Respiratory system
Scope
Apart from their use to provide non-specific support for recuperation and repair, specific phytotherapeutic strategies include the following.
• inflammatory catarrhal conditions of the upper respiratory mucosa (e.g. common cold, rhinitis, sinusitis, otitis media)
Because of its use of secondary plant products, particular caution is necessary in applying phytotherapy in cases of known allergic reactions to specific medicinal plant products.
Rationale and orientation
To the Chinese, the lungs were the internal organs most in contact with the exterior. So as well as ascribing to them the source of the body’s rhythm and the site of the catalysis of vital energies, they were seen to be the organs in charge of defences. In earlier times the role of the respiratory system was obvious in all cultures; the first cry was generally taken to be the first sign of life, the bronchial gasp on the deathbed the last, and a consistent fear throughout history was the hacking, bloody cough of consumption or tuberculosis, the disease that once cast its baleful influence over the popular imagination like cancer and AIDS now do, the constant reminder of how fatal debility followed weakening of the lungs. It was obvious that the lungs, even more than the stomach, were susceptible to contagion, the conceptual medieval precursor to viruses and bacteria. In this imagery, the key to resistance lay not in attacking alien invaders but in strengthening innate resources. Traditional strategies for treating respiratory disease were notably founded on supportive and tonifying remedies. Given that the modern virus remains as elusive as it ever was, an emphasis on supporting defences may seem appropriate again.
Modern interpretations of respiratory illness have shifted in recent years to identifying underlying inflammatory processes, involving leukotrienes and cytokines. Given that most pathologies have a strong inflammatory element, this is a promising avenue of further research for phytotherapy.1
This is, however, the one area where the divide between traditional and modern approaches is not very wide. Elsewhere, there are very few modern endorsements of early treatment strategies.2 Modern medical science, which at first embraced such agents in the earlier part of this century, now sees no role for their use. For example, modern editions of Martindale’s Extra Pharmacopoeia claim that: ‘There is little evidence to show that expectorants are effective’. Some modern drugs may have expectorant activity, such as bromhexine, but they are usually referred to as ‘mucolytic’. The impact of traditional remedies on the respiratory system is relatively poorly researched. Reliable external measures of change in mucosal function are elusive; many respiratory diseases are either self-limiting or are among some of the most persistent conditions in the clinic. Even in asthma, where peak flow rates provide a simple measure of benefit, the complexity of the condition and the usual presence of confounding and violent influences make easy characterisation of the condition, and the measurement of all but the most powerful across-the-board remedies, unreliable.
A sense that traditional approaches should be relegated to history is possibly reinforced in the medical psyche by the knowledge that one of the most dramatic advances of modern drugs was in controlling at last the old scourge of tuberculosis. However, this dismissal is not as conclusive as once thought. Tuberculosis is making a serious come-back on the world stage, attacking first the very impoverished and malnourished as it always did. As modern drugs struggle with this new manifestation, there may once again be value in looking at the lessons from the past, that treatment should be based on supportive remedies in a regime of convalescence. With the luxury of choice, with the option of taking modern drugs where these are necessary, but also being able to select more supportive strategies at other times, there is real value in reviewing the treatments forged out of desperate but not always unsuccessful battles with disease in earlier times. These lessons are fortunately quite well learnt.
The dominant feature of respiratory conditions is how readily changes in their behaviour are appreciated subjectively. The often immediate effects of eating and drinking different foods and drinks, of temperature and humidity changes and of the various treatments used through history have been the main guide in determining therapeutic strategy. From such experience has come the view of the respiratory mucosa and musculature as being particularly sensitive to reflex responses, notably from the upper digestive tract, from the pharynx to the stomach. There is a persistent tradition in many cultures that respiratory problems are extensions of digestive dysfunctions. Embryology supports such links, with the bronchial tree originating as a diverticulum of the pharyngeal zone of the alimentary duct and sharing common vagal innervation, and the association, for example, between asthma and histamine H2 receptors in the stomach3 add further support to such connections.
Phytotherapeutics
Part of the problem with expectorants probably arises from confusion over their definition. Another stems from the difficulties involved with measuring their efficacy.
Overview of expectorants
• An expectorant is a substance that enhances those physiological mechanisms by which respiratory tract secretions are cleared from the lungs. In the course of doing this they often render the consistency of respiratory tract secretions more fluid and/or more demulcent. They do not necessarily increase the quantity of coughed-up phlegm, nor are they necessarily antitussive (see below).
• Since reflex and warming expectorants act by different mechanisms, and on different parts of the lung tissue, an effective herbal prescription can combine these two types of expectorants, but depending on the patient’s condition as noted above.
• The effect and mechanism of action of reflex expectorants have been demonstrated by scientific experiments. However, since their effect seems to involve vagal stimulation of secretory glands, there may also be vagal stimulation of smooth muscle tissue in the lungs. Hence they should be used with caution in asthma, and combined with bronchiolar spasmolytics (but not anticholinergics that can dry respiratory secretions).
• Many lower respiratory tract disorders will benefit from the action of expectorants, but particularly those where mucus is tenacious and difficult to cough up. However, it depends on the cause of a cough whether an expectorant action is also antitussive.
The four definitions of expectorants given below highlight the difficulties. The dictionary meaning is only concerned with the actual oral production of phlegm or sputum. Since the majority of mucus produced from the lungs is swallowed, this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are more useful, but probably the best definition comes from Brunton, a 19th century pharmacologist. Brunton’s functional definition best explains the various ways in which medicinal plants can act as expectorants.
Definitions of expectorants
• Oxford Dictionary – ‘Promoting the ejection of phlegm by coughing or spitting.’
