herbal and homeopathic medicine: understanding the

158 Homeopathy is frequently confused with holistic medicine and with herbal products. The latter is particularly problematic when homeopathic medicines are made from herbs with which they share the same nomenclature. However, homeopathy differs in both toxicity and therapeutic paradigm with important implications for use and future research. The article illustrates this with cases and a review of the history of homeopathy.

Seminars in Integrative Medicine, Vol 1, No 3 (September), 2003: pp 158-166

HERBAL AND HOMEOPATHIC MEDICINE: UNDERSTANDING THE DIFFERENCE JOYCE C. FRYE, DO, MBA, FACOG INTRODUCTION

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From the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Correspondence: Joyce C. Frye, 2131 St. James Place, Philadelphia, PA 19103. © 2003 Elsevier Inc. All rights reserved. 1543-1150/03/103-0006$30.00/0 10.1016/S1543-1150(03)00030-9

umerous studies have documented the increased use of Complementary and Alternative Medicine (CAM) during this last decade.1 Since the passage of the Dietary Supplement Health and Education Act (DSHEA) in 1994, this increased utilization has been fed, in part, by manufacturer claims of amazing benefits for nutritional and herbal supplements. Unfortunately, patients often lack the sophistication to evaluate the quality of the evidence for these recommendations, and physicians frequently lack the time or interest to research studies that document these potential benefits in obscure journals. Physicians read the occasional toxicity report regarding the use of an herb and are becoming increasingly aware of potential herb– drug interactions in the hospital setting, particularly in the perioperative period. In this environment, physicians may find it easiest to dismiss the entire field as useless and/or dangerous. This dismissal of the field increases the likelihood that patients will not communicate about the supplements they are using. In turn, this adds to the possibility that patients may use substances inappropriately and with potentially dire consequences under the assumption that “natural” means “safe.” A case will illustrate. In 1998, Jones and Lawson reported an alarming case of neonatal congestive heart failure (CHF) attributed to maternal use of Blue Cohosh (Caulophyllum thalictroides), which is an herb that is also available as a homeopathic medicine.2 Although other apparent causes of CHF appear to have been ruled out, scant information is provided about the purported causative agent. Jones and Lawson state only that the mother took three times the recom-

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mended dose of one tablet per day for 3 weeks, and that the tablets came from a store selling “naturopathic products.” Their report prompted a reply from New Zealand physicians citing another case with a similar outcome.3 In contrast, the author, obstetrician, has given homeopathic preparations of Caulophyllum on numerous occasions. One patient, gravida 3 para 2 had undergone two previous Caesarian sections as the result of failed inductions at 43 weeks. During her third pregnancy, her cervix remained firm, long, and closed at 40 weeks, which suggested that a similar outcome was likely. She was given a single dose of Caulophyllum 1M (a concentration of 10⫺1000) every 3 days. After three doses, she delivered a healthy infant after a 3-hour labor at 41 1⁄2 weeks. Jones and Lawson do not describe the source or dose of the Caulophyllum preparation used, nor do they indicate that the preparation was chemically assayed once the problem was discovered. Thus, the report does not clarify whether herbal or homeopathic Caulophyllum was ingested, was a standardized extract, was produced according to good manufacturing practices (GMP), or may have been contaminated. This article focuses on the importance of clarifying these issues.

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onfusion between herbs and homeopathic medicines is common and not surprising, since at least one third of the approximately 2000 homeopathic preparations are derived from herbs and called by their botanical names. For example, aloe is aloe whether referring to its herbal or homeopathic form. Although the historic background, manufacturing processes, potential toxicity, and indications for use are significantly different, the common taxonomic nomenclature leaves little obvious distinction to the uninitiated. There is further confusion between the terms homeopathicand holistic. Uninformed patients often think of homeopathy as a fancy word for the entire spectrum of “natural” medicine and believe that homeopathy incorporates the gamut of vitamins, herbs, manual therapies, lifestyle change, and so on. This is a more apt description of naturopathy. (Indeed, Jones et al indicate the tablets came from a store selling “naturopathic products”2). While naturopathic practitioners often in-

