Native Healers. Anita Ralph
all essential factors in the safe use of these traditionally used herbs. PA's are not absorbed through the skin, so external use is safe. Internal use of these herbs should be avoided in pregnancy, as this is one situation where evidence of rare harm has been found.
Systematic reviews and multifaced case analysis studies were com-missioned by the National Institute of Medical Herbalists in 2016. The findings are now published and show that although establishing directly causality of poisoning by PAs, could not be established, adverse events arising from ingestion of these plants is a rare harm, and that a patient-specific risk: benefit analysis should always be conducted before these plants are prescribed.26
By far the most common feature of herbal medicine adverse reactions we have observed in our practice setting is when a patient reports a (self-limiting) change to bowel movements early on in the treatment. Sometimes there can be temporarily increased diuresis, or other idiosyncratic reactions related to normal healing responses. Sometimes patients will report an increase in coughing, and expulsion of mucous from the nose when being treated for a cold for example. Mucous is produced by the body to both protect the membranes of the body and also as a vehicle to eliminate pathogens or the results of successful infection reactions. Producing more mucous more easily is exactly what the body needs to do to clear the respiratory tract of debris so that healing can occur. Here is a real case history showing the sort of thing that can happen.
Case history
Background
A 38-year-old woman presents with depression, recurrent colds and rhinitis following several miscarriages in the last 18 months. She is exhausted, and feels cold and miserable. She has a regular menstrual cycle but experiences heavy, painful periods. She eats a varied diet but is slightly overweight for her height. She has difficulty sleeping through the night, waking frequently, and feels anxious with occasional palpitations. She is pale, her tongue is pale, and she has a full ‘jumpy’ pulse despite a ‘normal’ blood pressure of 120/80 mmHg.
Herbal intervention
Herbal medicines included chamomile flowers (Matricaria chamomilla L.), ginger root (Zingiber officinale Roscoe), nettle leaf (Urtica dioica L.), yarrow herb (Achillea millefolium L.), echinacea root (Echinacea purpurea (L.) Moench) and raspberry leaf (Rubus ideaeus L.). She also had a night-time herbal medicine containing passionflower herb (Passiflora incarnata L.) and motherwort (Leonurus cardiaca L.). She was happy to include other herbal teas, especially chamomile and fennel, cinnamon and ginger, and oat flower and lemon balm.
Dietary advice
She was advised to try to avoid bread in her diet (she tended to eat bread for breakfast and lunch), and to try to find a non-wheat alternative. This was partly to create more variety in her diet. A multi-grain, seed, nut and fruit muesli with live plain yoghurt was suggested for breakfast, and a buckwheat and lentil tabbouleh with handfuls of green herbs (parsley, mint, coriander) with a tahini sauce was suggested as a possible lunch.
What happened next
The patient telephoned within a week of starting the herbal medicine feeling she was experiencing palpitations. On questioning, she was experiencing them mornings and evenings when going to bed and waking from sleep. She had reported palpitations at her first visit, and was reminded of this. She agreed that she had been anxious about allowing herself to sleep more, when she was already very tired during the day. The herbalist encouraged her to embrace the sleep, and allow her body to rest and re-charge.
The review consultation
The patient returned for a follow-up consultation 3 weeks later, reporting she was sleeping very well. So well, in fact, that the herbal medicine was now making her feel ‘drowsy’. She had begun to make changes to her diet, and was enjoying the new foods. The rhinitis was gone. She had had another menstrual period, this time heavy but much less painful than usual. She was encouraged to continue with the daytime and night-time herbs for another month/cycle.
Another review
Within that time her sleep continued to be good, the drowsiness gradually disappeared and her next menstrual cycle was moderately heavy with no pain. The palpitations had gone, except for some on the day of her period (a disappointment for this lady who wanted desperately to conceive). Her pulse was strong but less ‘jumpy’, and her tongue was more pink rather than pale. She felt less ‘depressed’ although she continued to suffer from a propensity to low mood. She went on to have two full-term pregnancies.
It can be seen from this complex but typical case history, that it is difficult to put all of the presenting symptoms into a single conventional diagnosis, or to conclude that improvements were down to any single intervention introduced by the herbalist, whether dietary or herbal. This case does illustrate the ideas of the perceived importance by the herbalist of restoring sleep, in this case by using herbal medicine (passionflower and motherwort), of improving circulation (yarrow and ginger), and the concept of ‘tonics’ (nettle, oat flowers, raspberry leaf). The extra nutrition achieved through dietary change and through the nourishing herbs can be delivered by the improved circulation, and improved digestive function. The tongue and pulse can be monitored and give extra information to what the patient reports in terms of symptoms. The patient reported mild ‘adverse effects’ (possibly nocebo effects), early in treatment, but was persuaded to continue, and the symptoms disappeared.
Placebo and nocebo
The placebo effect
Be enthusiastic. Remember the placebo effect—30% of medicine is showbiz.
—Ronald Spark
It is very likely that over the years you will find people who claim that all complementary medicine, including herbal medicine, works mainly by the placebo effect. Well, before we dismiss that, let's take a closer look at just what the placebo effect is.
The word placebo is derived from the Latin for ‘I shall please’. If you were living in medieval England a placebo would be someone who tells you what you want to hear, rather than telling you the truth: a sycophant.
Moving forward into the 1800s, a dictionary from 1811 defined placebo as a medicine designed more to please than benefit the patient. In the 20th century, placebos were thought of as a medicine that the doctor thought was beneficial, but which turned out to be ineffective or inert.
Of course doctors have (and still do in some parts of the world) given placebo medicines deliberately, and their beneficial effects have been documented in many cultures. So currently we view the placebo effect as a positive response to an inert medication.
If there can be positive responses to inert medications, there can also be negative ones. When a patient responds negatively to a medicine that subsequently turns out to be inert, this is termed a nocebo response.
Modern-day medicine has had the placebo effect on its radar for quite a few years now, as it is regarded as an irritating and confounding effect in drug trials of new pharmaceutical medicines that needs to be screened out as far as possible.
You are a placebo responder. Your body plays tricks on your mind. You cannot be trusted.
—Ben Goldacre
A lot of research has gone into trying to identify ‘placebo responders’ so that they can be excluded from clinical trials. This has turned out to be impossible, however. In the real world the meanings we ascribe to all sorts of things can play into healing and our responses to medicines. The term ‘placebo effect’ is quite correct when we are dealing with clinical drug trials, but in the real world what we are really talking about is meaning responses.
The anthropologist Daniel Moerman has studied this area for many years. In his book Meaning, Medicine and the Placebo Effect, Moerman states that:
A human being is simultaneously a cultural and a biological creature…what we think, say and know about the world