• Boyd (1954) – ‘An expectorant may be pharmacologically defined as a substance which increases the output of demulcent respiratory tract fluid.’
• Lewis (1960) – ‘Expectorants increase the secretions of the respiratory tract and so reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the presence of increased quantities of fluid mucus, expectorants produce a “productive cough” which is less exhausting and less painful to the patient.’
• Brunton (1885) – ‘Remedies which facilitate the removal of secretions from the air passages. The secretion may be rendered easier of removal by an alteration in its character or by increased activity of the expulsive mechanism.’
Why expectorants?
Many respiratory conditions are characterised by abnormal mucus (catarrh) that can narrow airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from the airways.
If expectorants can render this catarrh more fluid and/or assist in its expulsion, then a clinical benefit should be achieved.
Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways (such as tenacious abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and larger airways. The sensitivity progressively decreases in the finer airways and in the very fine airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex, whereas for tracheitis the stimulus is strong.) By clearing abnormal mucus or by changing its character and making it more demulcent, expectorants can allay cough and are therefore antitussive.
In spite of the incomplete scientific case and lack of a consensus orthodox view, traditional approaches to expectoration are strong and consistent across cultures and history. They include mechanisms that are rational and usually immediately apparent.
The following are categories of herbal remedies acting on the respiratory tract.
Stimulating (reflex) expectorants
These are remedies that provoke increased mucociliary activity by reflex stimulation of the upper digestive wall. The classic examples were originally used as emetics. It was noted that this drastic action was accompanied by a noticeable expectoration. In fact, traditional practitioners in Britain used emesis as a technique to clear the lungs in asthma and chronic bronchitis until quite recent times. Application of these remedies in sub-emetic doses was thus a consistent feature in all major herbal traditions. Herbs such as ipecacuanha, squills and Lobelia have been standards in Western medicine. There is some limited modern investigation of mechanisms involved. For example, ipecac-induced emesis is thought to be mediated through both peripheral and central 5-HT3 receptors.4 Other plants have been used as stimulating expectorants, although not used as emetics; members of the Primula, Bellis, Saponaria and Polygala genera are often included in this category in Western traditions. High saponin levels seem to be a common feature of this group and saponins are certainly nauseating in high doses.
Contraindications for stimulating expectorants
Although there is no firm evidence of unsuitability, as gastric irritants they can transiently upset some individuals (immediately relieved by withdrawing or changing the remedy). In addition, the use of stimulating expectorants should be kept under review in cases of:
Warming expectorants (mucolytics)
Many of the spices were highly prized in the cold damp climates of northern Europe for their apparent ability to counteract associated chest problems. In particular, ginger had an almost mythical reputation; where this or imported cinnamon and cloves were not available, Europeans resorted to fennel, aniseed, garlic, mustard and horseradish for the same ends. Later cayenne or chilli peppers were used for this purpose, although generally taken to be too drying in most cases. The effect of the pungent spices probably includes increased blood flow to the respiratory mucosa, a reflex irritation of the upper digestive mucosa (as with the stimulating expectorants) and, especially in the sulphur-containing garlic and mustard family, a decrease in the thickness of mucus by altering the structure of its mucopolysaccharide constituents; the sensation usually is of a clearing of catarrh and the shifting of congestion up from the lungs.5 A simple infusion of fresh ginger and cinnamon remains one of the most effective home treatments for the common cold.
Essential oils from various herbs (either administered as essential oils or contained in herbal extracts or tinctures) are the most important agents that directly influence goblet cells to secrete more respiratory tract fluid and mucus. Boyd studied the effects of several essential oils in various experimental models (see Chapter 2). The most pronounced increase of respiratory tract fluid was seen after ingestion of oil of anise. Interestingly ingestion of oil of eucalyptus had a moderate effect that was not eliminated by cutting afferent gastric nerves. This finding supports the premise that essential oils do not generally act as reflex expectorants.
Contraindications for warming expectorants
The use of warming expectorants may be contraindicated or inappropriate in gastro-oesophageal reflux.
Traditional therapeutic insights into the use of warming expectorants
There is a close association in traditional medicine between catarrhal congestion and the digestive/assimilative functions. The warming remedies were seen to act seamlessly across both respiratory and digestive functions treating disturbances in either or both together. Symptoms most often found with catarrhal conditions might include abdominal distension, loss of appetite and loose stools.
Respiratory demulcents
These herbs contain mucilage and have a soothing and anti-inflammatory action on the lower respiratory tract. Although the mechanism is not clear, an opposite effect to that of the stimulating expectorants has been postulated; that is the effect is a reflex one from the demulcent effect on the pharynx and upper digestive tract, again involving common embryonic origins and vagal innervation.
The major respiratory demulcent herbs are Althaea officinalis (marshmallow root or leaves) and other members of the Malvaceae (mallows), Ulmus spp. (slippery elm), members of the Plantago genus, Cetraria islandica (Iceland moss) and Chondrus crispus (Irish moss). Tussilago (coltsfoot) and Symphytum (comfrey) were very widely popular before concerns about pyrrolizidine alkaloids constrained their sale.
Pronounced antitussive activity has been demonstrated experimentally with oral doses of 1000 mg/kg body weight of extract of Althaea officinalis (marshmallow), with comparable effects at 50 mg/kg of the isolated polysaccharides.6 These animal studies might suggest enormous doses necessary for clinical effect but if, as implied, the effect is a mechanical one, it is likely that only marginal increases in dose would be necessary to have similar impact in larger animals like humans (see also Chapter 2 under Mucilages).