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clude both herbs and homeopathic medicines among the modalities used, homeopathy is a unique medical therapeutic system distinguished by the methods of both selecting and manufacturing medicines. Better understanding by both patients and practitioners should help reduce risk and guide future research toward beneficial therapies. How should the consumer distinguish between homeopathic and herbal medicines, and learn the appropriate use for each form? How should the medical practitioner know when a patient’s use of a substance is causing potential harm, benefit, or merely “expensive urine?” Understanding these differences is important for both the practitioner and the consumer in order to maximize the possibility of benefit and minimize risk in the use of these substances. Herbal Medicine Herbs or botanical medicines were obviously mankind’s first known pharmacologic agents. Even today, more than 50% of conventionally used drugs have their origins in traditionally used herbs. The search for new agents to identify and isolate is ongoing in collaborations, such as those among The Institute for Economic Botany at the New York Botanical Gardens with the National Cancer Institute and with Pfizer Pharmaceuticals.4 Proponents of botanical medicine assert that the synergistic effect of the multiple compounds present in the whole plant or plant part, allows the compounds to act more gently, safely, and effectively than the single-identified, active ingredient around which a patented pharmaceutical product is formulated (often referred to as reductionist medicine). The pharmacologic action of herbs, however, is known to vary widely, depending on the season of harvest, growth conditions, and the parts of the plant used. Jimsonweed, for example, has toxic components that change seasonally; this plant is edible in one season and toxic in another. Traditional herbal wildcrafters passed this information from generation to generation. Modern mass production may be less reliable. Poor quality manufacturing processes, including potential misidentification, improper collection or use of plant parts, contamination, unreliable dosages, and the dilution or substitution of expensive or hard-to-find herbs, lead to significant concerns about activity and toxicity. In addition, rising safety concerns

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exist regarding the previously unrecognized toxicity of herbs and herb– herb or herb– drug interactions. Homeopathic Medicine Dr Royal Copeland was a US Senator, the former Health Commissioner of New York State, and a homeopathic physician. He introduced and secured passage of the 1938 federal Food, Drug, and Cosmetic Act (FDCA), which grants identical legal status to the homeopathic and allopathic pharmacopoeias. Thus, homeopathic preparations are formulated in accordance with the strict requirements of the Homoeopathic Pharmacopoeia Convention of the United States (HCPUS), which determines whether substances have undergone sufficient testing to be considered official homeopathic drugs within the meaning of the FDCA. In addition to plants, other sources of homeopathic medicines include chemicals, minerals, animal fluids (eg, venom, milk), and nosodes. Nosodes are defined by the HPCUS as “homeopathic attenuations of: pathological organs or tissues; causative agents such as bacteria, fungi, ova, parasites, virus particles, and yeast; disease products; excretions or secretions.” Homeopathic medicines are prepared according to GMP. Unlike herbs, the FDA is charged with regulating the manufacture, marketing, and sale of these drugs. Homeopathic drugs (also known as remedies) are ultra-high dilution substances (ie, in the range of 10⫺3 g/cc to over 10⫺100,000 g/cc) that counterintuitively are observed to be more clinically effective with increasing dilution. While skeptics frequently dismiss the observed effects of homeopathic treatment as placebo response, toxicity has not been a concern. Preparation of a homeopathic medicine involves serial dilutions of 1:10 or 1:100 in a process known as potentization. Vigorous shaking or succussion is required between each dilution step. The medicines are delivered in numerous oral and topical dosage forms, including but not limited to medicated pellets (most common), tablets, liquids, ointments, and suppositories. Labeling is by the Latin name of the substance and the potency which refers to the level of dilution carried out in its preparation—X for 10fold dilutions and C for 100-fold dilutions. For example, a 30C potency has been diluted 100-fold, 30 times to a concentration of 10⫺60. With the exception of nosodes that are only available by prescription, homeopathic medicines in potencies

