. . .... . Ashwagandha . . .......... . .. ... . . . ... . Gotu Kola .. .. ......... ...... .. . . .... . Astragalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cat's Claw ........................... . Botanical Antioxidants (Grape Seed, Green Tea, Pine Bark) ..... .... . ... .. ... . Pharmacology and Toxicology . . . . . . . . . . . . . . Clinical and Epidemiological Studies ... .. ... . Indications and Dosage ...... . . . . .... .. . .

Immune Stimulants . .. ............ . .... . Coneflower (Echinacea) ... . .. ... .. . . .... . Plant, Crude Drug, and Constituents ........ . Pharmacology and Toxicology . . . . . . . . . . . . . . Studies on Therapeutic Efficacy . ........... . Indications, Dosages, and Risks . . . . . . . . . . . . . European Mistletoe . .. ....... .. ... . . ... . Plant, Constituents, and Actions . . . . . . - . . . . . . . Clinical Efficacy Studies ...... . . ......... . Indications, Dosages, and Risks . . . . . . . . . . . . . Medicinal Yeasts ... .. ............ . . ... . Goldenseal ......... ....... .. ..... ... .

Therapeutic Significance . . ......... . ..... .

331 332 332 333 334

334 335 336 336 337 337 338 338

339 339 340 341

341 342 342 343 344 346 347 347 349 350 350 351

352

10 Appendix The 100 Most Commonly Prescribed Herbal Medications in Germany . . . . ... . .... 357

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

Table of Contents XIX