Respiratory demulcents were popular for children’s cough and generally for dry, irritable and ticklish coughing. They were seen as intrinsically contraindicated in wet, damp chest problems, although they can sometimes be quite well suited to these if there is an irritable element.
Contraindications for respiratory demulcents
The use of respiratory demulcents may be inappropriate in profuse catarrhal or congestive conditions of the mucosa (but see above).
Traditional therapeutic insights into the use of respiratory demulcents
As with other respiratory remedies, there is a close association between effects here and on the digestive tract. Respiratory demulcents are at their most appropriate if there are parallel indications in the gut: dry inflamed conditions such as gastritis and oesophagitis associated with hyperacidity, dry constipation and its various associated problems.
Application
Respiratory demulcents are best taken before meals. They are particularly effective taken in cold aqueous infusions. However, if gastro-oesophageal reflux is contributing to the pathology, as can be the case in asthma, they should be taken after meals.
Long-term therapy with respiratory demulcents is usually well tolerated.
Respiratory spasmolytics
Respiratory spasmolytics relax the bronchioles of the lungs. Traditionally they included the solanaceous plants (the nightshade family) with powerful atropine-related antiparasympathetic constituents: Datura, Atropa and Solanum were the prominent antiasthmatics of early history. As could now be explained pharmacologically, these remedies tended also to dry up the mucosa and had other less desirable effects, so less powerful remedies were also popular. Ephedra sinica (ma huang) from Asia was popular when it reached Europe and works through a sympathomimetic action. Other gentle remedies include culinary herbs such as hyssop and especially thyme, horehound, the North American gumplant, Grindelia camporum and elecampane (Inula helenium).
Plant remedies traditionally used as respiratory spasmolytics
• Ephedra (ma huang), Datura stramonium (jimson weed), Atropa belladonna (deadly nightshade), Solanum dulcamara (bittersweet), Hyssopus (hyssop), Thymus vulgaris (thyme), Lobelia inflata (lobelia), Marrubium vulgare (horehound), Grindelia camporum (gumplant), Euphorbia hirta (pill-bearing spurge), Coleus forskohlii, Glycyrrhiza (licorice), Inula (elecampane).
Contraindications for respiratory spasmolytics
The use of respiratory spasmolytics may be contraindicated or inappropriate in the following:
Application
Respiratory spasmolytics may be taken at any time of the day as required for immediate effect.
Long-term therapy with respiratory spasmolytics is acceptable in the case of the gentler examples, but not for the solanaceous plants or Ephedra, and in all cases there should be attention to treatment of underlying causes rather than relying on symptomatic relief.
Anticatarrhals
There are a range of popular herbal treatments for a range of respiratory mucosal conditions whose action still remains mysterious. Indications for their use range from catarrhal congestion to some types of mucosal hypersensitivity such as hayfever and allergic rhinitis.
Plant remedies traditionally used as anticatarrhals
• Euphrasia spp. (eyebright), Plantago lanceolata (ribwort), Sambucus nigra flowers (elder), Mentha piperita (peppermint), Nepeta hederacea (ground ivy), Solidago virgaurea (goldenrod), Verbascum thapsus (mullein flowers) and Hydrastis canadensis (golden seal). Ephedra also has pronounced anticatarrhal activity.
Anticatarrhal herbs for the upper respiratory tract include eyebright, ribwort, Ephedra, elder, peppermint, ground ivy and golden seal. Golden seal is particularly indicated where there is copious yellow to green discharge of a chronic nature. Golden rod may also fit into this category. Anticatarrhal herbs for the lower respiratory tract include mullein, Ephedra and ribwort.
Sage has a general drying effect on bodily secretions including the mucous membranes and may be indicated where secretions are particularly copious and watery.
Herbs modulating inflammation and allergy
The inflammatory basis of many respiratory conditions has been clearer in recent years, with the role of dietary approaches, for example increasing the consumption of omega-3 fatty acids, being increasingly justified.7 The role of plant flavonoids and phenolics (such as the proprietary remedy Pycnogenol derived from the Pinus pinaster – maritime pine) as at least an adjunct for inflammatory respiratory conditions such as allergic rhinitis8 and childhood asthma9 has been supported in double blind, controlled clinical trials against placebo. Traditional remedies such as Ephedra and Scutellaria baicalensis (Baical skullcap) have been refocused on the management of mild asthmatic conditions.
A number of herbs in recent years have accumulated a reasonable evidence base of efficacy in dealing with upper respiratory disease and in asthmatic symptoms. In the first instance, research has been driven by products in the over-the-counter (OTC) industry, given that ‘cough-cold’ is the largest single OTC sector, especially in winter. Generally these remedies have in common preclinical research pointing to various anti-inflammatory activities, but there is little suggestion that they have antiviral or other wider asthmatic properties. The remedies most researched in this area include Petasites hybridus (butterbur) and the South African Pelargonium sidoides (umckaloabo).
Petasites is a traditional European remedy that has been used less in recent years since its pyrrolizidine alkaloid (PA) content was confirmed. Two pyrrolizidine alkaloid reduced proprietary extracts, one from the root and one from the leaf, have come on the market with claims to treat allergic rhinitis and migraine. Preclinical studies have shown that the sesquiterpenes isopetasin, oxopetasin and petasin are active constituents. They have demonstrated smooth muscle relaxant activity and in addition their esters inhibited the in vitro synthesis of leukotrienes, COX-2 and PGE2.10 Clinical trials of the efficacy of Petasites in allergic rhinitis have included a significant study showing comparability with a conventional antihistamine11 and one showing reduced reaction to the inflammatory agonist adenosine monophosphate (AMP).12 Other trials have been smaller or less rigorous,13 though add to the case for this new discovery.