up to 30C are generally available in health stores and natural food markets. Higher potencies are directly available from homeopathic pharmaceutical manufacturers. In classical homeopathy, as described by the founder, German physician Samuel Hahnemann (1755 to 1843), only single-substance preparations are used. According to principles laid out by Hahnemann, the choice of remedy is complicated for the uninitiated consumer who tries to treat a particular problem. Thus, some homeopathic pharmaceutical companies also produce combination or complex remedies that combine several different homeopathic substances (usually in 3X to 6X potencies) for the treatment of specific conditions. Since the DSHEA, products from nutraceutical and herbal manufacturers that combine homeopathic substances with herbs and nutritional supplements are not unusual to find, thereby creating even further confusion about any potential effect. Herbal Caulophyllum Blue Cohosh (Caulophyllum thalictroides) is a common North American herb that is available as dried powder, tablets, tea, and tinctures. The aerial parts, roots, and rhizomes have all been used to extract active ingredients. The chemical components include the alkaloids anagyrine, baptofoline, magnoflorine, and methylcytisine; the saponins caulosaponin and cauloside D; and citrollol, gum, phosphoric acid, phytosterol, resin, and starch. In animal studies, one of the glycosides has been demonstrated to stimulate smooth muscle in the coronary vessels, small intestine, and uterus. The primary active ingredient, methylcytisine, is pharmacologically similar to nicotine but less potent. Adverse reactions include chest pain, hypertension, abdominal cramps, diarrhea, hyperglycemia, and mucous membrane irritation. Traditional uses included anticonvulsant, antirheumatic, and antispasmodic actions, as well as an increased menstrual flow and induction of labor.5 Nuclear magnetic resonance (NMR) spectroscopic assay of the rhizome identified the novel alkaloid thalictroidine along with nine others. One (N-Methylcytisine) was teratogenic in rat embryo culture, and one (taspine) showed high embryotoxicity.6 The German Commission E Monographs do not include Caulophyllum or Blue Cohosh (Table 1);7 however, the well-respected herbalist, James Duke,8 states that he would suggest it to his daugh-

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TABLE 1. Herbs listed as Unapproved by the German Commission E Monographs and Their Primary Homeopathic Uses Common name

Botanical name

Botanical contraindication

Barbery

Berberis vulgaris

Toxic berberine ⬎0.5g

Borage Calendula Chamomile Colocynth

Borago officinalis Calendulae herba Chamaemelum nobile Colocynthis fructus

Toxic pyrrolizidine alkaloids No evidence of therapeutic use Allergic reactions Toxic cucurbitacin

Ergot

Secale cornutum

Toxic alkaloids

Eyebright Hawthorn berry

Euphrasia officinalis Crataegi fructus (Crataegus oxyacantha) Marrubium vulgare

No evidence of therapeutic use No evidence of therapeutic use

Hyssopus officinalis Szygii cumini semen Stramonii folium (Datura stramonium) Pulmonariae herba Majoranae herb,aetheroleum Origanum majorana Ledi palustris herba (Ledum palustre) Aconiti tuber (Aconitum napellus)

Seizures from oil No evidence of therapeutic use Toxic L-hyoscyamine and Lscopolamine alkaloids No evidence of therapeutic use Toxic arbutin and hydroxyquinone Abortifacient

Horehound, black Hyssop Jambolan seed Jimsonweed Lungwort Marjoram Marsh Tea Monkshood

Mugwort Nutmeg Nux vomica Oleander leaf Pasque flower

Peony Periwinkle Rhododendron

Rue

Toxic aconitine

Artemisia vulgaris Myristicae semen, aril Nux moschata Strychni semen

Abortifacient; allergic reactions Dose related hallucinations, atropine effect, abortifacient Toxic strychnine

Oleandri folium (Nerium odorum) Pulsatillae herba (Pulsatilla nigricans)

Inotropic; accidental poisonings

Paeoniae flos, radix (Paeonia officinalis) Vincae minoris herba Rhododendriferruginei folium (Rhododendron chrysanthum) Rutae folium, herba (Ruta graveolens)

Saffron

Croci stigma (Crocus sativus)

Sarsaparilla

Sarsaparillae radix (Sarsaparilla officinalis) Senecionis herba (Senecio aureus)

Senecio herb (Golden ragwort)

Toxic pyrrolizidine alkaloids

Toxic protoanemonin; CNS, urinary tract effects; abortifacient No evidence of therapeutic use

Primary Homeopathic uses Radiating pain esp. renal colic Hypertension; arthritis Wound healing Irritability Colic esp. gallbladder, intestines Circulatory problems; uterine hemorrhage Inflammed eyes Arrythmia; CHF; arteriosclerosis Mucous membrane irritations Bronchial inflammation Diabetes ADHD; delirium; febrile convulsions; Parkinson’s Pulmonary edema Precocious sexual development Puncture wounds; rheumatism Inflammation after exposure to wind or shock with high anxiety Epilepsy Confusion and drowsiness GI disturbance; Type A personality Eczema; paralytic conditions Hormonal and circulatory problems; breech version Hemorrhoids and fissures

Destruction of blood components Toxic diterpene, grayanotoxine, and hydroxyquinone

Eczema; menorrhagia

Toxic furanocoumarins; hepatic and renal damage; phototoxicity Dose related purpura, thrombocytopenia, abortifacient Gastric irritation; kidney impairment Toxic pyrrolizidine alkaloids

Periosteal and tendon injuries

Rheumatism

Hemorrhages when the blood is dark and stringy Urinary tract infections Amenorrhea; backache; upper respiratory inflammation

This is not sufficient information for a homeopathic prescription and should not be construed as a recommendation for use. CHF ⫽ Congestive heart failure; ADHD ⫽ Attention deficit and hyperactivity disorder; GI ⫽ Gastrointestinal.

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ter if she were having a slow delivery. He cites the dose recommended by Soule in The Roots of Healing as 20 to 30 drops of tincture. Other herbalists9,10 call this herb an emmenogogue or abortifacient early in pregnancy, but they recommend its use (often in combination with other herbs) in the last weeks of pregnancy for stalled labor, to prevent postmaturity, and for postpartum bleeding. Weed9 notes that Caulophyllum tends to lower blood pressure and may raise the fetal heart rate as it begins to work. In a survey of 500 members of the American College of Nurse-Midwives, 90 of 172 respondents acknowledge using herbal preparations for cervical ripening, induction, or augmentation of labor; and 64% of them used Caulophyllum. This same survey was sent to 48 midwifery educational programs, and 64% included instruction in the use of herbs for labor stimulation in their formal curricula.11 Homeopathic Caulophyllum Several studies have attempted to evaluate the use of homeopathic Caulophyllum for labor indications. While the methodology is not sufficiently robust to clearly demonstrate a benefit, there are no reported adverse events. In an animal study, Caulophyllum 30C lowered the rate of stillbirths in pigs by 50% [verum ⫽ 12/104 (10.3%) vs. placebo ⫽ 27/103 (20.8%)].12 Eid et al 13gave 22 primigravidas Caulophyllum 7C every hour in labor up to 4 doses. Labors in the verum group were 38% shorter than those in the placebo group. This study was not blinded, however, it was subsequently repeated as a randomized controlled trial (RCT) with similar results.14 In an RCT using a combination remedy, 93 women were given placebo or Caulophyllum combined with four other plant-derived remedies, all in 5C potency, twice daily in the ninth month of pregnancy. In the experimental group, labors were 40% shorter, and there were four times fewer complications than in the placebo group.15 In a fourth study described in the Cochrane Review, 40 women were treated in a RCT. The trial demonstrated no differences and no adverse events, but lacked a description of the randomization method and clinically meaningful outcomes. The reviewer comments, “It may be more appropriate to undertake further evaluation of individualised homeopathic therapies for induction of labour in future clinical trials.”16