Pelargonium is known in Germany for a range of respiratory conditions including acute bronchitis and has been marketed more widely as an OTC remedy for the common cold. In the former indication the clinical evidence, drawn from six randomised controlled trials, was judged as ‘encouraging’ in a recent meta-analysis.14 In relation to the common cold, a Cochrane review was tentatively positive in its conclusions, albeit from limited evidence (see also Chapter 2).15
There is less evidence for a proprietary preparation based on Sambucus nigra (elderberry), which as well as showing some promise clinically in the treatment of colds, has stimulated anti-inflammatory cytokines in human monocytes ex vivo.16
Antitussives
Antitussives are remedies that allay coughing. Some may work through soothing irritability (respiratory demulcents); others are claimed to relieve coughs at source, by removing congestive mucus or other mobile provocations (expectorants).
However, the term ‘antitussive’ is often used specifically to refer to remedies that depress the cough reflex and, in particular in herbal terms, to those with appreciable levels of cyanogenic glycosides. The notable example in the Western tradition is Prunus serotina (wild cherry). Another tradition was to use opiates, and the gentle version of that strategy, Lactuca (wild lettuce), is still applied to the problem in some traditions. Hops (Humulus lupulus) were also used for the same reason. Such cough suppressants are not ideal treatments and could even be counterproductive if they reduce cleansing of the lungs. However, there are many cases where they provide helpful relief and they may be the only solution for coughing not due to movable irritants (for example, nervous cough on the one hand, tumours on the other).
Topical agents
Throat applications
The surfaces at the back of the mouth and pharynx are the first point of contact for ingested or inhaled pathogens and irritants; the dense masses of lymphatic tissue in the region confirm their important role in defence. The use of gargles, lozenges and cough drops to mobilise local defences can be an effective way to encourage the body’s response to a wide range of respiratory infections. In the case of sore throats, demulcent remedies such as licorice and marshmallow,20 and astringents such as sage (Salvia species) and Hamamelis (witchhazel) could at least reduce irritation, and there are a range of remedies with more substantial reputations as topical anti-inflammatories. These can be used as levers to improve resistance and recovery in rhinitis, sinusitis and otitis as well as treating more local inflammations. Rather than attempting local antisepsis, resinous tinctures such as Calendula and myrrh, balm of Gilead, propolis and Tolu balsam appear to mobilise activity in the surrounding lymphatic tissues through the mildly provocative effect of their resins and essential oils. Other essential oil herbs can provide a mild antiseptic activity, for example thyme (Thymus vulgaris).
Plant remedies traditionally used as throat applications
• Calendula officinalis (marigold), Commiphora molmol (myrrh), Populus gileadensis (Balm of Gilead) – all in 90% alcohol extraction and most effectively combined with 1:1 or 1:2 extracts of Glycyrrhiza glabra (licorice); Salvia officinalis (sage), Thymus vulgaris (thyme); (for more soothing action) tannin- or mucilage-containing herbs such as Althaea officinalis (marshmallow), Rubus nigra (blackberry leaf), Hamamelis virginiana (witchhazel) and Ulmus fulva (slippery elm).
Inhalations
The obvious topical applications for the respiratory mucosa, traditional approaches to inhalations included smoking (Datura for asthma, for example, a high-risk treatment not recommended today), inhaling steam from herbal infusions to relieve congestion, and simple humidification. When the technology for extracting essential oils was developed these were frequent applications. Most apparent activity is found with the oils from mints (especially menthol), Eucalyptus, camphor, the Melaleuca family (tea tree – M. alternifolia, cajuput – M. leucadendron, niaouli – M. viridiflora), the Artemisia family (especially the aromatic A. abrotanum or southernwood21) and the pine family (turpentine – Pinus palustris, P. sylvestris, P. excelsa). These were widely used for symptomatic relief of respiratory congestion, although in the case of menthol there are doubts as to the real benefits (see peppermint monograph).22 It is possible that some volatile principles could exert anti-inflammatory effects23 (steam inhaled from chamomile flower infusions in some allergic rhinitis and pine oils in bronchitis, for example). Small doses of volatile oils may have a complex combination of activities, either reducing or stimulating ciliary activity24 or mucosal secretions.25 (See also Essential oils in Chapter 2.)
Multipurpose remedies
As can be seen from the above, some herbs may fall into several categories. This is because they contain either several active components or a group of active components acting in several different ways. For example, Verbascum (mullein) contains saponins that are expectorant, mucilage that is demulcent and iridoids that are anticatarrhal. Lobelia, although an emetic and stimulating expectorant, was used primarily as a relaxant remedy in 19th century North America; it thus has a broad spectrum of effects on the respiratory system. Probably the broadest acting remedy in common use, however, is Glycyrrhiza (licorice) which combines a saponin stimulant effect, a soothing effect and appreciable anti-inflammatory properties.
Phytotherapy for respiratory conditions
Allergic and non-allergic rhinitis
Rhinitis is an inflammation of the lining of the nose characterised by one or more of the following symptoms: nasal congestion, nasal discharge, sneezing and itching. Acute infectious rhinitis (and sinusitis) is usually due to the common cold and the appropriate treatment is described later in this chapter. Chronic infectious rhinitis is treated using the same approach as described later under chronic sinusitis. Allergic rhinitis is triggered by inhaled allergens and may be perennial or seasonal (hayfever). Non-allergic or vasomotor rhinitis has no identified medical cause, although in naturopathic traditions it is understood as being caused or exacerbated by diet. Rhinitis may also be drug-induced, rhinitis medicamentosus, by overuse of nasal sprays containing decongestants.
In phytotherapy for rhinitis, it is important to identify whether or not inhaled allergens are involved, since this determines the approach to treatment. Allergic rhinitis is usually characterised by sneezing, itching, nasal discharge, conjunctivitis and nasal congestion. There will usually be a family history of allergy and secretions are often copious, clear and thin. Diagnosis is confirmed by positive skin prick test or radioallergosorbent test (RAST) to aeroallergens. In contrast, non-allergic rhinitis is mainly characterised by chronic nasal congestion with a scant, thin, whitish discharge. Skin prick tests and RAST are negative, and it usually has an adult onset.
The acute allergic response in rhinitis results from the interaction of an inhaled allergen with a specific IgE antibody on the surface of mast cells and basophils. This leads to the release of histamine and other factors that cause the acute symptoms. In chronic, persistent rhinitis, T cells recruit eosinophils (in a process quite similar to asthma) and this leads to chronic symptoms such as nasal blockage, loss of smell and nasal hyper-reactivity.
Allergens involved in seasonal allergic rhinitis are usually grass pollens, but pollens from other plants including trees may be implicated. In perennial allergic rhinitis, house dust mite, molds, cockroaches and cats are common sources of allergen.
Treatment
The approach suggested for the herbal treatment of rhinitis is to control symptoms and remove causes. Avoidance measures to reduce exposure to aeroallergens should be part of this treatment, such as the standard procedures to reduce levels of dust mite allergens. Staying at high altitudes or by the sea can substantially reduce pollen exposure (sea breezes are low in pollen).
Dietary exclusions should be trialled for both allergic and non-allergic rhinitis. Herbalists believe that diet can create a state of hypersensitivity and catarrh of the mucous membranes that predisposes to rhinitis. The dietary components that contribute to this process do not necessarily give a positive reaction on the RAST or skin prick test. They include dairy products, wheat, salt and refined carbohydrates. Excessive consumption of these should be avoided by sufferers of rhinitis and complete exclusion of one component (e.g. dairy products) should be tried for at least 2 months, or prior to and during the allergy season.
In order for an allergic reaction to occur, an allergen must penetrate deep into the nasal lining. If the mucous membranes are healthy and intact, the allergen will never reach the mast cells to trigger an allergic reaction. This is why traditional herbalists have stressed the importance of healthy upper respiratory mucous membranes in the management of allergic rhinitis and rely on upper respiratory anticatarrhal herbs (which is really just another way of saying herbs that promote a healthy condition of the mucous membranes) as their mainstay of treatment.
Eyebright is often misunderstood in mass-market products and popular literature. Because of the common name it is often promoted to help vision. But this has never been the case. Because of its favourable effect on upper respiratory mucous membranes, the conjunctiva acquires a healthy sheen, hence the ‘eye is bright’. The herb will have this effect if taken orally or applied topically.
Essential aspects of treatment are as follows
• Immune-enhancing herbs such as Echinacea root and Astragalus. This is especially the case for allergic rhinitis
• Antiallergic herbs only in the case of allergic rhinitis, including Albizia, Baical skullcap and Nigella
• Upper respiratory anticatarrhal herbs for both types of rhinitis, including Euphrasia, Hydrastis and Plantago lanceolata
• When treating seasonal allergic rhinitis, treatment must be commenced 6 weeks before the season starts and continued through the season. Any helpful dietary exclusions should also follow this time pattern
• Stress can exacerbate rhinitis and should be treated if it is considered to be a factor with tonic herbs, nervine tonics, sedative herbs and adaptogens as appropriate
• Treatment of rhinitis at a deeper level may involve the use of depuratives (e.g. Galium – clivers), lymphatics (e.g. Phytolacca – poke root) and choleretics and other liver herbs.
Case history
A 30-year-old female patient with chronic persistent rhinitis. Symptoms were worse in the morning with clear nasal discharge and irritated eyes. She was sensitive to house dust mite and had suffered tonsillitis, adenoids and otitis media as a child. She regularly took antihistamines.
Treatment consisted of a dairy-free diet, protective measures against house dust mite and the following herbs:
| Echinacea angustifolia root | 1:2 | 30 mL |
| Picrorrhiza kurroa | 1:2 | 5 mL |
| Zingiber officinale | 1:2 | 5 mL |
| Euphrasia officinalis | 1:2 | 25 mL |
| Scutellaria baicalensis | 1:2 | 20 mL |
| Albizia lebbek | 1:2 | 20 mL |
| total | 105 mL |
Dose: 8 mL with water twice a day.
Hydrastis 500 mg tablets, one tablet three times a day. After 3 months of herbs, her antihistamine use was greatly reduced and symptoms were very much improved. Note that Picrorrhiza can be replaced by Andrographis if it is not available.
Common cold and influenza
The common cold (acute rhinitis) is a benign viral infection of the upper respiratory tract that usually occurs in the winter months. Viruses commonly involved are rhinovirus, adenovirus, influenza virus and parainfluenza virus. It usually begins with a sore throat, nasal congestion, sneezing with clear discharge and mild fever. After a few days, a mucopurulent discharge occurs due to secondary bacterial infection. A few days of bed rest may be necessary and full recovery usually occurs 7 to 10 days after onset. Complications or sequelae include acute sinusitis, sore throat, tonsillitis and otitis media (covered in this chapter).
In contrast, influenza is often a more severe respiratory infection which can result in loss of life. The main viruses that cause influenza are enveloped viruses known as influenza A and B. These viruses are capable of mutating and new strains constantly appear. Sometimes influenza A virus can exchange a segment of its genetic material with another virus. This produces a new strain of influenza A to which no-one is immune, leading to a worldwide outbreak or pandemic. These have occurred in 1918, 1957, 1968 and 2009. Influenza is also mainly a winter disease. The influenza virus can produce a range of disease, from a mild common cold to fatal pneumonia (especially in the elderly or severely debilitated). True influenza is usually differentiated from other ‘flu-like’ illnesses by its marked systemic illness with high fever, malaise and muscle pain. Bed rest is usually always required.