THE WAYS HOMEOPATHY IS DIFFERENT Conceptual Framework Homeopathic prescribing is classically based on the Principle of Similars. This principle states that any substance that can create symptoms in a healthy person can be used to treat similar symptoms in a sick person. Hahnemann derived this concept while translating Cullen’s Materia Medica. He read that Peruvian bark (the source of quinine) was useful in treating malaria, because it was bitter. Reasoning that many bitter substances do not treat malaria, he experimented by ingesting the Peruvian bark. He developed symptoms of malaria that ceased when he stopped taking the Peruvian bark and recurred when he took it again. Hahnemann recalled that centuries earlier Hippocrates and Paracelcus were known to have made observations regarding the action of similar substances. He went on to conduct a series of observations and experiments, called provings(much like a challenge–rechallenge exercise in modern pharmaceutical adverse event evaluation), in which, for the first time, substances were tested for their effects on healthy rather than sick people. Hahnemann went on to prove, and then use medicinally, approximately 200 substances during his lifetime. He was the first person to formalize this principle into a system of medicine, which he named homeopathy (from the Greek meaning similar suffering). Unfortunately, he was also outspoken in his criticism of allopathic (or regular) doctors, which elicited a backlash that has continued to this day and interferred with open-minded and objective inquiry into his precepts. Hans Gram introduced homeopathy in the United States. As an American of Danish descent, Gram returned to Copenhagen to study. While studying in Copenhagen, he was converted to homeopathy. Following his return to New York, Gram, who was medically and socially prominent, was able to convert other practitioners, and the practice of homeopathy spread throughout the surrounding states. Throughout the last half of the nineteenth century, greater successes in cure with homeopathic treatment are well documented.17 Homeopathic practice was favored by the clergy, press, educated community leaders, and mothers. Mothers especially favored homeopathic treatments for their children. At homeopathic medicine’s peak, there were 16 homeopathic medical

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colleges, and in 1900, President McKinley attended the dedication of a monument to Hahnemann in Washington DC.18 Choosing a Homeopathic Medicine In addition to the regulation and standardization of the preparation of homeopathic medicines, the practice of homeopathy differs importantly in the method of selecting the appropriate medicine and in the dosing schedule. Provings included as many as 150 symptoms induced by the experimental substance in the otherwise healthy subjects. In therapeutic use, the choice of medicine is based on a person’s total symptom picture. This includes symptoms on the mental and emotional level, as well as the details of local symptoms, with the goal of finding a single medicine that matches the entire symptom complex. In chronic disease, the total complex arises from those symptoms that are characteristic of the disease in addition to, and often more importantly, the predispositions, preexisting conditions, and social and environmental factors surrounding the onset of the disease. People who have the same conventional diagnosis are frequently treated with one of a number of different medicines because of the unique etiology and symptom picture of each individual. For example, arthritis of the knee would be treated with a different medicine depending on whether the arthritis occurred in the right or left knee, as well as on other specific features of the pain (eg, the activity, patient’s emotional reaction to the pain or aggravating factors such as time of day, temperature). With exposure to particularly potent environmental conditions or virulent organisms and in trauma, people’s responses become more uniform, thereby making it possible to choose one or a select few remedies that will work for most people under those conditions. In epidemic situations, the remedy that best matches the order of presentation and constellation of symptoms of the illness is known as the genus epidemicus, which can also be used prophylactically. Homeopathic medicine was first used for a wide-scale epidemic in 1801, when Hahnemann observed that a child, who was being treated with a homeopathic preparation of belladonna, resisted scarlet fever even though all three siblings were affected. Hahnemann wondered whether the belladonna had acted prophylactically, so he began giving it to children in other families when the first child in that family became

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ill. Doing so, he found belladonna to be protective despite a 90% attack rate among the untreated. The method was so successful that regular physicians adopted this method. By 1838, the Prussian government made the use of belladonna mandatory.19 Along with Aconitum, belladonna is often used when an acute, high fever is the presenting symptom. Similarly, in trauma, Arnica has come to be known as the first remedy for head injury, bruising, and hemorrhage. Likewise, the remedy first considered for puncture wounds is Ledum, for nerve injury it is Hypericum, and for dysfunctional labor it is Caulophyllum, to name a few. The Materia Medica more extensively describes the appropriate use of these and other medicines. There are a number of therapeutic indications for homeopathic Caulophyllum. Many are related to uterine function, though not exclusively in pregnancy (eg, dysmenorrhea). Spasmodic pain in other areas, such as arthritic small joints, is also included. For labor, Castro20 describes the indication as follows: “Labour pains may appear in the groin, bladder and legs, and fly from one place to another. Cervix is rigid and does not dilate. Feels chilly, with trembling or shivering, even when covered up. Contractions are short and very painful. The only marked emotional state to look for is irritability (not anger) with the exhaustion and trembling.” In addition, she recommends against using Caulophyllum routinely to prepare for labor without first consulting a homeopath to advise on this remedy’s use, as well as whether any other homeopathic medicines may be needed. Dosing According to classic homeopathic theory, doses are only repeated as necessary and are discontinued when the problem is resolving. Additional different remedies might be needed as the condition evolves, and as the symptom picture changes. However, FDA rules for over-the-counter (OTC) medications require that a specific indication and dosing schedule be included on the label. This may be a source of confusion for the consumer (as well as the nonhomeopathic physician, who made an effort to learn what homeopathic medicines a patient is taking), who is advised by a homeopathic practitioner to take a particular remedy based on a total symptom complex but finds that the primary indication on the label is different from the chief complaint. Likewise, a consumer may choose a remedy based on the label indica-