(For prevention of respiratory infections, see Chapter 8.)
Treatment
The basic treatment approaches for the common cold and influenza are similar. However, in the case of more severe forms of influenza, treatment is more vigorous (e.g. higher or more repeated doses), and the use of St John’s wort (Hypericum perforatum) and garlic (Allium sativum) as putative antiviral agents is included.
Essential aspects of treatment are as follows:
• Diaphoretics and heating remedies to manage and improve febrile responses. For the most direct agents, circulatory stimulants Zingiber (ginger, especially fresh grated) and cinnamon taken in hot water can dramatically improve mucosal symptoms and fend off the sensation of cold. For more gentle but sustained effects, especially in children, hot teas of Mentha piperita (peppermint), Eupatorium perfoliatum (boneset), Nepeta cataria (catmint), Achillea (yarrow), Tilia (lime flowers) and Sambucus (elderflower) are well-established diaphoretic approaches, which in the context of a cold can exert surprisingly different effects than when consumed at other times. Asclepias tuberosa (pleurisy root) is indicated if there are pulmonary or bronchial complications. Allium sativum (garlic, taken raw) may also be useful as a general and warming defensive agent
• Immune-enhancing herbs such as Echinacea root and Andrographis to help support the body’s fight against the virus. Andrographis is particularly suited to acute respiratory infections, whereas the data for Echinacea root is mixed. Note that Astragalus and tonics such as Panax ginseng are contraindicated in the acute stage of infection. Pelargonium sidoides and elderberry also have positive clinical data and may support immunity and have other relevant activities
• Anticatarrhal herbs for upper respiratory catarrh, especially Euphrasia (eyebright), Sambucus (elderflower) and Hydrastis (golden seal). Traditionally, Hydrastis was said to be contraindicated in the acute stage of infection, so its use may be best in the later stages of the secondary bacterial infection
• Hypericum (St John’s wort) as an antiviral treatment for influenza.
Since these are acute disorders, dosages should be high and often.
Case histories
The following case history demonstrates the value of immune-enhancing therapy as an early intervention. John aged 42 was about to fly from Brisbane to London (24 h) and had just caught a cold. He was concerned about the adverse effect of flying on his condition. He was prescribed Echinacea angustifolia root tablets 500 mg and was advised to take two tablets every hour, if possible. By the time John arrived in London his cold was almost gone. He continued to take two Echinacea root tablets every few hours the next day and the cold did not reappear.
The next case history illustrates a more complete approach to treating the common cold. Anne, aged 38, presented with the early stages of a cold including a clear discharge and fever. She was treated with the following formula and recovered quickly with only mild symptoms:
| Echinacea angustifolia root | 1:2 | 40 mL |
| Picrorrhiza kurroa | 1:2 | 10 mL |
| Zingiber officinale | 1:2 | 5 mL |
| Achillea millefolium | 1:2 | 25 mL |
| Sambucus nigra flower | 1:2 | 20 mL |
| total | 100 mL |
Dose: 5 mL with 40 mL hot water five to six times daily.
Treatment was also supplemented with regular intake of peppermint infusions and up to six allicin-releasing garlic (Allium sativum) tablets (5000 mg fresh weight equivalent) a day. Rest was also advised.
Note: for the treatment of influenza the above regime could be followed but the elderflower could be replaced by a high hypericin extract of St John’s wort which has antiviral activity. Where Picrorrhiza is referred to it can be replaced with appropriate doses of Andrographis.
Acute and chronic bacterial sinusitis
With sinusitis, drainage of the sinuses is partially blocked, usually by congestion and mucosal oedema. This results in stasis that allows a bacterial infection to take hold. Pain is caused by either negative pressure (due to absorption of gases by the vasculature) or the positive pressure of mucosal congestion.
Factors involved in the aetiology of chronic sinusitis include pollution, occupational dust exposure, tobacco smoke, adenoids, allergy (especially in children), rhinitis, cold and damp weather, dental problems, trauma and flying. A deviated nasal septum or other structural causes may be present. Phytotherapists also believe that dietary factors can cause excessive mucus discharge, which may cause and sustain the disease. Particularly implicated are dairy products, salt and wheat. Stasis and congestion may be aggravated if the patient has inadequate fluid intake.
Treatment
The treatment approaches for acute and chronic bacterial sinusitis are similar. For acute sinusitis the dose should be higher and given more frequently and treatment may need to be supplemented with diaphoretics etc., as for acute rhinitis, if fever is present. Key aspects are:
• supporting the immune system in its fight against the bacteria involved using immune-enhancing herbs such as Echinacea and Andrographis
• anticatarrhal herbs (e.g. Euphrasia) to help clear the stasis
• mucolytic herbs to help clear the stasis, such as Allium sativum (garlic) and Armoracia (horseradish)
• particularly indicated is Hydrastis (golden seal), which has antimicrobial and anticatarrhal properties and is a mucous membrane trophorestorative. Regularly chewing a Hydrastis tablet can be very beneficial, but they are exceedingly bitter
• A steam inhalation containing antimicrobial and anti-inflammatory essential oils, such as tea tree, pine or aniseed oils, or chamomile flowers, may be useful.
For chronic sinusitis only
• Patients with chronic sinusitis should avoid antihistamines and steroid-based decongestant drugs as these will weaken immunity in the region further.