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tion and find that the homeopathic medicine does little good when not chosen according to the homeopathic Principal of Similars. Fortunately, in that case, such use is also unlikely to cause any harm.

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he astute reader, who understood the Principle of Similars and the concept of potentizing by dilution, may wonder why the homeopathic use of Caulophyllum is similar to the traditional, Native American herbal use in stimulating labor. Actually, many medicines have the same use in allopathic as in homeopathic practice (although the homeopathic practitioner might choose other remedies after noting the finer degrees of individual differences in people who have the same diagnosis). According to Coulter,17 “Hahnemann and his followers proved many traditional medicines and found that their customary uses could be justified by the law of similars.” Among the first were quinine, described previously, and mercury, whose toxicity symptoms are nearly identical to syphilis. Others included Digitalis for arrhythmia, Colchicum for gout, Euphrasia (Eyebright) for eye diseases, and Uva ursi for urinary tract conditions. In 1882, homeopathic and allopathic physicians were using the same remedies in approximately 80% of 418 recognized disease categories, and most were introduced through the homeopathic Materia Medica.21

Dose Is the difference Hormesis is defined as “the stimulating effect of subinhibitory concentrations of any toxic substance on any organism.”22 Charaka, the firstcentury author of the first treatise on Ayurvedic medicine, tells his readers that “plants powerful enough to cure disease are often the very plants which are most poisonous when used by those who do not understand their properties.”23 Among Western medicinal herbs, Digitalis purpurea, commonly known as Foxglove provides an example of hormesis. In describing one brand of digitoxin that is identical in action to the whole leaf of the plant, The Physicians’ Desk Reference indicates its use as “the treatment of heart failure, atrial flutter, atrial fibrillation, and supraventricular tachycardia” and goes on to add under the “Warning” section that “Many of the arrhythmias for which

digitalis is advised are identical with those reflecting digitalis intoxication.”24 According to University of Massachusetts toxicologist Edward Calabrese, “Poisons that injure or kill at high doses can have the opposite effect at low doses. . .and the paradox holds true for every conceivable measure of health— growth, fertility, life span, and immune and mental function. The effect is known as hormesis, from the Greek word for excite.”25 He and other researchers studying the Biological Effects of Low Level Exposures (BELLE) to chemical agents and radioactivity have noted that paradoxic, dose-response relationships, including U-shaped, hormesis, and biphasic dose-response curves, are actually common.26 Calabrese and his associate, Linda Baldwin, found more than 4500 examples of such effects in the scientific literature, with the results being mostly incidental to rather than the subject of the investigation. These effects are possibly universal. Indeed, like most substances, even water is toxic in excess. German scientists Rudolf Arndt and Hugo Schulz independently came to this conclusion in the late 1900s based on their experiments with animals and yeast. The Arndt-Schulz Law (sometimes known as Arndt’s Law) states, “weak stimuli excite physiologic activity, moderately strong ones favor it, strong ones retard it, and very strong ones arrest it.”22 Whether a concentration is considered therapeutic or toxic depends on the desired effect and the individual’s sensitivity. Thus, it would seem that in instances in which the herbal and homeopathic forms of a substance are used for similar indications, this occurs because they fall within the same range on the dose– response curve. Whereas, for substances that are primarily recognized as toxic, the more dilute homeopathic preparations are found to be therapeutic. In pharmacology, the LD50 marks the dose of a substance at which it becomes lethal for 50% of the population. In many cases, only one type of action may be recognized, because that action occurs over a wide range of conditions or concentrations, or because it is predominant under usual conditions or at usual concentrations. When the opposite action occurs, that action is frequently dismissed as anomalous. In the future, definition of an HD50 on the lower end of the continuum may be possible, which would mark the concentration at which the substances’ action is homeopathic for 50% of the population. Even more exciting, further refinement could come from the

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new realm of toxicogenomics, which is the study of interactions between toxic chemicals and genes. Polymorphisms affecting enzyme action, DNA binding, and metabolism of a compound make the substance less or more toxic.27 Ideally, with knowledge of a person’s genome, practitioners would be able to predict the ways in which that person will respond to a substance without resorting to the 50% rule. Mechanism of Action Calabrese and the BELLE group are careful to distance themselves from homeopathy in an effort to avoid “guilt by association,” which they suggest deterred scientists from investigating the hormesis effect earlier. The major, modern medical objection to homeopathy is the high level of dilution. At 12C or 24X, the resulting concentrations are below Avogadro’s number, which suggests that there can be no remaining molecule of original substance and no biologic explanation for activity as it is presently understood. Conventional physicians, who are unable to conceive of information transfer in biologic systems at a submolecular level, have dismissed homeopathy as placebo. In this age of satellites, cell phones, and wi-fi, this seems a particularly Newtonian limitation. Nonetheless, a plausible explanation would be welcome, indeed, if homeopathy is to find its place in the therapeutic armamentarium. Most investigators believe that the highly polar molecular structure of water must play a role. Just as an ice crystal can take an infinite number of forms but reduces in its chemical analysis to H2O, water molecules are thought to be able to form clusters that may be unique to the substance diluted in it. Support for this theory was recently found when investigators in South Korea studying fullerenes found that, with increasing dilution, dissolved molecules clumped and moved closer together instead of further apart as predicted.28 Further research will be needed to elucidate this phenomenon.

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r Smith’s patient seems to have ingested enough Caulophyllum to put her infant on the wrong side of the dose response curve. Case reports and warnings about this possibility are appropriate; however, as with any conventional

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medication, these reports and warnings should be used as an impetus to therapeutic dose finding. When commenting on the liver toxicity apparently associated with use of kava kava (Piper methysticum), Edzard Ernst, Director of Complementary Medicine at the University of Exeter, observed that more than 70 million doses were consumed in Germany alone before reports of toxicity caused it to disappear from the markets. He asks “what next?” and recommends first to understand whether the cases of toxicity are incidental and predictable and occur with what frequency; to view this data in relation to the known benefits; and to compare the risk– benefit profile with similarly acting drugs.29 When the adverse effects of the conventional drugs are greater (as many herbalists would argue is often the case), use of the herb may prevail. Current furor over the use/misuse of Ephedra should stimulate the same discussion. Investigations of adverse events attributed to herbs should be at least as thorough as they would be for conventional medications in exploring all of the potentially contributory factors including misuse, dose, and contamination. Medical practitioners who lambast CAM as risky, alienate patients who use CAM and miss an opportunity to educate these patients about ways to evaluate risks and benefits of individual therapies. This creates the significant possibility that the proverbial “baby” of a potentially beneficial therapy will be “thrown out with the bathwater.” After all, heparin was not thrown out of the allopathic armamentarium for causing bleeding, and digitalis was not thrown out for causing cardiac arrhythmia. Appropriate therapeutic ranges and indications were found through open-minded scientific inquiry. Current use of herbal and homeopathic preparations unfamiliar to conventional practitioners deserves no less. While regulation of the quality and purity of herbal products clearly needs attention, this has been addressed for any homeopathic medicine listed in the Homeopathic Pharmacopoeia of the United States (HPUS) (indicated on the label). Health care providers and consumers need more education about the appropriate uses of both herbs and homeopathic medicines. In the meantime, however, homeopathic preparations of herbs can be used safely even when the herbal form is considered toxic.