• Chronic sinusitis may represent a vicarious elimination and this can be additionally treated with depuratives such as Galium (cleavers), and lymphatics such as Phytolacca (poke root)
• Exposure to the environmental factors listed above should be reduced and a dairy-free, low-salt diet should be trialled for at least 3 months. Antiallergic herbs may also be relevant
• The sinuses are relatively inaccessible regions of the body and once a chronic infection has taken hold it can be difficult to eradicate.
The following topical treatment can be beneficial:
| Capsicum annuum | 1:3 | 20 mL |
| Lobelia inflata | 1:8 | 20 mL |
| Hydrastis canadensis | 1:3 | 20 mL |
| Commiphora molmol | 1:5 | 20 mL |
| Myrica cerifera | 1:2 | 20 mL |
| TOTAL | 100 mL |
Work over the affected sinuses for 10 minutes once to twice a day. Keep away from the eyes. Use a glove or wash hands after using.
The Capsicum and Myrica act as decongestants, the myrrh is antiseptic and Lobelia assists penetration. The properties of Hydrastis are given above. If Lobelia is unavailable, substitute with a saponin-containing herb such as Bupleurum or Aesculus (horsechestnut).
Case history
A male patient aged 36 presented with chronic sinusitis that followed a bout of the common cold. There was a history of allergic rhinitis with chronic use of antihistamines and nasal steroids. Antibiotics had failed to resolve the condition, which had been present for 4 years. The patient had a high dairy intake and had been a cigarette smoker. Treatment consisted of the following:
| Echinacea angustifolia root | 1:2 | 40 mL |
| Euphrasia officinalis | 1:2 | 30 mL |
| Hydrastis canadensis | 1:3 | 25 mL |
| Phytolacca decandra | 1:5 | 5 mL |
| total | 100 mL |
Dose: 5 mL with water three times daily
In addition, allicin-releasing garlic (Allium sativum) tablets (5000 mg fresh weight equivalent) three per day and Picrorrhiza 500 mg tablets, two per day, were prescribed. The patient was placed on a dairy-free and low-salt diet and advised not to use antihistamines and steroid decongestant drugs. The above sinus rub was also prescribed.
After a period of 6 months of treatment, symptoms were considerably improved.
Note that the Picrorrhiza can be substituted by Andrographis and the E. angustifolia root by a mixture of E. purpurea and E. angustifolia roots.
Chronic tonsillitis and chronic sore throat
Chronic sore throat may be a symptom of other disorders, such as sinusitis. However, it may exist in its own right as a chronic bacterial infection in a patient with or without tonsils. The organism usually responsible is a group A Streptococcus.
The approaches to the herbal treatment of chronic tonsillitis and chronic sore throat are similar. The main aspects of treatment are as follows:
• Immune-enhancing herbs. Being a chronic condition, Astragalus may be used as well as Echinacea root and Andrographis. Echinacea root is best taken as a liquid to obtain a local effect on the throat
• Lymphatic and depurative herbs are particularly indicated in tonsillitis and include Phytolacca, Echinacea root, Galium and Arctium lappa (burdock)
• Anticatarrhal herbs, particularly eyebright and golden seal
• A local treatment such as a throat spray or lozenge using herbs such as:
• A dairy-free diet rich in fruit and vegetables should be observed.
Example liquid formula
| Echinacea purpurea/angustifolia root | 1:2 | 40 mL |
| Euphrasia officinalis | 1:2 | 25 mL |
| Phytolacca decandra | 1:5 | 5 mL |
| Salvia fructicosa | 1:2 | 15 mL |
| Hydrastis canadensis | 1:3 | 25 mL |
| total | 110 mL |
Dose: 8 mL with water twice a day. Ideally gargle medicine briefly before swallowing.
Case history
A male patient aged 65 complained of a chronic sore throat that had been present for years. Other conditions were also being treated, but for the sore throat he was prescribed:
| Echinacea angustifolia root | 1:2 | 5 mL once a day with water |
| Echinacea angustifolia root | 1:2 | 40 mL |
| Propolis | 1:5 | 30 mL |
| Salvia officinalis | 1:2 | 30 mL |
| total | 100 mL |
Dose: 2 mL in 10 mL water as a gargle on the affected area of the throat twice a day. Swallow after use.
After 8 weeks the sore throat was considerably improved and with continuing treatment it became a minor trouble.
Otitis media
Inflammation of the middle ear, or otitis media, can be divided into suppurative or acute otitis media (AOM), and inflammation accompanied by effusion, termed non-suppurative or secretory otitis media or otitis media with effusion (OME). Viral upper respiratory tract infection is most commonly associated with the onset of AOM, although the major infection present is bacterial. Symptoms can include pain, purulent discharge from the ear, hearing loss, vertigo, tinnitus and fever. Examination will demonstrate a red, dull and bulging or perforated ear drum.
Recurrent AOM is common, affecting between 10% and 20% of children up to 12 months of age.26 Young children have immature immunity and short and poorly functional Eustachian tubes (the latter results in poor middle ear ventilation). Chronic otitis media with discharge from the ear can result from ineffectively treated acute or recurrent otitis media. The infection is clearly bacterial.
OME is an enigmatic disorder that also usually occurs in children. Examination of the ear drum shows that it is retracted (‘sucked in’) and there is fluid in the middle ear cavity that can lead to conductive hearing loss. Allergy, nasal infection and chronic sinus infection may be involved and it is associated with increased frequency of respiratory infections. Medical treatment can involve the use of grommets to drain the middle ear cavity. The overuse of antibiotics is probably ill advised, although bacterial infection may play a role in some patients with this disorder.