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REFERENCES 1. Wooton JC, Sparber AG: Surveys of complementary and alternative medicine, in Micozzi MS (ed): Current Review of Complementary Medicine. Philadelphia, PA, Current Medicine, 1999, pp 139-153 2. Kelly G, Husband A, Waring M: Phenolic phytoestrogens. Quarterly Review of Natural Medicine 5:63-77, 1998 3. Wright IMR: Neonatal effects of maternal consumption of blue cohosh. Journal of Pediatrics 134(3) 1999 4. The Institute for Economic Botany: New York Botanical Garden. 2003. Ref Type: Electronic Citation 5. Fetrow CW, Avila JR: Professional’s Handbook of Complementary and Alternative Medicines. (ed 2). Springhouse, PA, Springhouse, 2001 6. Kennelly EJ, Flynn TJ, Mazzola EP, et al: Detecting potential teratogenic alkaloids from blue cohosh rhizomes using an in vitro rat embryo culture. Journal of Natural Products 62(10):1385-1389, 1999 7. Weed S: Menopausal Years the Wise Woman Way. Woodstock, NY, Ash Tree Publishing, 1992 8. Duke JA: The Green Pharmacy. Emmaus, PA, Rodale Press, 1997 9. Weed SS: The Wise Woman Herbal for the Childbearing Year. Woodstock, NY, Ash Tree Publishing, 1986 10. Stapleton H, Tiran D: Herbal medicine, in Tiran D, Mack S (eds): Complementary Therapies for Pregnancy and Childbirth. London, England, Harcourt, 2000, 105-128 11. McFarlin BL, Gibson JH, O’Rear J, et al: A national survey of herbal preparation use by nurse-midwives for labor stimulation: Review of the literature and recommendations for practice. Journal of Nurse Midwifery 44(3):205-216, 1999 12. Day C: Control of stillbirths in pigs using homoeopathy. Veterinary Record 114(9):216, 1984 13. Eid P, Felisi E, Sideri M: Applicability of homeoepathic Caulophyllum thalictroides during labour. British Homoeopathic Journal 82(4):245-248, 1993 14. Eid P, Felisi E, Sideri M: Super-placebo ou action pharmacologique? Une etude en double aveugle, randomisee avec un remede homeopathique (Caulophyllum thalictroides) dans le travail de l’accouchement. Proceedings of the 5th Congress

of the OMHI (International Organization for Homeopathic Medicine), Paris, France, Oct 20, 1994 15. Dorfman P, Lassere M, Tetau M: Preparation a l’accouchement par homeopathic: Experimentation en doubleinsu versus placebo. Cahiers de Biotherapie 94:77-81, Apr 1987 16. Smith CA: Homoeopathy for induction of labour (Cochrane Review). The Cochrane Library 1. 2002. The Cochrane Library, Oxford. Ref Type: Electronic Citation 17. Coulter H: Divided Legacy: The Conflict Between Homoeopathy and the American Medical Association. Berkeley, CA, North Atlantic Books, 1982 18. Frye JC: Homeopathy in office practice, in Randall J (ed): Primary Care. Philadelphia, PA, Saunders, 1997, pp 845865 19. Hoover TA: Homeopathic prophylaxis. Journal of the American Institute of Homeopathy 94(3):168-175, 2001 20. Castro M: Homeopathy for Pregnancy, Birth, and Your Baby’s First Year. New York, NY, St. Martin’s Press, 1993 21. Potter SOL: Index of comparative therapeutics: in Coulter H: Divided Legacy, Berkeley, CA, North Atlantic Books, 1982 22. Dorland’s Illustrated Medical Dictionary (ed 28). Philadelphia, PA, Saunders, 1994 23. Patnaik N: The Garden of Life: An Introduction to the Healing Plants of India. New York, NY, Doubleday, 1993 24. Crystodigin: Physician’s Desk Reference. Montvale, NJ, Medical Economics, 1996, pp 1433 25. Hiveley W: Is radiation good for you? Or dioxin? Or arsenic? Discover 23(12), 2002 26. Biological Effects of Low Level Exposures. BELLE. 2003. Ref Type: Electronic Citation 27. Begley S: Poisons aren’t toxic to everyone equally, creating a dilemma. Wall Street Journal C1, 2003 28. Samal S, Geckeler KE: Unexpected solute aggregation in water on dilution. Chem Commun 21:2224-2225, 2001 29. Ernst E: Second thoughts about Kava. American Journal of Medicine 113:347-348, Sept 2002