Treatment
The treatments of acute and chronic otitis media are similar to the treatments of acute and chronic sinusitis respectively (with the exclusion of the topical treatment).
OME should be regarded as an allergic disorder, as well as possibly a vicarious elimination. A dairy-free, low-salt diet should be tried or otherwise a full elimination diet. However, the presence of microorganisms that contribute to the inflammation or the malfunction of the Eustachian tube should also be considered. If adenoids are implicated, then the OME should be treated similarly to tonsillitis. The following herbs are emphasised during OME treatment:
• Antiallergic and decongestant herbs such as Albizia, Scutellaria baicalensis and Nigella
• Upper respiratory anticatarrhal herbs such as Euphrasia, Solidago, Hydrastis, Plantago lanceolata and Glechoma hederacea
• Depurative and lymphatic herbs such as Galium (clivers) and Phytolacca
• Immune-enhancing herbs, particularly Echinacea root and Astragalus, to correct the presence of allergy and possibly infection
• Chewing on a Hydrastis tablet (difficult for children because of its bitterness) will accentuate its mucous membrane trophorestorative and antibacterial effects on the upper respiratory tract.
Example liquid formula for AOM
| Echinacea purpurea/angustifolia root | 1:2 | 35 mL |
| Sambucus nigra flower | 1:2 | 25 mL |
| Pelargonium sidoides | 1:5 | 20 mL |
| Euphrasia officinalis | 1:2 | 25 mL |
| total | 105 mL |
Adult dose is 5 mL with warm water five to six times a day for acute AOM and 5 mL three times a day as a preventative for recurrent AOM. Children’s doses should be calculated from the application of an appropriate dosage rule.
Acute bronchitis
Acute bronchitis is an acute inflammation of the trachea and bronchi. It commonly follows the common cold, influenza, measles or whooping cough. Patients with chronic bronchitis are particularly prone to develop episodes of acute bacterial bronchitis (where their sputum turns from grey or white to yellow or green). Other factors that can predispose to this kind of bacterial infection include cold, damp, dust and cigarette smoking.
Initially there is an irritating, unproductive cough that eventually progresses over a few days to copious, mucopurulent sputum. Infection usually starts in the trachea and progresses to the bronchi and with this spread there is a general febrile disturbance with temperatures of 38°C to 39°C. Gradual recovery should occur over the next 4 to 8 days. However, it may progress to bronchiolitis or bronchopneumonia.
Treatment
Being an acute disorder, it is important to give frequent doses of herbs and, if possible, to follow the progression of the infection, adapting the treatment to the various stages:
• Antiseptic herbs such as Inula helenium, Thymus vulgaris and Allium sativum (garlic) should be prescribed throughout the course of the infection and preferably should be continued for 1 week into recovery to prevent relapse
• During the dry, unproductive cough phase, demulcents such as Althaea glycetract should be prescribed. This combines well with a small quantity of Glycyrrhiza (licorice) (see under Chronic obstructive pulmonary disease below)
• Diaphoretic herbs are indicated during the febrile phase, particularly Asclepias tuberosa (pleurisy root), which is almost a specific for acute lower respiratory tract infections. It is often combined with Zingiber (ginger) to enhance its effectiveness. Other diaphoretics such as Tilia and Achillea can also be prescribed
• Expectorant herbs, which include Inula helenium, Thymus vulgaris, Polygala and other saponin-containing herbs, Foeniculum (fennel), Pimpinella (aniseed) and Marrubium (white horehound) can be prescribed throughout the course of the disorder
• Anticatarrhal herbs, especially Verbascum, Plantago lanceolata and Hydrastis, may be indicated when the sputum is particularly copious or if the productive cough lingers beyond the acute stage
• Antitussive herbs should be used to help the cough, especially at night, and Prunus serotina (wild cherry) is particularly indicated if tracheitis predominates.
Whooping cough
Whooping cough or pertussis is a highly infectious disease caused by Bordetella pertussis. About 90% of cases occur in children under 5 years.
The first stage consists of respiratory infection lasting about 1 week during which conjunctivitis, rhinitis and an unproductive cough are present. Diagnosis is difficult at this stage, since it resembles other respiratory infections.
The coughing stage follows and is characterised by severe bouts of coughing. Each paroxysm consists of many short sharp coughs, gathering in speed and duration and ending in a deep inspiration when the characteristic whoop may be heard. The paroxysms can end with vomiting. This stage can last from one to several weeks. The sputum is particularly tenacious and difficult to expectorate.
Treatment
The treatment approach is similar to acute bronchitis but different aspects of the treatment are emphasised:
• Immune-enhancing herbs such as Echinacea and Andrographis and respiratory antiseptic herbs such as Inula helenium, Thymus vulgaris and Allium sativum (garlic) should be prescribed throughout to treat the infection and prevent complications
• In the coughing stage, expectorant herbs such as Inula helenium, Thymus vulgaris, Polygala, Glycyrrhiza (licorice) and other saponin-containing herbs, Foeniculum (fennel), Pimpinella (aniseed) and Marrubium (white horehound) should be emphasised to loosen the tenacious sputum
• Also, antitussive and demulcent herbs are required to dampen and soothe the cough reflex. If vomiting is occurring, these should be extended by gastrointestinal spasmolytics such as Viburnum opulus. (See also the marshmallow-licorice formulation below under Chronic obstructive pulmonary disease)
• Respiratory spasmolytics with expectorant activity, such as Grindelia and Inula helenium, should also be emphasised in the coughing stage. A combination of Inula, Glycyrrhiza and Lobelia is worth trying for the most severe symptoms
• Mucolytic herbs such as Allium sativum and Armoracia may also be required to help loosen the tenacious sputum.